Comparison of morbidities in very low birthweight and normal birthweight infants during the first year of life in a developing country

Neurologic Complications of Poverty: the Associations Between Poverty as a Social Determinant of Health and Adverse Neurologic Outcomes

PURPOSE OF REVIEW

Increasing attention has been paid in recent decades to social determinants of health as a risk factor for disease development and disease severity. While traditionally heart disease, family history, lipid profile, and tobacco use have all been associated with increased risk of neurological disease, numerous studies now show that the influence of poverty may be just as strong a risk factor. This study summarizes the recent literature on poverty as it contributes to neurological disease.

RECENT FINDINGS

Children growing up in poverty have increased risk for cognitive deficits and behavioral disorders as reported by Noble et al. (Dev Sci. 9(6):642-54, 2006) and Farah et al. (Brain Res. 1110(1):166-74, 2006) as well as worse outcomes when it comes to epilepsy management and disease course as discussed by Camfield et al. (Epilepsia. 57(11):1826-33, 2016). In adulthood, as the number of social determinants of health increases, the incidence of stroke and severe stroke increases significantly as reported by Reshetnyak et al. (Stroke. 51:2445-53, 2020) as does exposure to neurologically significant infectious diseases and incidence of dementia as reported by Sumilo et al. (Rev Med Virol. 18(2):81-95, 2008) and Zuelsdorff et al. (Alzheimer's Dement. 6(1):e12039, 2020). Social determinants of health including poverty should be considered a risk factor for disease. More attention is needed from clinicians as well as from a public health perspective to address this disparity.

Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature

BACKGROUND

Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries.

METHODS

High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed.

RESULTS

6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified.

CONCLUSION

Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.

Growth and neurodevelopmental outcome of VLBW infants at 1 year corrected age

OBJECTIVE

To evaluate growth and neurodevelopmental outcome of very low birth weight infants (VLBW) and compare with term normal birth weight infants (NBW) till 12 months corrected age.

DESIGN

A prospective cohort study.

SETTING

Tertiary care neonatal unit in northern India.

SUBJECTS

37 VLBW infants and 35 NBW infants born between January 2007 and December 2007.

INTERVENTIONS

Anthropometric measurements were recorded and Z-scores were computed serially at birth, discharge, 40 weeks post menstrual age (PMA), and at 1, 3, 6 and 12 months of corrected age. Developmental quotient (DQ) at 12 months corrected age was assessed.

RESULTS

Z-scores for weight, length and head circumference (HC) at birth were -1.21(±0.92), -0.98(±1.32) and -0.70(±1.14), respectively for VLBW infants and -0.37(±0.72), -0.11(±0.96) and 0.05(±0.73) respectively for NBW infants. VLBW infants had a significant drop in all Z-scores by discharge (P<0.001). There was a catch up to birth scores by 12 month age. VLBW infants had significantly lower Z-scores for weight, length and HC at one year corrected age as compared to NBW infants (P =0.01, 0.04 and 0.001, respectively). DQ at 12 months was significantly lower in VLBW infants (91.5+7.8) than NBW infants (97.5±5.3) (P <0.001). DQ of small for gestational age (SGA) and appropriate for gestational age (AGA) VLBW infants was comparable.

CONCLUSIONS

VLBW infants falter in their growth during NICU stay with a catch-up later during infancy. In comparison to NBW infants, they continue to lag in their physical growth and neurodevelopment at 1 year of corrected age.

Neonatal risk factors for respiratory morbidity during the first year of life among premature infants

CONTEXT AND OBJECTIVE

There have been dramatic increases in very low birth weight infant survival. However, respiratory morbidity remains problematic. The aim here was to verify associations between pulmonary mechanics, pulmonary structural abnormalities and respiratory morbidity during the first year of life.

DESIGN AND SETTING

Prospective cohort study at Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro.

METHODS

Premature infants with birth weight < 1500 g were studied. Lung function tests and high-resolution chest tomography were performed before discharge. During the first year, infants were assessed for respiratory morbidity (obstructive airways, pneumonia or hospitalization). Neonatal lung tests and chest tomography and covariables potentially associated with respiratory morbidity were independently assessed using relative risk (RR). RR was subsequently adjusted via logistic regression.

RESULTS

Ninety-seven newborn infants (mean birth weight: 1113 g; mean gestational age: 28 weeks) were assessed. Lung compliance and lung resistance were abnormal in 40% and 59%. Tomography abnormalities were found in 72%; respiratory morbidity in 53%. Bivariate analysis showed respiratory morbidity associated with: mechanical ventilation, prolonged oxygen use (beyond 28 days), oxygen use at 36 weeks, respiratory distress syndrome, neonatal pneumonia and patent ductus arteriosus. Multivariate analysis gave RR 2.7 (confidence interval: 0.7-10.0) for simultaneous lung compliance and chest tomography abnormalities. Adjusted RR for neonatal pneumonia and mechanical ventilation were greater.

CONCLUSIONS

Upon discharge, there were high rates of lung mechanism and tomography abnormalities. More than 50% presented respiratory morbidity during the first year. Neonatal pneumonia and mechanical ventilation use were statistically significant risk factors.

Reducing length of stay in hospital for very low birthweight infants by involving mothers in a stepdown unit: an experience from Karachi (Pakistan)

PROBLEM

Clinical care of infants with a very low birth weight (less than 1500 g) in developing countries can be labour intensive and is often associated with a prolonged stay in hospital. The Aga Khan University Medical Center in Karachi, Pakistan, established a neonatal intensive care unit in 1987. By 1993-4, very low birthweight infants remained in hospital for 18-21 days.

STRATEGIES FOR CHANGE

A stepdown unit was established in September 1994, with mothers providing all basic nursing care for their infants before being discharged under supervision.

KEY MEASURES FOR IMPROVEMENT

We analysed neonatal outcomes for the time periods before and after the stepdown unit was created (1987-94 and 1995-2001). We compared these two time periods for survival after birth until discharge, morbidity patterns during hospitalisation, length of stay in hospital, and readmission rates to hospital in the four weeks after discharge.

EFFECTS OF CHANGE

Of 509 consecutive, very low birthweight infants, 494 (97%) preterm and 140 (28%) weighing < 1000 g at birth), 391 (76%) survived to discharge from the hospital. The length of hospitalisation fell significantly from 1987-90, when it was 34 (SD 18) days, to 16 (SD 14) days in 1999-2001 (P < 0.001). Readmission rates to hospital did not rise, nor did adverse outcomes at 12 months of age.

LESSONS LEARNT

Our results indicate that it is possible to involve mothers in the active care of their very low birthweight infants before discharge. This may translate into earlier discharge from hospital to home settings without any increase in short term complications and readmissions.

Neurodevelopmental outcome of very low birth weight babies admitted to a Malaysian nursery

OBJECTIVE

To examine the prevalence and pattern of neurodevelopmental handicap at 2 years of age in very low birth weight infants (VLBW) admitted in 1993 to a level 3 Malaysian nursery.

METHODS

All VLBW babies born in the hospital or referred for neonatal care during 1993 were enrolled prospectively in the study. At 2 years of age development was assessed using the Griffiths mental scales. Neurological, hearing and visual assessments were graded into five groups according to functional handicap. Control infants were randomly selected during attendance at a primary health care clinic.

RESULTS

One hundred and fifty VLBW infants were admitted and 82 (54.6%) survived to 2 years, of whom 77 (93.9%) were assessed. The mean General Quotient (GQ) on the Griffiths Scales was 94 (15.7) for the study group and 104 (8.3) for the 60 controls. For GQ, 21 (27.3%) of the study population were 1 or more SD below the mean (18 between 1 and 2 SD and 3 > 2 SD) compared with 1 (1.6%) of the controls who was 1-2 SD below the mean. Visual impairment occurred in 2 study infants and none of the controls. There was no hearing impairment in either group. Cerebral palsy occurred in 3 (1 mild and 2 moderate-severe) of the study group and none of the controls. Functionally 18 (23.3%) of the study group had mild handicap, 1 (1.3%) moderate, 2 (2.5%) severe, 2 (2.5%) multiply severe and 54 (70.2%) were normal.

CONCLUSION

Although survival was low, overall rates of functional handicap were similar to those reported in developed countries but the proportion with moderate or severe handicap was low.