Setting research priorities to improve global newborn health and prevent stillbirths by 2025

Background

In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025.

Methods

We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.

Results

Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.

Conclusion

These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

Risk Factors and Outcome of Neonates Born through Meconium Stained Amniotic Fluid in a Tertiary Hospital of Nepal

Introduction: The incidence of meconium aspiration syndrome is still high in the developing world contributing significantly to the neonatal mortality. The study was aimed to know the risk factors contributing to meconium aspiration syndrome and neonatal outcome in a tertiary government hospital of the country.Materials and Methods: It was a hospital based cross sectional study done over a period of three months. All live newborns born through meconium stained liquor were enrolled and all the details regarding mother, neonate were recorded. Odd’s ratio and bivariate analysis was done to assess the risk factors for meconium aspiration syndrome.Result: Out of all the deliveries 14.6% were meconium stained amniotic fluid and meconium aspiration syndrome developed in 6.6% of the neonates. Low Apgar score and premature rupture of membranes was significantly associated with the risk of occurrence of meconium aspiration syndrome. Neonates who developed meconium aspiration syndrome had mortality of 11.3%.Conclusion: Perinatal asphyxia and premature rupture of membranes were significantly associated with the development of meconium aspiration syndrome and neonates who developed meconium aspiration syndrome had high mortality.J Nepal Paediatr Soc 2015;35(1):44-48

Intrauterine growth curves for singleton live babies in Paropakar Maternity and Women's Hospital in Nepal

BACKGROUND

To construct birth weight, crown heel length and head circumference centile chart referenced to gestational age for Nepalese infants.

METHODS

The study was conducted over a period of six months. It included consecutive live births from 28 to 42 weeks of gestation. Their birth weight, crown-heel length and head circumference were recorded. Smoothed percentile values along with curves were created using the Lambda Mu Sigma (LMS) method. The curves were compared with one of the Indian study.

RESULTS

A total of 9710 newborns were measured. The mean birth weight, crown-heel length, head circumference at 40 weeks were 3023g, 49.22cm and 33.61cm respectively. Smoothed percentile values calculated gave the cutoffs for defining small and large gestational age for Nepalese newborns. Comparison with Indian study showed significant difference (p<0.01) in weight. The Indian babies weighed less than Nepalese babies.

CONCLUSIONS

The referenced growth standards help in clinical assessment, defining and identifying high risk newborns, thus, leading to improved care and management of neonates. It should help public health policy makers to track population difference due to several factors, intervene and find response over time.

Developing community-based intervention strategies and package to save newborns in Nepal

In Nepal, the proportion of under 5 deaths that are neonatal (0-28 days) has been increasing in the last decade, due to faster declines in infant and child mortality than in neonatal mortality. This trend is likely due to a focus on maternal and child survival programs that did not adequately address newborn health needs. Policy and actions to save newborn lives resulted from increased attention to newborn deaths in 2001, culminating in the endorsement of the National Neonatal Health Strategy in 2004, a milestone that established newborn health and survival as a national priority. Operationalization of the National Neonatal Health Strategy took place in 2007 with the development of the Community-Based Newborn Care Package (CB-NCP). This paper describes how national stakeholders used global, regional and in-country research and policies to develop the CB-NCP, thus outlining key ingredients to make newborn health programming a reality in Nepal. A technical working group was constituted to review existing evidence on interventions to improve newborn survival, develop a tool to prioritize neonatal interventions, and conduct program learning visits to identify key components appropriate to the Nepal context that should be included in the Community Based Integrated Newborn Care Package. The group identified interventions based on the evidence of impact on newborn survival, potential mechanisms within the existing health system to deliver the interventions, and linkages with existing programs and different tiers of the health system. Not only was Nepal one of the first countries in south-east Asia where government adopted a national strategy to reduce neonatal deaths, but it was also one of the first to endorse a package of neonatal interventions for pilot testing and scaling up through existing community-based health systems that provide basic health services throughout the country. CB-NCP was designed to be gradually scaled up throughout the country by integration with Safe Motherhood and Child survival programs that are currently operating at scale. Under Ministry of health and Population leadership, a network of academia, professional bodies and partners developed a common vision for improving newborn health and survival, and launched district-level pilot programs to demonstrate and learn how newborn health interventions could be effectively and efficiently delivered and scaled up in Nepal.

Fitting Community Based Newborn Care Package into the health systems of Nepal

Community-based strategies for delivering effective newborn interventions are an essential step to avert newborn death, in settings where the health facilities are unable to effectively deliver the interventions and reach their population. Effective implementation of community-based interventions as a large scale program and within the existing health system depends on the appropriate design and planning, monitoring and support systems. This article provides an overview of implementation design of Community-Based Newborn Care Package (CB-NCP) program, its setup within the health system, and early results of the implementation from one of the pilot districts. The evaluation of CB-NCP in one of the pilot districts shows significant improvement in antenatal, intrapartum and post natal care. The implementation design of the CB-NCP has six different health system management functions: i) district planning and orientation, ii) training/human resource development, iii) monitoring and evaluation, iv) logistics and supply chain management, v) communication strategy, and vi) pay for performance. The CB-NCP program embraced the existing system of monitoring with some additional components for the pilot phase to test implementation feasibility, and aligns with existing safe motherhood and child health programs. Though CB-NCP interventions are proven independently in different local and global contexts, they are piloted in 10 districts as a "package" within the national health system settings of Nepal.

State of maternal, newborn and child health programmes in Nepal: what may a continuum of care model mean for more effective and efficient service delivery?

The cost-effective interventions exist across the continuum of maternal to child survival at each level of the health system that can contribute to achieve the Millennium Development Goals 4 and 5. However, implementation inefficiency, low coverage and equity gaps along this continuum remain a serious challenge to Nepal's efforts to achieve these goals. This paper proposes a continuum of care model; discusses the readiness of policy and programs to provide high impact interventions across the continuum; identifies existing gaps in MNCHN programs; and recommends policy and program actions to improve coverage, equity, effectiveness and efficiency along the continuum of MNCHN service delivery in Nepal. The literature review includes systematic desk review, followed by discussions and deliberations amongst a group of professionals and MNCH experts in Nepal. Within the government health system in Nepal, a continuum of care approach is feasible, as policies and plans exist to ensure an integrated approach across the maternal to child care continuum. However, health programs largely remain vertically oriented. Achieving integration across the maternal to child continuum of care remains a challenge at each level of health system. An integrated system of program management for maternal, newborn and child health would be a feasible solution to enable an efficient and effective delivery of intervention packages. A collaborative and partnership approach to strengthen health systems, building managerial capacity, improving governance and engaging the private and civil sectors remains vital to achieve effective coverage and improve equity across the continuum of care.

Short-Term Outcome of Mechanical Ventilation in Neonates

Mechanical ventilation of newborn has been practiced for several years with several advances made in the way. As compared to the Western world and our neighbouring countries, neonatal ventilation in our country is still in its infancy. Objectives: To analyze the common indications and outcome of neonates requiring mechanical ventilation. Methods: This was a prospective observational study conducted on neonates requiring mechanical ventilation within first 24 hours of birth over a period of nine months. Results: Birth asphyxia was the commonest indication for ventilation (59.67%) followed by asphyxia with meconium aspiration syndrome (MAS) (17.74%), hyaline membrane disease (HMD) (8.06%), MAS (6.45%) and intrauterine pneumonia (6.45%). Out of 62 babies, 22 (35.48%) survived. Babies with asphyxia had highest survival rate (51.35%). Neonates with HMD did not survive. Term babies and babies weighing ≥2500g had higher survival rate of 40.47% and 41.46% respectively, while babies less than 32 weeks had survival rate of 16.66% only. Conclusions: Mechanical ventilation reduces the neonatal mortality; hence, facilities for neonatal ventilation should be included in the regional and central hospitals providing level II neonatal care. Key words: neonatal ventilation; hyaline membrane disease; low birth weight DOI: 10.3126/jnps.v31i1.3463J Nep Paedtr Soc 2010;31(1):35-38

Fetal Hydantoin Syndrome: A Case Report

A term baby born to an epileptic mother who was treated with Phenytoin until 10weeks of pregnancy was born with multiple congenital anomalies and diagnosed to have Fetal Hydantoin Syndrome. Infants of mothers who have taken hydantoin during pregnancy have been found to have broad multisystem patterns of abnormalities, including mental retardation, craniofacial anomalies, nail and digital hypoplasia and prenatal onset of growth deficiency. The discussion aims to bring to attention the potential hazard of the use of hydantoin drug during reproductive age to all medical practitioners. Key words: Congenital anomalies, epilepsy, fetal hydantoin syndrome, phenytoin. DOI: 10.3126/jnps.v30i1.2463 Journal of Nepal Paediatric Society Vol.30(1) 2010 57-59

Kangaroo Mother Care for Low Birth Weight Babies: A prospective Observational Study

Introduction: Kangaroo Mother Care is the low cost, humane technique for caring low birth weight babies by direct skin to contact with the mother. Objective: The Prospective observational study was done to see the effect of KMC especially on weight gain on low birth weight babies weighing 2000 grams or less at Special Care Baby Unit of Paropakar Maternity and Women's hospital, Kathmandu. Method: The study was conducted in Special Care Baby Unit (SCBU) of Paropakar Maternity and Women's Hospital over 7 months period May 2007 to Nov. 2008 (from Baishakh 2064 to Kartik 2065). The method of care consisted of skin to skin contact between the mother and the infant. Result: It was observed that babies had good weight gain of average 30gms/day and had short duration of hospital stay of average 9 days. Babies had less morbidities like hypothermia, apnea, skin infections and oral thrush. 100% babies had exclusive breast feeding and KMC was acceptable to mothers. Conclusion: Kangaroo Mother Care shows early and good weight gain in low birth weight babies. It is simple, low cost technique and well acceptable by mother and family and can be continued at home. Key words: Kangaroo mother   doi:10.3126/jnps.v29i1.1593 J. Nepal Paediatr. Soc. Vol.29(1) p.6-9

Collodion Baby

DOI = 10.3126/jnps.v28i2.1391J. Nepal Paediatr. Soc. Vol.28(2) 2008 p.68

Thanatophoric Dysplasia

doi:10.3126/jnps.v29i1.1599J. Nepal Paediatr. Soc. Vol.29(1) p.33-34