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Wu AG, Luch S, Slusher TM, Fischer GA, Lunos SA, Bjorklund AR. The novel LESS (low-cost entrainment syringe system) O 2 blender for use in modified bubble CPAP circuits: a clinical study of safety. Front Pediatr 2024; 12:1313781. [PMID: 38410763 PMCID: PMC10894966 DOI: 10.3389/fped.2024.1313781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/25/2024] [Indexed: 02/28/2024] Open
Abstract
Background Bubble continuous positive airway pressure (bCPAP) is used in resource-limited settings for children with respiratory distress. Low-cost modifications of bCPAP use 100% oxygen and may cause morbidity from oxygen toxicity. We sought to test a novel constructible low-cost entrainment syringe system (LESS) oxygen blender with low-cost modified bCPAP in a relevant clinical setting. Methods We conducted a clinical trial evaluating safety of the LESS O2 blender among hospitalized children under five years old in rural Cambodia evaluating the rate of clinical failure within one hour of initiation of the LESS O2 blender and monitoring for any other blender-related complications. Findings Thirty-two patients were included. The primary outcome (clinical failure) occurred in one patient (3.1%, 95% CI = 0.1-16.2%). Clinical failure was defined as intubation, death, transfer to another hospital, or two of the following: oxygen saturation <85% after 30 min of treatment; new signs of respiratory distress; or partial pressure of carbon dioxide ≥60 mmHg and pH <7.2 on a capillary blood gas. Secondary outcomes included average generated FiO2's with blender use, which were 59% and 52% when a 5 mm entrainment was used vs. a 10 mm entrainment port with 5-7 cm H2O of CPAP and 1-7 L/min (LPM) of flow; and adverse events including loss of CPAP bubbling (64% of all adverse events), frequency of repair or adjustment (44%), replacement (25%), and median time of respiratory support (44 h). Interpretation Overall the LESS O2 blender was safe for clinical use. The design could be modified for improved performance including less repair needs and improved nasal interface, which requires modification for the blender to function more consistently.
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Affiliation(s)
- Andrew G Wu
- Division of Critical Care Medicine, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
| | - Sreyleak Luch
- Department of Pediatrics, Chenla Children's Healthcare, Kratie, Cambodia
| | - Tina M Slusher
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Pediatrics Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
| | - Gwenyth A Fischer
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
| | - Scott A Lunos
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, MN, United States
| | - Ashley R Bjorklund
- Department of Pediatrics, Division of Pediatric Critical Care, Hennepin Healthcare, Minneapolis, MN, United States
- Department of Pediatrics Global Pediatrics, University of Minnesota, Minneapolis, MN, United States
- Department of Pediatrics, Division of Pediatric Critical Care, University of Minnesota, Minneapolis, MN, United States
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Kumar P, Yadav A, Anand P, Debata P. Predictors of CPAP failure with RAM cannula interface for primary respiratory support in preterm neonates. Med J Armed Forces India 2024; 80:60-67. [PMID: 38261886 PMCID: PMC10793224 DOI: 10.1016/j.mjafi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background RAM cannula is used as interface for delivering nasal continuous positive airway pressure (nCPAP) in many neonatal care units though the bench to bedside evidence for its use in clinical settings in lacking. Methods In this prospective cohort study from tertiary care neonatal care unit, the primary objective was to determine the rate of CPAP failure using RAM interface, within 72 h of starting of therapy and secondary objective was to look for the incidence and severity of nasal trauma with the use of RAM interface for CPAP delivery. All inborn preterm neonates between 28 and 32 weeks of gestation and weight more than 1000 g who required non-invasive respiratory support within 6 h of life were included in the study. Results The enroled cohort of 250 neonates had mean gestational age of 30.73 ± 1.32 weeks and mean birth weight of 1410 ± 210 g. CPAP failure rate with the use of RAM interface was 31.2% (78/250) in the overall cohort. The failure rate was higher in subgroup of gestation between 28 and 30 week (52.1%) in comparison with the 31-32-week gestation (18.2%; p-value = 0.0001). Nasal trauma was present in 36 (14%) neonates; of whom 33 (91%) had mild and 2 (6%) and 1 (3%) had moderate and severe, respectively. On multivariate analysis, birth weight less than 1250 g, incomplete antenatal steroids, need for PEEP more than 5 cm & FiO2 > 30% at onset of distress and administration of surfactant were found be statistically significantly associated with CPAP failure with RAM interface. Conclusion The clinical outcomes with the use of RAM interface for CPAP administration are comparable to those with other interfaces with lesser incidence of nasal injury. The results of this study warrant future randomized trials to compare different CPAP interfaces for clinical outcomes and nasal injuries from the developing countries.
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Affiliation(s)
- Pradeep Kumar
- Senior Resident (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Anita Yadav
- Associate Professor (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Pratima Anand
- Chief Medical Officer (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Pradeep Debata
- Professor (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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Rauschendorf P, Bou Saba G, Meara GK, Roodaki N, Conde-Agudelo A, Garcia DEC, Burke TF. Effectiveness of a novel bubble CPAP system for neonatal respiratory support at a referral hospital in the Philippines. Front Pediatr 2023; 11:1323178. [PMID: 38161434 PMCID: PMC10757669 DOI: 10.3389/fped.2023.1323178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Aim To examine the impact of introducing and implementing the Vayu bubble continuous positive airway pressure (bCPAP) system on neonatal survival and neonatal respiratory outcomes in a neonatal intensive care unit (NICU) in the Philippines. Methods We compared clinical outcomes of 1,024 neonates before to 979 neonates after introduction of Vayu bCPAP systems into a NICU. The primary outcome was survival to discharge. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated. Analyses were undertaken separately for the entire NICU population and for neonates who received any form of respiratory support. Results The introduction of the Vayu bCPAP system was associated with (1) significant reductions in intubation (aOR: 0.75; 95% CI: 0.58-0.96) and in the use of nasal intermittent positive-pressure ventilation (NIPPV) (aOR: 0.69; 95% CI: 0.50-0.96) among the entire NICU population and (2) a significant increase in survival to discharge (aOR: 1.53; 95% CI: 1.09-2.17) and significant reductions in intubation (aOR: 0.52; 95% CI: 0.38-0.71), surfactant administration (aOR: 0.60; 95% CI: 0.40-0.89), NIPPV use (aOR: 0.52; 95% CI: 0.36-0.76), and a composite neonatal adverse outcome (aOR: 0.60; 95% CI: 0.42-0.84) among neonates who received any form of respiratory support. Conclusion The use of the Vayu bCPAP system in a NICU in the Philippines resulted in significant improvement in neonatal respiratory outcomes.
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Affiliation(s)
- Paula Rauschendorf
- Vayu Global Health Foundation, Boston, MA, United States
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Grace K. Meara
- Vayu Global Health Foundation, Boston, MA, United States
| | - Navid Roodaki
- Section of Neonatology, Department of Pediatrics, Ilocos Training and Regional Medical Center, San Fernando City, Philippines
- College of Medicine, Mariano Marcos State University, City of Batac, Philippines
- College of Medicine, University of Northern Philippines, Vigan City, Philippines
| | - Agustin Conde-Agudelo
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Daisy Evangeline C. Garcia
- Section of Neonatology, Department of Pediatrics, Ilocos Training and Regional Medical Center, San Fernando City, Philippines
| | - Thomas F. Burke
- Vayu Global Health Foundation, Boston, MA, United States
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Sturrock S, Sadoo S, Nanyunja C, Le Doare K. Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations. Res Rep Trop Med 2023; 14:121-134. [PMID: 38116466 PMCID: PMC10728307 DOI: 10.2147/rrtm.s410785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.
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Affiliation(s)
- Sarah Sturrock
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
| | - Samantha Sadoo
- Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Carol Nanyunja
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Kirsty Le Doare
- Centre for Neonatal and Paediatric Infection, St George’s, University of London, London, UK
- UK Health Security Agency, Salisbury, UK
- Makerere University, Johns Hopkins University, Kampala, Uganda
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Ehret DEY, Demtse Gebremedhin A, Hadgu Berhe A, Hailu Y, Metaferia G, Kessler K, Kessler R, Dunn M, Golan A, Stavel M, Belava J, Horbar JD, Edwards EM, Worku B, Dunn M, Abayneh M. High inter-rater reliability between physicians and nurses utilising modified Downes' scores in preterm respiratory distress. Acta Paediatr 2023; 112:2329-2337. [PMID: 37675588 DOI: 10.1111/apa.16957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/13/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
AIM To assess the inter-rater reliability of modified Downes' scores assigned by physicians and nurses in the Ethiopian Neonatal Network and to calculate the concordance of score-based treatment for preterm infants with respiratory distress. METHODS We included preterm infants admitted from June 2020 to July 2021 to four tertiary neonatal intensive care units (NICUs) of the Ethiopian Neonatal Network that presented with respiratory distress. We calculated the kappa statistic to determine the nurse and physician correlation for each component of the modified Downes' score and total score on admission and evaluated the concordance of scores above and below the treatment threshold of 4. RESULTS Of the 1151 eligible infants admitted, 817 infants (71%) had scores reported concurrently and independently by nurse and physician. The kappa statistic for modified Downes' score components ranged from 0.88 to 0.92 and was 0.89 for the total score. There was 98% concordance for score-based treatment. CONCLUSION Incorporation of the modified Downes' score on admission for preterm infants with respiratory distress was feasible in tertiary NICUs in Ethiopia. The kappa statistics showed near-perfect agreement between nurse and physician assessments, translating to a very high degree of concordance in score-based treatment recommendations. These results highlight an opportunity for task-shifting assessments and empowering nurses.
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Affiliation(s)
- Danielle E Y Ehret
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, United States
- Vermont Oxford Network, Burlington, Vermont, United States
| | | | - Amanuel Hadgu Berhe
- Department of Pediatrics and Child Health, Mekelle University, Mekelle, Ethiopia
| | - Yohanes Hailu
- Department of Pediatrics and Child Health, University of Gondar, Gondar, Ethiopia
| | - Gesit Metaferia
- Department of Pediatrics and Child Health, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Kaitlin Kessler
- University of Vermont Medical Center, Burlington, Vermont, United States
| | - Ryan Kessler
- University of Vermont Medical Center, Burlington, Vermont, United States
| | - Marie Dunn
- St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Miroslav Stavel
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | | | - Jeffrey D Horbar
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, United States
- Vermont Oxford Network, Burlington, Vermont, United States
| | - Erika M Edwards
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, Vermont, United States
- Vermont Oxford Network, Burlington, Vermont, United States
- University of Vermont College of Engineering and Mathematical Sciences, Burlington, Vermont, United States
| | - Bogale Worku
- Ethiopian Pediatrics Society, Addis Ababa, Ethiopia
| | - Michael Dunn
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Mahlet Abayneh
- Department of Pediatrics and Child Health, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Usman F, Farouk ZL, Tsiga-Ahmed FI, Abdussalam M, Jalo RI, Mohammad SS, Aliyu MH. Improvised bubble continuous positive airway pressure ventilation use in neonates in resource-limited settings: a systematic review and meta-analysis. J Perinat Med 2023; 51:840-849. [PMID: 35263514 DOI: 10.1515/jpm-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/14/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In the face of limited fiscal and technical resources, improvised methods have been used to provide effective and sustainable ventilatory support in low-resource settings to reduce neonatal mortality associated with respiratory complications. This study assessed the use of improvised bubble continuous positive airway pressure (ibCPAP) ventilation among neonates with respiratory complications and determined its effect on neonatal outcomes in low- and middle-income countries (LMICs). CONTENT Hospital-based studies conducted between 2010 and 2020 in LMICs were reviewed. Rayyan® software for systematic review was used for screening and article selection. We used Stata® Statacorp Texas USA software to estimate pooled prevalence, proportion estimates, weighted mean differences and 95% Confidence Interval (CI), using the random effects model. SUMMARY A total of 193 articles were generated and 125 were reviewed. Thirteen articles with 806 neonates on ibCPAP ventilation were included. The pooled prevalence of ibCPAP use was 7.0% (95% CI: 3.0%-13.0%). There was a significant difference in mean oxygen saturation before and after ibCPAP use (-1.34% [95% CI: -1.65% to -1.02%, p<0.01). The duration of oxygen requirement among neonates on ibCPAP was 6.5 hours less than controls (0.27 days [95%CI: -0.49 to -0.05, p<0.01). OUTLOOK IbCPAP had no effect on the respiratory rate, duration of admission, mortality and survival. IbCPAP use in LMIC hospitals is low and its use improved oxygen saturation and duration on oxygen among the neonates, but had no impact on length of stay, respiratory rate, mortality or survival.
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Affiliation(s)
- Fatima Usman
- Department of Pediatrics, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Zubaida L Farouk
- Department of Pediatrics, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Fatimah I Tsiga-Ahmed
- Department of Community Medicine, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Muhammed Abdussalam
- Department of Pediatrics, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Rabiu I Jalo
- Department of Community Medicine, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, USA
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Abdallah Y, Mkony M, Noorani M, Moshiro R, Bakari M, Manji K. CPAP failure in the management of preterm neonates with respiratory distress syndrome where surfactant is scarce. A prospective observational study. BMC Pediatr 2023; 23:211. [PMID: 37138252 PMCID: PMC10155133 DOI: 10.1186/s12887-023-04038-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/26/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The mainstay in the management of preterm neonates with respiratory distress syndrome (RDS) include early Continuous Positive Airway Pressure (CPAP), timely surfactant replacement and mechanical ventilation. Preterm neonates with RDS who fail CPAP are at higher risk for chronic lung disease as well as death. Unfortunately, in low resource settings CPAP may be the only treatment available for these neonates. OBJECTIVE To determine the prevalence of CPAP failure among premature newborns with RDS and associated factors. METHODS We conducted a prospective observational study over the first 72 h of life on 174 preterm newborns with RDS receiving CPAP at Muhimbili National Hospital (MNH). At MNH newborns with Silverman Andersen Score (SAS) of ≥ 3 are commenced on CPAP; surfactant and mechanical ventilation are very scarce. Study newborns not maintaining oxygen saturation > 90% or with SAS score ≥ 6 despite being on 50% oxygen and PEEP of 6 cmH2O and those with > 2 episodes of apnoea needing stimulation or positive pressure ventilation in 24 h were considered as CPAP failure. The prevalence of CPAP failure was determined as a percentage and factors associated were determined by logistic regression. A p-value of < 0.05 was considered significant and 95% confidence interval was used. RESULTS Of the enrolled newborns, 48% were male and 91.4% were in-born. The mean gestational age and weight were 29 weeks (range 24-34 weeks) and 1157.7 g (range 800-1500 g) respectively. Of the mothers 44 (25%) received antenatal corticosteroids. Overall CPAP failure was 37.4% and among those weighing ≤ 1200g, it was 44.1% . Most failure occurred within the first 24 h. No factor was identified to be independently associated with CPAP failure. Mortality among those who failed CPAP was 33.8% and 12.8% among those who did not. CONCLUSIONS In resource limited settings like ours with low up take of antenatal corticosteroids and scarce surfactant replacement a significant portion of preterm neonates especially those weighing ≤ 1200 g with RDS fail CPAP therapy.
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Affiliation(s)
- Yaser Abdallah
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Martha Mkony
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mariam Noorani
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Prakash R, De Paoli AG, Davis PG, Oddie SJ, McGuire W. Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2023; 3:CD015130. [PMID: 37009665 PMCID: PMC10064833 DOI: 10.1002/14651858.cd015130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
BACKGROUND Several types of pressure sources, including underwater bubble devices, mechanical ventilators, and the Infant Flow Driver, are used for providing continuous positive airway pressure (CPAP) to preterm infants with respiratory distress. It is unclear whether the use of bubble CPAP versus other pressure sources is associated with lower rates of CPAP treatment failure, or mortality and other morbidity. OBJECTIVES: To assess the benefits and harms of bubble CPAP versus other pressure sources (mechanical ventilators or Infant Flow Driver) for reducing treatment failure and associated morbidity and mortality in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2023, Issue 1); MEDLINE (1946 to 6 January 2023), Embase (1974 to 6 January 2023), Maternity & Infant Care Database (1971 to 6 January 2023), and the Cumulative Index to Nursing and Allied Health Literature (1982 to 6 January 2023). We searched clinical trials databases and the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials comparing bubble CPAP with other pressure sources (mechanical ventilators or Infant Flow Driver) for the delivery of nasal CPAP to preterm infants. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of the evidence for effects on treatment failure, all-cause mortality, neurodevelopmental impairment, pneumothorax, moderate-severe nasal trauma, and bronchopulmonary dysplasia. MAIN RESULTS We included 15 trials involving a total of 1437 infants. All trials were small (median number of participants 88). The methods used to generate the randomisation sequence and ensure allocation concealment were unclear in about half of the trial reports. Lack of measures to blind caregivers or investigators was a potential source of bias in all of the included trials. The trials took place during the past 25 years in care facilities internationally, predominantly in India (five trials) and Iran (four trials). The studied pressure sources were commercially available bubble CPAP devices versus a variety of mechanical ventilator (11 trials) or Infant Flow Driver (4 trials) devices. Meta-analyses suggest that the use of bubble CPAP compared with mechanical ventilator or Infant Flow Driver CPAP may reduce the rate of treatment failure (RR 0.76, 95% confidence interval (CI) 0.60 to 0.95; (I² = 31%); RD -0.05, 95% CI -0.10 to -0.01; number needed to treat for an additional beneficial outcome 20, 95% CI 10 to 100; 13 trials, 1230 infants; low certainty evidence). The type of pressure source may not affect mortality prior to hospital discharge (RR 0.93, 95% CI 0.64 to 1.36 (I² = 0%); RD -0.01, 95% CI -0.04 to 0.02; 10 trials, 1189 infants; low certainty evidence). No data were available on neurodevelopmental impairment. Meta-analysis suggests that the pressure source may not affect the risk of pneumothorax (RR 0.73, 95% CI 0.40 to 1.34 (I² = 0%); RD -0.01, 95% CI -0.03 to 0.01; 14 trials, 1340 infants; low certainty evidence). Bubble CPAP likely increases the risk of moderate-severe nasal injury (RR 2.29, 95% CI 1.37 to 3.82 (I² = 17%); RD 0.07, 95% CI 0.03 to 0.11; number needed to treat for an additional harmful outcome 14, 95% CI 9 to 33; 8 trials, 753 infants; moderate certainty evidence). The pressure source may not affect the risk of bronchopulmonary dysplasia (RR 0.76, 95% CI 0.53 to 1.10 (I² = 0%); RD -0.04, 95% CI -0.09 to 0.01; 7 trials, 603 infants; low certainty evidence). AUTHORS' CONCLUSIONS: Given the low level of certainty about the effects of bubble CPAP versus other pressure sources on the risk of treatment failure and most associated morbidity and mortality for preterm infants, further large, high-quality trials are needed to provide evidence of sufficient validity and applicability to inform context- and setting-relevant policy and practice.
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Affiliation(s)
- Raj Prakash
- Paediatrics, York and Scarborough Teaching Hospitals NHS Trust, York, UK
| | | | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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Poletto S, Trevisanuto D, Ramaswamy VV, Seni AHA, Ouedraogo P, Dellacà RL, Zannin E. Bubble CPAP respiratory support devices for infants in low-resource settings. Pediatr Pulmonol 2023; 58:643-652. [PMID: 36484311 DOI: 10.1002/ppul.26258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
Approximately 46% of the 5.2 million annual under-5 deaths derive from neonatal conditions commonly associated with hypoxemia or acute respiratory distress. It has been estimated that 98% of these deaths occur in low- and middle-income countries (LMICs). Effective implementation of noninvasive respiratory support at all levels of healthcare could significantly reduce neonatal mortality. Several factors limit the widespread and effective implementation of noninvasive respiratory support in LMICs, including inadequate infrastructure, lack of proper instrumentation, shortage of skilled staff, costly disposables, and difficulties in the supply of consumables and spare parts. The aim of this state-of-the-art paper is to provide a detailed evaluation of the commercially available devices providing noninvasive respiratory support in LMICs, focusing on bubblecontinuous positive airway pressure (bCPAP). bCPAP might be administrated using a variety of different commercial devices, including devices specifically designed for LMICs, as well as using self-made systems. We described all the equipment required for safe and effective implementation of bCPAP, including air and oxygen sourced, pressure-reducing valves and flowmeters, air-oxygen blending systems, humidifiers, respiratory support devices, patient circuits, and airway interfaces. Specifically, we critically evaluated the advantages and disadvantages of various existing solutions within the context of low-resource settings.
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Affiliation(s)
- Sofia Poletto
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | | | | | | | | | - Raffaele L Dellacà
- Technologies for Respiration Laboratory, Electronics, Information and Bioengineering Department (DEIB), Politecnico di Milano, Milan, Italy
| | - Emanuela Zannin
- Neonatal Intesive Care Unit at Fondazione Monza e Brianza per il Bambino e la sua Mamma (MBBM), Monza, Italy
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Hashmi A, Darakamon MC, Aung KK, Mu M, Misa P, Jittamala P, Chu C, Phyo AP, Turner C, Nosten F, McGready R, Carrara VI. Born too soon in a resource-limited setting: A 10-year mixed methods review of a special care baby unit for refugees and migrants on the Myanmar-Thailand border. Front Public Health 2023; 11:1144642. [PMID: 37124770 PMCID: PMC10130587 DOI: 10.3389/fpubh.2023.1144642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Preterm birth is a major public health concern with the largest burden of morbidity and mortality falling within low- and middle-income countries (LMIC). Materials and methods This sequential explanatory mixed methods study was conducted in special care baby units (SCBUs) serving migrants and refugees along the Myanmar-Thailand border. It included a retrospective medical records review, qualitative interviews with mothers receiving care within SCBUs, and focus group discussions with health workers. Changes in neonatal mortality and four clinical outcomes were described. A mix of ethnographic phenomenology and implementation frameworks focused on cultural aspects, the lived experience of participants, and implementation outcomes related to SCBU care. Results From 2008-2017, mortality was reduced by 68% and 53% in very (EGA 28-32 weeks) and moderate (EGA 33-36 weeks) preterm neonates, respectively. Median SCBU stay was longer in very compared to moderate preterm neonates: 35 (IQR 22, 48 days) vs. 10 days (IQR 5, 16). Duration of treatments was also longer in very preterm neonates: nasogastric feeding lasted 82% (IQR 74, 89) vs. 61% (IQR 40, 76) of the stay, and oxygen therapy was used a median of 14 (IQR 7, 27) vs. 2 (IQR 1, 6) days respectively. Nine interviews were conducted with mothers currently receiving care in the SCBU and four focus group discussions with a total of 27 local SCBU staff. Analysis corroborated quantitative analysis of newborn care services in this setting and incorporated pertinent implementation constructs including coverage, acceptability, appropriateness, feasibility, and fidelity. Coverage, acceptability, and appropriateness were often overlapping outcomes of interest highlighting financial issues prior to or while admitted to the SCBU and social issues and support systems adversely impacting SCBU stays. Interview and FGD findings highlight the barriers in this resource-limited setting as they impact the feasibility and fidelity of providing evidence-based SCBU care that often required adaptation to fit the financial and environmental constraints imposed by this setting. Discussion This study provides an in-depth look at the nature of providing preterm neonatal interventions in a SCBU for a vulnerable population in a resource-limited setting. These findings support implementation of basic evidence-based interventions for preterm and newborn care globally, particularly in LMICs.
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Affiliation(s)
- Ahmar Hashmi
- Institute for Implementation Science, University of Texas Health Sciences Center (UTHealth), Houston, TX, United States
- Department of Health Promotion and Behavioral Sciences, School of Public Health, University of Texas Health Sciences Center (UTHealth), Houston, TX, United States
| | - Mu Chae Darakamon
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Ko Ko Aung
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Mu Mu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Prapatsorn Misa
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | | | - Cindy Chu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Claudia Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Verena I. Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- *Correspondence: Verena I. Carrara
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11
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Tayler A, Ashworth H, Bou Saba G, Wadhwa H, Dundek M, Ng E, Opondo K, Mkony M, Moshiro R, Burke T. Feasibility of a novel ultra-low-cost bubble CPAP (bCPAP) System for neonatal respiratory support at Muhimbili National Hospital, Tanzania. PLoS One 2022; 17:e0269147. [PMID: 36584229 PMCID: PMC9803298 DOI: 10.1371/journal.pone.0269147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/03/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Continuous Positive Airway Pressure (CPAP) is recommended in the treatment of respiratory distress syndrome of premature newborns, however there are significant barriers to its implementation in low-resource settings. The objective of this study was to evaluate the feasibility of use and integration of Vayu bCPAP Systems into the newborn unit at Muhimbili National Hospital in Tanzania. STUDY DESIGN A prospective qualitative study was conducted from April 6 to October 6 2021. Demographic and clinical characteristics of patients treated with Vayu bCPAP Systems were collected and analyzed. Healthcare workers were interviewed until thematic saturation. Interviews were transcribed, coded, and analyzed using a framework analysis. RESULTS 370 patients were treated with Vayu bCPAP Systems during the study period. Mean birth weight was 1522 g (500-3800), mean duration of bCPAP treatment was 7.2 days (<1-39 d), and survival to wean was 81.4%. Twenty-four healthcare workers were interviewed and perceived Vayu bCPAP Systems as having become essential for treating neonatal respiratory distress at MNH. Key reasons were that Vayu bCPAP Systems improve patient outcomes, are easy to use, and more patients are now able to receive quality care. Barriers to integration included durability of oxygen tubing material and training. CONCLUSIONS It was feasible to implement and integrate Vayu bCPAP Systems into the care of neonates at Muhimbili National Hospital.
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Affiliation(s)
- Ashtyn Tayler
- Vayu Global Health Foundation, Boston, MA, United States of America
- * E-mail:
| | - Henry Ashworth
- Vayu Global Health Foundation, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Ghassan Bou Saba
- Vayu Global Health Foundation, Boston, MA, United States of America
| | - Hena Wadhwa
- Vayu Global Health Foundation, Boston, MA, United States of America
| | - Michelle Dundek
- Vayu Global Health Foundation, Boston, MA, United States of America
- Global Health Innovation Lab, Massachusetts General Hospital, Boston, MA, United States of America
| | - Ellie Ng
- Vayu Global Health Foundation, Boston, MA, United States of America
| | - Kennedy Opondo
- Vayu Global Health Foundation, Boston, MA, United States of America
| | - Martha Mkony
- Muhimbili National Hospital, Dar es Salaam, Tanzania
- Muhimbili University of Health Allied Sciences, Dar es Salaam, Tanzania
| | - Robert Moshiro
- Muhimbili National Hospital, Dar es Salaam, Tanzania
- Muhimbili University of Health Allied Sciences, Dar es Salaam, Tanzania
| | - Thomas Burke
- Vayu Global Health Foundation, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Global Health Innovation Lab, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard TH Chan School of Public Health, Boston, MA, United States of America
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12
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Samim SK, Debata PK, Yadav A, Kumar J, Anand P, Garg M. RAM cannula versus short binasal prongs for nasal continuous positive airway pressure delivery in preterm infants: a randomized, noninferiority trial from low-middle-income country. Eur J Pediatr 2022; 181:4111-4119. [PMID: 36114831 DOI: 10.1007/s00431-022-04620-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 12/26/2022]
Abstract
UNLABELLED To determine if RAM cannula is non-inferior to short binasal prongs (SBP) in providing nasal continuous positive airway pressure (CPAP) in preterm infants with respiratory distress syndrome (RDS). In this randomized, open-label, noninferiority trial from a low-middle-income country, we enrolled 254 preterm infants (28-34 weeks gestational age) with RDS who needed CPAP as primary respiratory support. The eligible infants were randomized to either RAM cannula or SBP interface groups. The primary outcome was CPAP failure (defined as the need for intubation or non-invasive positive pressure ventilation) within 72 h of randomization. The noninferiority margin was defined as a 10% or less absolute difference in CPAP failure rates. The secondary outcomes included nasal trauma and adverse events. We analyzed by per-protocol (primary) and intention to treat. CPAP failure has been seen in 25 infants (19.7%) in the RAM cannula group versus 22 (17.3%) in the SBP group (RD -2.36%; 95% CI -11.9 to 7.2 [beyond inferiority margin]; p = 0.6). Moderate and severe nasal trauma was less in RAM cannula (2.4 vs. 8.7%; RR 0.27; 95% CI 0.08-0.95; p 0.028). Duration of CPAP was also significantly shorter in the RAM cannula group (MD -12.4 h; 95% CI -20.34 to -4.46, p 0.017). There were no differences in other adverse events. CONCLUSIONS RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome. TRIAL REGISTRATION Registered at Clinical Trial Registry of India (CTRI/2020/03/024097). WHAT IS KNOWN • RAM cannula is used for providing supplemental oxygen therapy. There is conflicting evidence on its efficacy in delivering CPAP support in preterm infants. WHAT IS NEW • RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome. • RAM cannula causes less nasal trauma than short binasal prongs.
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Affiliation(s)
- S K Samim
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Pradeep Kumar Debata
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India.
| | - Anita Yadav
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pratima Anand
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Mehak Garg
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
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13
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Wilkes C, Subhi R, Graham HR, Duke T. Continuous Positive Airway Pressure (CPAP) for severe pneumonia in low- and middle-income countries: A systematic review of contextual factors. J Glob Health 2022; 12:10012. [PMID: 36269192 PMCID: PMC9586144 DOI: 10.7189/jogh.12.10012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Continuous positive airway pressure (CPAP) may have a role in reducing the high mortality in children less than 5 years with World Health Organization (WHO) severe pneumonia. More evidence is needed to understand important contextual factors that impact on implementation, effectiveness, and safety in low resource settings. Methods We conducted a systematic review of Medline, Embase and Pubmed (January 2000 to August 2020) with terms of "pneumonia", "CPAP" and "child". We included studies that provided original clinical or non-clinical data on the use of CPAP in children (28 days-4 years) with pneumonia in low- or middle-income countries. We used standardised tools to assess study quality, and grade levels of evidence for clinical conclusions. Results are presented as a narrative synthesis describing context, intervention, and population alongside outcome data. Results Of 902 identified unique references, 23 articles met inclusion criteria, including 6 randomised controlled trials, one cluster cross over trial, 12 observational studies, 3 case reports and 1 cost-effectiveness analysis. There was significant heterogeneity in patient population, with wide range in mortality among participants in different studies (0%-55%). Reporting of contextual factors, including staffing, costs, and details of supportive care was patchy and non-standardised. Current evidence suggests that CPAP has a role in the management of infants with bronchiolitis and as escalation therapy for children with pneumonia failing standard-flow oxygen therapy. However, CPAP must be implemented with appropriate staffing (including doctor oversight), intensive monitoring and supportive care, and technician and infrastructure capacity. We provide practical guidance and recommendations based on available evidence and published expert opinion, for the adoption of CPAP into routine care in low resource settings and for reporting of future CPAP studies. Conclusions CPAP is a safe intervention in settings that can provide intensive monitoring and supportive care, and the strongest evidence for a benefit of CPAP is in infants (aged less than 1 year) with bronchiolitis. The available published evidence and clinical experience can be used to help facilities assess appropriateness of implementing CPAP, guide health workers in refining selection of patients most likely to benefit from it, and provide a framework for components of safe and effective CPAP therapy. Protocol registration PROSPERO registration: CRD42020210597.
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Affiliation(s)
- Chris Wilkes
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Rami Subhi
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Hamish R Graham
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Trevor Duke
- Murdoch Children's Research Institution, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
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14
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Diala UM, Toma BO, Shwe DD, Ofakunrin AOD, Diala OO, John C. An assessment of improved outcomes using low-cost bubble CPAP in very low birthweight neonates in a Nigerian tertiary hospital. Trop Doct 2022; 52:503-509. [PMID: 35950793 DOI: 10.1177/00494755221107461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Respiratory distress contributes to the high burden of preterm mortality globally. The aim of our study was to evaluate the use of low-cost Bubble Continuous Positive Airway Pressure devices for treating respiratory distress and their outcomes in preterm infants weighing <1500g. Data was extracted from admission records of 211 infants over two distinct 4-year periods before and after introduction of bCPAP. With survival rates of 26.7% and 61.8% in the pre and post bCPAP eras respectively, significantly improved outcomes were found.
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Affiliation(s)
- Udochukwu M Diala
- Department of Paediatrics, 100570University of Jos, Jos, Plateau State, Nigeria.,Department of Paediatrics, 291849Jos University Teaching Hospital, Jos, Plateau Sate, Nigeria
| | - Bose O Toma
- Department of Paediatrics, 100570University of Jos, Jos, Plateau State, Nigeria.,Department of Paediatrics, 291849Jos University Teaching Hospital, Jos, Plateau Sate, Nigeria
| | - David D Shwe
- Department of Paediatrics, 100570University of Jos, Jos, Plateau State, Nigeria.,Department of Paediatrics, 291849Jos University Teaching Hospital, Jos, Plateau Sate, Nigeria
| | - Akinyemi O D Ofakunrin
- Department of Paediatrics, 100570University of Jos, Jos, Plateau State, Nigeria.,Department of Paediatrics, 291849Jos University Teaching Hospital, Jos, Plateau Sate, Nigeria
| | - Olubunmi O Diala
- Department of Family Medicine, 291849Jos University Teaching Hospital, Plateau State, Nigeria
| | - Collins John
- Department of Paediatrics, 100570University of Jos, Jos, Plateau State, Nigeria.,Department of Paediatrics, 291849Jos University Teaching Hospital, Jos, Plateau Sate, Nigeria
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15
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Rosa-Mangeret F, Benski AC, Golaz A, Zala PZ, Kyokan M, Wagner N, Muhe LM, Pfister RE. 2.5 Million Annual Deaths-Are Neonates in Low- and Middle-Income Countries Too Small to Be Seen? A Bottom-Up Overview on Neonatal Morbi-Mortality. Trop Med Infect Dis 2022; 7:64. [PMID: 35622691 PMCID: PMC9148074 DOI: 10.3390/tropicalmed7050064] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 12/29/2022] Open
Abstract
(1) Background: Every year, 2.5 million neonates die, mostly in low- and middle-income countries (LMIC), in total disregard of their fundamental human rights. Many of these deaths are preventable. For decades, the leading causes of neonatal mortality (prematurity, perinatal hypoxia, and infection) have been known, so why does neonatal mortality fail to diminish effectively? A bottom-up understanding of neonatal morbi-mortality and neonatal rights is essential to achieve adequate progress, and so is increased visibility. (2) Methods: We performed an overview on the leading causes of neonatal morbi-mortality and analyzed the key interventions to reduce it with a bottom-up approach: from the clinician in the field to the policy maker. (3) Results and Conclusions: Overall, more than half of neonatal deaths in LMIC are avoidable through established and well-known cost-effective interventions, good quality antenatal and intrapartum care, neonatal resuscitation, thermal care, nasal CPAP, infection control and prevention, and antibiotic stewardship. Implementing these requires education and training, particularly at the bottom of the healthcare pyramid, and advocacy at the highest levels of government for health policies supporting better newborn care. Moreover, to plan and follow interventions, better-quality data are paramount. For healthcare developments and improvement, neonates must be acknowledged as humans entitled to rights and freedoms, as stipulated by international law. Most importantly, they deserve more respectful care.
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Affiliation(s)
- Flavia Rosa-Mangeret
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Global Health Institute, University of Geneva, 1205 Geneva, Switzerland;
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Anne-Caroline Benski
- Obstetrics Division, Geneva University Hospitals, 1205 Geneva, Switzerland;
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Anne Golaz
- Center for Education and Research in Humanitarian Action, Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland;
| | - Persis Z. Zala
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
- Centre Medico-Chirurgical-Pédiatrique Persis, Ouahigouya BP267, Burkina Faso
| | - Michiko Kyokan
- Global Health Institute, University of Geneva, 1205 Geneva, Switzerland;
| | - Noémie Wagner
- Pediatric Infectious Diseases Division, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Lulu M. Muhe
- College of Health Sciences, Addis Ababa University, Addis Ababa 1000, Ethiopia;
| | - Riccardo E. Pfister
- Neonatal Division, Geneva University Hospitals, 1205 Geneva, Switzerland; (P.Z.Z.); (R.E.P.)
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
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16
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Lategan I, Price C, Rhoda NR, Zar HJ, Tooke L. Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa. Front Glob Womens Health 2022; 3:817817. [PMID: 35464776 PMCID: PMC9019119 DOI: 10.3389/fgwh.2022.817817] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/18/2022] [Indexed: 01/13/2023] Open
Abstract
Background Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality. Methods We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions. Results Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109). Conclusion This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.
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Affiliation(s)
- Ilse Lategan
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Caris Price
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Natasha Raygaan Rhoda
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SA-MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- *Correspondence: Lloyd Tooke
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17
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Khare C, Adhisivam B, Gupta A, Vaishnav D, Vishnu Bhat B. Evaluation of T-piece resuscitator in the delivery room management of pre-term neonates with respiratory distress syndrome in resource-limited settings: A pre-post intervention study. Trop Doct 2022; 52:262-269. [PMID: 35243942 DOI: 10.1177/00494755221076942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of our study was to evaluate the impact of the T-piece resuscitator in the delivery room management of pre-term neonates in a resource-limited setting. We compared the incidence rates of delivery room intubation, surfactant replacement therapy, pulmonary air leak syndrome, and pre-term very low birth weight infant mortality, before and after T-piece use. Bi-monthly neonatal resuscitation training sessions were conducted for healthcare providers during the study period. We emphasized hands-on experience with the T-piece resuscitator and delivery room early respiratory care practices during the post-intervention epoch. Our pre- and post-intervention data recorded statistically significant decline in delivery room intubations, a 32% decrease in surfactant replacement therapy, and a 57% decrease in air leaks in pre-term neonates. However, the use of T-piece resuscitator did not have a statistically significant effect on pre-term very low birth weight infant mortality.
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Affiliation(s)
- Chetan Khare
- Department of Neonatology, 390706All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India.,Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Bethou Adhisivam
- Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Avantika Gupta
- Department of Obstetrics and Gynaecology, 534693All India Institute of Medical Sciences, Nagpur, Maharashtra, India
| | - Dheeraj Vaishnav
- Department of Neonatology, 155196Geetanjali Institute of Medical Sciences, Udaipur, Rajasthan, India
| | - Ballambattu Vishnu Bhat
- Department of Neonatology, 29988Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.,Department of Paediatrics, 75452Aarupadai Veedu Medical College, Puducherry, India
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18
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Carns J, Liaghati-Mobarhan S, Asibon A, Ngwala S, Molyneux E, Oden M, Richards-Kortum R, Kawaza K, Chalira A, Lufesi N. A neonatal ward-strengthening program improves survival for neonates treated with CPAP at district hospitals in Malawi. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000195. [PMID: 36962324 PMCID: PMC10021714 DOI: 10.1371/journal.pgph.0000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 11/18/2022]
Abstract
From 2013-2015, a CPAP quality improvement program (QIP) was implemented to introduce and monitor CPAP usage and outcomes in the neonatal wards at all government district and central hospitals in Malawi. In 2016 the CPAP QIP was extended into healthcare facilities operated by the Christian Health Association of Malawi. Although clinical outcomes improved, ward assessments indicated that many rural sites lacked other essential equipment and a suitable space to adequately treat sick neonates, which likely limited the impact of improved respiratory care. The aim of this study was to determine if a ward-strengthening program improved outcomes for neonates treated with CPAP. To address the needs identified from ward assessments, a ward-strengthening program was implemented from 2017-2018 at rural hospitals in Malawi to improve the care of sick neonates. The ward-strengthening program included the distribution of a bundle of equipment, supplemental training, and, in some cases, health facility renovations. Survival to discharge was compared for neonates treated with CPAP at 12 rural hospitals for one year before and for one year immediately after implementation of the ward-strengthening program. In the year prior to ward strengthening, 189 neonates were treated with CPAP; in the year after, 232 neonates received CPAP. The overall rate of survival for those treated with CPAP improved from 46.6% to 57.3% after ward strengthening (p = 0.03). For the subset of neonates with admission weights between 1.00-2.49 kg diagnosed with respiratory distress syndrome, survival increased from 39.4% to 60.3% after ward strengthening (p = 0.001). A ward-strengthening program including the distribution of a bundle of equipment, supplemental training, and some health facility renovations, further improved survival among neonates treated with CPAP at district-level hospitals in Malawi.
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Affiliation(s)
- Jennifer Carns
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | | | - Aba Asibon
- Rice360 Institute for Global Health, Houston, TX, United States of America
| | - Samuel Ngwala
- Rice360 Institute for Global Health, Houston, TX, United States of America
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Maria Oden
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Rebecca Richards-Kortum
- Rice360 Institute for Global Health, Houston, TX, United States of America
- Department of Bioengineering, Rice University, Houston, TX, United States of America
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Alfred Chalira
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Malawi Ministry of Health, Lilongwe, Malawi
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19
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Tooke L, Ehret DEY, Okolo A, Dlamini‐Nqeketo S, Joolay Y, Minto’o S, Pillay S, Abdallah Y, Naburi H, Ndour D, Brobby N, Stevenson AG. Limited resources restrict the provision of adequate neonatal respiratory care in the countries of Africa. Acta Paediatr 2022; 111:275-283. [PMID: 34328232 DOI: 10.1111/apa.16050] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022]
Abstract
AIM Over two thirds of newborn deaths occur in Africa and South Asia, and respiratory failure is a major contributor of these deaths. The exact availability of continuous positive airway pressure (CPAP) and surfactant in Africa is unknown. The aim of this study was to describe the availability of newborn respiratory care treatments in the countries of Africa. METHODS Surveys, in English, French and Portuguese, were sent to neonatal leaders in all 48 continental countries and the two islands with populations over 1 million. RESULTS Forty-nine (98%) countries responded. Twenty-one countries reported less than 50 paediatricians, and 12 countries had no neonatologists. Speciality neonatal nursing was recognised in 57% of countries. Most units were able to provide supplemental oxygen. CPAP was available in 63% and 67% of the most well-equipped government and private hospitals. Surfactant was available in 33% and 39% of the most well-equipped public and private hospitals, respectively. Availability of CPAP and surfactant was greatly reduced in smaller cities. Continuous oxygen saturation monitoring was only available in 33% of countries. CONCLUSION The availability of proven life-saving interventions in Africa is inadequate. There is a need to sustainably improve availability and use of these interventions.
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Affiliation(s)
- Lloyd Tooke
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | - Danielle E. Y. Ehret
- Vermont Oxford Network Burlington VT USA
- Department of Pediatrics Robert Larner MD College of MedicineUniversity of Vermont Burlington VT USA
| | | | | | - Yaseen Joolay
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | | | - Shakti Pillay
- Groote Schuur Hospital Cape Town South Africa
- Department of Paediatrics University of Cape Town South Africa
| | - Yaser Abdallah
- The Agakhan University Dar es Salaam Tanzania
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
| | - Helga Naburi
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
| | | | - Naana Brobby
- Department of Child Health School of Medicine and Dentisty KNUST Kumasi Ghana
| | - Alexander G. Stevenson
- Mbuya Nehanda Maternity Hospital Harare Zimbabwe
- Department of Paediatrics University of Zimbabwe Harare Zimbabwe
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20
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Zapata HA, Fort P, Roberts KD, Kaluarachchi DC, Guthrie SO. Surfactant Administration Through Laryngeal or Supraglottic Airways (SALSA): A Viable Method for Low-Income and Middle-Income Countries. Front Pediatr 2022; 10:853831. [PMID: 35372140 PMCID: PMC8966228 DOI: 10.3389/fped.2022.853831] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/21/2022] [Indexed: 11/24/2022] Open
Abstract
Administration of liquid surfactant through an endotracheal tube for the treatment of respiratory distress syndrome has been the standard of care for decades. A skilled health care provider is needed to perform this procedure. In lower-income and middle-income countries (LMICs), healthcare resources are often limited, leading to increased mortality of premature infants, many of whom would benefit from surfactant administration. Therefore, having a simplified procedure for delivery of surfactant without the need for advanced skills could be life-saving, potentially diminish gaps in care, and help ensure more equitable global neonatal survival rates. Modifications to the standard approach of surfactant administration have been put into practice and these include: INtubation-SURfactant-Extubation (INSURE), thin catheter surfactant administration (TCA), aerosolized surfactant, and surfactant administration through laryngeal or supraglottic airways (SALSA). Although there is a need for larger studies to evaluate the comparative effectiveness of these newer methods, these methods are being embraced by the global community and being implemented in various settings throughout the world. Because the SALSA technique does not require laryngoscopy, a provider skilled in laryngoscopy is not required for the procedure. Therefore, because of the ease of use and safety profile, the SALSA technique should be strongly considered as a viable method of delivering surfactant in LMICs.
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Affiliation(s)
- Henry A Zapata
- Department of Pediatrics, Division of Neonatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Prem Fort
- Department of Pediatrics, Maternal, Fetal, Neonatal Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, United States.,Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Dinushan C Kaluarachchi
- Department of Pediatrics, Division of Neonatology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, United States
| | - Scott O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, United States
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21
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Swanson SJ, Martinez KK, Shaikh HA, Philipo GM, Martinez J, Mushi EJ. Every breath counts: Lessons learned in developing a training NICU in Northern Tanzania. Front Pediatr 2022; 10:958628. [PMID: 36090561 PMCID: PMC9452716 DOI: 10.3389/fped.2022.958628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/04/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Neonatal mortality rates in resource-limited hospitals of Sub-Saharan Africa (SSA) remain disproportionately high and are likely underestimated due to misclassification of extremely preterm births as "stillbirths" or "abortions", incomplete death registries, fear of repercussions from hospital and governmental authorities, unrecorded village deaths, and cultural beliefs surrounding the viability of premature newborns. While neonatology partnerships exist between high income countries and hospitals in SSA, efforts have largely been directed toward improving newborn survival through neonatal resuscitation training and provision of equipment to nascent neonatal intensive care units (NICUs). These measures are incomplete and fail to address the challenges which NICUs routinely face in low-resource settings. We draw on lessons learned in the development of a low-technology referral NICU in Tanzania that achieved an overall 92% survival rate among infants. LESSONS LEARNED Achieving high survival rates among critically ill and preterm neonates in SSA is possible without use of expensive, advanced-skill technologies like mechanical ventilators. Evidence-based protocols adapted to low-resource hospitals, mentorship of nurses and physicians, changes in hierarchal culture, improved nurse-infant staffing ratios, involvement of mothers, improved procurement of consumables and medications, and bedside diagnostics are necessary steps to achieving high survival rates. Our NICU experience indicates that low-technology solutions of thermoregulation, respiratory support via continuous positive airway pressure, feeding protocols and infection control measures can ensure that infants not only survive, but thrive. CONCLUSIONS Neonatal mortality and survival of preterm newborns can be improved through a long-term commitment to training NICU staff, strengthening basic neonatal care practices, contextually appropriate protocols, and limited technology.
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Affiliation(s)
- Stephen J Swanson
- Department of Paediatrics, Arusha Lutheran Medical Centre, Arusha, Tanzania.,Global Pediatrics Program, University of Minnesota, Minneapolis, MN, United States
| | - Kendra K Martinez
- Department of Paediatrics, Arusha Lutheran Medical Centre, Arusha, Tanzania.,Global Pediatrics Program, University of Minnesota, Minneapolis, MN, United States
| | - Henna A Shaikh
- Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Godbless M Philipo
- Department of Paediatrics, Arusha Lutheran Medical Centre, Arusha, Tanzania
| | - Jarian Martinez
- Department of Paediatrics, Arusha Lutheran Medical Centre, Arusha, Tanzania
| | - Evelyine J Mushi
- Department of Paediatrics, Arusha Lutheran Medical Centre, Arusha, Tanzania.,Department of Paediatrics and Child Health, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
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22
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Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.
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Affiliation(s)
- Osayame A Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
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23
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Wastnedge E, Waters D, Murray SR, McGowan B, Chipeta E, Nyondo-Mipando AL, Gadama L, Gadama G, Masamba M, Malata M, Taulo F, Dube Q, Kawaza K, Khomani PM, Whyte S, Crampin M, Freyne B, Norman JE, Reynolds RM. Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review. J Glob Health 2021; 11:04050. [PMID: 35003711 PMCID: PMC8709903 DOI: 10.7189/jogh.11.04050] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required. METHODS A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted. RESULTS 179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions. CONCLUSIONS Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.
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Affiliation(s)
- Elizabeth Wastnedge
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Donald Waters
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Sarah R Murray
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Brian McGowan
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Effie Chipeta
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Health Systems & Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luis Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gladys Gadama
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Martha Masamba
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Monica Malata
- Centre for Reproductive Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Frank Taulo
- Department of Obstetrics & Gynaecology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Kondwani Kawaza
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Sonia Whyte
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Mia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Bridget Freyne
- Malawi-Liverpool Wellcome Trust Research Program, Blantyre, Malawi
- Institute of Infection & Global Health, University of Liverpool, Liverpool, UK
| | - Jane E Norman
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Rebecca M Reynolds
- Medical Research Council Centre for Reproductive Health, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
- Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
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24
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, Pullattayil S AK, Cavallin F, Roehr CC, Trevisanuto D. Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis. Resuscitation 2021; 170:250-263. [PMID: 34757058 DOI: 10.1016/j.resuscitation.2021.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
AIM To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV). METHODS Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV. RESULTS Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia. LIMITATIONS CoE was very low for primary outcome. CONCLUSIONS Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | | | | | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences, Division, University of Oxford, Oxford, United Kingdom; Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom; University of Bristol, Women's and Children Division, Bristol, United Kingdom
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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25
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L Dundek M, Ng EK, M Brazil A, DiBlasi RM, Poli JA, Burke TF. Evaluation of a Bubble CPAP System for Low Resource Settings. Respir Care 2021; 66:1572-1581. [PMID: 33824173 PMCID: PMC9993569 DOI: 10.4187/respcare.08948] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite its established safety, efficacy, and relative simplicity, CPAP treatment is not widely available for newborns and infants in low- and middle-income settings. A novel bubble CPAP system was designed to address the gaps in quality and accessibility of existing CPAP systems by providing blended, humidified, and pressurized gases without the need for electricity, compressed air, or manual power. This was the first study that tested the performance of the system with a simulated patient model. METHODS: In a spontaneously breathing 3-dimensional printed nasal airway model of a preterm neonate, CPAP performance was assessed based on delivered pressure, oxygen level, and humidity at different settings. RESULTS: Preliminary device performance characteristics were within 5% among 3 separate devices. Performance testing showed accurate control of CPAP and oxygen concentration at all settings with the bubble CPAP system. Lung model pressure and oxygen concentration were shown to stay within ±0.5 cm H2O and ±4% of full scale of the device settings, respectively, with relative humidity > 80%. CONCLUSIONS: Performance testing of the bubble CPAP system demonstrated accurate control of CPAP and oxygen concentration with humidity levels suitable for premature newborns on noninvasive support.
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Affiliation(s)
- Michelle L Dundek
- Vayu Global Health Foundation, Boston, Massachusetts.
- Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ellie K Ng
- Vayu Global Health Foundation, Boston, Massachusetts
| | | | - Robert M DiBlasi
- Department of Respiratory Care Therapy, Seattle Children's Hospital and Regional Medical Center, Seattle, Washington
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Jonathan A Poli
- Department of Respiratory Care Therapy, Seattle Children's Hospital and Regional Medical Center, Seattle, Washington
| | - Thomas F Burke
- Vayu Global Health Foundation, Boston, Massachusetts
- Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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26
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Kleinhout MY, Stevens MM, Osman KA, Adu-Bonsaffoh K, Groenendaal F, Biza Zepro N, Rijken MJ, Browne JL. Evidence-based interventions to reduce mortality among preterm and low-birthweight neonates in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Glob Health 2021; 6:bmjgh-2020-003618. [PMID: 33602687 PMCID: PMC7896575 DOI: 10.1136/bmjgh-2020-003618] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/23/2020] [Accepted: 12/25/2020] [Indexed: 01/21/2023] Open
Abstract
Background Preterm birth is the leading cause of under-five-mortality worldwide, with the highest burden in low-income and middle-income countries (LMICs). The aim of this study was to synthesise evidence-based interventions for preterm and low birthweight (LBW) neonates in LMICs, their associated neonatal mortality rate (NMR), and barriers and facilitators to their implementation. This study updates all existing evidence on this topic and reviews evidence on interventions that have not been previously considered in current WHO recommendations. Methods Six electronic databases were searched until 3 March 2020 for randomised controlled trials reporting NMR of preterm and/or LBW newborns following any intervention in LMICs. Risk ratios for mortality outcomes were pooled where appropriate using a random effects model (PROSPERO registration number: CRD42019139267). Results 1236 studies were identified, of which 49 were narratively synthesised and 9 contributed to the meta-analysis. The studies included 39 interventions in 21 countries with 46 993 participants. High-quality evidence suggested significant reduction of NMR following antenatal corticosteroids (Pakistan risk ratio (RR) 0.89; 95% CI 0.80 to 0.99|Guatemala 0.74; 0.68 to 0.81), single cord (0.65; 0.50 to 0.86) and skin cleansing with chlorhexidine (0.72; 0.55 to 0.95), early BCG vaccine (0.64; 0.48 to 0.86; I2 0%), community kangaroo mother care (OR 0.73; 0.55 to 0.97; I2 0%) and home-based newborn care (preterm 0.25; 0.14 to 0.48|LBW 0.42; 0.27 to 0.65). No effects on perinatal (essential newborn care 1.02; 0.91 to 1.14|neonatal resuscitation 0.95; 0.84 to 1.07) or 7-day NMR (essential newborn care 1.03; 0.83 to 1.27|neonatal resuscitation 0.92; 0.77 to 1.09) were observed after training birth attendants. Conclusion The findings of this study encourage the implementation of additional, evidence-based interventions in the current (WHO) guidelines and to be selective in usage of antenatal corticosteroids, to reduce mortality among preterm and LBW neonates in LMICs. Given the global commitment to end all preventable neonatal deaths by 2030, continuous evaluation and improvement of the current guidelines should be a priority on the agenda.
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Affiliation(s)
- Mirjam Y Kleinhout
- Department of Neonatology, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Neonatology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands
| | - Merel M Stevens
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Kwame Adu-Bonsaffoh
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Obstetrics and Gynaecology, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nejimu Biza Zepro
- College of Health Sciences, Samara University, Semera, Afar, Ethiopia.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joyce L Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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27
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Dada S, Ashworth H, Sobitschka A, Raguveer V, Sharma R, Hamilton RL, Burke T. Experiences with implementation of continuous positive airway pressure for neonates and infants in low-resource settings: A scoping review. PLoS One 2021; 16:e0252718. [PMID: 34115776 PMCID: PMC8195417 DOI: 10.1371/journal.pone.0252718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Continuous positive airway pressure (CPAP) is the gold standard of care in providing non-invasive positive pressure support to neonates in respiratory distress in high-resource settings. While safety has been demonstrated in low-resource settings, there is a lack of knowledge on the barriers and facilitators to proper implementation. Objective To identify and describe the barriers, facilitators, and priorities for future implementation of CPAP for neonates and infants in low-resource settings. Methods A systematic search (database inception to March 6, 2020) was performed on MEDLINE, Embase, Web of Science, CINAHL, Global Health, and the WHO Global Index Medicus using PRISMA-ScR guidelines. Original research articles pertaining to implementation of CPAP devices in low-resource settings, provider or parent perspectives and experiences with CPAP, cost-benefit analyses, and cost-effectiveness studies were included. Inductive content analysis was conducted. Findings 1385 article were screened and 54 studies across 19 countries met inclusion criteria. Six major themes emerged: device attributes, patient experiences, parent experiences, provider experiences, barriers, and facilitators. Nasal trauma was the most commonly reported complication. Barriers included unreliable electricity and lack of bioengineering support. Facilitators included training, mentorship and empowerment of healthcare providers. Device design, supply chain infrastructure, and training models were imperative to the adoption and sustainability of CPAP. Conclusion Sustainable implementation of CPAP in low resource settings requires easy-to-use devices, ready access to consumables, and holistic, user-driven training. Further research is necessary on standardizing metrics, interventions that support optimal provider performance, and conditions needed for successful long-term health system integration.
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Affiliation(s)
- Sara Dada
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- * E-mail:
| | - Henry Ashworth
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Alina Sobitschka
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Göttingen, Göttingen, Germany
| | - Vanitha Raguveer
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of Illinois College of Medicine, Chicago, Illinois, United States of America
| | - Rupam Sharma
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- University of California Los Angeles Kern Medical Center, Bakersfield, California, United States of America
| | - Rebecca L. Hamilton
- Massachusetts General Hospital, Department of Anesthesiology, Boston, Massachusetts, United States of America
- Karolinska Institute, Department of Cell and Molecular Biology, Solna, Sweden
| | - Thomas Burke
- Vayu Global Health Foundation Boston, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital, Global Health Innovation Lab, Department of Emergency Medicine, Boston, Massachusetts, United States of America
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
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28
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Sivieri EM, Rub DM, Abbasi S, Eichenwald EC. Preserved pressure delivery during high-frequency oscillation of bubble CPAP in a premature infant lung model with both normal and abnormal lung mechanics. Pediatr Pulmonol 2021; 56:1136-1144. [PMID: 33497536 DOI: 10.1002/ppul.25267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bubble continuous positive airway pressure (BCPAP) generates pressure oscillations which are suggested to improve gas exchange through mechanisms similar to high frequency (HF) ventilation. In a previous in-vitro lung model with normal lung mechanics, significantly improved CO2 washout was demonstrated using an HF interrupter in the supply flow of a BCPAP system. The effect of HF with BCPAP on delivered airway pressure (Paw) has not been fully investigated in a lung model having abnormal pulmonary mechanics. OBJECTIVE To measure Paw in an infant lung model simulating normal and abnormal pulmonary compliance and resistance while connected to a BCPAP system with superimposed HF oscillations created using an in-line flow interrupter. DESIGN/METHODS A premature infant lung model with either: normal lung mechanics, compliance 1.0 ml/cm H2 O, airway resistance 56 cm H2 O/(L/s); or abnormal mechanics, compliance 0.5 ml/cm H2 O, airway resistance 136 cm H2 O/(L/s), was connected to BCPAP with HF at either 4, 6, 8, 10, or 12 Hz. Paw was measured at BCPAPs of 4, 6, and 8 cm H2 O and respiratory rates (RR) of 40, 60, and 80 breaths/min and 6.0 ml tidal volume. RESULTS Mean Paw averaged over all five frequencies showed no significant change from non-oscillated levels at all BCPAPs and RRs for both lung models. Paw amplitudes (peak-to-trough) during oscillation were significantly greater than the non-oscillated levels by an average of 1.7 ± 0.5 SD and 2.6 ± 0.5 SD cm H2 O (p < .001) for the normal and abnormal models, respectively. CONCLUSIONS HF oscillation of BCPAP using a flow interrupter did not alter mean delivered Paw compared to non-oscillated BCPAP for both normal and abnormal lung mechanics models. This simple modification to BCPAP may be a useful enhancement to this mode of non-invasive respiratory support.
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Affiliation(s)
- Emidio M Sivieri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David M Rub
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Soraya Abbasi
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric C Eichenwald
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Leak P, Yamamoto E, Noy P, Keo D, Krang S, Kariya T, Saw YM, Siek M, Hamajima N. Factors associated with neonatal mortality in a tertiary hospital in Phnom Penh, Cambodia. NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 83:113-124. [PMID: 33727743 PMCID: PMC7938092 DOI: 10.18999/nagjms.83.1.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022]
Abstract
This study aimed to identify hospital neonatal mortality rate (NMR) and the causes of neonatal deaths, and to understand risk factors associated with neonatal mortality in a national tertiary hospital in Cambodia. The study included all newborn infants, aged 0-28 days old, hospitalized in the Pediatrics department of Khmer-Soviet Friendship Hospital between January 2016 and December 2017. In total, 925 infants were included in the study. The mean gestational age was 35.9 weeks (range, 24-42 weeks). Preterm infants and low birth weight accounted for 47.5% and 56.7%, respectively. With respect to payment methods, the government (53.5%) and non-governmental organizations (NGO) (13.7%) paid the fees as the families were not in a financial position to do so. The hospital NMR at the Pediatrics department was 9.3%. Respiratory distress syndrome (37.2%) was the main cause of deaths followed by hypoxic-ischemic encephalopathy (31.4%) and neonatal infection (21.0%). Factors associated with neonatal mortality were Apgar score at 5th minute <7 (adjusted odds ratio (AOR) = 3.57), payment by the government or NGO (AOR = 11.32), admission due to respiratory distress (AOR = 11.94), and hypothermia on admission (AOR = 9.41). The hospital NMR in the Pediatrics department was 9.3% (95% confidence interval 7.50-11.35) at Khmer-Soviet Friendship Hospital; prematurity and respiratory distress syndrome were the major causes of neonatal mortality. Introducing continuous positive airway pressure machine for respiratory distress syndrome and creating neonatal resuscitation guidelines and preventing hypothermia in delivery rooms are required to reduce the high NMR.
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Affiliation(s)
- Ponloeu Leak
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Pediatrics Department, Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Eiko Yamamoto
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pisey Noy
- Pediatrics Department, Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Dane Keo
- Communicable Disease Control Department, Ministry of Health, Phnom Penh, Cambodia
| | - Sidonn Krang
- Communicable Disease Control Department, Ministry of Health, Phnom Penh, Cambodia
| | - Tetsuyoshi Kariya
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yu Mon Saw
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Meng Siek
- Pediatrics Department, Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia
| | - Nobuyuki Hamajima
- Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
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30
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Singh H, Kusuda S, McAdams RM, Gupta S, Kalra J, Kaur R, Das R, Anand S, Pandey AK, Cho SJ, Saluja S, Boutilier JJ, Saria S, Palma J, Kaur A, Yadav G, Sun Y. Machine Learning-Based Automatic Classification of Video Recorded Neonatal Manipulations and Associated Physiological Parameters: A Feasibility Study. CHILDREN-BASEL 2020; 8:children8010001. [PMID: 33375101 PMCID: PMC7822162 DOI: 10.3390/children8010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 11/16/2022]
Abstract
Our objective in this study was to determine if machine learning (ML) can automatically recognize neonatal manipulations, along with associated changes in physiological parameters. A retrospective observational study was carried out in two Neonatal Intensive Care Units (NICUs) between December 2019 to April 2020. Both the video and physiological data (heart rate (HR) and oxygen saturation (SpO2)) were captured during NICU hospitalization. The proposed classification of neonatal manipulations was achieved by a deep learning system consisting of an Inception-v3 convolutional neural network (CNN), followed by transfer learning layers of Long Short-Term Memory (LSTM). Physiological signals prior to manipulations (baseline) were compared to during and after manipulations. The validation of the system was done using the leave-one-out strategy with input of 8 s of video exhibiting manipulation activity. Ten neonates were video recorded during an average length of stay of 24.5 days. Each neonate had an average of 528 manipulations during their NICU hospitalization, with the average duration of performing these manipulations varying from 28.9 s for patting, 45.5 s for a diaper change, and 108.9 s for tube feeding. The accuracy of the system was 95% for training and 85% for the validation dataset. In neonates <32 weeks’ gestation, diaper changes were associated with significant changes in HR and SpO2, and, for neonates ≥32 weeks’ gestation, patting and tube feeding were associated with significant changes in HR. The presented system can classify and document the manipulations with high accuracy. Moreover, the study suggests that manipulations impact physiological parameters.
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Affiliation(s)
- Harpreet Singh
- Child Health Imprints (CHIL) Pte. Ltd., Singapore 048545, Singapore; (S.G.); (J.K.); (R.K.); (R.D.)
- Correspondence: ; Tel.: +65-91-9910861112
| | - Satoshi Kusuda
- Department of Pediatrics, Kyorin University, Tokyo 181-8612, Japan;
| | - Ryan M. McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI 53726, USA;
| | - Shubham Gupta
- Child Health Imprints (CHIL) Pte. Ltd., Singapore 048545, Singapore; (S.G.); (J.K.); (R.K.); (R.D.)
| | - Jayant Kalra
- Child Health Imprints (CHIL) Pte. Ltd., Singapore 048545, Singapore; (S.G.); (J.K.); (R.K.); (R.D.)
| | - Ravneet Kaur
- Child Health Imprints (CHIL) Pte. Ltd., Singapore 048545, Singapore; (S.G.); (J.K.); (R.K.); (R.D.)
| | - Ritu Das
- Child Health Imprints (CHIL) Pte. Ltd., Singapore 048545, Singapore; (S.G.); (J.K.); (R.K.); (R.D.)
| | - Saket Anand
- Department of Computer Science and Engineering, Indraprastha Institute of Information Technology, New Delhi 110020, India;
| | - Ashish Kumar Pandey
- Department of Mathematics, Indraprastha Institute of Information Technology, New Delhi 110020, India;
| | - Su Jin Cho
- College of Medicine, Ewha Womans University Seoul, Seoul 03760, Korea;
| | - Satish Saluja
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi 110060, India;
| | - Justin J. Boutilier
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin, Madison, WI 53706, USA;
| | - Suchi Saria
- Machine Learning and Healthcare Lab, Johns Hopkins University, 3400 N. Charles St, Baltimore, MD 21218, USA;
| | - Jonathan Palma
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA;
| | - Avneet Kaur
- Department of Neonatology, Apollo Cradle Hospitals, New Delhi 110015, India;
| | - Gautam Yadav
- Department of Pediatrics, Kalawati Hospital, Rewari 123401, India;
| | - Yao Sun
- Division of Neonatology, University of California, San Francisco, CA 92521, USA;
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Heenan M, Rojas JD, Oden ZM, Richards-Kortum R. In vitro comparison of performance including imposed work of breathing of CPAP systems used in low-resource settings. PLoS One 2020; 15:e0242590. [PMID: 33270660 PMCID: PMC7714113 DOI: 10.1371/journal.pone.0242590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/06/2020] [Indexed: 11/18/2022] Open
Abstract
Respiratory distress due to preterm birth is a significant cause of death in low-resource settings. The introduction of continuous positive airway pressure (CPAP) systems to treat respiratory distress significantly reduced mortality in high-resource settings, but CPAP was only recently introduced in low-resource settings due to cost and infrastructure limitations. We evaluated pressure stability and imposed work of breathing (iWOB) of five CPAP systems used in low resource settings: the Fisher and Paykel bubble CPAP, the Diamedica baby CPAP, the Medijet nCPAP generator, and the first (2015) and second (2017) generation commercially available Pumani CPAPs. Pressure changes due to fresh gas flow were evaluated for each system by examining the relationship between flow and pressure at the patient interface for four pressures generated at the bottle (0, 3, 5, and 7 cm H2O); for the Medijet nCPAP generator, no bottle was used. The slope of the resulting relationship was used to calculate system resistance. Poiseuille's law of resistance was used to investigate significant contributors to resistance. Resistance ranged from 0.05 to 1.40 [Formula: see text]; three CPAP devices had resistances < 0.4 [Formula: see text]: the Fisher and Paykel system, the Diamedica system, and the second generation Pumani bubble CPAP. The other two systems, the Medijet nCPAP generator and the first generation Pumani bCPAP, had resistances >1.0 [Formula: see text]. Imposed WOB was measured using an ASL5000 test lung to simulate the breath cycle for an infant (5.5 kg), a term neonate (4.0 kg), and a preterm neonate (2.5 kg). Imposed WOB ranged from 1.4 to 39.5 mJ/breath across all systems and simulated infant sizes. Changes in pressure generated by fresh gas flow, resistance, and iWOB differ between the five systems evaluated under ideal laboratory conditions. The available literature does not indicate that these differences affect clinical outcomes.
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Affiliation(s)
- Megan Heenan
- Rice 360°: Institute for Global Health, Rice University, Houston, Texas, United States of America
| | - Jose D. Rojas
- Department of Respiratory Care, School of Health Professions, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Z. Maria Oden
- Rice 360°: Institute for Global Health, Rice University, Houston, Texas, United States of America
- Department of Bioengineering, Rice University, Houston, Texas, United States of America
| | - Rebecca Richards-Kortum
- Rice 360°: Institute for Global Health, Rice University, Houston, Texas, United States of America
- Department of Bioengineering, Rice University, Houston, Texas, United States of America
- * E-mail:
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32
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Sivanandan S, Sankar MJ. CPAP Failure in Neonates: Practice, Experience, and Focus Do Matter! Indian J Pediatr 2020; 87:881-882. [PMID: 33034819 DOI: 10.1007/s12098-020-03501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Sindhu Sivanandan
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - M Jeeva Sankar
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Baiden F. Peer mentorship in the scale-up of neonatal continuous positive airway pressure in Malawi. Acta Paediatr 2020; 109:2179-2180. [PMID: 31876304 DOI: 10.1111/apa.15127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Frank Baiden
- Department of Clinical Research Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine London UK
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34
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Nørgaard M, Stagstrup C, Lund S, Poulsen A. To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries. J Trop Pediatr 2020; 66:339-353. [PMID: 31599959 DOI: 10.1093/tropej/fmz069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Bubble-continuous positive airway pressure (bCPAP) is a simple, low-cost ventilation therapy with the potential to lower morbidity and mortality in children in low- and middle-income countries (LMICs). AIM To examine (i) whether bCPAP is a safe and effective treatment for children in all age-groups presenting with respiratory distress from any cause, (ii) LMIC-implemented bCPAP devices including their technical specifications and costs and (iii) the setting and level of health care bCPAP has been implemented in. METHOD A systematic search was performed of Embase, PubMed and Web of Science. Inclusion criteria: bCPAP for children with respiratory distress in all age groups in LMICs. Database searches were performed up to 1 November 2018. RESULTS A total of 24 publications were eligible for the review. For neonates bCPAP was superior in improving survival and clinical progression compared with oxygen therapy and mechanical ventilation (MV). In two studies bCPAP was superior to low flow oxygen in reducing mortality in children 29 days to 13 months. Respiratory rate reductions were significant across all ages. Only three of six studies in children of all ages evaluated serious adverse events. In 12 studies comprising 1338 neonates treated with bCPAP, pneumothorax was reported 27 times. The majority of studies were carried out at tertiary hospitals in middle-income countries and 50% implemented the most expensive bCPAP-device. CONCLUSION In neonates and children below 13 months bCPAP is a safe treatment improving clinical outcomes and reducing the need for MV, without an increase in mortality. High-quality studies from non-tertiary settings in low-income countries are needed.
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Affiliation(s)
- Mathilde Nørgaard
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Cecilie Stagstrup
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Stine Lund
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Anja Poulsen
- Global Health Unit, Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
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35
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Sammour I, Karnati S. Non-invasive Respiratory Support of the Premature Neonate: From Physics to Bench to Practice. Front Pediatr 2020; 8:214. [PMID: 32457860 PMCID: PMC7227410 DOI: 10.3389/fped.2020.00214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/09/2020] [Indexed: 12/04/2022] Open
Abstract
Premature births continue to rise globally with a corresponding increase in various morbidities among this population. Rates of respiratory distress syndrome and the consequent development of Bronchopulmonary Dysplasia (BPD) are highest among the extremely preterm infants. The majority of extremely low birth weight premature neonates need some form of respiratory support during their early days of life. Invasive modes of respiratory assistance have been popular amongst care providers for many years. However, the practice of prolonged invasive mechanical ventilation is associated with an increased likelihood of developing BPD along with other comorbidities. Due to the improved understanding of the pathophysiology of BPD, and technological advances, non-invasive respiratory support is gaining popularity; whether as an initial mode of support, or for post-extubation of extremely preterm infants with respiratory insufficiency. Due to availability of a wide range of modalities, wide variations in practice exist among care providers. This review article aims to address the physical and biological basis for providing non-invasive respiratory support, the current clinical evidence, and the most recent developments in this field of Neonatology.
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Affiliation(s)
- Ibrahim Sammour
- Department of Neonatology, Lerner College of Medicine, Pediatric Institute, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, OH, United States
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36
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Kinshella MLW, Walker CR, Hiwa T, Vidler M, Nyondo-Mipando AL, Dube Q, Goldfarb DM, Kawaza K. Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review. Public Health Rev 2020; 41:6. [PMID: 32368359 PMCID: PMC7189679 DOI: 10.1186/s40985-020-00124-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 04/07/2020] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization. METHODS A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082). RESULTS Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation. CONCLUSIONS With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.
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Affiliation(s)
- Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Celia R. Walker
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Tamanda Hiwa
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Alinane Linda Nyondo-Mipando
- School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Paediatrics, Queen Elizabeth Central Hospital, Blantyre, Malawi
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Salimu S, Kinshella MLW, Vidler M, Banda M, Newberry L, Dube Q, Molyneux EM, Goldfarb DM, Kawaza K, Nyondo-Mipando AL. Health workers' views on factors affecting caregiver engagement with bubble CPAP. BMC Pediatr 2020; 20:180. [PMID: 32326900 PMCID: PMC7179004 DOI: 10.1186/s12887-020-02088-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background Severe respiratory distress is a leading cause of mortality among neonates in Malawi. Despite evidence on the safety, cost effectiveness and efficacy of bubble continuous positive airway pressure (CPAP) in managing the condition, its use in Malawian health facilities is limited and little is known about caregivers’ engagement with perspectives of bubble CPAP. The purpose of this study was to explore caregiver perspectives for bubble CPAP at both central and district hospitals and key factors that enable effective caregiver engagement in Malawi. Methods This was a descriptive qualitative study employing secondary analysis of 46 health care worker in-depth interviews. We interviewed the health workers about their thoughts on caregiver perspectives regarding use of bubble CPAP. We implemented the study at a tertiary facility and three district hospitals in southern Malawi. This was a part of a larger study to understand barriers and facilitators to implementing neonatal innovations in resource-constrained hospitals. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia). Health workers were purposively selected to include nurses, clinicians and district health management involved in the use of bubble CPAP. Results Emerging issues included caregiver fears around bubble CPAP equipment as potentially harmful to their new-borns and how inadequate information provided to caregivers exacerbated knowledge gaps and was associated with refusal of care. However, good communication between health care providers and caregivers was associated with acceptance of care. Caregivers’ decision-making was influenced by relatives and peer advocates were helpful in supporting caregivers and alleviating fears or misconceptions about bubble CPAP. Conclusions Since caregivers turn to relatives and peers for support, there is need to ensure that both relatives and peers are counselled on bubble CPAP for improved understanding and uptake. Health workers need to provide simplified, accurate, up-to-date information on the intervention as per caregivers’ level of understanding. Notably, contextualised comprehensible information will help alleviate caregivers’ fear and anxieties about bubble CPAP.
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Affiliation(s)
- Sangwani Salimu
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Mwai Banda
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Laura Newberry
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Queen Dube
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth M Molyneux
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children's and Women's Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Alinane Linda Nyondo-Mipando
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,School of Public Health and Family Medicine, Department of Health Systems and Policy, College of Medicine, University of Malawi, Blantyre, Malawi
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Nanda D, Nangia S, Thukral A, Yadav CP. A new clinical respiratory distress score for surfactant therapy in preterm infants with respiratory distress. Eur J Pediatr 2020; 179:603-610. [PMID: 31853688 DOI: 10.1007/s00431-019-03530-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 11/04/2019] [Accepted: 11/11/2019] [Indexed: 12/13/2022]
Abstract
The guidelines for surfactant therapy are largely based on studies done in developed coun1tries wherein the facility infrastructure, patient profile, and clinical practices are different from low- and middle-income countries (LMICs). Though SRT is widely practiced in developing countries, there exists variability in clinical practice. Our objective was to identify the factors which would predict the need of surfactant administration and develop a "clinical respiratory distress (RD) score" for surfactant administration in preterm neonates with respiratory distress. A prospective observational study was conducted in 153 preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress who were managed with CPAP and/or surfactant where indicated. Gestation < 32 weeks, no antenatal corticosteroid (ANS), hypothermia at admission, Apgar score < 3 at 1 minute, and Silverman score > 2 at 2 hours were found to be the significant factors in predicting surfactant requirement in multivariate regression analysis. A seven point scale was developed and categorized into two categories as < 4 and ≥ 4. The sensitivity, specificity, PPV, and NPV were 67%, 87%, 86%, and 68%, respectively, with a cutoff score ≥ 4. The positive likelihood ratio was 5.07 (95% CI 2.71-9.48), and negative likelihood ratio was 0.38 (95% CI 0.28-0.52). The observed rate of surfactant administration was found to be around 32% when the composite score was below four, and the rate increased to almost 86% when the composite score was ≥ 4. The predictive accuracy of the model was subsequently evaluated in a cohort of 56 preterm infants with respiratory distress.. Sensitivity, specificity and positive and negative predictive value during the validation phase were 97%, 73%, 85%, and 94%, respectively. With a composite score less than 4, the observed rate of surfactant administration was 6% (95% CI 1%-28%) as against the model predicted rate of 24%, while with composite score ≥ 4, the observed rate was 85% (95% CI 69%-94%) as against the model predicted rate of 90%.Conclusion: "Clinical RD score" is a simple score, which can be utilized for decision-making for early surfactant administration for preterm infants (260/7 to 346/7 weeks gestation) with respiratory distress.Trial Registration: NCT03273764What is Known:• Both CPAP and surfactant therapy are effective in management of preterm infants with RDS.• The efficacy of surfactant replacement therapy is better when it is administered early in the course of disease.What is New:• Many of the known risk factors for RDS do not predict surfactant requirement.• "Composite RD score" comprising of five independent predictors of surfactant requirement with a numeric cutoff may help decide which preterm neonates with respiratory distress need early surfactant administration in low- and middle-income countries.
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Affiliation(s)
- Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Siksha O Anusandhan University, Bhubaneswar, Odisha, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, Kalawati Saran Children's Hospital and Smt. Sucheta Kriplani Hospital, New Delhi, India.
| | - Anu Thukral
- Newborn Health Knowledge Centre, WHO Collaborating Centre for Training and Research in Neonatal Care, ICMR Centre for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - C P Yadav
- Epidemiology and Clinical Research Division, National Institute of Malaria Research (NIMR), Indian Council of Medical Research, New Delhi, India
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Dewez JE, Nangia S, Chellani H, White S, Mathai M, van den Broek N. Availability and use of continuous positive airway pressure (CPAP) for neonatal care in public health facilities in India: a cross-sectional cluster survey. BMJ Open 2020; 10:e031128. [PMID: 32114460 PMCID: PMC7053015 DOI: 10.1136/bmjopen-2019-031128] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine the availability of continuous positive airway pressure (CPAP) and to provide an overview of its use in neonatal units in government hospitals across India. SETTING Cross-sectional cluster survey of a nationally representative sample of government hospitals from across India. PRIMARY OUTCOMES Availability of CPAP in neonatal units. SECONDARY OUTCOMES Proportion of hospitals where infrastructure and processes to provide CPAP are available. Case fatality rates and complication rates of neonates treated with CPAP. RESULTS Among 661 of 694 government hospitals with neonatal units that provided information on availability of CPAP for neonatal care, 68.3% of medical college hospitals (MCH) and 36.6% of district hospitals (DH) used CPAP in neonates. Assessment of a representative sample of 142 hospitals (79 MCH and 63 DH) showed that air-oxygen blenders were available in 50.7% (95% CI 41.4% to 60.9%) and staff trained in the use of CPAP were present in 56.0% (45.8% to 65.8%) of hospitals. The nurse to patient ratio was 7.3 (6.4 to 8.5) in MCH and 6.6 (5.5 to 8.3) in DH. Clinical guidelines were available in 31.0% of hospitals (22.2% to 41.4%). Upper oxygen saturation limits of above 94% were used in 72% (59.8% to 81.6%) of MCH and 59.3% (44.6% to 72.5%) of DH. Respiratory circuits were reused in 53.8% (42.3% to 63.9%) of hospitals. Case fatality rate for neonates treated with CPAP was 21.4% (16.6% to 26.2%); complication rates were 0.7% (0.2% to 1.2%) for pneumothorax, 7.4% (0.9% to 13.9%) for retinopathy and 1.4% (0.7% to 2.1%) for bronchopulmonary dysplasia. CONCLUSIONS CPAP is used in neonatal units across government hospitals in India. Neonates may be overexposed to oxygen as the means to detect and treat consequences of oxygen toxicity are insufficient. Neonates may also be exposed to nosocomial infections by reuse of disposables. Case fatality rates for neonates receiving CPAP are high. Complications might be under-reported. Support to infrastructure, training, guidelines implementation and staffing are needed to improve CPAP use.
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Affiliation(s)
- Juan Emmanuel Dewez
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Hospital, New Delhi, Delhi, India
| | - Harish Chellani
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Sarah White
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Matthews Mathai
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nynke van den Broek
- Department of International Public Health, Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Nyondo-Mipando AL, Woo Kinshella ML, Bohne C, Suwedi-Kapesa LC, Salimu S, Banda M, Newberry L, Njirammadzi J, Hiwa T, Chiwaya B, Chikoti F, Vidler M, Dube Q, Molyneux E, Mfutso-Bengo J, Goldfarb DM, Kawaza K, Mijovic H. Barriers and enablers of implementing bubble Continuous Positive Airway Pressure (CPAP): Perspectives of health professionals in Malawi. PLoS One 2020; 15:e0228915. [PMID: 32053649 PMCID: PMC7018070 DOI: 10.1371/journal.pone.0228915] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Preterm birth complications are the leading cause of neonatal deaths. Malawi has high rates of preterm birth, with 18.1 preterm births per 100 live births. More than 50% of preterm neonates develop respiratory distress which if left untreated, can lead to respiratory failure and death. Term and preterm neonates with respiratory distress can often be effectively managed with Continuous Positive Airway Pressure (CPAP) and this is considered an essential intervention for the management of preterm neonates by the World Health Organization. Bubble CPAP may represent a safe and cost-effective method for delivering CPAP in low-income settings. OBJECTIVE The study explored the factors that influence the implementation of bubble CPAP among health care professionals in secondary and tertiary hospitals in Malawi. METHODS This was a qualitative study conducted in three district hospitals and a tertiary hospital in southern Malawi. We conducted 46 in-depth interviews with nurses, clinicians and clinical supervisors, from June to August 2018. All data were digitally recorded, transcribed verbatim and thematically analyzed. RESULTS Factors that influenced implementation of bubble CPAP occurred in an interconnected manner and included: inadequate healthcare provider training in preparation for use, rigid division of roles and responsibilities among providers, lack of effective communication among providers and between providers and newborn's caregivers, human resource constraints, and inadequate equipment and infrastructure. CONCLUSION There are provider, caregiver and health system level factors that influence the implementation of bubble CPAP among neonates in Malawian health facilities. Ensuring adequate staffing in the nurseries, combined with ongoing training for providers, team cohesion, improved communication with caregivers, and improved hospital infrastructure would ensure optimal utilization of bubble CPAP and avoid inadvertent harm from inappropriate use.
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Affiliation(s)
- Alinane Linda Nyondo-Mipando
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Mai-Lei Woo Kinshella
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Christine Bohne
- Institute for Global Health, NEST 360°, Rice University, Houston, Texas, United States of America
| | | | | | - Mwai Banda
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Laura Newberry
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jenala Njirammadzi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Tamanda Hiwa
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Felix Chikoti
- College of Medicine, IMCHA Project, Blantyre, Malawi
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Queen Dube
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Elizabeth Molyneux
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Joseph Mfutso-Bengo
- Department of Health Systems and Policy, School of Public Health and Family Medicine, College of Medicine, University of Malawi, Blantyre, Malawi
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Center of Bioethics for Eastern & Southern Africa (CEBESA), Blantyre, Malawi
| | - David M. Goldfarb
- Department of Pathology and Laboratory Medicine, BC Children’s and Women’s Hospital and University of British Columbia, Vancouver, Canada
| | - Kondwani Kawaza
- College of Medicine, IMCHA Project, Blantyre, Malawi
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
- Queen Elizabeth Central Hospital, Pediatrics, Blantyre, Malawi
| | - Hana Mijovic
- Department of Pediatrics, BC Children’s Hospital and University of British Columbia, Vancouver, Canada
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Lu MH, Li IC. Action research on neonatal nursing staff: Experiences caring for bubble continuous positive airway pressure patients. Kaohsiung J Med Sci 2020; 36:371-377. [PMID: 31889411 DOI: 10.1002/kjm2.12177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
The objective of this study was to understand the experiences of special care nursery (SCN) nurses tending patients on bubble continuous positive airway pressure (bCPAP). The action research (AR) method with focus group interview was used, and five focus-group interviews were conducted between November 2015 and January 2016. Twenty SCN nurses who had cared neonates on bCPAP for at least one shift were recruited and interviewed. Six themes were revealed in two stages. The first stage was "experience of change," three themes evolved: "resistance to change," "lack of confidence on new care model," and "request administrative supports and resources from the hospital level." The second stage was "willing to take challenge," three themes evolved: "pursuit of proficiency in bCPAP care," "mastering bPCAP: acquiring self-efficacy, becoming competent, and collaborating as a team," and "the development of creative care methods." In the future when confronted with nurses resisting to new policies or changes, administrators should embrace their emotions, address their insecurity and fear, and provide adequate training to improve confidence through familiarity. Application of this model can help with policy implementation, thereby improving the overall caring quality.
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Affiliation(s)
- Ming-Huei Lu
- School of Nursing, National Yang-Ming University, Taipei, Taiwan.,Department of Nursing, MacKay Children's Hospital, Taipei, Taiwan.,Department of Nursing, Mackay Medical College, New Taipei City, Taiwan
| | - I-Chuan Li
- Department of Nursing, Institute of Community Health Care, National Yang-Ming University, Taipei, Taiwan
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Van Wyk L, Tooke L, Dippenaar R, Rhoda N, Lloyd L, Holgate S, Alexander R, Smith J. Optimal Ventilation and Surfactant Therapy in Very-Low-Birth-Weight Infants in Resource-Restricted Regions. Neonatology 2020; 117:217-224. [PMID: 32454492 DOI: 10.1159/000506987] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 11/19/2022]
Abstract
In resource-restricted regions, respiratory distress syndrome (RDS) data are often underreported, making the determination of effective interventions and their outcome difficult. The combination of oxygen, nasal continuous positive airway pressure (CPAP) and surfactant therapy has the potential to prevent 42% of RDS-related deaths in sub-Saharan Africa, despite the financial implications. This article provides a brief overview on the status of RDS management, mainly nasal CPAP and surfactant therapy in very-low-birth-weight infants, in resource-restricted regions of sub-Saharan Africa. Data from the public health sector, as compared to the private health sector, of the Western Cape province, South Africa, are used to illustrate what RDS management strategies are able to accomplish in a resource-restricted region. Upscaling of all components (antenatal care, antenatal corticosteroids, prevention of hypothermia and RDS management strategies) are required to decrease premature infant mortality rates in resource-restricted areas.
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Affiliation(s)
- Lizelle Van Wyk
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa,
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Ricky Dippenaar
- NICU, N1 City and Blaauwberg Hospital, Cape Town, South Africa
| | - Natasha Rhoda
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Lizel Lloyd
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Sandi Holgate
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | | | - Johan Smith
- Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Panorama Medi-Clinic, Cape Town, South Africa
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Bubble CPAP in resource-poor settings: friend or foe? THE LANCET RESPIRATORY MEDICINE 2019; 7:923-925. [DOI: 10.1016/s2213-2600(19)30261-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/23/2022]
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Carns J, Kawaza K, Liaghati-Mobarhan S, Asibon A, Quinn MK, Chalira A, Lufesi N, Molyneux E, Oden M, Richards-Kortum R. Neonatal CPAP for Respiratory Distress Across Malawi and Mortality. Pediatrics 2019; 144:peds.2019-0668. [PMID: 31540968 DOI: 10.1542/peds.2019-0668] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aim in this observational study was to monitor continuous positive airway pressure (CPAP) usage and outcomes in newborn wards at 26 government hospitals in Malawi after the introduction of CPAP as part of a quality-improvement initiative. CPAP was implemented in 3 phases from 2013 through 2015. METHODS Survival to discharge was analyzed for neonates treated with nasal oxygen and/or CPAP with admission weights of 1 to 2.49 kg at 24 government hospitals with transfer rates <15%. This analysis includes neonates admitted with respiratory illness for 5.5 months before (621 neonates) and 15 months immediately after CPAP implementation (1836 neonates). A follow-up data analysis was completed for neonates treated with CPAP at all hospitals during an additional 11 months (194 neonates). RESULTS On implementation of CPAP, survival to discharge improved for all neonates admitted with respiratory distress (48.6% vs 54.5%; P = .012) and for those diagnosed with respiratory distress syndrome (39.8% vs 48.3%; P = .042). There were no significant differences in outcomes for neonates treated with CPAP during the implementation and follow-up periods. Hypothermia on admission was pervasive and associated with poor outcomes. Neonates with normal mean temperatures during CPAP treatment experienced the highest survival rates (65.7% for all neonates treated with CPAP and 60.0% for those diagnosed with respiratory distress syndrome). CONCLUSIONS A nurse-led CPAP service can improve outcomes for neonates in respiratory distress in low-resource settings. However, the results show that real-world improvements in survival may be limited without access to comprehensive newborn care, especially for small and sick infants.
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Affiliation(s)
- Jennifer Carns
- Rice 360 Institute for Global Health Technology, Houston, Texas.,Department of Bioengineering, Rice University, Houston, Texas
| | - Kondwani Kawaza
- Department of Pediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; and
| | | | - Aba Asibon
- Rice 360 Institute for Global Health Technology, Houston, Texas
| | - Mary K Quinn
- Rice 360 Institute for Global Health Technology, Houston, Texas
| | - Alfred Chalira
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Norman Lufesi
- Department of Clinical Services, Ministry of Health, Lilongwe, Malawi
| | - Elizabeth Molyneux
- Department of Pediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; and
| | - Maria Oden
- Rice 360 Institute for Global Health Technology, Houston, Texas.,Department of Bioengineering, Rice University, Houston, Texas
| | - Rebecca Richards-Kortum
- Rice 360 Institute for Global Health Technology, Houston, Texas; .,Department of Bioengineering, Rice University, Houston, Texas
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McCollum ED, Mvalo T, Eckerle M, Smith AG, Kondowe D, Makonokaya D, Vaidya D, Billioux V, Chalira A, Lufesi N, Mofolo I, Hosseinipour M. Bubble continuous positive airway pressure for children with high-risk conditions and severe pneumonia in Malawi: an open label, randomised, controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:964-974. [PMID: 31562059 PMCID: PMC6838668 DOI: 10.1016/s2213-2600(19)30243-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 12/14/2022]
Abstract
Background Pneumonia is the leading cause of death among children globally. Most pneumonia deaths in low-income and middle-income countries (LMICs) occur among children with HIV infection or exposure, severe malnutrition, or hypoxaemia despite antibiotics and oxygen. Non-invasive bubble continuous positive airway pressure (bCPAP) is considered a safe ventilation modality that might improve child pneumonia survival. bCPAP outcomes for high-risk African children with severe pneumonia are unknown. Since most child pneumonia hospitalisations in Africa occur in non-tertiary district hospitals without daily physician oversight, we aimed to examine whether bCPAP improves severe pneumonia mortality in such settings. Methods This open-label, randomised, controlled trial was done in the general paediatric ward of Salima District Hospital, Malawi. We enrolled children aged 1–59 months old with WHO-defined severe pneumonia and either HIV infection or exposure, severe malnutrition, or an oxygen saturation of less than 90%. Children were randomly assigned 1:1 to low-flow nasal cannula oxygen or nasal bCPAP. Non-physicians administered care; the primary outcome was hospital survival. Primary analyses were by intention-to-treat and interim and adverse events analyses per protocol. This trial is registered with ClinicalTrials.gov, number NCT02484183, and is closed. Findings We screened 1712 children for eligibility between June 23, 2015, and March 21, 2018. The data safety and monitoring board stopped the trial for futility after 644 of the intended 900 participants were enrolled. 323 children were randomly assigned to oxygen and 321 to bCPAP. 35 (11%) of 323 children who received oxygen died in hospital, as did 53 (17%) of 321 who received bCPAP (relative risk 1·52; 95% CI 1·02–2·27; p=0·036). 13 oxygen and 17 bCPAP patients lacked hospital outcomes and were considered lost to follow-up. Suspected adverse events related to treatment occurred in 11 (3%) of 321 children receiving bCPAP and 1 (<1%) of 323 children receiving oxygen. Four bCPAP and one oxygen group deaths were classified as probable aspiration episodes, one bCPAP death as probable pneumothorax, and six non-death bCPAP events included skin breakdown around the nares. Interpretation bCPAP treatment in a paediatric ward without daily physician supervision did not reduce hospital mortality among high-risk Malawian children with severe pneumonia, compared with oxygen. The use of bCPAP within certain patient populations and non-intensive care settings might carry risk that was not previously recognised. bCPAP in LMICs needs further evaluation before wider implementation for child pneumonia care. Funding Bill & Melinda Gates Foundation, International AIDS Society, Health Empowering Humanity.
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Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA; Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi; Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Smith
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Davie Kondowe
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Don Makonokaya
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | | | | | | | | | - Innocent Mofolo
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Mina Hosseinipour
- University of North Carolina Project Malawi, Lilongwe, Malawi; Division of Infectious Disease, University of North Carolina at Chapel Hill, NC, USA
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Okello F, Egiru E, Ikiror J, Acom L, Loe K, Olupot-Olupot P, Burgoine K. Reducing preterm mortality in eastern Uganda: the impact of introducing low-cost bubble CPAP on neonates <1500 g. BMC Pediatr 2019; 19:311. [PMID: 31484567 PMCID: PMC6724283 DOI: 10.1186/s12887-019-1698-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Complications of prematurity are the leading cause of deaths in children under the age of five. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). In low-income countries (LICs) there are limited treatment options for RDS. Due to their simplicity and affordability, low-cost bubble continuous positive airway pressure (bCPAP) devices have been introduced in neonatal units in LICs to treat RDS. This study is the first observational study from a LIC to compare outcomes of very-low-birth-weight (VLBW) neonates in pre- and post-CPAP periods. METHODS This was a retrospective study of VLBW neonates (weight < 1500 g) in Mbale Regional Referral Hospital Neonatal Unit (MRRH-NNU), a government hospital in eastern Uganda. It aimed to measure the outcome of VLBW neonates in two distinct study periods: A 14-month period beginning at the opening of MRRH-NNU and covering the period until bCPAP was introduced (pre-bCPAP) and an 18-month period following the introduction of bCPAP (post-bCPAP). After the introduction of bCPAP, it was applied to preterm neonates with RDS when clinically indicated and if a device was available. Clinical features and outcomes of all neonates < 1500 g were compared before and after the introduction of bCPAP. RESULTS The admission records of 377 VLBW neonates < 1500 g were obtained. One hundred fifty-eight were admitted in the pre-bCPAP period and 219 in the post-bCPAP period. The mortality rate in the pre- bCPAP period was 39.2% (62/158) compared with 26.5% (58/219, P = 0.012) in the post-bCPAP period. Overall, there was a 44% reduction in mortality (OR 0.56, 95%CI 0.36-0.86, P = 0.01). There were no differences in birthweight, sex, presence of signs of respiratory distress or apnoea between the two groups. CONCLUSION Specialized and resource-appropriate neonatal care, that appropriately addresses the challenges of healthcare provision in LICs, has the potential to reduce neonatal deaths. The use of a low-cost bCPAP to treat RDS in VLBW neonates resulted in a significant improvement in their survival in a neonatal unit in eastern Uganda. Since RDS is one of the leading causes of neonatal mortality, it is possible that this relatively simple and affordable intervention could have a huge impact on global neonatal mortality.
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Affiliation(s)
- F Okello
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Varimetrics Group Limited, P. O Box 2190, Mbale, Uganda
| | - E Egiru
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - J Ikiror
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - L Acom
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - Ksm Loe
- Diamedica UK Ltd, Grange Hill Industrial Estate, Bratton Fleming, UK
| | - P Olupot-Olupot
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - K Burgoine
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda.
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda.
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Hedstrom A, Perez K, Umoren R, Batra M, Engmann C. Recent progress in global newborn health: thinking beyond acute to strategic care? J Perinatol 2019; 39:1031-1041. [PMID: 31182774 DOI: 10.1038/s41372-019-0384-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 12/12/2022]
Abstract
Advancements in neonatal care globally highlight ongoing disparities in neonatal outcomes between low-income countries (LICs) and high-income countries (HICs). Drivers of this gap are primarily prematurity, infection, and intrapartum-related events. Significant success is being achieved; however, for neonatal outcomes in LIC to approximate those of HICs within a generation, acceleration of the current trajectory of progress is needed. This requires a renewed focus on newborn-specific and newborn-sensitive strategies. Newborn-specific strategies are those directly affecting the well-being of the neonate. Newborn-sensitive strategies address the broader macro-environmental drivers that affect underlying neonatal outcomes such as decreased poverty, improved sanitation, and increased maternal empowerment and health. To create such an enabling macro-environment requires significant political will, financing, advocacy, and policy generation. This manuscript highlights recent advances in newborn research, programming, policy, and funding, and highlights key opportunities to bend the curve on advancing neonatal health globally.
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Affiliation(s)
- Anna Hedstrom
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Krystle Perez
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Rachel Umoren
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Maneesh Batra
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Cyril Engmann
- Department of Pediatrics, University of Washington, Seattle, WA, USA. .,Department of Global Health, University of Washington, Seattle, WA, USA. .,Maternal, Newborn, Child Health and Nutrition, PATH, Seattle, WA, USA.
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48
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Won A, Suarez-Rebling D, Baker AL, Burke TF, Nelson BD. Bubble CPAP devices for infants and children in resource-limited settings: review of the literature. Paediatr Int Child Health 2019; 39:168-176. [PMID: 30375281 DOI: 10.1080/20469047.2018.1534389] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Early management of respiratory distress is critical to reducing mortality in infants and children in resource-limited settings. Bubble continuous positive airway pressure (bCPAP) can offer effective and affordable non-invasive respiratory support. Objective: To determine the best physical components of bubble CPAP circuits for respiratory support of children in low-resource settings. Methods: Using PubMed, CINAHL and LILACS, studies of any design in any language published before June 2017 which examined the physical components of bCPAP circuits were identified and reviewed. Results: After screening, the review included 45 articles: 17 clinical trials, 11 literature reviews, 10 technical assessments of bCPAP components, three reports of real-world implementation in low-resource settings, three cost analyses and one case report. There is no ideal bCPAP circuit for all settings and patients, but some choices are generally better than others in designing a circuit for low-resource settings. Oxygen concentrators are usually the best source of oxygen. As yet, there is no affordable and accurate oxygen blender. Nasal prongs are the simplest patient interface to use with the fewest complications but are not the cheapest option. Expiratory limbs should be at least 1 cm in diameter. Home-made pressure generators are effective, safe and affordable. Conclusion: This narrative review found many studies which evaluated the real clinical outcomes with bCPAP in the target population as well as technical comparison of bCPAP components. However, many studies were not blinded or randomised and there was significant heterogeneity in design and outcome measures. Abbreviations: bCPAP, bubble continuous positive airway pressure; CPAP, continuous positive airway pressure; FiO2, fractional oxygen concentration; HFNC, high-flow nasal cannula; HIC, high-income countries; LMIC, low- and middle-income countries; NP, nasopharyngeal; O2, oxygen; PEEP, positive end-expiratory pressure; PICO, Population, Intervention, Comparison and Outcome.
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Affiliation(s)
- Alice Won
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Daniela Suarez-Rebling
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Arianne L Baker
- b Department of Pediatrics , Harvard Medical School , Boston , USA.,c Department of Emergency Medicine , Harvard Medical School , Boston , MA , USA
| | - Thomas F Burke
- a Division of Global Health and Human Rights, Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA.,b Department of Pediatrics , Harvard Medical School , Boston , USA
| | - Brett D Nelson
- b Department of Pediatrics , Harvard Medical School , Boston , USA.,d Division of Global Health, Department of Pediatrics , Massachusetts General Hospital , Boston , USA
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49
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Hubbard RM, Choudhury KM, Lim G. Treatment Patterns and Clinical Outcomes in Neonates Diagnosed With Respiratory Distress Syndrome in a Low-Income Country: A Report From Bangladesh. Anesth Analg 2019; 126:1684-1686. [PMID: 29481437 DOI: 10.1213/ane.0000000000002865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Respiratory distress syndrome remains a leading cause of neonatal mortality worldwide. This retrospective study describes practice patterns for respiratory distress syndrome in a resource-limited setting and seeks to identify both risk factors for mortality and beneficial treatment modalities. Health, demographic, and treatment data were collected. Potential associations were analyzed using univariable and multivariable logistic regression. Of 104 children included for analysis, 38 died. Although most children were initially treated with noninvasive respiratory support, 59 progressed to invasive ventilation. Requirement for invasive ventilation was associated with death. A clear trend toward improved survival in mechanically ventilated patients was seen with surfactant administration.
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Affiliation(s)
- Richard M Hubbard
- From the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kamal M Choudhury
- Department of Pediatric Surgery, Bangladesh Institute of Research and Rehabilitation for Diabetes, Endocrine, and Metabolic Disorders-II Hospital, Dhaka, Bangladesh
| | - Grace Lim
- From the Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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50
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Backes CH, Notestine JL, Lamp JM, Balough JC, Notestine AM, Alfred CM, Kern JM, Stenger MR, Rivera BK, Moallem M, Miller RR, Naik A, Cooper JN, Howard CR, Welty SE, Hillman NH, Zupancic JAF, Stanberry LI, Hansen TN, Smith CV. Evaluating the efficacy of Seattle-PAP for the respiratory support of premature neonates: study protocol for a randomized controlled trial. Trials 2019; 20:63. [PMID: 30658678 PMCID: PMC6339409 DOI: 10.1186/s13063-018-3166-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND At birth, the majority of neonates born at <30 weeks of gestation require respiratory support to facilitate transition and ensure adequate gas exchange. Although the optimal approach to the initial respiratory management is uncertain, the American Academy of Pediatrics endorses noninvasive respiratory support with nasal continuous positive airway pressure (nCPAP) for premature neonates with respiratory insufficiency. Despite evidence for its use, nCPAP failure, requiring intubation and mechanical ventilation, is common. Recently, investigators have described a novel method to deliver bubble nCPAP, termed Seattle-PAP. While preclinical and pilot studies are encouraging regarding the potential value of Seattle-PAP, a large trial is needed to compare Seattle-PAP directly with the current standard of care for bubble nCPAP (Fisher & Paykel CPAP or FP-CPAP). METHODS/DESIGN We designed a multicenter, non-blinded, randomized controlled trial that will enroll 230 premature infants (220/7 to 296/7 weeks of gestation). Infants will be randomized to receive Seattle-PAP or FP-CPAP. The primary outcome is respiratory failure requiring intubation and mechanical ventilation. Secondary outcomes include measures of short- and long-term respiratory morbidity and cost-effectiveness. DISCUSSION This trial will assess whether Seattle-PAP is more efficacious and cost-effective than FP-CPAP in real-world practice among premature neonates. TRIAL REGISTRATION ClinicalTrials.gov, NCT03085329 . Registered on 21 March 2017.
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Affiliation(s)
- Carl H Backes
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA. .,Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA. .,The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Jennifer L Notestine
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Jane M Lamp
- OhioHealth Research Institute, Riverside Methodist Hospital, Columbus, OH, USA
| | - Jeanne C Balough
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Allison M Notestine
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Crystal M Alfred
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Juli M Kern
- Pediatrix Medical Group of Ohio, Columbus, OH, USA
| | - Michael R Stenger
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Brian K Rivera
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Mohannad Moallem
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Randy R Miller
- Pediatrix Medical Group of Ohio, Columbus, OH, USA.,Mt. Carmel St. Ann's Hospital, Westerville, OH, USA
| | - Apurwa Naik
- OhioHealth, Grant Medical Center, Columbus, OH, USA
| | - Jennifer N Cooper
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Center for Surgical Outcomes, The Research at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Christopher R Howard
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, USA
| | - Stephen E Welty
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, USA.,Seattle Children's Neonatology Program, CHI Franciscan Health, Tacoma, WA, USA
| | - Noah H Hillman
- SSM Health, Cardinal Glennon Children's Hospital, St. Louis University, St. Louis, MO, USA
| | - John A F Zupancic
- Division of Newborn Medicine, Harvard Medical School, Boston, MA, USA.,Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Thomas N Hansen
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, USA
| | - Charles V Smith
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA, USA
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