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Answer the following medical question. | What does research say about The effects of kangaroo mother care on physiological parameters of premature neonates in neonatal intensive care unit: A systematic review.? | The effects of Kangaroo mother care (KMC) on physiological parameters in preterm infants have been reported in the literature by experimental and quasi-experimental studies, and varying findings have been presented. The present study was conducted to determine the effects of KMC on the physiological parameters of premature newborns in the Neonatal Intensive Care Unit. The review was conducted according to the specified keywords by scanning the EBSCO-host, Cochrane Library, Medline, PubMed, ScienceDirect, Web of Science, and TR index databases using the keywords "kangaroo care AND preterm AND vital signs." The pool mean differences (MDs) were calculated, adopting a 95% confidence interval (CIs) using the Stata 16 software for the meta-analysis [PROSPERO: CRD42021283475]. Eleven studies for systematic review and nine studies for meta-analysis, including 634 participants, were found eligible for inclusion. It was determined that the "temperature" (z = 3.21; p = 0.000) and "oxygen saturation" (z = 2.49; p = 0.000) values created a positive effect in general in the kangaroo care group; however, there was no sufficient evidence to state that it affected the "heart rate" (z = -0.60; p = 0.55) and "respiratory rate" (z = -1.45; p = 0.15) values. In the present study, the duration of KMC application had statistically different effects on temperature and oxygen saturation (SpO Our results provided references for clinical implications, and the "temperature" and "oxygen saturation (SpO The goal of the NICU nurse is to improve the infant's well-being. The application of KMC is a unique care for the nurse in maintaining the newborn's well-being. The vital signs of newborns hospitalized in the NICU with critical problems may be out of normal limits. KMC is an essential developmental care practice that ensures that the neonate's vital signs are kept within normal limits by relaxing the neonate, reducing stress, increasing comfort, and supporting interventions and treatments. KMC application is unique for each mother‑neonate pair. Depending on the tolerance of the mother and infant in terms of duration, it is recommended to perform KMC in the NICU under the supervision of a nurse. Neonatal nurses should support mothers in giving KMC in the NICU since KMC has ameliorative effects on the vital signs of premature neonates. |
Answer the following medical question. | What does research say about Nursing Care During Neonatal Electroencephalographs.? | Electroencephalography (EEG) enables the precise evaluation of a neonate's condition. Three factors that determine the quality of care during this procedure are knowledge, experience, and attitude. The role of the nurse during EEG recordings was evaluated in this study, and the requirements for successfully performing neonatal EEGs, along with practical suggestions, are presented. Evidence in the literature as well as clinical expertise forms the basis for this review. From our observations and practice during EEGs, we found that the following conditions must be met to successfully perform an EEG examination in a newborn: safety, a period of sleep and calm wakefulness of the neonate, good technical conditions, and no external interferences. Key conditions include the maintenance of safety rules and cooperation between nurses, EEG technicians, and parents. The EEG examinations in neonates weighing less than 1500 g or those requiring respiratory support should only be performed by a trained neonatal intensive care unit nurse. |
Answer the following medical question. | What does research say about Making neonatal intensive care: cost effective.? | With the improvement in neonatal care in last two decades, the survival of very low birth weight (VLBW), extremely low birth weight (ELBW), fetus diagnosed with malformations, and congenital heart disease and severe birth asphyxia has increased significantly. These infants when admitted to the neonatal intensive care unit (NICU) need numerous interventions depending upon the severity of sickness and postnatal course like need of mechanical ventilation (MV) or noninvasive ventilation, surfactant administration, placement of central lines, total parenteral nutrition, and numerous medications. The duration of NICU and hospital stay of these high-risk infants varies from few days to few weeks to few months. Long stay in the hospital leads to high hospital bills and increase the cost of neonatal care substantially. The cost of NICU stay varies from 90 USD to 1250-2500 USD per day as per various studies, depending upon the level of care and sickness of the admitted infants. In developed countries, the burden of NICU cost is often taken care by the government or insurance companies but in many developing countries the parents bear the substantial cost of NICU admission of their infants. There are many interventions which when implemented in the NICU will lead to reduction of the cost and will make the NICU cost effective. In this review, we cover various interventions mostly from our own published work which have shown to reduce the NICU cost and make it more cost effective with equivalent and better neonatal outcomes, especially in developing countries like ours. |
Answer the following medical question. | What does research say about Prolonged pain in premature neonates hospitalised in neonatal intensive care units: A scoping review.? | Exposure to repetitive pain during the neonatal period has been shown to have important short and long-term effects on the neurodevelopment of the premature neonate and can contribute to experienced prolonged pain. A uniform taxonomy of neonatal prolonged pain is still lacking to this day which contributes to suboptimal prolonged pain management in neonatal intensive care units. Accordingly, a scoping review exploring the state of knowledge about prolonged pain in preterm neonates hospitalised in the neonatal intensive care unit will contribute to the developing field of neonatal prolonged pain and provide recommendations for clinical prolonged pain management. To determine the scope, extent, and nature of the available literature on prolonged pain in premature neonates hospitalised in neonatal intensive care units. Scoping review. An electronic search was conducted from inception to November 2023 in the databases of CINAHL, PubMed, Medline, Web of Science, GeryLit.org and Grey Source Index. Included studies discussed concepts related to neonatal prolonged pain such as definitions of prolonged pain, indicators of prolonged pain, contexts that result in prolonged pain, prolonged pain evaluation tools, consequences of prolonged pain and interventions for prolonged pain management. Key concepts of neonatal prolonged pain were identified in the 86 included articles of this scoping review such as definitions (n = 26), indicators (n = 39), contexts (n = 49), scales (n = 56), consequences of prolonged pain (n = 30) and possible interventions for prolonged pain management (n = 22). Whilst a consensus on a definition has yet to be achieved, no proximate event was shown to cause prolonged pain and a time criterion was identified by authors as being relevant in defining prolonged pain. Interestingly, the context of hospitalisation was identified as being the most indicative of prolonged pain in premature neonates and should guide its evaluation and management, whilst only limited pain management interventions and consequences were discussed. The findings of this scoping review contribute to the foundation of growing knowledge in neonatal prolonged pain and shed light on the ambiguity that currently exists on this topic in the scientific literature. This review summarises knowledge of key concepts necessary for a better understanding of prolonged pain and stresses the importance of considering contexts of hospitalisation for prolonged pain evaluation and management in neonatal intensive care units, with the objective of improving developmental outcomes of premature neonates. A scoping review reveals that the contexts of prolonged pain in premature neonates hospitalised in the neonatal intensive care unit are essential in guiding its evaluation and management. |
Answer the following medical question. | What does research say about Neonatal Sepsis: A Review of Pathophysiology and Current Management Strategies.? | Early-onset sepsis, occurring within 72 hours of birth, and late-onset sepsis, occurring after this time period, present serious risks for neonates. While culture-based screening and intrapartum antibiotics have decreased the number of early-onset cases, sepsis remains a top cause of neonatal morbidity and mortality in the United States. To provide a review of neonatal sepsis by identifying its associated risk factors and most common causative pathogens, reviewing features of the term and preterm neonatal immune systems that increase vulnerability to infection, describing previous and the most current management recommendations, and discussing relevant implications for the neonatal nurse and novice neonatal nurse practitioner. An integrative review of literature was conducted using key words in CINAHL, Google Scholar, and PubMed. Group B streptococcus and Escherichia coli are the most common pathogens in early-onset sepsis, while Coagulase-negative staphylococci comprise the majority of cases in late-onset. The neonatal immune system is vulnerable due to characteristics including decreased cellular activity, underdeveloped complement systems, preferential anti-inflammatory responses, and insufficient pathogenic memory. Blood cultures remain the criterion standard of diagnosis, with several other adjunct tests under investigation for clinical use. The recent development of the sepsis calculator has been a useful tool in the management of early-onset cases. It is vital to understand the mechanisms behind the neonate's elevated risk for infection and to implement evidence-based management. Research needs exist for diagnostic methods that deliver timely and sensitive results. A tool similar to the sepsis calculator does not exist for preterm infants or late-onset sepsis, groups for which antibiotic stewardship is not as well practiced.Video Abstract available athttps://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=40. |
Answer the following medical question. | What does research say about Neonatal Pain: Perceptions and Current Practice.? | DISCLOSURE STATEMENT : The authors have nothing to disclose. Neonates may experience more than 300 painful procedures and surgeries throughout their hospitalization. Prior to 1980,
there was a longstanding misconception that neonates do not experience pain. Current studies demonstrate that not only do
neonate’s experience pain, but due to their immature nervous systems, they are hypersensitive to painful stimuli. Poorly
treated pain during the neonatal period may lead to negative long-term consequences. Proper assessment of a neonate’s pain
is vital. Standardized pain scales allow for consistency between providers and individualized treatment plans for neonates. The
use of non-pharmacological treatments such as, nonnutritive sucking, facilitated tucking, kangaroo care, swaddling and heel
warming may all be beneficial in alleviating a neonate’s pain. Pharmacological treatments in the neonate have been well
established and may include, but are not limited to opioids and non-opioid analgesics. Pharmacological and non-pharmacological
interventions can be used in conjunction with each other to increase the efficacy of analgesia. Neonatal Pain: Perceptions and Current Practice |
Answer the following medical question. | What does research say about Neonatal red blood cell transfusion.? | Transfusions are more common in premature infants with approximately 40% of low birth weight infants and up to 90% of extremely low birth weight infants requiring red blood cell transfusion. Although red blood cell transfusion can be life-saving in these preterm infants, it has been associated with higher rates of complications including necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity and possibly abnormal neurodevelopment. The main objective of this review is to assess current red blood cell transfusion practices in the neonatal intensive care unit, to summarize available neonatal transfusion guidelines published in different countries and to emphasize the wide variation in transfusion thresholds that exists for red blood cell transfusion. This review also addresses certain issues specific to red blood cell processing for the neonatal population including storage time, irradiation, cytomegalovirus (CMV) prevention strategies and patient blood management. Future research avenues are proposed to better define optimal transfusion practice in neonatal intensive care units. |
Answer the following medical question. | What does research say about Evidence-based skin care in preterm infants.? | Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term infants. Few address the complex task of skin barrier maintenance in preterm, very preterm, and extremely preterm infants. Here, we provide an evidence-based review of the literature on skin care of preterm neonates. Interestingly, the stratum corneum does not fully develop until late in the third trimester, and as such, the barrier function of preterm skin is significantly compromised. Numerous interventions are available to augment the weak skin barrier of neonates. Plastic wraps reduce the incidence of hypothermia while semipermeable and transparent adhesive dressings improve skin quality and decrease the incidence of electrolyte abnormalities. Tub bathing causes less body temperature variability than sponge bathing and can be performed as infrequently as once every four days without increasing bacterial colonization of the skin. Topical emollients, particularly sunflower seed oil, appear to reduce the incidence of skin infections in premature neonates-but only in developing countries. In developed countries, studies indicate that topical petrolatum ointment increases the risk of candidemia and coagulase-negative Staphylococcus infection in the preterm population, perhaps by creating a milieu similar to occlusive dressings. For preterm infants with catheters, povidone-iodine and chlorhexidine are comparably effective at preventing catheter colonization. Further studies are necessary to examine the safety and efficacy of various skin care interventions in premature infants with an emphasis placed on subclassifying the patient population. In the interim, it may be beneficial to develop guidelines based on the current body of evidence. |
Answer the following medical question. | What does research say about Families as partners in neonatal neuro-critical care programs.? | Parents of neonates with neurologic conditions face a specific breadth of emotional, logistical, and social challenges, including difficulties coping with prognostic uncertainty, the need to make complex medical decisions, and navigating new hopes and fears. These challenges place parents in a vulnerable position and at risk of developing mental health issues, which can interfere with bonding and caring for their neonate, as well as compromise their neonate's long-term neurodevelopment. To optimize neurologic and developmental outcomes, emerging neonatal neuro-critical care (NNCC) programs must concurrently attend to the unique needs of the developing newborn brain and of his/her parents. This can only be accomplished by embracing a family-centered care environment-one which prioritizes effective parent-clinician communication, longitudinal parent support, and parents as equitable partners in clinical care. NNCC programs offer a multifaceted approach to critical care for neonates at-risk for neurodevelopmental impairments, integrating expertise in neonatology and neurology. This review highlights evidence-based strategies to guide NNCC programs in developing a family-partnered approach to care, including primary staffing models; staff communication, implicit bias, and cultural competency trainings; comprehensive and tailored caregiver training; single-family rooms; flexible visitation policies; colocalized neonatal and maternal care; uniform mental health screenings; follow-up care referrals; and connections to peer support. IMPACT: Parents of neonates with neurologic conditions are at high-risk for experiencing mental health issues, which can adversely impact the parent-neonate relationship and long-term neurodevelopmental outcomes of their neonates. While guidelines to promote families as partners in the neonatal intensive care unit (NICU) have been developed, no protocols integrate the unique needs of parents in neonatal neurologic populations. A holistic approach that makes families true partners in the care of their neonate with a neurologic condition in the NICU has the potential to improve mental and physical well-being for both parents and neonates. |
Answer the following medical question. | What does research say about Proposing a care practice bundle for neonatal encephalopathy during therapeutic hypothermia.? | Neonates with neonatal encephalopathy (NE) often present with multi-organ dysfunction that requires multidisciplinary specialized management. Care of the neonate with NE is thus complex with interaction between the brain and various organ systems. Illness severity during the first days of birth, and not only during the initial hypoxia-ischemia event, is a significant predictor of adverse outcomes in neonates with NE treated with therapeutic hypothermia (TH). We thus propose a care practice bundle dedicated to support the injured neonatal brain that is based on the current best evidence for each organ system. The impact of using such bundle on outcomes in NE remains to be demonstrated. |
Answer the following medical question. | What does research say about Neonatal hypertension.? | Neonatal hypertension (HT) is a frequently under reported condition and is seen uncommonly in the intensive care unit. Neonatal HT has defined arbitrarily as blood pressure more than 2 standard deviations above the base as per the age or defined as systolic BP more than 95% for infants of similar size, gestational age and postnatal age. It has been diagnosed long back but still is the least studied field in neonatology. There is still lack of universally accepted normotensive data for neonates as per gestational age, weight and post-natal age. Neonatal HT is an important morbidity that needs timely detection and appropriate management, as it can lead to devastating short-term effect on various organs and also poor long-term adverse outcomes. There is no consensus yet about the treatment guidelines and majority of treatment protocols are based on the expert opinion. Neonate with HT should be evaluated in detail starting from antenatal, perinatal, post-natal history, and drug intake by neonate and mother. This review article covers multiple aspects of neonatal hypertension like definition, normotensive data, various etiologies and methods of BP measurement, clinical features, diagnosis and management. |
Answer the following medical question. | What does research say about Antibiotic stewardship in perinatal and neonatal care.? | The spread of antibiotic resistance due to the use and misuse of antibiotics around the world is now a major health crisis. Neonates are exposed to antibiotics both before and after birth, often empirically because of risk factors for infection, or for non-specific signs which may or may not indicate sepsis. There is increasing evidence that, apart from antibiotic resistance, the use of antibiotics in pregnancy and in the neonatal period alters the microbiome in the fetus and neonate with an increased risk of immediate and long-term adverse effects. Antibiotic stewardship is a co-ordinated program that promotes the appropriate use of antibiotics, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms. This review addresses some of the controversies in antibiotic use in the perinatal period, examines opportunities for reduction of unnecessary antibiotic exposure in neonates, and provides a framework for antibiotic stewardship in neonatal care. |
Answer the following medical question. | What does research say about Emotional Responses of Neonatal Intensive Care Nurses to Neonatal Death.? | The study was planned as a descriptive qualitative study to determine the emotional responses of neonatal intensive care nurses to work in the neonatal unit and to neonatal deaths. The sample of the study consisted of 7 nurses who work at the neonatal intensive care unit since data saturation was achieved. The data were collected using the "Semi-Structured In-Depth Interview Guide for Nurses". The data were analyzed using the content analysis method. Following codes were reached as a result of the study: 'happiness-sadness', 'professional satisfaction-exhaustion', 'empathy', 'responsibility-guilt', 'hope-despair' under the theme of being a nurse at neonatal unit'; 'unforgettable first loss', 'professionalism in intervention-and then: sadness, 'mature-premature difference', 'difficulty in giving hurtful news-inability to associate with death' and 'attachment-burnout' under the theme of experiencing neonatal loss.It was seen that nurses' emotions about working at neonatal intensive care unit were generally positive; however, these emotions changed to negative after neonate's relapsing and death. |
Answer the following medical question. | What does research say about How is bioelectrical impedance used in neonatal intensive care? A scoping review.? | Poor growth and nutrition management in the neonatal period can have a negative impact upon both the short- and long-term outcomes for the infant. Improvements in bioelectrical impedance technology and accompanying licencing agreements now make this enhanced device available for use in infants as small as 23 weeks gestational age. An exploration of this technology and its use is now timely. The aim of the scoping review was to answer the following question: in preterm and sick term infants in the neonatal intensive care unit, how is bioelectrical impedance being utilized, in what situations, and when? The scoping review was conducted using Arksey and O'Malley's (Int J Soc Res Methodol 8(1):19-32, 2005) framework. Forty-nine papers were initially identified and 16 were included in the scoping review. Three studies were experimental designs, and 13 were observational studies. The review found that BIA was used in neonatal intensive care in three main ways, for, (1) fluid status evaluation, (2) as a measure of adequate nutrition and growth, (3) to validate the technology as an outcome measure in neonates. There is a paucity of recent robust research papers which investigate the use of bioelectrical impedance in preterm neonates. Available evidence spans a range of 30 years, with technological advancement reducing the application of older studies to the modern neonatal setting. Although this technology may be helpful for decision-making around fluid management and nutrition, in preterm infants, robust evidence is needed to demonstrate the clinical benefit of bioelectrical impedance beyond that of usual care. • Clinical decisions regarding neonatal nutrition and fluid management are currently based upon the interpretation of vital signs, fluid balance, weight trend, biochemical markers, and physical examination. • Bioelectrical Impedance Analysis (BIA) is a non-invasive method of assessing body composition which is now available to be used in infants as small as 23 weeks gestation. • Bioelectrical Impedance has been used in three main ways in the NICU, for fluid status evaluation, for measuring nutrition and growth and to validate BIA as an outcome. • There is a lack of recent robust research data to support the use of the device within clinical decision making in neonatal intensive care. |
Answer the following medical question. | What does research say about Overcoming the barriers to using kangaroo care in neonatal settings.? | Skin-to-skin contact, or kangaroo care (KC), has benefits for babies and parents, improving clinical outcomes, temperature control, breastfeeding rates and child-parent bonding; it reduces morbidity and mortality. Barriers to KC for neonates may include a lack of training for nurses, lack of time, maternal or child physical or mental ill health, and inappropriate settings. With education and helpful management, neonatal nurses can advocate for KC for all babies. Parents may need information and encouragement to begin with. Therefore, nurses can improve the experiences of their patients and, in the long run, free time to perform clinical procedures. |
Answer the following medical question. | What does research say about Assessment of Pain in the Newborn: An Update.? | Preterm and term neonate pain assessment in neonatal intensive care units is vitally important because of the prevalence of procedural and postoperative pain. Of the 40 plus tools available, a few should be chosen for different populations and contexts (2 have been validated in premature infants). Preterm neonates do not display pain behaviors and physiologic indicators as reliably and specifically as full-term infants, and are vulnerable to long-term sequelae of painful experiences. Brain-oriented approaches may become available in the future; meanwhile, neonatal pain assessment tools must be taught, implemented, and their use optimized for consistent, reproducible, safe, and effective treatment. |
Answer the following medical question. | What does research say about Training in neonatal neurocritical care: A case-based interdisciplinary approach.? | Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans. |
Answer the following medical question. | What does research say about Caring for Dying Infants: A Systematic Review of Healthcare Providers' Perspectives of Neonatal Palliative Care.? | The palliative and hospice care movement has expanded significantly in the United States since the 1960s. Neonatal end of life care, in particular, is a developing area of practice requiring healthcare providers to support terminally ill newborns and their families, to minimize suffering at the end of the neonate's life. This paper seeks to systematically summarize healthcare providers' perspectives related to end of life, in order to identify needs and inform future directions. Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically reviewed the literature discussing healthcare provider perspectives of neonatal end of life care ranging from year 2009 to 2020. To be included in the review, articles had to explicitly focus on perspectives of healthcare providers toward neonatal end of life care, be published in academic peer-reviewed sources, and focus on care in the United States. Thirty-three articles were identified meeting all inclusion criteria. The literature covers, broadly, provider personal attitudes, experiences delivering care, practice approaches and barriers, and education and training needs. The experiences of physicians, physician assistants, nurse practitioners, and nurses are highlighted, while less is discussed of other providers involved with this work (e.g., social work, physical therapy). Future research should focus on developing and testing interventions aimed at training and supporting healthcare providers working with neonates at end of life, as well as addressing barriers to the development and implementation of neonatal palliative teams and guidelines across institutions. |
Answer the following medical question. | What does research say about Prevention Strategies for Neonatal Skin Injury in the NICU.? | The purpose of this article was to determine specific skin injury prevention interventions for neonates in the NICU. The design was a systematic review. PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, and Scopus were systematically searched to identify quantitative studies identifying skin injury preventions for neonates in the NICU. The outcomes included skin integrity or skin condition. Nineteen studies were included in the review. Twelve studies included a randomized design. Barriers were the main interventions for the prevention of pressure injury, medical adhesive skin injury, diaper dermatitis, and general skin condition. The types of barriers included hydrocolloids, polyurethane-based dressings, film-forming skin protectant, or emollients. Nonbarrier interventions included rotation between a mask and nasal continuous positive airway pressure (NCPAP) interfaces, utilization of prescribed guidelines to decrease pressure injuries, and use of a lower concentration of chlorhexidine gluconate as a disinfectant. |
Answer the following medical question. | What does research say about Thrombosis in the Neonatal Intensive Care Unit.? | Neonates have the highest risk for pathologic thrombosis among pediatric patients. A combination of genetic and acquired risk factors significantly contributes to this risk, with the most important risk factor being the use of central venous catheters. Proper imaging is critical for confirming the diagnosis. Despite a significant number of these events being life- and limb-threatening, there is limited evidence on what the appropriate management strategy should be. Evaluation and treatment of any neonate with a clinically significant thrombosis should occur at a tertiary referral center that has proper support. |
Answer the following medical question. | What does research say about The difficult neonatal airway.? | Airway management is one of the most crucial aspects of neonatal care. The occurrence of a difficult airway is more common in neonates than in any other age group, and any neonatal intubation can develop into a difficult airway scenario. Understanding the intricacies of the difficult neonatal airway is paramount for healthcare professionals involved in the care of newborns. This chapter explores the multifaceted aspects of the difficult neonatal airway. We begin with a review of the definition and incidence of difficult airway in the neonate. Then, we explore factors contributing to a difficult neonatal airway. We next examine diagnostic considerations specific to the difficult neonatal airway, including prenatal imaging. Finally, we review management strategies. The importance of a multidisciplinary team approach and the role of communication and collaboration in achieving optimal outcomes are emphasized. |
Answer the following medical question. | What does research say about Preterm infant mental health in the neonatal intensive care unit: A review of research on NICU parent-infant interactions and maternal sensitivity.? | Caregiving relationships in the postnatal period are critical to an infant's development. Preterm infants and their parents face unique challenges in this regard, with infants experiencing separation from parents, uncomfortable procedures, and increased biologic vulnerability, and parents facing difficulties assuming caregiver roles and increased risk for psychological distress. To better understand the NICU parent-infant relationship, we conducted a review of the literature and identified 52 studies comparing observed maternal, infant, and dyadic interaction behavior in preterm dyads with full-term dyads. Eighteen of 40 studies on maternal behavior found less favorable behavior, including decreased sensitivity and more intrusiveness in mothers of preterm infants, seven studies found the opposite, four studies found mixed results, and 11 studies found no differences. Seventeen of 25 studies on infant behavior found less responsiveness in preterm infants, two studies found the opposite, and the remainder found no difference. Eighteen out of 14 studies on dyad-specific behavior reported less synchrony in preterm dyads and the remainder found no differences. We identify confounding factors that may explain variations in results, present an approach to interpret existing data by framing differences in maternal behavior as potentially adaptive in the context of prematurity, and suggest future areas for exploration. Las relaciones de prestación de cuidados en el período postnatal son críticas para el desarrollo del infante. Los infantes nacidos prematuramente y sus progenitores enfrentan retos únicos a este respecto, con los infantes que experimentan la separación de sus progenitores, procedimientos incómodos, así como un aumento en la vulnerabilidad biológica; y los progenitores enfrentando dificultades al asumir el papel de cuidadores y el aumento de riesgo de angustia sicológica. Para comprender mejor la relación progenitor-infante en la Unidad Neonatal de Cuidados Intensivos (NICU), llevamos a cabo una revisión de la literatura e identificamos 52 estudios que comparan la observada conducta de interacción materna, del infante y de la díada en díadas de infantes prematuros con díadas de infantes de gestación completa. Dieciocho de 40 estudios sobre la conducta materna encontraron una menos favorable conducta, incluyendo una baja en la sensibilidad y más intrusión en el caso de madres de infantes prematuros; 7 estudios encontraron que se daba la situación opuesta; 4 estudios presentaron resultados mixtos; y 11 estudios no encontraron diferencias. Diecisiete de 25 estudios sobre el comportamiento del infante encontraron una menor capacidad de respuesta en infantes prematuros; dos estudios encontraron que se daba la situación opuesta; y el resto de los estudios no encontró ninguna diferencia. Ocho de 14 estudios sobre el comportamiento específico de la díada reportaron menos sincronía en las díadas con infantes prematuros y el resto de los estudios no encontró ninguna diferencia. Identificamos factores confusos que pudieran explicar las variaciones en los resultados, presentamos un acercamiento para interpretar la información existente por medio de enmarcar las diferencias en la conducta materna como potencialmente adaptable en el contexto del nacimiento prematuro, y sugerimos futuras áreas para ser exploradas. Les relations de soin dans la période postnatale sont critiques pour le développement du nourrisson. Les bébés nés avant terme et leurs parents font face à des défis uniques à cet égard, avec les bébés faisant l'expérience de la séparation des parents, des procédures désagréables et difficiles, et une vulnérabilité biologique accrue, et les parents faisant face aux difficultés assumant des rôles de soignants et étant à risque plus élevé de détresse psychologique. Afin de comprendre la relation parent-nourrisson USIN nous avons passé en revue toutes les recherches et identifié 52 études comparant le comportement d'interaction dyadique, maternel et du nourrisson chez des dyades prématurées avec des dyades à plein terme. 18 des 40 études sur le comportement maternel ont trouvé un comportement moins que favorable, y compris une sensibilité décrue et plus d'intrusion chez les mères de nourrissons prématurés, 7 études ont trouvé le contraire, 4 études ont trouvé des résultats mélangés, et 11 études n'ont trouvé aucune différence. 17 études sur 25 sur le comportement du nourrisson ont trouvé une réaction moindre chez les nourrissons prématurés deux études ont trouvé le contraire, et le reste n'a trouvé aucune différence. 8 études sur 14 sur le comportement spécifique à la dyade ont fait état de moins de synchronie chez les dyades avant terme et les autres études n'ont trouvé aucune différence. Nous identifions des facteurs confondants qui pourraient expliquer des variations dans les résultats et nous présentons une approche pour interpréter les données existantes en cadrant des différences dans le comportement maternel comme étant potentiellement adaptatives dans le contexte de la prématurité et nous suggérons des domaines futurs d'exploration. Betreuungsbeziehungen in der postnatalen Phase sind für die Entwicklung eines Säuglings entscheidend. Frühgeborene und ihre Eltern sind in dieser Hinsicht mit besonderen Herausforderungen konfrontiert: Die Säuglinge erleben die Trennung von ihren Eltern, unangenehme Prozeduren und eine erhöhte biologische Anfälligkeit. Die Eltern hingegen haben Schwierigkeiten, die Rolle der Betreuenden einzunehmen, und ein erhöhtes Risiko für psychische Probleme. Um die Eltern-Säuglings-Beziehung auf der Neugeborenen-Intensivstation besser zu verstehen, haben wir Literatur ausgewertet und 52 Studien identifiziert, in denen das beobachtete Mutter-Kind-Interaktionsverhalten bei Frühgeborenen-Dyaden mit dem von Reifgeborenen-Dyaden verglichen wurde. 18 von 40 Studien zum mütterlichen Verhalten ergaben ein ungünstigeres Verhalten der Mütter der Frühgeborenen, einschließlich geringerer Sensibilität und größerer Aufdringlichkeit, 7 Studien ergaben das Gegenteil, 4 Studien zeigten gemischte Ergebnisse und 11 Studien stellten keine Unterschiede fest. 17 von 25 Studien über das Säuglingsverhalten stellten eine geringere Reaktionsfähigkeit bei Frühgeborenen fest, zwei Studien fanden das Gegenteil und in den übrigen wurde kein Unterschied festgestellt. 8 von 14 Studien zum dyadenspezifischen Verhalten berichteten eine geringere Synchronität bei Frühgeborenen-Dyaden, während die übrigen keine Unterschiede feststellten. Wir identifizieren Störfaktoren, die Unterschiede in den Ergebnissen erklären könnten, und stellen einen Ansatz zur Interpretation vorhandener Daten vor, indem wir Unterschiede im mütterlichen Verhalten als potenziell adaptiv im Kontext der Frühgeburtlichkeit betrachten. Außerdem schlagen wir künftige Forschungsbereiche vor. 产后期的护理关系对婴儿的发育至关重要。早产婴儿及其父母在这方面面临着独特的挑战, 婴儿会经历与父母分离、不舒服的治疗过程和生物学脆弱性的增加, 而父母则面临着难以承担看护者角色的困难以及心理困扰的风险增加。为了更好地理解NICU中的母婴关系, 我们进行了文献综述, 并确定了52项研究, 比较了早产婴儿和足月婴儿中观察到的母亲、婴儿和双人互动行为。在40项关于母亲行为的研究中, 有18项发现了不太有利的行为, 包括早产婴儿的母亲表现出较低的敏感性和更多的侵入性, 有7项研究发现相反的结果, 有4项研究发现混合结果, 有11项研究未发现差异。在25项关于婴儿行为的研究中, 有17项发现早产婴儿的反应能力较低, 有2项研究发现相反的结果, 其余研究未发现差异。在14项关于双人特定行为的研究中, 有8项报告称早产母婴组的同步性较低, 其余研究没有发现差异。我们确定了可能解释结果差异的混杂因素, 并提出了一种方法, 通过将母亲行为的差异界定为在早产背景下的潜在适应性来解释现有数据, 我们还提出了未来的研究方向。. تعد علاقات تقديم الرعاية في فترة ما بعد الولادة ذات أهمية محورية لنمو الرضيع. يواجه الخدج وأولياء أمورهم تحديات فريدة في هذا الصدد، حيث يعاني الرضع من الانفصال عن والديهم، وإجراءات غير مريحة، وزيادة الضعف البيولوجي، ويواجه الآباء صعوبات في تولي أدوار مقدمي الرعاية وزيادة خطر الإصابة بالضيق النفسي. لفهم العلاقة بين الوالدين والرضيع بشكل أفضل، أجرينا مراجعة للأدبيات وحددنا 52 دراسة تقارن سلوك التفاعل بين الأمهات والرضيع وسلوكيات تفاعل ثنائيات الخدج مع ثنائيات كاملة المدة. وجدت 18 من 40 دراسة حول سلوك الأمهات سلوكًا أقل إيجابية، بما في ذلك انخفاض الحساسية والمزيد من التدخل لدى أمهات الخدج، بينما وجدت 7 دراسات عكس ذلك، وتوصلت 4 دراسات إلى نتائج مختلطة، ولم تجد 11 دراسة أي فروق. وجدت 17 من 25 دراسة حول سلوك الرضع استجابة أقل عند الخدج، ووجدت دراستان عكس ذلك، ولم تتوصل بقية الدراسات إلى أي فروق. وتوصلت 8 من أصل 14 دراسة حول السلوك الثنائي المحدد إلى وجود تزامن أقل في الثنائيات الخدج ولم تجد بقية الدراسات أي اختلافات. حددت الدراسة العوامل المتضاربة التي قد تفسر الاختلافات في النتائج، ونقدم منهجاً لتفسير البيانات الموجودة من خلال تأطير الاختلافات في سلوك الأم على أنها قابلة للتكيف في سياق الخداج، ونقترح مجالات مستقبلية للاستكشاف. |
Answer the following medical question. | What does research say about Pitfalls and Limitations of Platelet Counts and Coagulation Tests in the Neonatal Intensive Care Unit.? | The assessment of hemostasis and the prediction of bleeding risk are of great importance to neonatologists. Premature infants are at an increased risk for bleeding, particularly intra-cranial hemorrhages (most commonly intra-ventricular hemorrhages (IVH)), gastrointestinal hemorrhages, and pulmonary hemorrhages. All severe bleeding, but especially severe IVH, is associated with poor neurodevelopmental outcomes, and other than prenatal steroids, no intervention has reduced the incidence of this serious complication. As a result, there is a need in neonatology to more accurately identify at-risk infants as well as effective interventions to prevent severe bleeding. Unfortunately, the commonly available tests to evaluate the hemostatic system were established using adult physiologic principles and did not consider the neonate's different but developmentally appropriate hemostatic system. This review will describe the changes in the platelet count and tests of hemostasis throughout development, the limitations of these tests to predict neonatal bleeding and the utility of treating abnormal results from these tests with platelet and/or fresh frozen plasma (FFP) transfusions in non-bleeding infants. |
Answer the following medical question. | What does research say about Neonatal Gastric Perforation: 14-Year Experience from a Tertiary Neonatal Intensive Care Unit.? | Neonatal gastric perforations (NGPs) are rare and account for 7 to 12% of all gastrointestinal perforations in the neonatal period. The etiology and prognostic factors associated with NGP remain unclear. The aim of this study is to review the cases of NGP in our neonatal intensive care unit (NICU) in the past 14 years and describe the risk factors, clinical presentation, and outcomes associated with it. A retrospective chart review of neonates with gastric perforation admitted to the NICU between June 2006 and December 2020 was performed. Data regarding their antenatal and neonatal characteristics, laboratory and radiological results, intra-operative findings, hospital course, and outcomes were recorded. We identified 350 patients with gastrointestinal perforation at our center during the study period of which 14 (4%; nine males and five females) patients were diagnosed with NGP during surgery. A total of 71% neonates were born preterm (range: 24-39 weeks, median: 34 weeks). Two neonates (14%) were SGA. Only one neonate received cardiopulmonary resuscitation at birth. In all neonates, except two, perforation occurred within the first 10 days of life (median: 4 days, range: 1-22 days). In total, 79% infants received feeds prior to perforation. Ten neonates had a feeding tube, and one neonate had a gastrostomy tube placed prior to perforation. Abdominal distension and pneumoperitoneum were present in all neonates. Majority of the babies had metabolic acidosis (64%) and elevated C-reactive protein (79%). Most (86%) neonates received surgical intervention within 12 hours. Overall survival in our study was 93%. NGP is a rare entity seen mostly in preterm infants within the first 10 days of life. Clinical presentation is similar to perforation anywhere along the gastrointestinal tract and definite diagnosis requires exploratory laparotomy. With prompt recognition and surgical intervention, the overall mortality related to neonatal gastric perforation is low. · Neonatal gastric perforation is a rare but life threatening entity with unclear etiology.. · Prematurity is associated with an increased incidence of gastric perforations in the neonate.. · Laparotomy is required for definitive diagnosis and treatment.. |
Answer the following medical question. | What does research say about Music therapy for preterm neonates in the neonatal intensive care unit: An overview of systematic reviews.? | To summarise the quantity and quality of evidence for using music therapy for preterm infants in the neonatal intensive care unit (NICU). We performed an overview of evidence for the effectiveness and safety of MT for preterm infants in the NICU. We performed a random-effects meta-analysis of data from studies that fit the definition of MT. We identified 12 eligible systematic reviews and the methodological quality by AMSTAR-2 ranged from moderate to critically low. We identified 14 eligible randomised trials and 7 observational studies where the intervention fits the definition of MT. Meta-analysis of the RCTs showed that MT significantly decreases heart rate, mean difference (MD) (95% CI), -3.21 [-5.22, -1.19], respiratory rate, MD -2.93 [-5.65, -0.22], and maternal anxiety, MD -17.50 [-20.10, -14.90], and increases feeding volume, MD 29.59 [12.79, 46.38]. Long-term neurodevelopmental or safety outcomes were not reported. GRADE assessment of outcomes ranged from low to very low, downgraded for high risk of bias in the included studies, inconsistency and imprecision. Low to very low certainty evidence suggests that MT in preterm infants improves short-term physiological parameters, feeding and maternal anxiety but safety and long-term outcomes were not reported. |
Answer the following medical question. | What does research say about Has Quality Improvement Really Improved Outcomes for Babies in the Neonatal Intensive Care Unit?? | During the past decade, the emergence of outcome measurement and quality improvement in the neonatal intensive care unit, far more than the introduction of new research approaches or novel therapies, has had a profound effect on improving outcomes for premature neonates. Collection of outcome data, review of those data, and strategies to identify and resolve problems using continuous quality improvement methods can dramatically improve patient outcomes. It is likely that further initiatives in quality improvement will continue to have additional beneficial effects for the neonate. |
Answer the following medical question. | What does research say about Neonatal anesthesia.? | The physiology of the preterm and term neonate is characterized by a high metabolic rate, limited pulmonary, cardiac and thermoregulatory reserve, and decreased renal function. Multisystem immaturity creates important developmental differences in drug handling and response when compared to the older child or adult. Neonatal anesthetic management requires an understanding of the pharmacophysiologic limitations of the neonate as well as the pathophysiology of coexisting surgical disease. This review addresses the pertinent aspects of neonatal physiology and pharmacology, general considerations in the anesthetic care of surgical neonates, and concludes with a brief review of the anesthetic management of neonates with necrotizing enterocolitis, diaphragmatic hernia, and tracheoesophageal fistula. |
Answer the following medical question. | What does research say about Traditional neonatal care practices in Jordan: A qualitative study.? | Traditional practices during the first months of neonatal life are common in developing countries, such as Jordan. Many international studies and reports have highlighted the fact that traditional neonatal practices are the cause of high neonatal mortality and morbidity rates in some countries. The aim of the present study was to identify neonatal care practices in Jordan. A descriptive, qualitative research design was used across four Jordanian cities across diverse regions. Forty mothers of neonates were interviewed over a period of 6 months (from January to June 2016). Thematic and content analysis was undertaken following Braun and Clarke's six step analysis. The results indicated that in Jordan, home-based neonatal care comprises non-biomedical practices. Rubbing the neonate's skin with salt, swaddling, prelacteal feeding, and other treatment modalities are common. Further studies are necessary to determine and report on the pros and cons of these practices in regard to neonatal health. |
Answer the following medical question. | What does research say about Fresh Frozen Plasma Administration in the Neonatal Intensive Care Unit: Evidence-Based Guidelines.? | Neonates receiving fresh frozen plasma (FFP) should do so according to evidence-based guidelines so as to reduce inappropriate use of this life-saving and costly blood product and to minimize associated adverse effects. The consensus-based uses of FFP in neonatology involve neonates with active bleeding and associated coagulopathy. However, because of limited and poor-quality evidence, considerable FFP utilization occurs outside these recommendations. In this review, we describe what we conclude are currently the best practices for the use of FFP in neonates, including interpreting neonatal coagulation tests and strategies for reducing unnecessary FFP transfusions. |
Answer the following medical question. | What does research say about Neonatal hypertension: an educational review.? | Hypertension is encountered in up to 3% of neonates and occurs more frequently in neonates requiring hospitalization in the neonatal intensive care unit (NICU) than in neonates in newborn nurseries or outpatient clinics. Former NICU neonates are at higher risk of hypertension secondary to invasive procedures and disease-related comorbidities. Accurate measurement of blood pressure (BP) remains challenging, but new standardized methods result in less measurement error. Multiple factors contribute to the rapidly changing BP of a neonate: gestational age, postmenstrual age (PMA), birth weight, and maternal factors are the most significant contributors. Given the natural evolution of BP as neonates mature, a percentile cutoff of 95% for PMA has been the most common definition used; however, this is not based on outcome data. Common causes of neonatal hypertension are congenital and acquired renal disease, history of umbilical arterial catheter placement, and bronchopulmonary dysplasia. The treatment of neonatal hypertension has mostly been off-label, but as evidence accumulates, the safety of medical management has increased. The prognosis of neonatal hypertension remains largely unknown and thankfully most often resolves unless secondary to renovascular disease, but further research is needed. This review discusses important factors related to neonatal hypertension including BP measurement, determinants of BP, and management of neonatal hypertension. |
Answer the following medical question. | What does research say about The hypertensive neonate.? | Hypertension in neonates is increasingly recognized because of improvements in neonatal intensive care that have led to improved survival of premature infants. Although normative data on neonatal blood pressure remain limited, several factors appear to be important in determining blood pressure levels in neonates, especially gestational age, birth weight and maternal factors. Incidence is around 1% in most studies and identification depends on careful blood pressure measurement. Common causes of neonatal hypertension include umbilical catheter associated thrombosis, renal parenchymal disease, and chronic lung disease, and can usually be identified with careful diagnostic evaluation. Given limited data on long-term outcomes and use of antihypertensive medications in these infants, clinical expertise may need to be relied upon to decide the best approach to treatment. This review will discuss these concepts and identify evidence gaps that should be addressed. |
Answer the following medical question. | What does research say about Infant-Guided, Co-Regulated Feeding in the Neonatal Intensive Care Unit. Part II: Interventions to Promote Neuroprotection and Safety.? | Feeding skills of preterm neonates in a neonatal intensive care unit are in an emergent phase of development and require careful support to minimize stress. The underpinnings that influence and enhance both neuroprotection and safety were discussed in Part I. An infant-guided, co-regulated approach to feeding can protect the vulnerable neonate's neurologic development, support the parent-infant relationship, and prevent feeding problems that may endure. Contingent interventions are used to maintain subsystem stability and enhance self-regulation, development, and coping skills. This co-regulation between caregiver and neonate forms the foundation for a positive infant-guided feeding experience. Caregivers select evidence-based interventions contingent to the newborn's communication. When these interventions are then titrated from moment to moment, neuroprotection and safety are fostered. |
Answer the following medical question. | What does research say about The educational needs of neonatal nurses regarding neonatal palliative care.? | Studies have shown that education can improve the knowledge, attitudes, and beliefs of neonatal nurses regarding neonatal palliative care. However, no study has investigated the need for neonatal nurse education in neonatal palliative care in Taiwan. The purpose of this study was to explore neonatal nurses' experiences in caring for dying neonates and their educational backgrounds regarding palliative care, as well as to assess their educational needs. A cross-sectional survey was used for this research. A research structural questionnaire was used to investigate the research goals. One hundred fifteen nurses participated in this survey. Few participants indicated having received neonatal palliative care education (13%), but most responded that palliative care is necessary in neonatal nursing education (97.4%). Participants also responded that they were often or always exposed to death in NICU (62.6%), but few reported providing pain management to dying neonates (8.7%) and few had experience providing symptomatic care for dying neonates (19.1%). Fifty percent ranked "pain control" as the area in which they most required training. Another high-ranked need was in discussing with parents and families the outcomes of CPR and their neonate's progress. Research indicates that the education currently provided to neonatal nurses does not meet their distinctive needs. Neonatal nurses in Taiwan expressed an urgent desire for training in pain control and communication. Research suggests that the most important topics to trainees are pain management and end-of-life communication. Additionally, non-pharmacological pain control interventions are valuable and should be included in an educational program. |
Answer the following medical question. | What does research say about Effects of Kangaroo Care on Neonatal Pain in South Korea.? | Blood sampling for a newborn screening test is necessary for all neonates in South Korea. During the heel stick, an appropriate intervention should be implemented to reduce neonatal pain. This study was conducted to identify the effectiveness of kangaroo care (KC), skin contact with the mother, on pain relief during the neonatal heel stick. Twenty-six neonates undergoing KC and 30 control neonates at a university hospital participated in this study. Physiological responses of neonates, including heart rate, oxygen saturation, duration of crying and Premature Infant Pain Profile (PIPP) scores were measured and compared before, during and 1 min and 2 min after heel sticks. The heart rate of KC neonates was lower at both 1 and 2 min after sampling than those of the control group. Also, PIPP scores of KC neonates were significantly lower both during and after sampling. The duration of crying for KC neonates was around 10% of the duration of the control group. In conclusion, KC might be an effective intervention in a full-term nursery for neonatal pain management. |
Answer the following medical question. | What does research say about Neonatal mortality risk assessment using SNAPPE- II score in a neonatal intensive care unit.? | There are many scoring systems to predict neonatal mortality and morbidity in neonatal intensive care units (NICU). One of the scoring systems is SNAPPE-II (Score for Neonatal Acute Physiology with Perinatal extension-II). This study was carried out to assess the validity of SNAPPE-II score (Score for Neonatal Acute Physiology with Perinatal Extension-II) as a predictor of neonatal mortality and duration of stay in a neonatal intensive care unit (NICU). This prospective, observational study was carried out over a period of 12 months from June 2015 to May 2016. Two hundred fifty five neonates, who met the inclusion criteria admitted to NICU in tertiary care hospital, BPKIHS Hospital, Nepal were enrolled in the study and SNAPPE-II score was calculated. Receiver Operating Characteristic (ROC) curve was constructed to derive the best SNAPPE-II cut-off score for mortality. A total of 305 neonates were admitted to NICU over a period of one year. Among them, 255 neonates fulfilled the inclusion criteria. Out of 255 neonates, 45 neonates (17.6%) died and 210 were discharged. SNAPPE-II score was significantly higher among neonates who died compared to those who survived [median (IQR) 57 (42–64) vs. 22 (14–32), P < 0.001]. SNAPPE II score had discrimination to predict mortality with area under ROC Curve (AUC): 0.917 (95% CI, 0.854–0.980). The best cut - off score for predicting mortality was 38 with sensitivity 84.4%, specificity 91%, positive predictive value 66.7% and negative predictive value 96.5%. SNAPPE II score could not predict the duration of NICU stay ( P = 0.477). SNAPPE- II is a useful tool to predict neonatal mortality in NICU. The score of 38 may be associated with higher mortality. Survival of the newborns admitted to the NICUs does not depend only on birth weight and gestational age, but also on other perinatal factors and physiological parameters, particularly those related with severity of their diseases [ 1 – 6 ]. Scoring systems have been developed and used to assess the severity of the illness and to predict the mortality, morbidity and prognosis of neonates in neonatal intensive care units (NICU). Birth weight, gestational age and APGAR score were the only parameters assessed previously to predict mortality and morbidity. However, the association between mortality prediction and these three factors were not much accurate [ 6 – 8 ]. In 1993, Richardson et al. [ 5 ] had formulated the physiology-based score; score for Neonatal Acute Physiology (SNAP), which contains 34 parameters for neonates of all birth-weights and validated it as a predictor of mortality and morbidity [ 3 – 5 ]. They made this score easier by reducing the number of parameters to six. To this score, three more perinatal variables namely birth weight, APGAR scores and small for gestational age (SGA) status were added and renamed it as SNAP II with Perinatal Extension (SNAPPE-II) score [ 7 ]. Data validating SNAPPE II score from Nepal are lacking. As the clinical profile of neonates and their outcomes may be different in our scenario, we aimed to assess the validity of this score to predict mortality and duration of NICU stay in a resource poor NICU set-up of Nepal. This may help in prioritizing the treatment of sick newborns as well as counselling of their parents about disease severity. This prospective, observational study was carried out during the period from June 2015 to May 2016 at NICU in a tertiary care hospital of eastern Nepal. All newborns admitted to NICU were included in the study. Newborns who died or were discharged in < 24 h after admission, those with congenital malformations incompatible with life, those neonates who did not require ABG (Arterial blood gas analysis) or catheterization, home deliveries with unknown APGAR score and those discharged against medical advice were excluded from our study. Informed consent from parents was taken before conducting this study then participants were enrolled consecutively. This study was approved by the ethical committee of the hospital. The SNAPPE-II score was calculated on the basis of recommended physiological and clinical factors [ 7 ], evaluated prospectively within the first 12 h of admission after stabilization. Noninvasive mean blood pressure in (mmHg) was measured with the use of appropriate cuff size in left or right arm via vital sign monitor (Nihon Kohden Corporation, japan). Temperature was measured in axilla using commercially available mercury thermometer (35 to 42 °C) keeping thermometer for 3 min in axilla. Serum pH and PaO2/FiO2 was calculated by arterial blood gas analysis (ABG) using blood gas and electrolytes analyzer ABL 800 basic (Radiometer, Denmark) available in our NICU. All types of neonatal seizure were included in this score. Birth-weight of inborn neonates was measured by electronic weighing machine (Hardik Meditech, Delhi, India) (±5 g error) without clothing. Birth-weight of outborn neonates was recorded from their details mentioned on referral slips. Urine output (ml/kg/hr) was measured using Pediatric urine collecting bag or by catheterization. Modified Ballard score was used to assess the gestational age. Lubchenco’s [ 9 ] intrauterine growth chart was used for classification as small for gestational age as birth-weight < 10th percentile for gestational age. Neonates were treated as per hospital protocols and they were discharged from NICU as per standard NICU protocol. Data were entered in MS excel and coded where necessary. SPSS version 20.0 was used for data analysis. Comparison between survivors and non-survivors was performed using Mann-Whitney test. Chi-square test was used for qualitative variables. The power of SNAPPE II score to predict the neonatal mortality was evaluated by means of Receiver Operating Characteristics (ROC) curve. Optimal cut-off score to predict mortality was determined by visual inspection of the curve at a level that combined maximum sensitivity and optimal specificity. Positive predictive values and negative predictive values were calculated for different cut-off scores. P values less than 0.05 was considered as statistically significant. A total of 305 neonates were admitted to NICU over a period of one year (June 2015 to May 2016). Among them, 35 neonates were excluded who did not meet the inclusion criteria. Two hundred seventy neonates were enrolled in the study of which 15 neonates left against medical advice (LAMA). Among 255 neonates completing the study, 92 (36.1%) were preterm and 163 (63.9%) were term neonates. Mean (SD) birth-weight was 2422.9 (858.2) g and mean (SD) gestational age was 36.8 (0.2) weeks. Out of 255 neonates, 45 (17.6%) died and 210 were discharged. Neonates with SNAPPE II score 40 to 60, mortality rate was 36.7%, score of ≥40 had mortality rate of 55.1% and score of ≥60 had 100% mortality. General characteristics of neonates admitted to NICU have been shown in Table 1 . The median (IQR) SNAPPE II score was significantly higher in the babies who died in comparison to those who survived [57 (42–64) vs. 22(14–32), P < 0.001]. Average duration of NICU stay was 4 days. There was no significant correlation between SNAPPE II score and duration of NICU stay ( P = 0.477). Table 1 General characteristics of the neonates admitted in NICU Characteristics n = 255 Gender, n (%) Male 175 (69%) Female 80 (31%) Mean Gestational age, mean (SD) week 36.8 (0.2) Gestational age, n (%) Term 163 (63.9%) Preterm 92 (36.1%) Mean Birth weight, mean (SD) gram 2422.9 (858.2) Birth weight n (%) < 1000 g 8 (3.1%) 1000 g to 2500 g 102 (40%) > 2500 g 145 (56.9%) Outcome, n (%) Discharged 210 (82.4%) Expired 45 (17.6%) SNAPPE II score, mortality (%) ≥ 40 55.1% 40–60 36.7% ≥ 60 100% SNAPPE II score ≥ 38 Sensitivity 84.4% Specificity 91% Positive predictive value 66.7% Negative predictive value 96.5% General characteristics of the neonates admitted in NICU Area under curve (AUC) in ROC curve was 0.917 [95% CI 0.854–0.980] as shown in Fig. 1 , which validates the utility of SNAPPE II score to predict neonatal mortality in NICU. The best cut-off SNAPPE II score in predicting overall mortality was 38. Sensitivity, specificity, positive and negative predictive value of score ≥ 38 in estimating overall mortality were 84.4, 91, 66.7 and 96.5% respectively. Fig. 1 Receiver operating characteristics curve (ROC) for SNAPPE-II score for prediction of mortality Receiver operating characteristics curve (ROC) for SNAPPE-II score for prediction of mortality The present study documented that the SNAPPE II score of the neonates who died in the NICU was higher than in those who survived. The higher the score of SNAPPE- II, the higher was the mortality risk of neonates. SNAPPE II score of ≥38 was the best to predict mortality with sensitivity 84.4%, specificity 91%, positive predictive value (PPV) 66.7% and negative predictive value (NPV) of 96.5%. There was no significant correlation between SNAPPE II score and duration of NICU stay. This result supports the study done by original author Richardson et al. (AUC 0.91) [ 10 ], Zupanic et al. (AUC 0.90) [ 11 ] and Mia et al. [ 12 ] in Soetomo Hospital, Indonesia in which AUC was 0.863. In studies conducted in a tertiary care hospital, Indonesia [ 12 ] (score of ≥40), in a general pediatric hospital in Paraguay [ 13 ] (score of ≥40), Niranjan et al. in India [ 14 ] (score of ≥37) & in Indira Gandhi Institute of Child Health, India [ 15 ] (score of ≥37) were all associated with higher mortality which is similar to our results. But in contrast to our results, studies conducted in a hospital of indonesia [ 16 ] (with a score of ≥51), by Ucar et al. [ 17 ], (score of ≥33), Dammann et al. [ 18 ], (a score of ≥30) were associated with high mortality. In two studies done in India by Niranjan et al. [ 14 ] and (Harsha & Archana) [ 15 ] with cut-off score of ≥37 in both studies, Sensitivity (84.4% vs. 76.1% & 76.9%), specificity (91% vs. 87.1% & 87.9%) and NPV (96.5% vs. 52.6%) were higher in our study than these two studies. But positive predictive value in our study was less (66.7 vs. 95. 3%). Variation in the cut-off score and discrimination might be due to the factors affecting the score such as diseases, severity of illness, quality of care in NICU etc. There was no significant correlation between SNAPPE II score and duration of NICU stay ( P = 0.477). But SNAPPE II score had positive correlation with duration of NICU stay as correlation coefficient was r = 0.045 which is similar to a study done by Harsha & Archana [ 15 ] in India where P = 0.255 for duration of NICU stay. Other studies also reported similar findings [ 19 , 20 ]. All newborns who were born at home and those neonates who left NICU against medical advice were excluded from the study. Birth-weight and Apgar score of outborn neonates were taken from referral card. These were the limitations of this study. Thus, SNAPPE II score is a useful tool to asess the severity of illness and prognosis. These findings can be implicated in NICU routinely to know the most critical newborn for prioritizing the management and for the purpose of counselling the parents. This score might also be used to compare the effectiveness of various NICU across the country which will help to improve the facilities provided by different NICUs. SNAPPE II score can be used to predict the severity of diseases and associated mortality and may help in prioritizing the treatment of sick newborns as well as counselling of their parents about disease severity. We conclude that SNAPPE II scoring system may be a useful tool to predict neonatal mortality in resource poor NICU setting. Arterial blood gas analysis Area under ROC Curve Neonatal intensive care unit Receiver Operating Characteristic Score for Neonatal Acute Physiology Score for Neonatal Acute Physiology with Perinatal Extension II Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Mr. Dharanidhar Baral, statistician, BP Koirala institute of Health sciences (BPKIHS). DM: conception and design, acquisition of data, analysis and interpretation of data and drafting of the manuscript. RRS and NKB involved in conception and design of the study and critical analysis of data. DS: interpretation of data and critically reviewed the manuscript for intellectual content. All authors read and approved the final manuscript. None. Available upon reasonable request to corresponding author. Approved by institutional ethical review committee (IRC) B.P. Koirala Institute of Health Sciences, Dharan, Nepal and written consent for participation was taken before conducting the study. Ref. no. 447/071/072- IRC. Not applicable The authors declare that they have no competing interests. Neonatal mortality risk assessment using SNAPPE- II score in a neonatal intensive care unit The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units Outcome prediction in Greek neonatal intensive care units using a score for neonatal acute physiology (SNAP) The clinical risk index of babies (CRIB) score in India An assessment of the severity, proportionality and risk of mortality of very low birth weight infants with fetal growth restriction. 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SNAPPE-II (score for neonatal acute physiology with perinatal extension) as a predictor of mortality in NICU SNAPPE-II (score for neonatal acute physiology with perinatal extension-II) in predicting mortality and morbidity in NICU Score for Neonatal Acute Physiology Perinatal Extension II (SNAPPE II) as the predictor of neonatal mortality hospitalized in neonatal intensive care unit The efficacy of SNAPPE.II-II in predicting morbidity and mortality in extremely low birth weight infants SNAP-II and SNAPPE-II as predictors of death among infants born before the 28th week of gestation. Inter-institutional variations Profile of neonates admitted in paediatric ICU and validation of score for neonatal acute physiology (SNAP) Role of score for neonatal acute physiology (SNAP) in predicting neonatal mortality |
Answer the following medical question. | What does research say about Neonatal hypothermia and associated factors among neonates admitted to neonatal intensive care unit of public hospitals in Addis Ababa, Ethiopia.? | Neonatal hypothermia is a worldwide problem and an important contributing factor for Neonatal morbidity and mortality especially in developing countries. High prevalence of hypothermia has been reported from countries with the highest burden of Neonatal mortality. So the aim of this study was to assess the prevalence of Neonatal hypothermia and associated factors among newborn admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa. An institutional based cross-sectional study was conducted from March 30 to April 30, 2016, in Public Hospitals in Addis Ababa and based on admission rate a total of 356 Neonates with their mother paired were enrolled for the study. Axillary temperate of the newborn was measured by a digital thermometer at the point of admission. Multivariate binary logistic regression, with 95% confidence interval and a p -value < 0.05 was used to identify variables which had a significant association. The prevalence of Neonatal hypothermia in the study area was 64% . Preterm delivery (AOR = 4.81, 95% CI: 2.67, 8.64), age of Neonate ≤24 h old (AOR = 2.26, 95% CI: 1.27, 4.03), no skin to skin contact with their mother immediately after delivery (AOR = 4.39, 95% CI: 2.38, 8.11), delayed initiation of breastfeeding (AOR = 3.72, 95% CI: 2.07, 6.65) and resuscitation at birth (AOR = 3.65, 95%CI: 1.52, 8.78) were significantly associated with hypothermia. The prevalence of Neonatal hypothermia in the study area was high. Preterm delivery, age ≤ 24 h old, no skin to skin contact immediately after delivery, delayed initiation of breastfeeding and resuscitation at birth were independent predictors of Neonatal hypothermia. Therefore attention is needed for thermal care of preterm newborn and use of low-cost thermal protection principles of warm chain especially on early initiation of breastfeeding, skin to skin contact immediately after delivery and warm resuscitation. The online version of this article (10.1186/s12887-018-1238-0) contains supplementary material, which is available to authorized users. World Health Organization (WHO) defined Neonatal hypothermia as an axillary temperature less than 36.5 °c. Reduction of thermal stability has a long-term physiologic effect that leads to, death due to hypoxia, and hypotension [ 1 ]. Globally an estimated of four million newborns die within the first four weeks of life, which accounts 2/3rd of all deaths in the first year of life and 40% of under five deaths. Most Neonatal deaths (99%) arise in low and middle-income countries [ 2 , 3 ]. In Ethiopia also there is high Neonatal mortality, 37 deaths per 1000 live birth [ 4 ]. Hypothermia is one of the important causes for Neonatal death and morbidity in developing countries, which increases mortality by five times, and recent studies showed that every 1 °c decrement of body temperature increases mortality by 80% [ 2 , 5 , 6 ]. The prevalence is high among countries with the highest burden of Neonatal mortality [ 7 ]. It is a problem of both home delivered (32 - 85%) and institutional delivery (11 to 90%) [ 8 ]. A study in Bangladesh reported 34% of Neonates had hypothermia out of NICU admission [ 9 ]. Reports in developing country show that greater than 90% of Neonates were hypothermic (temperature less than 36.5 °C) and 10.7% of the newborn were at less than 35.0 °C [ 10 , 11 ]. In West African sub-region, a prevalence rate of 62% at the point of admission was reported [ 12 ]. In Ethiopia also there was a prevalence of hypothermia ranging from 53 to 69.8% [ 8 , 13 ]. Prematurity is one of the risk factors for Neonatal hypothermia and it is the leading cause of Neonatal mortality which accounts 37% of Neonatal death in Ethiopia [ 4 ]. And the prevalence of preterm birth ranges from 10 - 25.9% [ 14 , 15 ]. Both physical characteristics and environmental factors predispose the preterm infant to hypothermia [ 16 ]. In Ethiopia lack of adequate perinatal care is one of the factors for onset of hypothermia, there is a high prevalence of home delivery which accounts 73% and Institutional deliveries accounts only 26% [ 17 ]. Low socio-economic status, poor kangaroo mother care practice, low birth weight, bathing of a newborn within 24 h, delayed initiation of breastfeeding, a traditional practice of oil massage of Neonates and inadequate knowledge of thermal care among health workers are determinant factors for hypothermia [ 2 , 18 , 19 ]. Although hypothermia is rarely a direct cause of death, it contributes to Neonatal mortality as a comorbidity of severe Neonatal infections, preterm birth, and asphyxia [ 8 ]. Mortality rate was significantly higher among hypothermic babies (RR = 2.26, CI = 1.14–4.48). Even though predisposing factors for hypothermia are easily preventable the problem of hypothermia remains an unanswered question and it is highly prevalent in developing nations including sub-Sahara Africa [ 2 ]. Ethiopia applies thermal care principle which is one of the components of essential newborn care (ENBC) recommended by WHO. Despite this intervention, the problem of hypothermia remains a challenge in Ethiopia [ 1 , 20 ]. And the achievement of sustainable development goal (SDG) 3 of ensuring healthy lives and promote well-being for all at all age requires a remarkable reduction of Neonatal death. Even though reduction of Neonatal hypothermia contributes to the achievement of SDG 3, it sustains as a challenge [ 21 ]. Providing ENBC including thermal care or prevention of Neonatal hypothermia is one part of nursing care, but the problem of Neonatal hypothermia remains a worldwide problem, especially in sub-Saharan Africa. Therefore, the purpose of this study was to determine the prevalence of Neonatal hypothermia and associated factors among Neonates admitted to NICU of Public Hospitals in Addis Ababa. So, this study will provide baseline data on the prevalence of Neonatal hypothermia and identification of possible factors for the onset of Neonatal hypothermia in the area will have greater input to program managers and policy makers for designing, proper implementation and evaluation programs on reduction of Neonatal mortality and improvement of newborn care to achieve SDG 3. In addition, the study will help to improve quality of newborn care in the nursing profession, specifically thermal protection, by low - tech preventive measures and early detection and referral of hypothermia. An institutional based cross -sectional study design was conducted from March 30 to April 30, 2016, to determine the prevalence of Neonatal hypothermia and associated factors among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa. The study was conducted in six Public Hospitals in Addis Ababa, Ethiopia, that have their own NICU; namely; Tikur Anbessa Specialized Teaching Hospital that has its own Neonatal Intensive Care Unit (NICU) with an average NICU admission of 240 Neonates per month, St. Paul’s Hospital Millennium Medical College with an average NICU admission of 210 Neonates per month, Yekatit 12 Hospital Medical College with an average NICU admission of 170 Neonates per month, Gandhi Memorial Specialized Hospital with an average NICU admission of 192 Neonates per month, Zewditu Memorial Hospital with an average NICU admission of 110 Neonates per month and Tirunesh Beijing General Hospital with an average NICU admission of 60 Neonates per month. The study was conducted in all Public Hospitals in Addis Ababa that has their own NICU, because the level of perinatal care given, standards of NICU, and accessibility of thermal prevention materials are somewhat different in each Hospital. The source populations were all Neonates who were admitted to NICU of public Hospitals in Addis Ababa. Randomly Selected Neonates admitted to NICU of public Hospitals in Addis Ababa from March 30 to April 30, 2016, were the study population. All Neonates with their mother admitted to NICU of Public Hospitals in Addis Ababa during the study period were included in the study. Sample size was calculated by using single population proportion formula: \documentclass[12pt]{minimal}
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\begin{document}$$ \mathrm{n}=\frac{\kern0.50em \left(\mathrm{z}a/2\right){2}^{\ast }\ \mathrm{pq}}{d2} $$\end{document} n = z a / 2 2 ∗ pq d 2 By considering 10% none response rate of participants, the final sample size was 356 . Where n = the required sample size. \documentclass[12pt]{minimal}
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\begin{document}$$ {\displaystyle \begin{array}{l}d=m\arg in\ of\ error\ between\ the\ sample\ and\ population=5\%=0.05\\ {}Z=s\tan dard\ normal\ distribution\ value\ at\ 95\% confidence\ level\\ {}Z\ \alpha /2=1.96\ for\ 95\% confidence \operatorname {int} erval\\ {}p=\Pr evalence\ of\ Neonatal\ hypothermia\ \left(69.8\%\right)\end{array}} $$\end{document} d = m arg in of error between the sample and population = 5 % = 0.05 Z = s tan dard normal distribution value at 95 % confidence level Z α / 2 = 1.96 for 95 % confidence int erval p = Pr evalence of Neonatal hypothermia 69.8 % from the previous study conducted in Gondar University Teaching and Referral Hospital, Northwest Ethiopia [ 13 ]. There were a total of six Public Hospitals in Addis Ababa that have their own organized NICU and they have a total average number of 982 admissions to NICU per month and a total sample size of 356 Neonates were selected from the six Hospitals. Then participants was selected by using systematic random sampling technique, that is every three admission until the required sample size was obtained (K = 2.75, approximately every 3 admissions was taken). The number of Neonates surveyed from each Hospital was allocated proportionally to the total average number of admission per month from all Hospitals. The instrument for data collection was semi-structured pre-tested questionnaire which was adopted and modified from a study conducted in Ethiopia, Gondar University Hospital, Nigeria and Uganda [ 12 , 13 , 19 ]. The questionnaire contains items to assess the temperature of the newborn during admission to NICU and associated factors for the onset of hypothermia (Additional file 1 ). Axillary temperate of the newborn was measured for three minute by using digital thermometer (model of MT-101 MT-111) which can measure from 32.0 ° C to 42.9 °C (89.6 °F to 109.9 °F) that had measurement accuracy of ±0.1 °C for the temperature range of (35.5 °C – 42.0 ° C) and ± 0.2 °C for the temperature range of (32.0 ° C - 35.5 ° C or above 42.0 °C) at point of admission. The thermometer was disinfected by using 70% ethyl alcohol disinfectant with a damp cloth after every measure of axillary temperature of the newborn to prevent infection transmission. And other data such as; medical diagnosis, and CPR history was collected from the chart of the newborn and socio-demographic data and obstetric history was collected from their mother by using semi-structured pre-tested questionnaire. Infrared thermometer (model of Kintrex IRT0421) with a measurement range of (− 60 °C to 50 °C) and measurement accuracy of ±2 ° C was used to measure the room temperature of the NICU. And data collection was done carefully by six BSc nurses. Neonatal hypothermia Neonatal hypothermia Socio-demographic characteristics of the mother Maternal age, parity, residence, ethnicity, educational status, occupation and income. Neonatal, obstetric and environmental factors of the neonate: Socio-demographic characteristics of the mother Maternal age, parity, residence, ethnicity, educational status, occupation and income. Neonatal, obstetric and environmental factors of the neonate: Age of newborn in hour, sex of newborn, low birth weight, mode of delivery, pregnancy type (single / multiple), prematurity, skin to skin contact with mother immediately after delivery, bathing before age of 24 h, CPR, delayed initiation of breastfeeding, room temperature of NICU, place of delivery, application of oil massage, obstetric complication during pregnancy and Medical diagnosis during admission. Hypothermia : an axillary temperature of less than 36.5 °c Cold stress(mild hypothermia) : an axillary temperature of 36.0 to 36.4 °C Moderate hypothermia : an axillary temperature of 32.0 to 35.9 °C Severe hypothermia: an axillary temperature of < 32.0 °C Normothermic: an axillary temperature of 36.5 to 37.5 °C Hyperthermia: an axillary temperature of > 37.5 °C Admission temperature : The first temperature obtained from neonates at admission to NICU Inborn : a new born that was delivered from the study Hospital Out born: a new born that was deliver other than the study Hospital Hypothermia : an axillary temperature of less than 36.5 °c Cold stress(mild hypothermia) : an axillary temperature of 36.0 to 36.4 °C Moderate hypothermia : an axillary temperature of 32.0 to 35.9 °C Severe hypothermia: an axillary temperature of < 32.0 °C Normothermic: an axillary temperature of 36.5 to 37.5 °C Hyperthermia: an axillary temperature of > 37.5 °C Admission temperature : The first temperature obtained from neonates at admission to NICU Inborn : a new born that was delivered from the study Hospital Out born: a new born that was deliver other than the study Hospital The questionnaire was prepared in English and translated to Amharic, and back-translated into English by two language experts to check for consistency of the questionnaire. The data was collected by six BSc. nurse experts. Thermometer calibration was done for the reliability of the thermometer before using the instrument for data collection. Three day training and clear orientation were provided on the process of data collection for data collectors. A pretest was done by 5% of the study population in another Hospital three weeks before the actual data collection to evaluate the clarity of questions and validity of the instrument and reaction of respondents to the questions. Data collectors were closely monitored and guided by two MSc. nurse supervisors during data collection. The data was cleaned manually, coded and entered into Epi info version 3.5 and exported to SPSS version 20 software for further analysis. After coding, and entering the data to the software descriptive statistics were used to calculate the result in proportion, frequencies, cross tabulation, and measure of central tendency. Tables and graphs were used to present the result. A bivariate binary logistic regression was used to identify candidate variables for the final model (multivariate binary logistic regressions) at p - value < 0.20. Finally the independent predictors or variables which had significant association were identified by using multivariate binary logistic regressions. The cut point to declare the presence of an association between the dependent and independent variable was p – value < 0.05 or AOR, 95% CI. A total of 356 mothers with their neonates were included in the study with 100% response rate. The mean age of mothers was 28 years (SD = 5.6) and more than half of the mothers were in the age group between 20 and 29 (51.1%) years of age. One hundred twenty seven (35.7%) were Oromo in ethnicity and majority of the mothers 206 (57.9%) were Orthodox followers. Two hundred seventy six (77.5%) were urban residents. Eighty respondents (22.2%) were unable to read and write and 144 (40.4%) of respondents were housewife. The mean monthly income of the family was 54 US dollar (SD = 11US dollar) and 117 (32.9%) had a monthly income of below average. And 191 respondents (53.7%) were primiparous (Table 1 ). Table 1 Socio-demographic characteristics of mothers of neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Variables Categories Frequency Percentage (%) Age of mother (years) 15–19 17 4.8 20–29 182 51.1 30–39 145 40.7 40–49 12 3.4 Ethnicity Amhara 121 34.0 Tigre 55 15.4 Oromo 127 35.7 Gurage 37 10.4 Other 16 4.5 Religion Orthodox 206 57.9 Protestant 59 16.6 Muslim 88 24.7 Other 3 0.8 Residence Urban 276 77.5 Rural 80 22.5 Educational status Unable to read and write 80 22.5 Primary school 77 21.6 Secondary school 102 28.7 Diploma and above 97 27.2 Occupation House wife 144 40.4 Government employ 79 22.2 Private business 92 25.8 Student 27 7.6 Farmer 14 3.9 Monthly income of the family Below average 117 32.9 Average (43–65 US dollar) 129 36.2 Above average 110 30.9 Parity Primiparous 191 53.7 Multiparous 165 46.3 Socio-demographic characteristics of mothers of neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Majority of Neonates were males 204 (57.3%) and the median age of the newborn was 3 h. And most of the neonates 233 (65.4%) were in the age group of ≤24 h. The mean birth weight was 2440 g (SD 721 g). More than half 183 (51.4%) of the Neonates had birth weight ≥ 2500 g. The mean gestational age (GA) was 36 weeks ±2.8 weeks, most of them, 202 (56.7%) were with GA < 37 weeks. Only 126 (35.4%) of Neonates had early initiation of breastfeeding within one hour after birth. Eighty four (23.6%) had received resuscitation (CPR) during birth (Table 2 ). Table 2 Neonatal characteristics of respondents among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Variables Categories Frequency Percentage (%) Age of Newborn (hour) ≤24 233 65.4 24–72 60 16.9 > 72 63 17.7 Sex of new born Male 204 57.3 Female 152 42.7 Birth weight(grams) < 1000 10 2.8 1000–1499 32 9.0 1500–2499 131 36.8 2500–4000 179 50.3 > 4000 4 1.1 Gestational age (weeks) < 28 weeks 2 0.6 28- < 32 weeks 25 7.0 32- < 37 weeks 175 49.2 37-42 weeks 152 42.7 > 42 weeks 2 .6 Started breast feeding within one hour after birth Yes 126 35.4 No 230 64.6 Received CPR during birth Yes 84 23.6 No 272 76.4 Neonatal characteristics of respondents among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Most of the pregnancies 311 (87.4%) were single and the majority of Neonates 286 (80.3%) were born without any obstetric complication. More than half 213 (59.8%) were delivered through SVD. Sixty five (18.3%) of the newborn were bathed before 24 h old and more than half of Neonates 188 (52.8%) had no skin to skin contact immediately after birth. And 41 (11.5%) had Oil massage of the skin after birth. One hundred seventy (47.8%) were out born neonates and of them, nine (2.5%) delivered at home. More than half 190 (53.4%) deliver during day time. Majority of Neonates 329 (92.4%) were admitted to NICU at room Temperature ≥ 25 ° C (Table 3 ). Table 3 Obstetric and Environmental characteristics of respondents among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Variables Categories Frequency Percentage (%) Obstetric complication during pregnancy Yes 70 19.7 No 286 80.3 pregnancy type Single 311 87.4 Twine 41 11.5 Triple 4 1.1 Mode of delivery SVD 213 59.8 Instrumental 32 9.0 C/S 111 31.2 skin to skin contact immediately after delivery Yes 168 47.2 No 188 52.8 Place of delivery Inborn 186 52.2 Out born 170 47.8 setting for out born delivery Missing (Inborn) 186 52.2 Other Hospital 69 19.4 Health Centre 76 21.3 Private health facility 13 3.7 Traditional birth center 3 0.8 Homes 9 2.5 Oil massage of the skin immediately after birth Yes 41 11.5 No 315 88.5 Bathed the new born before 24 h old Yes 65 18.3 No 291 81.7 Time of delivery Day time 190 53.4 Night time 166 46.6 Room Temperature of NICU < 25 ° C 27 7.6 Obstetric and Environmental characteristics of respondents among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Medical diagnoses during admission were reviewed from medical record of the newborn and 116 (32.6%) were admitted for the reason of respiratory distress, 173 (48.6%) diagnosed as low birth weight and 202 (56.7%) were diagnosed as preterm, and 84 (23.6%) diagnoses as perinatal asphyxia (Table 4 ). Table 4 Medical diagnoses of neonates during admission among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Variable Categories Frequency Percentage (%) Diagnosis during Admission Respiratory distress 116 32.6 Preterm 202 56.7 Jaundice 55 15.4 Sepsis 83 23.3 LBW 173 48.6 Perinatal asphyxia 84 23.6 Congenital anomaly 35 9.8 Meconium aspiration syndrome 22 6.2 Small for gestational age 15 4.2 hypoglycemia 15 4.2 Other 16 4.5 The total cumulative frequency for diagnosis is greater than 100% because the Neonate may have more than one clinical diagnosis during admission. Medical diagnoses of neonates during admission among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] The prevalence of neonatal hypothermia among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa was 228 (64%). Among them, more than half 184 (80.7%) were moderate hypothermic and the remaining 44 (19.3%) were mild hypothermic babies (Fig. 1 ). Fig. 1 Classification of temperature among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Classification of temperature among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] And the prevalence of hypothermia was high among preterm 155 (76.7%), low birth weight 127 (73.4%), age ≤ 24 h 171 (73.4%), and among out born delivery 112 (65.9%) (Fig. 2 ). Fig. 2 Comparison of Hypothermia with gestational age among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Comparison of Hypothermia with gestational age among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] In bivariate logistic regression analysis the following factors were significantly associated with hypothermia; age of newborn ≤24 h old, low birth weight, preterm delivery, no skin to skin contact to their mother immediately after delivery, no early initiation of breastfeeding within one hour, resuscitation at birth (CPR), obstetric complication during pregnancy, multiple Pregnancy and night-time delivery. Then those variables which are significant on bivariate analysis were entered to multiple logistic regressions to see independent predictors. Accordingly, Neonates with the age of ≤24 h old were 2 times more likely to have hypothermia when compared to age greater than 24 h (AOR = 2.26, 95% CI: 1.27, 4.03). Preterm Neonates were 4.8 times more likely to have hypothermia when compared to term delivery (AOR = 4.81, 95% CI: 2.67, 8.64). And newborn who had no skin to skin contact to their mother immediately after delivery were 4.3 times more likely to be hypothermic when compared to those who have skin to skin contact (AOR = 4.39, 95% CI: 2.38, 8.11). Those Neonates who had no early initiation of breastfeeding within one hour after birth were 3.7 times more likely to develop hypothermia when compared to those who have started within one hour after birth (AOR = 3.72, 95% CI: 2.07, 6.65). And Neonates who had resuscitation at birth (CPR) were 3.6 times more likely to be hypothermic when compared to those who had no resuscitation (AOR = 3.65, 95% CI: 1.52, 8.78) (Table 5 ). Table 5 Bivariate and multivariate logistic regression analysis of associated factors among Neonates admitted to Neonatal Intensive Care Unit of Governmental Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] Variables Hypothermic (228) Non Hypothermic (128) COR (95% CI) AOR (95% CI) P - value N (%) N (%) Age of Neonate (hour) ≤ 24 171(73.4) 62(26.6) 3.19(2.02,5.05) 2.26(1.27, 4.03) .005* > 24 57(46.3) 66(53.7) 1.0 1.0 Birth weight (grams) < 2500 127(73.4) 46(26.6) 2.24(1.44,3.5) 1.33(0.75,2.36) 0.331 ≥ 2500 101(55.2) 82(44.8) 1.0 1.0 Gestational age (weeks) < 37 155(76.7) 47(23.3) 3.66(2.32,5.76) 4.81(2.67, 8.64) 0.001* ≥ 37 73(47.4) 81(52.6) 1.0 1.0 skin to skin contact Yes 71(42.3) 97(57.7) 1.0 1.0 0.001* No 157(83.5) 31(16.5) 6.92(4.23,11.32) 4.39(2.38, 8.11) Early initiation of breast feeding Yes 45(35.7) 81(64.3) 1.0 1.0 0.001* No 183(79.6) 47(20.4) 7.0(4.32,11.38) 3.72(2.07, 6.65) CPR received Yes 76(90.5) 8(9.5) 7.5(3.48, 16.15) 3.65(1.52, 8.78) 0.004* No 152(55.9) 120(44.1) 1.0 1.0 Obstetric complication during pregnancy Yes 62(88.6) 8(11.4) 5.6(2.59, 12.13) 1.43(0.57, 3.56) 0.440 No 166(58) 120(42) 1.0 1.0 Pregnancy type Single 190(61.1) 121(38.9) 1.0 1.0 0.145 Multiple 38(84.4) 7(15.6) 3.46(1.45,7.99) 2.14(0.77, 5.97) Time of delivery Day time 108(56.8) 82(43.2) 1.0 1.0 0.352 Night time 120(72.3) 46(27.7) 1.98(1.26, 3.09) 1.32(0.73, 2.37) * Significant at p -value ≤ 0.05 Bivariate and multivariate logistic regression analysis of associated factors among Neonates admitted to Neonatal Intensive Care Unit of Governmental Hospitals in Addis Ababa, Ethiopia, 2016 [ n = 356] * Significant at p -value ≤ 0.05 The prevalence of Neonatal hypothermia among newborn in this study was 64%. This was almost similar with a study conducted in Nigeria (62%) [ 12 ], in Bahir Dar, Ethiopia (67%) [ 22 ] and Gondar, Northwest Ethiopia (69.8%) [ 13 ]. And it was lower than a study conducted in Nepal (92.3%) [ 10 ], Zimbabwe (85%) [ 8 ] and Uganda (83%) [ 19 ]. But it was higher than a study conducted in South Africa (21%) [ 23 ], Bangladesh (34%) [ 9 ] and Pakistan (49.5%) [ 24 ]. This variation might be due to the difference in temperature measurement site, ecological, economic and cultural difference between the study areas. There was high prevalence of hypothermia among out born delivery (65.9%); this might be due to lack of proper thermal care practice during inter-facility transportation. Neonates are transported from ward to ward or to other Hospital without proper wrapping. This finding was higher than a study done in Bangladesh which was 43% for out born and 22% for inborn but lower than Nigeria which was 90.9% for out born and 61.1% for inborn [ 9 , 12 , 23 ]. This might be due to the difference in inter-Hospital transport thermal care services, distance traveled to the hospital and economical difference. This study revealed that Neonates with the age of 24 h old or less were 2 times more likely to have hypothermia than age greater than 24 h (AOR = 2.26, 95%CI: 1.27, 4.03). This could be due to the fact that newborns have no adequate adipose brown tissue and had no shivering thermogenesis so they are not capable for thermoregulation. This is similar to a study conducted in Bangladesh, (AOR = 2.23 95% CI: 1.22, 4.0) [ 9 ]. Preterm Neonates were 4.8 times more likely to have hypothermia when compared to term Neonates (AOR = 4.81, 95% CI: 2.67, 8.64). The possible reason might be preterm Neonates have immature and thin skin that increase heat loss through radiation, underdeveloped hypothalamic control, they lack efficient neural mechanisms for temperature control by shivering, have decreased glycogen stores, have decreased fat for insulation and have less brown adipose tissue, so they have decreased ability to regulate their body temperature, by producing heat through non - shivering thermogenesis [ 2 , 25 , 26 ]. This is almost similar to a study done in Pakistan in which preterm Neonates were 4 times more likely to develop hypothermia when compared to term newborn [ 24 ]. But it is higher than a study conducted in Iran in which preterm Neonates were 1.73 times more likely to be hypothermic than term one [ 27 ]. This variation might be due to the difference in the thermal care of preterm newborn, standard of delivery room and NICU. Neonates who had no skin to skin contact with their mother immediately after delivery were 4.3 times more likely to develop hypothermia when compared with those who have skin to skin contact immediately after delivery (AOR = 4.39, 95% CI: 2.38, 8.11). The possible reason could be in the utero body temperature of the fetus is consistent with maternal temperature; Neonates who had skin to skin contact immediately after delivery with their mother gain heat through conduction which is consistent with their temperature in the womb during exposure of the newborn to extra uterine environment [ 28 ]. This finding is almost similar with a study conducted in Gondar, North west Ethiopia in which those who had no skin to skin contact were 3 times more likely to develop hypothermia [ 13 ]. Putting newborn together with the mother or kangaroo mother care is an important means of prevention of hypothermia [ 29 ]. Those Neonates who had no early initiation of breastfeeding within one hour after birth were 3.7 times more likely to be hypothermic when compared to those who had started breastfeeding within one hour after birth (AOR = 3.72, 95% CI: 2.07, 6.65). This might be due to the reason that breast milk is the source of energy or calories to produce heat for thermoregulation and they have no adequate adipose tissue for glucose breakdown which results in hypothermia [ 25 ]. And it is consistent with a study done in Nigeria but lower than a study done in Gondar, North west Ethiopia in which those who were delayed in initiation of breast feeding were 7.5 times more likely to be hypothermic [ 13 , 18 ]. This difference in magnitude might be due to difference in study setup, knowledge of mothers on good positioning and attachment of breast feeding and difference in place of delivery. Neonates who had resuscitation at birth were 3.6 times more likely to be hypothermic when compared to those who had no resuscitation (AOR = 3.65, 95% CI: 1.52, 8.78). This is due to the fact that Neonates who need resuscitation are those who had birth asphyxia; there is no enough oxygen which is needed for mitochondrial oxidation in the brown adipose tissue, for heat production. And during resuscitation at birth temperature control may not be properly taken care of; during emergency condition resuscitation may be done without wrapping the baby and in cold table. This finding is higher than study done in Bangladesh in which Neonates that had resuscitation were 2 times more likely to be hypothermic(AOR = 2.15, 95% CI:1.4–3.32) [ 9 ] and a study done in Iran in which those who had resuscitation at birth were almost 2 times more likely to be hypothermic (AOR =1.91, p value = 0.001) [ 27 ]. This variation may be due to the difference in thermal care practice during resuscitation, warm resuscitation or not and difference in time of resuscitation. In bivariate analysis, low birth weight was statistically significant with the onset of hypothermia but in multiple logistic regression analysis it was not significant but there was a high prevalence of hypothermia among low birth weight neonates 127 (73.4%) compared with 101 (55.2%) normal birth weight. This is consistent with a study done in Pakistan 58.1%, Nigeria 89.1% and Gondar, Northwest Ethiopia 58 (89.2%) [ 13 , 18 , 24 ]. Even though the study was conducted in multiple Hospitals, it was done with small sample size and it was conducted with short period of time or in one season so factors like climatic changes or seasonal variations were not addressed. The prevalence of Neonatal hypothermia among Neonates admitted to Neonatal Intensive Care Unit of Public hospitals in Addis Ababa was high 228 (64%). Preterm delivery, age of newborn ≤24 h, and absence of skin to skin contact with their mother immediately after delivery, delayed in early initiation of breastfeeding within one hour after birth and resuscitation at birth were factors that had significant association with Neonatal hypothermia. Therefore attention is needed for thermal care of preterm newborn and on the principle of WHO warm chain especially on early initiation of breast feeding, skin to skin contact and warm resuscitation. It is better to increase the practice of skin to skin contact immediately after delivery which is the effective warm chain principle especially in developing countries in which advanced warming instruments and incubators are not present. Additional file 1: English version questionnaire, for the assessment of Neonatal Hypothermia and associated factors among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia. (DOCX 23 kb) English version questionnaire, for the assessment of Neonatal Hypothermia and associated factors among Neonates admitted to Neonatal Intensive Care Unit of Public Hospitals in Addis Ababa, Ethiopia. (DOCX 23 kb) Degree centigrade Degree farhanite Adjusted odds ratio Confidence interval Cardio pulmonary resuscitation Essential newborn care Gestational age Millennium development goal Neonatal Intensive Care Unit Relative risk Sustainable development goal Statistical Package for Social Sciences World Health Organization The authors would like to thank Addis Ababa University for funding this study. Our thanks also goes to for all study participants, supervisors and data collectors for their unreserved efforts and willingness to take part in this study. Addis Ababa University had covered all the costs for data collection instruments, data collection, data entry and payments for supervisors and advisors. The data that support the findings of this study are available from the corresponding authors upon reasonable request. BW was involved in the conception, design, analysis, interpretation, report and manuscript writing; BB and TY were participated in the design, analysis, interpretation and report writing. FH was involved in designing the study, analysis, report and manuscript writing. And all authors have read and approved the final manuscript. Ethical approval was obtained from Institutional Review Board of Addis Ababa University, School of Allied Health Sciences, Department of Nursing and Midwifery and submitted to each Hospital. In addition, Permission was obtained from all hospitals involved in this study, to conduct research on their property: namely; Tikur Anbessa Specialized Teaching Hospital, St. Paul’s Hospital Millennium Medical College, Yekatit Hospital Medical College, Gandhi Memorial Specialized Hospital, Zewditu Memorial Hospital, and Tirunesh Beijing General Hospital. All mothers that were involved in the study were asked for their willingness after they became informed about the purpose of the study and confidentiality of all the data. And an Informed written consent was obtained from all mothers of the newborn that were selected for the study. Mother of the newborns provided consent for them to participate in the study, and also they provided consent on behalf of the newborns to participate in the study. The study participants right to withdraw from the study at any time during data collection was respected. In the event of the mother's child being under the age of providing their own consent, written informed consent was received from the child's grandmother on behalf of the mother and child. Not applicable. The authors declare that they have no competing interests. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Neonatal hypothermia and associated factors among neonates admitted to neonatal intensive care unit of public hospitals in Addis Ababa, Ethiopia Neonatal hypothermia in sub-Saharan Africa : A review Hypothermia of newborns is associated with excess mortality in the first 2 months of life in Guinea- Bissau, West Africa Risk of mortality associated with neonatal hypothermia in southern Nepal STATE-OF-THE-ART neonatal hypothermia in low resource settings : a review The global burden of neonatal hypothermia: systematic review of a major challenge for newborn survival Admission hypothermia among neonates presented to neonatal intensive care unit Incidence and seasonality of hypothermia among newborns in southern Nepal Luke Incidence and risk factors of neonatal hypothermia at referral hospitals in Tehran, Islamic Republic of Iran Point-of-admission hypothermia among high-risk Nigerian newborns Proportion of neonatal hypothermia and associated factors among newborns at Gondar University teaching and Refferal hospital, Northwest Ethiopia: a hospital based cross sectional study Elimination of admission hypothermia in preterm very low-birth-weight infants by standardization of delivery room management Prevalence and risk factors for hypothermia on admission in Nigerian babies < 72 h of age Neonatal hypothermia in Uganda: prevalence and risk factors Neonatal hypothermia among hospitalized high risk newborns in a developing country Fetal and neonatal thermal physiology Thermal protection of the newborn in resource-limited environments Incidence and risk factors of neonatal hypothermia at referal hospitals in tehran, islamic republic of Iran Kangaroo mother care to prevent neonatal deaths due to preterm birth complications |
Answer the following medical question. | What does research say about Neonates as intrinsically worthy recipients of pain management in neonatal intensive care.? | One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers. |
Answer the following medical question. | What does research say about Modified Pathway to Survival highlights importance of rapid access to quality institutional delivery care to decrease neonatal mortality in Serang and Jember districts, Java, Indonesia.? | Three-quarters of births in Indonesia occur in a health facility, yet the neonatal mortality rate remains high at 15 per 1000 live births. The Pathway to Survival (P-to-S) framework of steps needed to return sick neonates and young children to health focuses on caregiver recognition of and care-seeking for severe illness. In view of increased institutional delivery in Indonesia and other low- and middle-income countries, a modified P-to-S is needed to assess the role of maternal complications in neonatal survival. We conducted a retrospective cross-sectional verbal and social autopsy study of all neonatal deaths from June through December 2018, identified by a proven listing method in two districts of Java, Indonesia. We examined care-seeking for maternal complications, delivery place, and place and timing of neonatal illness onset and death. The fatal illnesses of 189/259 (73%) neonates began in their delivery facility (DF), 114/189 (60%) of whom died before discharge. Mothers whose neonate’s illness started at their delivery hospital and lower-level DF were more than six times (odds ratio (OR) = 6.5; 95% confidence interval (CI) = 3.4-12.5) and twice (OR = 2.0; 95% CI = 1.01-4.02) as likely to experience a maternal complication as those whose neonates fell fatally ill in the community, and illness started earlier (mean = 0.3 vs 3.6 days; P < 0.001) and death came sooner (3.5 vs 5.3 days; P = 0.06) to neonates whose illness started at any DF. Despite going to the same number of providers/facilities, women with a labour and delivery (L/D) complication who sought care from at least one other provider or facility on route to their DF took longer than those without a complication to reach their DF (median = 3.3 vs 1.3 hours; P = 0.01). Neonates’ fatal illness onset in their DF was strongly associated with maternal complications. Mothers with a L/D complication experienced delays in reaching their DF, and nearly half the neonatal deaths occurred in association with a complication, suggesting that mothers with complications first seeking care at a hospital providing emergency maternal and neonatal care might have prevented some deaths. A modified P-to-S highlights the importance of rapid access to quality institutional delivery care in settings where many births occur in facilities and/or there is good care-seeking for L/D complications. Neonatal mortality (NM) in 2018 constituted 47% of the global 5.3 million under-5 years (U5) deaths [ 1 ], and nearly 80% of neonatal deaths occurred during the early neonatal (EN) period of the first seven days of life [ 2 ]. Pregnancy and labour and delivery (L/D) complications are the most important risk factors for perinatal mortality ((PM) = stillbirths plus EN deaths) [ 3 - 8 ], with care provided during L/D affording the greatest reductions in NM [ 9 , 10 ] and prevention of stillbirth [ 10 ]. Delivering in a health facility has been shown to decrease the risk of PM due to intrapartum complications by 43% to 58% [ 8 ], with higher-level facilities capable of providing basic (BEmONC) and comprehensive (CEmONC) emergency obstetric and newborn care best positioned to deliver the intrapartum care needed to contribute to maternal, perinatal, and neonatal survival [ 9 , 10 ]. Over the past three decades, institutional delivery in Indonesia progressively increased from 18% of all live births in 1989-1994 to 40% in 1998-2002, reaching 75% in 2013-2017 [ 11 - 16 ], but with only 32% of births still taking place in hospitals [ 16 ]; now, the government seeks to extend hospital coverage to remote and underserved areas [ 17 ]. During the same time period (1990-2017), Indonesia’s neonatal mortality rate decreased by 52%, from 31 deaths per 1000 live births in 1990 [ 18 ] to 15 per 1000 in 2013-2017 [ 16 ]. By 2017, Indonesia had nearly achieved Sustainable Development Goal 3.2.2, which is to reduce NM in all countries to at least as low as 12 per 1000 by 2030 [ 19 ]. Further NM reduction by Indonesia will depend on its success in decreasing early neonatal mortality (ENM), which fell by 44% from 1990-2017, compared to the 52% decrease in NM during the same period [ 11 , 16 ]. These trends were paralleled globally. Over the two decades prior to 2013-2018, the percentage of institutional deliveries increased by 46% globally, with the largest increases in regions with initially low levels such as West and Central Africa (49%) and South Asia (132%). By 2013-2018, 76% of all births worldwide, including 58% in sub-Saharan Africa and 72% in South Asia, were in a health facility [ 20 ]. Simultaneously, from 1990-2018, NM decreased globally by 51%, from 37 to 18 deaths per 1000 live births, and in all world regions from 35%, from 48 to 31 per 1000, in West and Central Africa to 71%, from 21 to 6 per 1000 in Eastern Europe and Central Asia [ 18 ]. Meanwhile, the share of neonatal deaths due to ENM increased from 71% to 80% during that time [ 2 ]. We conducted the Every Mother and Newborn Counts (EMNC) study of maternal and neonatal deaths in Serang and Jember districts, Java, to inform policy, planning, and intervention selection to combat maternal and neonatal mortality in Indonesia. Estimates of the causes of neonatal deaths in Indonesia are based on statistical models [ 21 ]; and while pregnancy and delivery complications and delivery without a skilled attendant have been identified as risk factors for NM [ 22 , 23 ], we found just one study from Indonesia on care-seeking for severe neonatal illness in the era of increased institutional delivery [ 24 ] and none on care-seeking for maternal complications in the context of neonatal death. To fill these gaps, we aimed to investigate neonatal causes of death and, for the identified deaths, to examine maternal care, care-seeking for maternal complications, and care-seeking for neonatal illness along the Pathway to Survival (P-to-S) framework (Figure S1 in the ) [ Online Supplementary Document 25 ] developed to support the implementation of the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) approach [ 26 ]. The Pathway depicts household and community preventive measures meant to maintain health, and care-seeking needed to return sick young children to health [ 27 ], and has proven to be a useful model in settings where many or most children die at home [ 28 , 29 ]. However, it was not designed to examine preventive maternal care and care-seeking for sick ENs. Given the high rate of institutional delivery, the strong association of maternal complications with PM, and the fact that most neonatal deaths occur during the EN period, we hypothesized that most neonatal deaths are among children whose mothers had a complication and whose fatal illnesses began in their delivery facility (DF). In support of Indonesia’s and global efforts to identify and monitor the impact of appropriate policies and interventions against NM, we sought to develop an extended P-to-S that highlights maternal care and mothers’ response to complications and to examine mothers’ and their fatally ill neonates’ steps along this Pathway. We previously examined care-seeking for sick neonates and neonatal causes of death [ 30 ]. We now focus on maternal complications, mothers’ care-seeking for their complications, delivery place, and association of the complications with newborns’ place of illness onset and severity. We described the study populations and methods extensively elsewhere [ 30 ]. Briefly, this was a retrospective cross-sectional study that examined all neonatal deaths from June to November 2018 in Serang District of Banten Province and July to December 2018 in Jember District of East Java Province, both in Java, Indonesia. We selected the six-month recall period based on the need to minimize this potential source of bias in a study that required detailed information, including on the chronology of care-seeking actions taken by the mother for herself and her newborn. We selected the districts based on the representativeness of their provinces in terms of maternal and neonatal mortality levels, quality of health facilities and local government commitment, population size, and mix of urban, rural, and remote communities [ 31 ]. We used the Neonatal Deaths from Informant/Neonatal Deaths Follow On Review (NODE-IN/NODE-FOR) double capture method adapted from a similar method for maternal deaths [ 32 ] to identify and list possible neonatal deaths. We asked local informants most knowledgeable about vital events in the community to list all known neonatal deaths and stillbirths, together with the parents’ contact information and age at death of neonates. We conducted follow-up interviews with the families to determine which cases met the study eligibility criteria, including that the child was born alive, was of gestational age ≥28 weeks, died on day 0-27 following birth, died during the recall period, and their parents being residents of one of the study districts. We conducted a verbal and social autopsy (VASA) interview with the main caregiver (usually the mother) of each eligible neonate using a questionnaire adapted from the Johns Hopkins Institute for International Programs VASA instrument [ 27 ]. The instrument contains the 2016 World Health Organization verbal autopsy (VA) form [ 33 ], which includes questions on maternal complications, neonatal illness signs and symptoms, and the place of birth and death. Social autopsy questions, including those needed to identify maternal antenatal care (ANC) and care-seeking for maternal complications and neonatal illnesses, are interspersed chronologically with the VA questions throughout the questionnaire. We examined pregnancy (before labour onset) and L/D complications defined by algorithms of illness signs and symptoms ( box 1 ). We defined “Any complication” as having one or more of preeclampsia/eclampsia, prolonged rupture of membranes (PROM), antepartum haemorrhage (APH), fever during labour, prolonged labour, malpresentation or cord complication. We defined care-seeking delays as the time to decide to seek care (“delay 1”) and to reach the DF after deciding to seek care (“delay 2”) for the mother’s L/D symptom(s). We defined delivery place as “delivery hospital” (DH), “lower-level delivery facility” (LLDF) and “community” (home, on route to a health facility, other place). Only hospitals in Indonesia can be accredited as CEmONC facilities, while only the highest level LLDFs (puskesmas: community health centers overseen by the Ministry of Health) can be BEmONC facilities. We were not able to determine which hospitals and LLDFs in our sample were CEmONC- and BEmONC-capable or accredited. Pregnancy complications (start before labour onset) − Maternal anaemia: severe anaemia − Maternal diabetes: diabetes mellitus − Preeclampsia/eclampsia: (high blood pressure during the last three months of pregnancy and blurred vision) or convulsions during pregnancy − Antepartum haemorrhage: Any vaginal bleeding in the last three months of pregnancy Labour/delivery complications (start after labour onset) − Maternal anaemia: same as for pregnancy − Preeclampsia/eclampsia: (High blood pressure during labour/delivery and blurred vision) or (convulsions during labour/delivery and no fever during labour) − Prolonged rupture of membranes: Water broke 24/more hours before baby was born − Fever during labour: fever during labour − Maternal infection: Fever during labour and (foul smelling amniotic fluid or foul-smelling vaginal discharge during delivery) − Prolonged labour: Labour lasted 12/more hours − Malpresentation: newborn delivered not head first − Cord complication: Cord delivered first or around the newborn’s neck more than once We used Fisher’s exact test to assess the association of maternal complications with: providers/facilities where mothers sought care on route to their DF, the timing of neonates’ death before or after discharge from their birth facility, and the likelihood of neonates’ referral from the birth facility. We used the χ 2 test of proportions to examine the association of maternal complications with the place where neonates’ fatal illnesses began and, for neonates delivered in a facility, with the timing of death in relation to discharge from the facility. We used the t test of equivalence of means to evaluate the number of providers/facilities where women sought care for their L/D complications on route to their DF and the Wilcoxon two-sample test with normal approximation of Z to assess their delays 1 and 2, as well as to explore the association of neonates’ age at illness onset and death with place of illness onset. We examined skewness and kurtosis of test samples to assess normality, with acceptable limits from -1 to 1, to determine whether to use the Wilcoxon or t test to evaluate significance (at P < 0.05). We developed logistic regression models to examine variables associated with delivery place (DH, LLDF, community) and delivery place by onset of neonates’ fatal illness. Possible predictor variables included any maternal complication (yes, no), mothers’ education level (primary, secondary, higher), insurance coverage (yes, no), ANC attendance (four or more visits (ANC4+), less than four), and time to reach the nearest health facility in an emergency (less than 30 minutes, 30 minutes or more). Cases with missing data for any variable were excluded from analyses. To account for the finding that many neonates died in their DF before discharge, we modified the P-to-S graphic to incorporate women’s care-seeking for their complications, delivery place, and place of neonates’ illness onset. The NODE-IN/NODE-FOR process yielded 902 potential neonatal deaths or stillbirths, of which 272 (30.2%) were confirmed as study-eligible neonatal deaths. During home visits, 31.2% cases were ineligible due to being stillbirths, 21.9% due to having occurred outside of the study period, 12.5% due to having a gestational age <28 weeks, 2.2% due to being >27 days old at death, and 2.0% due to either being duplicate cases or having unconfirmable eligibility. Just over 95% (259/272) of eligible cases had a complete VASA interview, so we included them in the analysis. Among these, the mean recall period since death was 5.4 (standard deviation (SD) = 2.0) months. To assess the completeness of our study sample, we compared the 272 confirmed neonatal deaths to official health system records. The 272 deaths comprised 1.6 and 2.2 times more neonatal deaths than reported by Serang and Jember district records, respectively; and, in total, the 272 deaths comprised 92.3% of all neonatal deaths captured by NODE-IN/NODE-FOR and the health system records. Almost 80% of the 259 neonatal deaths with a complete VASA interview died within one week of birth ( ). Altogether, 215 (83.0%) and 191 (73.7%) of 259 neonates had been born and had died in a health facility, respectively; 114 (44.0%) had been born and had died in the same facility without leaving, including 91 (75.2%) of 121 hospital births and 23 (24.5%) of 94 lower-level facility (LLF) births. The odds of either a neonate born in a hospital vs a neonate born elsewhere or a neonate born in a LLF vs a neonate born elsewhere dying in their birth facility without leaving were 15.2 (95% confidence interval (CI) = 8.3-27.9) and 0.3 (95% CI = 0.2-0.5), respectively. Table 1 Characteristics of mothers and newborns LLDF – lower-level delivery facility, SD – standard deviation *Highest level attended. We found no difference in the ages of the 215 mothers who delivered in a health facility and 44 who delivered in the community (29.1 vs 29.8; P = 0.57), nor in the ages of the 189 mothers whose neonate’s fatal illness started in a health facility and 70 whose neonate’s fatal illness started in the community (29.0 vs 29.9, P = 0.41). We also found no difference in the schooling level of mothers who delivered in a health facility and the community (chi-square (χ 2 ) = 4.27; P = 0.12), nor of mothers whose neonate’s fatal illness began in a health facility and the community (χ 2 = 3.78; P = 0.15). shows the age at illness onset and at death of the 259 neonates, according to their location at onset and when their fatal illness began. Illness onset for groups one through three was in the community, while for groups four and five illness began in the LLDF and DH, respectively. Illness started at a younger age and death occurred earlier for neonates whose illness started at their DF vs in the community. The earlier illness onset of neonates in their LLDF, compared to neonates at their DH, was due to five DH outliers whose illness started at 13 days of age. Table 2 Age at onset of fatal illness and death of neonates, by place of illness onset CI – confidence interval, IQR – interquartile range, SBA – skilled birth attendant, LLDF – lower-level delivery facility, DH – hospital-delivery *From Wilcoxon 2-sample test with normal approximation of Z. shows the mothers’ maternal complications by the same categories of neonate’s place of illness onset as displayed in Table 3 . The most common complications were prolonged labour, malpresentation, and PROM. Mothers whose neonate’s fatal illness started in their DF, whether a hospital, LLDF or any facility, had more complications than mothers whose neonate’s illness began in the community; as did mothers whose neonate’s illness started in their DH, compared to those whose neonate’s illness began in their LLDF. Table 2 Maternal complications, by place where fatal neonatal illness began OR – odds ratio, CI – confidence interval, Precl/ecl – preeclampsia/eclampsia during last three months of pregnancy or labour/delivery, PROM – prolonged rupture of membranes, APH – antepartum haemorrhage, SBA – skilled birth attendant, DH – delivery hospital, LLDF – lower-level delivery facility * P < 0.001. † P = 0.046. shows the same complications for mothers of neonates whose illness started in their DF, but additionally categorized by whether the neonate died before leaving the facility or after being discharged alive. Mothers whose neonate died before leaving their DH were 2.8 times more likely to have a complication than mothers whose baby died after discharge. There was no such excess for women whose newborn’s fatal illness began in their LLDF and died there without leaving. There were also differences within and between the two groups of women in complication types, with PROM, preeclampsia/eclampsia, APH and malpresentation more common among women whose neonates died in their DH before discharge than among those whose neonates left alive; and, nearly so, the opposite pattern for LLDF deaths. Table 4 Maternal complications, by delivery facility level where fatal neonatal illness began and timing of death Pre/ecl – preeclampsia/eclampsia during last three months of pregnancy or labour/delivery, PROM – prolonged rupture of membranes, APH – antepartum haemorrhage, OR – odds ratio, CI – confidence interval, LLDF – lower-level delivery facility, DH – delivery hospital *By χ 2 test of proportions. †Preeclampsia/eclampsia, prolonged rupture of membranes, antepartum haemorrhage, or malpresentation among women with any complication. ‡ By Fisher’s exact test. Most neonates discharged alive were referred, including 41/51 (80.4%) LLDF deliveries and 16/24 (66.7%) DH deliveries; LLDF neonates were referred more often (70.3% vs 26.1%; P < 0.001) and earlier (mean age 4.0 vs 43.9 hours; P = 0.01). Maternal complications were not associated with neonates’ referral from LLDFs (24/33 (72.7%) with vs 28/41 (68.3%) without a complication; P = 0.68) or DHs (21/83 (25.3%) with vs 9/32 (28.1%) without a complication, P = 0.76). Almost all neonates, equally among those whose mother did and did not have a complication, were referred due to a lack of equipment, medicines, procedures and/or trained providers needed to deliver quality newborn care vs insurance or other matters (LLDFs: 21/24 (87.5%) with vs 24/27 (88.9%) without a complication; P = 1.00; DHs: 20/21 (95.2%) with vs 8/9 (88.9%) without a complication; P = 0.52). All known (26/30) referrals from a DH, and all but four of 50 known referrals from a LLDF, were to a hospital. When adjusted for other potential explanatory factors, DH delivery was strongly associated with having one or more maternal complications and any insurance coverage ( ). Delivery in any facility was associated with the same factors, but the significant factors for LLDF delivery were ANC4+, insurance coverage, and travel time. Analyses of neonates whose illness began in their DF yielded similar results, but with DH delivery even more strongly associated with maternal complications (adjusted odds ratio (aOR) = 4.0; 95% CI = 2.3-6.9); and LLDF delivery no longer significantly related to ANC4+ (aOR = 2.7; 95% CI = 0.8-8.9). Table 5 Unadjusted and logistic regression-adjusted analyses of factors possibly associated with delivering in a hospital and a lower-level facility* DH – delivery hospital, OR – odds ratio, CI – confidence interval, aOR – adjusted odds ratio, LLDF – lower-level delivery facility *All factors with univariate P < 0.20 allowed to enter the logistic regression models. †Maternal complications include preeclampsia/eclampsia, prolonged rupture of membranes, antepartum haemorrhage, fever during labour, prolonged labour, foetal malpresentation and/or cord complication. ‡Insurance coverage includes National Health Insurance (NHI), government beneficiaries not covered by NHI, employer-provided and other private insurance. Among 172 women with one or more L/D symptoms who delivered in a facility, 100 sought care from at least one other provider or facility on route to their DF. There was no difference in delay 1 (0.08 vs 0.03 hours; P = 0.62) for the 74/100 women with a L/D complication and 26 with symptom(s) that did not meet the box 1 criteria for a complication. However, while the 100 women went to the same number of providers/facilities, those with a complication took significantly longer to reach their DF than those without a complication ( ). The symptoms of 89 of these 100 women started in the community without a skilled birth attendant (SBA). Providers/facilities they visited most often before reaching their DF included hospitals (28.4% of women with a complication vs 0.0% without; Figure 1 P = 0.003) (all of whom delivered at a hospital), puskesmas (25.4% vs 18.2%; P = 0.57) and private midwives (20.9% vs 18.2%; P = 1.00). In contrast to these 100 women, there was no difference in arrival time between the 22 women with and 50 without a complication (median = 0.3 vs 0.2 hours; P = 0.59) who went directly to their DF. 100 women who sought care from at least one other provider/facility on route to their delivery facility. L/D Sxs – labour/delivery symptoms not meeting the criteria for a complication, L/D Cmps – labour/delivery complications, IQR – interquartile range, CI – confidence interval. One hundred ten of the 172 women delivered in a hospital and drove the findings for the total 172 women: of the 110 women, 79 sought care from at least one other provider/facility on route to their DH, of whom the 62 with a L/D complication took the same 3.3 hours to reach their DH as all 74 women with a complication took to reach their DF. These 62 women and the 17 without a complication went to the same number of providers/facilities on route to their DH (mean = 2.6 vs 2.4; P = 0.41), and there was some indication that those with a complication took almost one hour longer to reach their DH, but this was not statistically significant (median = 3.3 vs 2.5 hours; P = 0.12). There was no difference in delay 1 (median = 0.08 vs 0.17 hours; P = 0.28) for these 62 and 17 women. Of the 31/110 women who went directly to their DH, 23 with and eight without a complication took the same time (0.0 vs 0.02 hours; P = 0.74) to reach it. Among the 62 women who delivered in a LLDF, 12 with and nine without a complication who sought care from at least one provider/facility on route to their LLDF went to 2.3 and 2.0 facilities ( P = 0.19) and reached their LLDF in 0.9 and 0.5 hours ( P = 0.29), respectively, while the 27 women with and 14 without a complication who went directly to their LLDF arrived in 0.3 and 0.4 hours ( P = 0.72), respectively. In total, the 110 women who delivered at DH went to more facilities than the 62 women who delivered at LLDF (mean = 2.1 vs 1.4; P < 0.001), and they took longer to reach their DF (median = 2.0 vs 0.5 hours; P < 0.001). Having National Health Insurance (NHI) coverage did not affect whether women with and without a L/D complication sought delivery care at multiple providers/facilities (NHI: 35/54 (64.8%) with vs 12/23 (56.5%) without a complication, P = 0.49; no NHI: 39/70 (55.7%) with vs 13/25 (52.0%) without a complication, P = 0.75). presents our modified P-to-S, which adds maternal antenatal and delivery care to the left side of the original Pathway, and recognition and care-seeking for maternal complications and emergency neonatal care to the right side. Figure 2 Modified Pathway to Survival. Colour and shape key: orange diamond = health condition/outcome; blue rectangle/oval = inside-the-home preventive care, illness recognition and care provision; purple rectangle/oval = outside-the-home preventive care, care-seeking and health care provision; yellow rectangle = informal care; light green rectangle = mixed informal and formal health care providers/facilities; bright green rectangle/diamond = formal health care provider/facility. B/CEmOC – Basic and Comprehensive Emergency Obstetric Care (to prevent neonatal illness), B/CEmNC – Basic and Comprehensive Emergency Neonatal Care (to treat neonatal illness). Our companion study [ 30 ] focused on care-seeking for sick neonates, including those whose illnesses started in the community. Following the modified Pathway’s maternal care steps provides a summary of the findings discussed in detail above. Nearly all (90%) of the 259 women achieved ANC4+, including 109 (91%) who delivered at DH, 88 (94%) who delivered at LLDF, and 35 (81%) women who delivered in the community. One hundred thirty-six (53%) of the women had a maternal complication that they were able to report at interview; 85 (63%) delivered at DH, 39 (29%) at LLDF, and 3 (1%) and 9 (3%) delivered with and without an SBA in the community. Of 85 babies delivered at a hospital whose mother had a complication, the fatal illnesses of 83 (98%) began in a hospital and two (2%) went home healthy; 70 (84%) of the 83 died before discharge, and 13 (16%) left alive, 10 (77%) of whom were referred to another hospital (n = 9/10) or unknown facility (n = 1/10). Of 39 babies delivered at LLDF whose mother had a complication, the fatal illnesses of 33 (85%) began in the LLDF and six (15%) went home healthy; 10 (30%) of the 33 died before discharge and 23 (70%) left alive, 20 (87%) of whom were referred to a hospital (n = 17/20) or other LLDF (n = 3/20). Two (67%) of the three babies delivered by an SBA in the community whose mother had a complication were sick at birth; one was referred to a hospital and the other one to a LLDF. We did not collect referral data for babies of women who delivered without an SBA. Indonesia’s roadmap to attaining and exceeding its Countdown to 2030 maternal and neonatal mortality reduction targets [ 34 ] lies in ensuring that all births take place in a BEmONC- or CEmONC-capable facility and that, in line with Indonesian government policy, all women with complications deliver in a CEmONC facility [ 35 ]. Indeed, we found a strong connection between maternal complications and delivery place, especially hospital delivery. More than 70% of neonates’ fatal illnesses began in their birth facility, and more than 60% of these neonates’ mothers had one or more complications, more than twice the rate of mothers who delivered at home and nearly twice as great in DH- vs LLDF-deliveries. However, this was most often associated with EN illness onset, on average at several hours of age for facility deliveries that were ill at birth vs nearly four days for neonates whose illnesses began in the community; and facility onset led to death in three and a half days compared to more than five days for community-onset illnesses. While most women with a complication delivered at a hospital, delays related to visiting multiple providers and facilities before reaching the DH may have contributed to the deaths. Nearly 80% of the deaths identified by the EMNC study were of ENs, the deaths most likely to have a maternal underlying cause [ 3 , 7 ]. Also, nearly 80% of neonates whose illness started in their DH and 30% of those whose illness started in their LLDF died before leaving; mothers of neonates who died in their DH were more likely to have a complication than those whose neonates left their DH alive, and their complications were also more likely to differ, with preeclampsia, PROM, APH, and malpresentation being most problematic. These findings again suggest a strong connection between maternal complications, as well as the types of complications, and neonatal illness severity. Other studies in low- and middle-income countries (LMIC) have also found malpresentation [ 7 , 36 ], hypertensive disorders [ 7 , 37 ] and APH [ 37 , 38 ] to be strongly associated with EN death. Among LLDF-delivered neonates, these complications were nearly significantly more common among those discharged alive, although we did not find an association between maternal complications and neonatal referral either from LLDF or DH. Nevertheless, the higher referral rate and earlier referral of neonates from LLDF suggest a decreased capability of LLDFs to care for these sick newborns. Hospitals and LLDFs faced the same shortcomings in quality of care indicators that mothers, both those with and without complications, reported necessitated referral of their newborns, although, given their higher referral rate, apparently at greater levels in LLDFs. These findings suggest that many women delivered at facilities incapable of providing emergency obstetric and neonatal care. Multivariable analysis of delivery place confirmed the strong association of maternal complications with hospital delivery, and a weaker association with LLDF delivery of sick neonates. Women’s knowledge of intrapartum danger signs [ 39 ] and the presence of complications during labour [ 40 ] have previously been shown to increase institutional delivery. Insurance coverage and travel time were stronger predictors of facility delivery for women who delivered a sick neonate in an LLDF; while insurance coverage also promoted hospital delivery for all women and women whose neonate’s illness began in the DH. Other studies have shown a positive effect of NHI coverage on institutional delivery in Indonesia [ 41 , 42 ]. To our best knowledge, this is the first study to examine the effect of any insurance coverage, including private insurance and government assistance to beneficiaries not covered by NHI, on facility delivery. ANC4+ has also been previously shown to increase institutional delivery in Indonesia [ 16 , 41 ] and elsewhere [ 43 , 44 ]. We found ANC4+ to be associated with LLDF- but not DH-delivery, and not in women whose neonate’s fatal illness began in the LLDF. These findings suggest that rapid access, including distance and cost considerations, took precedence over the benefit incurred from ANC visitation in women with maternal complications. Rapid access to delivery care is especially critical in the case of a woman in labour with a complication. Women in the EMNC study with and without L/D complications took the same amount of time to decide to seek care and went to the same number of providers/facilities before reaching their DF, yet those with complications more frequently went to a hospital on route and took on average up to two hours longer to reach their DF. Such delays were greater in women who delivered at a hospital, suggesting their need for more care before being discharged or referred and potentially more severe outcomes as the result of any delay in accessing definitive care. Although having any insurance coverage increased facility delivery, NHI coverage did not decrease women’s seeking care for their L/D complications at multiple providers/facilities on route to their DF, despite NHI policy that women with emergency complications should go directly to a hospital without a need for referral [ 45 ]. An increased delay in reaching appropriate care for maternal complications and neonatal illnesses due to multiple referrals has also been found in other settings [ 46 ]. This study and a companion study of care-seeking for 259 neonatal deaths along the P-to-S identified the need for a modified Pathway that recognizes the importance of rapid access to quality institutional delivery care in settings where many births occur in facilities and/or there is good care-seeking for L/D complications. This is the case in many LMICs, as other studies have found an increase in institutional births accompanied by shifting of high-risk births with maternal complications to facilities [ 47 , 48 ]. The original P-to-S (Figure S1 in the ) was designed more than a quarter century ago as a program development and evaluation tool in support of the WHO/UNICEF IMCI approach of promoting wellness, illness recognition and care-seeking for one-week to 59-month-old children whose illnesses started at home [ Online Supplementary Document 25 ]. The IMCI chart booklet was updated in 2014 to include care of ENs [ 49 ], but the Pathway has not been updated accordingly. With the epidemiological transition to neonatal death as the main driver of U5 mortality, a modified P-to-S is needed that examines inadequate access to quality BEmONC and CEmONC for all parturient women and especially those with maternal complications. Other authors have depicted pathways aimed at newborn survival [ 50 , 51 ], but none that incorporate all the elements of the original P-to-S. The modified Pathway that we present preserves and builds on the original, and should prove a useful supporting tool in the development and monitoring of interventions against neonatal and child mortality that recognize the importance of antenatal and delivery care, care-seeking for maternal complications, and provision of quality BEmONC and CEmONC for women and newborns. The modified Pathway includes steps at which delays in deciding to seek health care and reaching appropriate care both for women with complications and sick children can be assessed. The Three Delays model for examining the contribution to maternal mortality of these two delay types plus the delay in the provision of quality care once reaching an appropriate facility was formulated nearly three decades ago [ 52 ], and has since been used in multiple studies of maternal death and adapted to assess delays contributing to NM [ 53 ]. However, the model has seldom (and, to our knowledge, never before in Indonesia) been applied to evaluate the impact of delays in care-seeking for maternal complications on neonatal death [ 28 ] or stillbirth [ 54 ]. Assessment of, and determining the reasons for, these delays at key steps in the Pathway will make it an even more powerful supporting tool in the fight against NM. All the study data are from interview reports, mainly of the mothers of the deceased neonates, so are subject to possible recall and reporting biases. However, the recall period was shorter than for many VASA studies, which should have minimized recall bias. We defined algorithms of maternal complications based on reports of individual obstetric illness signs and symptoms in the 2016 WHO VA questionnaire, which for some conditions are somewhat limited. For example, hypertension, blurred vision, and convulsions are the only symptoms available with which to construct an algorithm for preeclampsia/eclampsia. Therefore, we may have underestimated the proportion of women with some complications, but this should not have affected the relative levels estimated for women who delivered at a facility and in the community. Small sample size for some sub-group analyses limits our definitiveness in drawing certain conclusions, for example, that neonates whose mothers had particular complications were more likely than those whose mothers had other complications to be discharged alive from their LLDF. The VASA study was not designed to assess the quality of care provided by delivery facilities, and we could not determine which facilities were capable of providing BEmONC and CEmONC. Increased access to institutional delivery by itself, in the absence of improvements in the quality of care, will not decrease NM and in some instances may even have a detrimental effect [ 48 ]. Our findings, that a major portion of neonatal deaths were related to maternal complications and subsequent newborn illnesses cared for in delivery facilities, call for a follow-up study to directly assess the quality of care provided for L/D complications and neonatal illnesses. Most neonatal deaths in two districts of Java, Indonesia were of infants whose fatal illnesses started on the day of birth at their DF. Most of these newborns’ mothers had one or more maternal complications, and many mothers with a L/D complication visited multiple providers/facilities before reaching their DF, leading to delays that might have contributed to their newborn’s death. Given the global trend toward increasing institutional delivery, especially in LMICs, and the increased share of neonatal deaths due to ENM, ANC providers should instruct women about complications for which they should go directly to a CEmONC-capable hospital for delivery; and governmental and institutional policy should support women in following these instructions. A modified Pathway to Survival highlights the increased importance of rapid access to quality institutional delivery care in settings where many births occur in facilities and/or there is good health care-seeking for L/D complications. Health systems in LMICs should consider incorporating use of the modified P-to-S into their ongoing maternal, neonatal and child health program development and monitoring activities. The authors would like to acknowledge the support from: the governments and health offices of East Java Province and Jember District, Banten Province and Serang District; puskesmas (community health centers), heads of sub-districts, heads of villages, and all respondents in the study areas. We would like to thank our colleagues from the Ministry of Health who provided substantial support especially in the initial phase of the study. We also would like to thank all the members of the EMNC study team, especially Ms. Akhir Rianty for assistance with the training, Ms. Nancy Kosasih, Ms. Yenny Fitrianingsih, the data collectors, and data entry team too numerous to mention all by name here; USAID Jalin project staff, especially Dr Luna M. Mehrain, and the Center for Family Welfare at the University of Indonesia (CFW UI) management team who were instrumental in the implementation of the study. We thank Dr Massee Bateman (deceased) of USAID for promoting funding of the EMNC study and Dr Anhari Achadi of the CFW UI for helping to secure the funding, and Dr Sigit Sulistyo of USAID for providing support to the conduct of the study. We would like to also thank Mr. Omair Azam and Mr. Ali Zazri from Vital Strategies for their support in managing the implementation of the study. Ethics statement: The EMNC study was approved by the Ethics Committee for Research and Community Services, Faculty of Public Health, University of Indonesia (Approval letter Number: 633/UN2.F10/PPM.00.02/2018) and the Biomedical Research Alliance of New York (BRANY) IRB (Approval for Investigator-Initiated Protocol 1003214-S-17-30460-00). All respondents provided written informed consent prior to being interviewed. Data availability: The dataset and dictionaries used for this study are available in USAID’s Development Data Library ( https://www.usaid.gov/data ). Questions about data access can be addressed to [email protected] . Funding: This study was made possible by the support of the American people through the United States Agency for International Development (USAID) under the terms of Contract Number: AID-497-C-17-00001. Information about the funder can be accessed at https://www.usaid.gov . The contents of this article are the sole responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authorship contributions: ELA and PWS provided high-level oversight and ELA led and guided conduct of the EMNC study. EHW and HDK facilitated adaptation of the JHU/IIP VASA questionnaire for the EMNC study and training of the VASA interviewers. ELA, KL, TR, FN and TA provided input for adaptation of the VASA tool and implementation guidelines based on their knowledge of the local Indonesian context. ELA and TA adapted the MADE-IN/MADE-FOR method of identifying maternal deaths to the NODE-IN/NODE-FOR method to identify neonatal deaths. HDK, PWS, ELA, and EHW, with input provided by SAN and SS, developed the VASA study methodology. KL, TR, FN and TA set up field aspects of the study, maintained communication with local stakeholders, and together with SAN and SS supervised field activities during conduct of the study. PED monitored data quality, including supervising data entry in the field and working closely with field coordinators to resolve any data-related issues; and organized, integrated and managed the NODE-IN/NODE-FOR and VASA data sets. HDK recognized the need for an updated Pathway to Survival; and HDK, ELA, PWS and EHW contributed to the development of the Pathway. HDK developed and conducted the data analysis and drafted and revised the manuscript. All authors reviewed and provided inputs to subsequent drafts of the manuscript and approved the final version. Disclosure of interest : The authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and declare the following activities and relationships: HDK, PWS, PED, SAN, SS, EHW, KL, TR, FN, TA and ELA report that USAID supported their work on the EMNC study under sub-agreements with Vital Strategies and Center for Family Welfare, Faculty of Public Health, University of Indonesia (PUSKA). HDK and EHW report that Vital Strategies covered their travel expenses to the study site to provide consultative services. HDK reports receiving salary support for work on other studies through grants from the Bill and Melinda Gates Foundation. EHW reports working on a separate USAID contract; and receiving a consulting fee from Johns Hopkins University for work on a different project funded by the Bill and Melinda Gates Foundation. Vital Strategies funded the article processing charges. Modified Pathway to Survival highlights importance of rapid access to quality institutional delivery care to decrease neonatal mortality in Serang and Jember districts, Java, Indonesia Labour complications remain the most important risk factors for perinatal mortality in rural Kenya. Maternal health during pregnancy and perinatal mortality in Bangladesh: evidence from a large-scale community-based clinical trial. Prospective community-based cluster census and case-control study of stillbirths and neonatal deaths in the West Bank and Gaza Strip. 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Answer the following medical question. | What does research say about iNICU - Integrated Neonatal Care Unit: Capturing Neonatal Journey in an Intelligent Data Way.? | Neonatal period represents first 28 days of life, which is the most vulnerable time for a child’s survival especially for the preterm babies. High neonatal mortality is a prominent and persistent problem across the globe. Non-availability of trained staff and infrastructure are the major recognized hurdles in the quality care of these neonates. Hourly progress growth charts and reports are still maintained manually by nurses along with continuous calculation of drug dosage and nutrition as per the changing weight of the baby. iNICU (integrated Neonatology Intensive Care Unit) leverages Beaglebone and Intel Edison based IoT integration with biomedical devices in NICU i.e. monitor, ventilator and blood gas machine. iNICU is hosted on IBM Softlayer based cloud computing infrastructure and map NICU workflow in Java based responsive web application to provide translational research informatics support to the clinicians. iNICU captures real time vital parameters i.e. respiration rate, heart rate, lab data and PACS amounting for millions of data points per day per child. Stream of data is sent to Apache Kafka layer which stores the same in Apache Cassandra NoSQL. iNICU also captures clinical data like feed intake, urine output, and daily assessment of child in PostgreSQL database. It acts as first Big Data hub (of both structured and unstructured data) of neonates across India offering temporal (longitudinal) data of their stay in NICU and allow clinicians in evaluating efficacy of their interventions. iNICU leverages drools based clinical rule based engine and deep learning based big data analytical model coded in R and PMML. iNICU solution aims to improve care time, fills skill gap, enable remote monitoring of neonates in rural regions, assists in identifying the early onset of disease, and reduction in neonatal mortality. The online version of this article (doi:10.1007/s10916-017-0774-8) contains supplementary material, which is available to authorized users. Globally 15 million babies are born preterm (before the completion of normal 37 weeks of gestation) every year i.e. more than 1 in 10 babies is born preterm [ 1 ]. In India alone, 23% (>3.5millions) of preterm births are annually reported [ 1 ]. These babies are extremely vulnerable and usually die due to several birth complications, acquired infections and damage to their brain, lungs or eyes. Preterm birth complications account for 0.748 million deaths per year in India which is 26% of the world’s neonatal deaths [ 2 ]. In India, major causes of preterm deaths are pre-maturity/ preterm (35%), neonatal infections (33%), intra-partum related complications/ birth asphyxia (20%) and congenital malformations (9%) [ 2 ]. Preterm babies who are able to survive would remain immune challenged and are highly prone to learning, hearing and visual disabilities [ 3 ]. Orders of severity and complications in preterm birth are usually inversely associated with gestational age that has 3 categories: extremely preterm (<28 weeks), very preterm (28 to <32 weeks) and moderate to late preterm (32 to <37 weeks). Neonates born in <32 weeks of gestation are grouped under “critical care group” and need to be maintained in intensive care units specialized in the care of ill or premature newborn infants, termed as NICU. Based on the criticality of the newborns, there are 3 defined levels of NICU: Level I stabilize sick newborns and low-birth weight babies, which do not require intensive care. Level II are equipped to support sick newborns other than those who need ventilator support and surgical care. The level III units are the neonatal intensive care units (NICUs) [ 4 ]. In last decade, India has seen a decline in the neonatal mortality but observed rate was found to be slower than the expected [ 5 ]. In 2011, Govt. of India has recognized the need of further expansion of neonate care centers by 30–50% [ 6 ]. Thus, Ministry of Health & Family welfares developed 448 new Sick Newborn Care Units (SNCU) with level 2 facility containing a total of 6408 beds which has supported >6,00,000 babies by 2013 [ 7 ]. The number of trained manpower with proper infrastructure is still daunting need in NICU settings [ 8 ]. NICU’s still needs more number of skilled clinical labors in order to uphold the current load of preterm births. Moreover, NICU’s requires skilled nurses in the ratio of 1:1–3 (Nurses/Patients) based on the severity of newborn’s health admitted to the NICU [ 9 ]. NICU employs several medical devices to monitor & maintain the physiological parameters of the newborn such as; ventilator, incubator, ECG monitor, blood pressure monitor, pulse oximeter, transcutaneous oxygen/carbon dioxide monitor etc. along with the infusion pump to deliver drugs and fluids. These devices produce humongous amount of proprietary data each second and store the information maximum for 72 h. For example, single ECG produces 86.4 million readings, impedance measurement by ECG leads result in 5.4 million data points, blood oxygen saturation reading gives 0.08 million data points per day for a single patient [ 10 ]. Till now lot of this crucial physiological data from these devices remain unexplored. Doctors usually consider only the maximum/average values of these physiological parameters such as, heart rate, respiratory rate etc., on hourly basis, noted manually by nurses on nursing charts/notes which also inculcates high error rate. Processing of this high frequency voluminous physiological data streams is still a big challenge but could yield significant insights to provide the quality care of neonates. Recent literature showed that physiological markers can provide early insights before the clinical signs become apparent. For example, HeRo score based on the heart rate variability with decelerations can be used as an indicator of early onset of sepsis [ 11 ]. It has also been seen that the clinical signs alone are sometimes subtle for example, apnea and feeding intolerance alone cannot be considered as the clear indicators of sepsis [ 12 ]. Thus, inclusion of physiological markers along with neonatal score and clinical signs could help in identifying the actual prognostic and/or diagnostic markers for various neonatal indications. Introduction of longitudinal translational informatics with careful workflow design incumbent with predictive algorithms could integrate manifolds of data from biomedical devices (physiological parameters), clinical documents, laboratory reports, pharmacy reports and diagnosis codes, to help in early prognosis, prevention, and diagnosis of preterm babies. However, collating diverse types of data from multiple sources itself poses few issues such as; cost, processing, storage, network bandwidth, confidentiality which could be readily addressed in current ICT setup. Thus, automation of NICU workflow by a robust big data infrastructure could facilitate monitoring and storage of the physiological and clinical phenotype parameters at various timeframes, and also help in clinical markers discovery process. Immediate benefits of implementing similar automated tool e.g. POE, has been reported to reduce transcription errors, turn-around times and timely support of results in USA [ 13 ]. This data collection can help in training semi-skilled trained manpower and improving clinical protocols in providing care to neonates in emerging countries like India. Specialized training of clinical care people is required in order to support several challenging tasks especially associated to the care of neonates at NICU. One challenge is the rapid weight changes of the neonate’s body, which affects their nutrition demand and pharmacokinetic/ pharmacodynamics properties of drugs administered to child [ 14 ]. Thus, continuous calculation is needed and is performed manually by neonatologists to determine the appropriate nutrition and drug dosage. Moreover, the entire workflow of NICU involves the engagement of various medical experts such as, neonatologists (consultant/resident doctor/junior doctor), nutritionists, respiratory therapists, pharmacists, and specially trained nurses in corporation with ophthalmologists, microbiologists, cardiologists and surgeons. Complex concurrent care pathway flows among the interdisciplinary team in NICU are mediated by the trained clinical staff. The nurses not only follow the specialist instructions but also prepare the manual charts and reports for the hourly progress of the baby. Thus, these manual reports are highly prone to human error. For achieving these goals, we are presenting in this paper, Cloud, IoT and Data Analytics based software solution, iNICU (integrated Neonatal Intensive Care Unit). iNICU is a comprehensive integrated platform especially designed to address all the current issues of NICU such as tedious workflow, integration of the data generated by multiple devices at one place, automatic drug/nutrition calculator, auto-discharge summary, complete assessment sheets for all critical biological systems of newborns, digitalized prescription, laboratory reports, nursing notes, prenatal data, notifications/alerts to the doctor, parent engagement, predictive analytics and NICU management (Fig. 1 ). Our vision is to provide complete automation with analytics to benchmark for the quality care of the newborns. iNICU allows concurrent real time access of multiple infants to clinical experts and thus, improves the care time. Key long term benefits of our solution are care time improvement, filling skill gap, remote monitoring of rural regions by experts, early identification of disease, and reduction in neonatal mortality. However, the scope of this article is to demonstrate the concept, development and workflow of iNICU. Field-testing of the system is ongoing in five pilot NICU sites in India. The major aim of field testing is to improve usability and standardization of assessment of various diseases in NICU environment. Fig. 1 Benefits of iNICU Benefits of iNICU The architecture of the iNICU system illustrated in Fig. 2 , which mainly consist of three parts i.e. the machine data integration, clinical interface for iNICU and data analytics engine (consisting of data, associated clinical rules and notifications). Fig. 2 iNICU Architecture iNICU Architecture The machine data integration (MDI) layer is divided into two blocks a) MDI client b) MDI server. MDI client provides wrapper on HL7 and RS 232 allowing interaction of iNICU system with various devices. These devices provide data over WAN, Network or Serial cable. Device vendors like GE, Philips, Nihon Kohden support HL7 (Health Level Protocol) protocol for data retrieval from their devices. iNICU uses open source HAPI (HL7 API) and supports HL7 2.X version to fetch data from various devices in NICU setting. Separate thread is initiated for each supporting device to acquire concurrent live data feeds. Various device specific HL7 adaptations (such as Medibus for Dragger, Intelivue for Philips and Carescape for GE) are used to establish connection with each of the medical device. For RS 232 interface, iNICU uses RXTX Java based communication API. This is hosted on Raspberry, Arduino and Intel Edison board and placed on the acquisition device. The MDI client layer fetches data over serial port and pass acquired data to MDI server layer. Data aggregation from these devices is carried out using IoT gateway (i.e. Cybertan and Intel IoT gateway). MDI Server layer is implemented using open source Apache Kafka. MDI Server subscribes to real time streams of data coming from various MDI client implementations. It uses Apache Cassandra to store unstructured data. MDI Server piece also integrated with Lab Information Management System via ASTM protocol (JAVA ASTM API). The doctor/nurse interface is built using service oriented architecture. The server part is implemented using Java 1.8 language leveraging Spring Boot framework. User Interface layer is built using responsive AngularJS (JavaScript Framework) and HTML5. This allows User Interface layer to be responsive and it can run seamlessly on Tablet, Laptop and Mobile devices. JSON based REST API integration connects AngularJS and Spring layers. Patient data is accessed either from Hospital Information System as ADT (Admission Discharge Transfer) events through HL7 Integration or manually entered by the Hospital administration. Clinical data stored in PostgreSQL and Hibernate allows access of database from Java business layer. Various Neonatal calculators are coded using Drools rule engine and stored as metadata. Solution is hosted on IBM Softlayer based cloud infrastructure. Growth charts are implemented using high charts and JavaScript. Cloud component allows only HTTPS based communication protected by 256-bit encryption with web interface. Clinical data is stored in PostgreSQL and waveform/machine data is stored in Apache Cassandra. Normalized data was fetched from both unstructured and structured data stores. Disease based neonatal score help to categorize infant into different diseases. Incoming facts (urine output, Respiratory Rate, Heart Rate, SpO2 etc.) of child act as input to Clinical Rules and matching rules inferences are executed. These inferences generate alarm and notification which are send via SMS/Google Cloud Messaging and Apple Push Notification Service to doctor, nurses and patients (specific one). iNICU automates the entire workflow of NICU from the admission of newborn till its discharge. It caters the entire responsibility of doctors, nurses and paramedical staff and also provides analytics for the child healthcare and hospital management system. iNICU system can be broadly classified into four important sections: 1) Digitization of clinical investigation, 2) Clinical care time improvement by auto-calculators, 3) Neonatal scores based real-time alarms, and 4) Deep learning based analytical model for early prediction of disease onset. Dashboard is a collated view of NICU facility of the hospital along with the necessary personal and clinical details of the admitted newborns (see Fig. 3 ). Once the personal data, maternal history, birth related child data and initial assessment of child’s health have been updated in the digitized admission form, baby is admitted to the NICU/iNICU. Every admitted neonate is color-coded based on health condition i.e. critical, satisfactory and stable, so that attention could be prioritized from the first view itself. It also displays the NICU level of newborn along with the critical life supporting device parameters such as heart rate, peripheral oxygen saturation, respiratory rate and pulse rate. The dashboard gives a quick, consolidated and informative view of all neonates along with their necessary monitoring parameters and notifications/ alerts. Tabulated view in dashboard will also give a printable comprehensive table depicted weight change, feeding pattern, ventilator usage, major diagnosis (in order) for all admitted neonates. Fig. 3 Dashboard View of iNICU Dashboard View of iNICU Physiological streams from monitors, ventilators and blood gas machine can be viewed for every child (Fig. 4 ). New device can be added to iNICU using add-device module. iNICU seamlessly links with Laboratory Information Management System (LIMS) and PACS. Thus, raw data from laboratory reports as well as Image data can be viewed through iNICU (Fig. 5 ). Control charts visualization was used to see the trend of vital parameters such as bilirubin in neonatal jaundice. Fig. 4 Real Time Device Data of iNICU Fig. 5 Laboratory Test Records in iNICU Real Time Device Data of iNICU Laboratory Test Records in iNICU Neonatologist’s panel has been split into 5 major sections: assessment sheet, prescription, feed/nutrition, notes and growth Charts (Fig. 6 ). Assessment sheet designed to monitor the progression and/or development of any of the known neonatal clinical events in all major biological system such as; metabolic, respiratory, infections, renal, CNS, cardiac, jaundice, malformations. Each assessment sheet was carefully design to capture the workflow of neonatologist. Each sheet has 3 panels of Clinical assessment, Action (Investigation, Medications) and Plan along with causes and associated events. Based on clinician assessment (i.e. jaundice in Fig. 6 ) an auto generated progress notes for each assessment entry is generated. Moreover, assessment sheet of events such as Jaundice has clinical decision recommendations like NICE (< 35 weeks of gestation) or Bhutani charts (≥ 35 weeks of gestation) for starting phototherapy or exchange transfusion. Similarly in case of hypernatremia assessment sheet, deficit calculator allows consideration of lean weight loss and insensible losses in management of sodium level. The prescription section contains the information related to medication needs of the baby such as drug name, route of intake, dose, frequency, start date, time, end date, any special comments, active and past medication record. The baby feed can either be given as expressed breast milk (EBM), formula milk, EBM supplemented with human milk fortifier lactodex (HMF) or intravenous fluids (IVFs) as decided by the doctor. Neonatologist defines the mode, time interval and volume of the feed to be given to the baby in the Feed/Nutrition section. Doctor notes are designed for doctors to incorporate diagnosis, issues, plans and special notes as free text. Growth curves are the dynamic curves used to give the instant view on the advancement of growth parameters of the infant as per the Fenton’s standard (weekly basis). Thus, sudden drop or rise in the height, weight and head circumference of the newborn can be noted and immediate attention could be provided. These instructions are linked to nursing notes which gets auto populated, thus enforcing the nurses to follow the doctor’s advice without any error. Fig. 6 Doctor’s Panel with expanded Jaundice Assessment Screen at iNICU Doctor’s Panel with expanded Jaundice Assessment Screen at iNICU Nursing notes are observatory notes to capture hourly and/or daily clinical observations of neonates by the nurses. Measurement of height, length and head circumference of the baby is captured daily and any weight gain/loss would be auto populated and notified. Nursing notes also capture derived value of vital physiological parameters from the medical devices. Fluid intake and medication details with any added instructions are auto-populated from the doctor’s section and generate periodic reminders for the prescribed medication. Head-to-Toe assessment, physiotherapy, phototherapy if recommended can be monitored and recorded by the nurse in their respective sections. These simple separate observatory sheets for various different needs and auto-filled instructions/reminders provide a holistic and hassle free interface to the nursing staff thereby minimizing the possibility of any error. All personal information, maternal history, child details at birth, doctor’s notes with issues, diagnosis and medication details get auto-populated to create a complete discharge summary of a neonate that can be downloaded in just one click. List of all the discharged patients can be accessed through the discharged patients tab along with his/her discharge summary. Tracing the entire medical history of any admitted newborn become much easier and safely maintained in the software. Hospital analytics allows administrator to see division of patients across different levels of NICU, infection rate present in NICU (compare to standard), mortality score, human breast milk consumption score and death counts due to major NICU diseases like sepsis, NEC and asphyxia. iNICU improves clinical care time by integrating several key calculators used in the neonatal care such as, gestation calculator, dose Calculator, nutrition calculator (EN and PN), calorie calculator, dextrose calculator. Total fluids requirements vary as per the gestational age and weight of the baby [ 15 ]. Nutrition requirement needs to be computed in a step-wise orderly manner for feed, medication, IV fluids (dextrose/salts) and blood transfusion, if any, on daily basis (Fig. 7 ). However, preterm and critically ill neonates (usually under 1200 g) are unable to receive normal feed by mouth. Total Parenteral Nutrition (TPN) is then used to deliver medication and all essential nutrients intravenously to the newborn [ 16 ]. TPN includes mixture of fluids, electrolytes, sugar, amino acids (proteins), vitamins, minerals, and lipids. Nutrition calculator of iNICU auto-computes daily nutritional needs of neonate. iNICU also maintains the entire record of the feeds consumed by the infants. Also, iNICU drug dose calculator auto-computes and auto populates the correct volume/ amount of drug as per the current weight of baby (Supplementary Fig. 1 ). Fig. 7 Nutrition Calculator Screen at iNICU Nutrition Calculator Screen at iNICU Neonatal Scores are statistical indexes, which can reproducibly predict mortality and specific morbidities in the neonates. These scores are well accepted among major clinical communities for the risk assessment of newborn at NICU [ 17 ]. iNICU has integrated nine neonatal scores to support the clinicians in physiological system assessment of each of the newborn. For example; APGAR [ 18 ] and BALLARD [ 19 ] are used to predict the overall status of the physical and neuro muscular activities of the infant, respectively. Others scores implemented in iNICU are; Downes [ 20 ] and Silverman Anderson for respiratory distress syndrome [ 21 ], Bell’s staging for metabolic systems [ 22 ] and Bind Score for Jaundice [ 23 ], HIE scores by Sarnat & Sarnat for CNS [ 24 ], Rodwell for sepsis [ 25 ] and Volpes for heart’s condition [ 26 ]. Although above statistical scores help the clinicians in predicting the disease state of neonates, there is a need of more robust and improved analytical model that could utilize the multiple data fields with high accuracy [ 27 , 28 ]. Multiple medical fields have been clustered into two buckets of structured (EMR/HIS and observatory fields from Doctor’s & Nursing notes) and unstructured data (medical devices integration, LIMS and PACS) (Fig. 8 ). These two buckets completely capture the vital signs, clinical observations, physiological derived data/waveforms, imaging data, microbiology reports that represents the overall health status of the neonate. From the data hub, all these fields are captured to compute existing consensus based neonatal scores as discussed in above section to build clinical rules engine. Predicted diseases generate alerts for the hospital staff. Until date, iNICU captures 136 fields excluding laboratory data (Supplementary Table 1 ). Essential features based on fields used in neonatal scores, maternal history and birth related data are fed as input layer to Neural network. The output layer is build using disease identification (from systematic assessment) and doctor notes. An aggregate health status score has also been computed using disease severity index which used to raise alerts for doctors. Using pilot data, various case-control cohorts for above neonatal diseases will validate the predictive physiological models. Currently, iNICU is the first and the only such initiative present in the Indian health industry and has already been deployed at four major hospitals having a total of >50 NICU beds for the pilot run. Fig. 8 Overview of iNICU Analytical Framework Overview of iNICU Analytical Framework Since iNICU data acquisition is currently ongoing, we have leveraged publicly available critical neonatal dataset MIMIC-III (Medical Information Mart for Intensive Care) used to build disease specific models leveraging deeplearning4j technology [ 29 ]. MIMIC-III comprises 7863 neonates with 1576-recorded vitals (Supplementary Table 2 ). However, iNICU currently captures 136 essential vitals (excluding lab results). MIMIC III vitals can be majorly characterized as observational, physiological and laboratory related data. Out of >1500 reported vitals, 34 seems to be crucial for newborn as it is being observed in >70% of the data. Also, top 11 fields are mandatory observatory fields that need to be recorded once for most of the patients. Few common physiological fields such as HR, RR, SpO 2 which is captured with high frequency per patient. Standard laboratory vitals such as hematocrit, platelet, RBC etc. are captured frequently. Other infrequent vitals seem to be disease or condition specific and thus, need not be recorded for every admitted newborn. Newborn data has total 872 icd9_codes used for the billing. Supplementary Table 3 represents these icd9_codes with their patient frequency. ICD 9 code vs patient frequency was utilized to select top 4 disease conditions which are respiratory problems, jaundice, prematurity and heart problems, for neonate population which accounts for 56% (4399) of data. iNICU is designed to automate NICU workflow with user friendly design and features for doctors and nurses. In resource crunch settings in India, care of a child takes precedence over entering the longitudinal clinical care data by intensivist. iNICU system allows saving of data in retrospective manner for analytics which helps to reduce neonatal mortality and morbidity. Major architectural challenges addressed in iNICU were: 1) capturing entries with minimal chances of error and 2) capturing the multi-dimensional clinical electronic patient records from lab, devices and other third party systems. To overcome these, we have designed time series (longitudinal) database based on different neonatal episodes/events. Major neonatal events are classified as separate assessments linking the relevant laboratory tests, device parameters, and interventions to identify clinically relevant features. In addition, relationships between events and result of interventions are well captured through automated progress notes. To overcome clinician difficulty in pattern recognition from physiological data, we have pre-computed scores e.g. PhysiScore which could predict the morbidity status of the neonates based on physiological streams for first 3 h of life [ 30 ]. To enhance iNICU usability, we provide clinicians various clinical recommendations such as NICE or Bhutani charts for phototherapy/transfusion in Jaundice, daily recommended diet values from ESPGHAN etc. Auto-generated daily progress notes, inbuilt calculators and less typing will reduce the clinician’s efforts and increase their care time. Assessment scores are accompanied by pictures and guidelines (e.g Ballard) to assist the clinicians. System generates reminders based on defined clinical guidelines i.e. BPD classification based on 28 days of ventilator usage for preterm babies at 36 weeks. However, physiological data based alarms (i.e. apnea, bradycardia and desaturation) need to be validated by nurses/doctors as a check for any device artifact. To ensure data completeness or avoid incorrect entry, we have various validations such as; pop-up reminders for mandatory fields, mostly auto-filled data from lab/device if possible, only allowable ranges in drop down. We also have user manuals and training sessions for doctors and nurses. To handle issues related to power outage and network connectivity, iNICU system deployment in rural areas allows offline-working capability. Server residing in local network is regularly synchronize with cloud infrastructure based on availability of services. iNICU also captures quality indicators such as VAP, CLABSI, antibiotic and ventilator usage which allows the NICU units to monitor and compare their NICU performances. Vital parameters are provided in tabular, line series and control chart visualizations. Each NICU sites has its implementation and control technique. Additionally feedback from each NICU unit to further improve the usability is being incorporated. iNICU is a cloud-based solution leveraging IoT and Big Data, connecting the generated source data from various devices, LIMS and EMR/HIS. It’s a cumulative repository to assimilate and disseminate neonate health information. This application is designed to automate the responsibilities of various roles/owners (Nurse, Resident Doctor, Senior Doctor, Pediatrician, and Administrator). It has an interacting interface that captures the details for every neonate and virtually eliminates human error. Continuous monitoring, data recording and notifications related to every neonate are easily accessible through the cloud-based application. All essential parameter of a neonate’s progress like growth charts and automatic calculators e.g. nutrition is provided to reduce manual effort to trace them on paper and thereby reduce care time. Clinical rule engine and Deep learning based analytical model would ensure early onset of disease prediction and thus, reduce infant mortality. American Academy of Pediatrics (AAP) has reported critical functional areas that need to covered for complete pediatric care such as immunization management, growth tracking, medication dosing, and patient identification [ 31 ]. Thus, iNICU data is extended into integrated Child Health Record (ICHRCloud) application, which is an engagement platform to record and monitor the immunization schedule, health, growth, and developmental profile of the child from birth to the age of 20 years. Thus, iNICU with iCHR cloud would provide complete growth surveillance of the child. iNICU/iCHR cloud has also been recognized as one of the best innovative solutions to three nationwide challenges in 2016. 1) Smartcamp challenge for Health Tech organized by IBM in association with T-Hub, 2) Innovate for Digital India Challenge (IFDI) 2.0 by Intel and Department of Science and Technology, Government of India and 3) Centre for Innovation Incubation and Entrepreneurship Healthcare Accelerator program anchored at IIM-Ahmedabad. In near future, we plan to link our iNICU solutions at various sites into NICU Analytics as a Service (NICaaS), a grid which will bridge the gap of specialized doctors for NICUs across the country by providing services in the field of Neonatology with a network of remotely connected NICUs. It will act as a grid across the country allowing neonatologists connected with the tertiary care centers. This ensures expert advice for acute diagnosis and early intervention for premature neonates in NICUs. This will enhance the reachability and save the time of neonatologists without compromising on quality care for neonates. ESM 1 (DOCX 67 kb) ESM 2 (XLSX 58 kb) ESM 3 (XLSX 36 kb) (DOCX 67 kb) (XLSX 58 kb) (XLSX 36 kb) This article is part of the Topical Collection on Mobile & Wireless Health Electronic supplementary material The online version of this article (doi:10.1007/s10916-017-0774-8) contains supplementary material, which is available to authorized users. We would like to thank DST, IBM, T-Hub and IIM-A for recognizing the iNICU as an innovative sustainable solution in child healthcare. We thank Dr. Praveen Venkatagiri and Dr. Adarsh Somashekhar at Neonatal Care and Research Institute for their critical comments. SKB acknowledges J C Bose National Fellowship GAP0093 of Department of Science and Technology, Govt. of India. This study was funded by Oxyent Medical Private Limited. Harpreet Singh declares that he has no conflict of interest. Gautam Yadav declares that he has no conflict of interest. Raghuram Mallaiah declares that he has no conflict of interest. Preetha Joshi declares that she has no conflict of interest. Vinay Joshi declares that he has no conflict of interest. Ravneet Kaur declares that he shas no conflict of interest. Suneyna Bansal declares that she has no conflict of interest. Samir K. Brahmachari declares that he has no conflict of interest. This article does not contain any studies with human participants or animals performed by any of the authors. iNICU – Integrated Neonatal Care Unit: Capturing Neonatal Journey in an Intelligent Data Way Assessment of special care newborn units in India Reducing neonatal mortality in India: Critical role of access to emergency obstetric care Challenges in scaling up of special care newborn units-lessons from India Is the number of beds in special care newborn units in India adequate? Cost-analysis of healthcare in a private-sector neonatal intensive care unit in India Big data in neonatal intensive care HeRO monitoring to reduce mortality in NICU patients Early-onset neonatal sepsis Immediate benefits realized following implementation of physician order entry at an academic medical center Evaluation of changes in oral drug absorption in preterm and term neonates for biopharmaceutics classification system (BCS) class I and II compounds Neonatal disease severity scoring systems A proposal for a new method of evaluation of the newborn infant A simplified score for assessment of fetal maturation of newly born infants A clinical scoring system for the diagnosis of respiratory failure preliminary report on childhood status Asthmaticus Controlled clinical trial on effects of water mist on obstructive respiratory signs, death rate and necropsy findings among premature infants Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging Clinical report from the pilot USA kernicterus registry (1992 to 2004) Neonatal encephalopathy following fetal distress: A clinical and electroencephalographic study Early diagnosis of neonatal infection Health informatics for neonatal intensive care units: An analytical modeling perspective Transforming neonatal care through translational bioinformatics Integration of early physiological responses predicts later illness severity in preterm infants Special requirements of electronic health record systems in pediatrics |
Answer the following medical question. | What does research say about Kangaroo mother care: opportunities and implications for rural Pakistan.? | Neonatal mortality comprises 40% of total under-5 mortality, globally. Kangaroo mother care (KMC) is one of the most cost-effective interventions to reduce neonatal mortality. KMC does not require highend equipment, intensive care facilities or technical knowledge. A recent meta-analysis reported that KMC may reduce neonatal mortality in preterm and low birth weight neonates up to 36%. A review of enablers and barriers of KMC suggests that KMC can be integrated in maternal health care system by giving awareness, involving family and giving ownership of the intervention to the community. If supported with minimal incentives it would reduce the cost of health care substantially, reduce patient burden on hospitals by reducing hospital stay in postnatal period. It will reduce financial burden, time strain and help eliminate social taboos regarding preterm and low birth weight neonates. Hospital and community based KMC interventions should be tested in Pakistan . |
Answer the following medical question. | What does research say about Determinants of time to full enteral feeding achievement among infants with birth weight 1000-2000g admitted to the neonatal intensive care unit of public hospitals in Hawassa city, Sidama region Ethiopian, 2019: A retrospective cohort study.? | Competing Interests: The authors have declared that no competing interests exist. Nutritional care during the neonatal period is a cornerstone towards achieving optimal care. However, very limited data is available on optimizing parenteral and enteral nutrition that directly affects infant survival among Ethiopian neonates. Therefore, the objective of this study is to identify determinants of time to full enteral feeding achievement among low-birth-weight neonates admitted to neonatal intensive care units of public hospitals in Hawassa city. A facility-based retrospective cohort study was conducted in Adare general hospital and Hawassa University’s comprehensive specialized hospital from August 2018 to 2019. Charts of infants with a birth weight of 1000-2000g (n = 273) neonates who were admitted to the neonatal intensive care unit (ICU) were reviewed. The sample size for each hospital was allocated proportionally and subjects were selected by using a simple random sampling technique. Data were entered using Epi. data version 3.1, and analysis was performed using SPSS version 20. Kaplan-Meier estimator and a Cox proportional hazard model were used. The mean (SD) age when an enteral feed (trophic feeding) was first commenced was 2.13(1.373) days. The median time to achieve full enteral feeding was 8 days with IQR (7–10 days). Gestational age reduces the time to full enteral feeding by 18.8% for each additional week of gestation (AHR = 0.812, p-value = 0.003). The time to achieve full enteral feeding was shorter by 70.4% among neonates who were small for gestational age, as compared with that appropriate for gestational age (AHR = 0.296, p-value<0.001). According to this study, the time that the neonate takes to achieve full enteral feeding was relatively short. Gestational age and weight for gestational were the determinants for time to full enteral feeding achievement. Further research needs to be conducted to explore further, in addition to current findings. The data set of this manuscript is available on 10.6084/m9.figshare.19661451 (doi.org) at the public repository. During the neonatal period, nutritional care is a cornerstone towards providing optimal care to reduce the risk of short-and long-term adverse outcomes [ 1 , 2 ]. Low birth weight is defined as weight at birth less than 2500 grams. More than 20 million infants are born with low birth weight (LBW) every year and over 96% of them are in developing countries [ 3 ]. In those countries, LBW has been a major predictor of child survival [ 4 ]. LBW can be caused due to preterm birth (birth before 37 complete weeks of gestation), small size for gestational age (weight for gestation less than 10th percentile), or both [ 3 ]. Nutritional care provided to LBW neonates, especially infants with a birth weight of 1000-2000g, is largely either parenteral or enteral nutrition or a combination of both [ 5 ]. In most developing countries like Ethiopia, where resources are limited, intravenous fluid instead of parenteral nutrition mainly entails the provision of a maintenance fluid composed of only glucose and electrolyte [ 6 ]. The introduction of enteral feeding for those infants will be delayed for several days or longer after birth due to fear of worsening clinical conditions [ 7 ]. For many days after delivery, high-risk newborns may stay on maintenance fluid without receiving enteral feeding. This delayed introduction of enteral feeding tends to reduce the gastrointestinal tract’s functional adaptability and increases the need for intravenous fluid, which is risky for different infections and metabolic illnesses [ 8 ]. The sequels of a delay in providing adequate postnatal nutrition are significant when they are combined with cumulative deficiencies in protein and energy stores. This results in slower growth, worse neurodevelopmental outcomes, poor bone health, and an increased risk of developing metabolic syndrome later in life [ 9 , 10 ]. Studies carried out in developed countries show that low birth weight-related morbidity and mortality can be substantially reduced by optimizing parenteral and enteral infant nutrition [ 2 , 6 , 11 ]. However, this is more challenging in developing countries due to differences in low-birth-weight patterns and clinical setup amongst populations. For example, in many of those countries, infants that are cared for are generally greater than 1000 grams. Since it is difficult to establish full enteral feeding faster as much as possible in those whose birth weight is less than 1000grams [ 6 ]. This makes the clinician stick with maintenance fluid along with or without a minimal volume of enteral feeding, as the result of the risk of feeding intolerance (FI) and necrotizing enterocolitis (NEC). Early introduction of enteral nutrition and rapid achievement to full enteral feeding is the ultimate goal for all low-birth-weight neonates in the nutritional care of preterm infants, as it reduces the need for central venous access and thus the risk of infection, and thereby reduces the length of hospital stay [ 12 , 13 ]. However, in developing countries like Ethiopia, there are very limited parenteral and enteral nutrition practices, despite a high prevalence of infants with a birth weight of 1000-2000g. Thus, to optimize the nutritional management of these infants during the early neonatal period, it is important to set and identify factors associated with the time to full enteral feeding achievement along with different considerations in clinical outcomes. Therefore, this study aims to identify determinants of time to full enteral feeding achievement among infants with a birth weight of 1000-2000g admitted to the neonatal intensive care unit of public hospitals in Hawassa city. The findings of this study are used as evidence to improve enteral feeding practices that are needed to reduce the risk of short-and long-term adverse outcomes of infants with birth weight 1000-2000g. The study was conducted in public hospitals in Hawassa city administration, Sidama Ethiopia. Hawassa is the administrative center of SNNPR and Sidama regional state. It is located 275 kilometers south of Addis Ababa. There are 3 public hospitals, 4 non-governmental hospitals, 11 Governmental and 1 non-governmental health center, and 7 diagnostic laboratories in the city. Hawassa university’s comprehensive specialized hospital and Adare general hospital were the two public hospitals that provided the service during the period. The Hawassa University’s comprehensive specialized hospital has a catchment population of 12 million people and it serves about 43,384 patients per year. The Pediatrics department of the hospital has a well-organized neonatal intensive care unit, including personnel and equipment. It provides continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illnesses. Adare general hospital is not a teaching hospital but provides both preventive and curative services for more than 1,368,341 people. The neonatal ICU is one of the units in the hospital, which gives services under the pediatrics department. The hospital NICU gives all the services, including those with high-risk neonates, except those who need other specialties. A facility-based retrospective cohort study design was employed from November 2019 to December 2019. All infants with a birth weight of 1000-2000g who were admitted to the neonatal ICU of public hospitals in Hawassa city, Sidama region, Ethiopia. All randomly selected infants with birth weight 1000–2000 who were admitted to the neonatal ICU of public hospitals during the study period in Hawassa city, Sidama region, Ethiopia. All LBW newborns between 1000 and 2000 grams who were admitted to NICU within 24 hours of delivery in the selected public hospitals All infants with a birth weight of 1000-2000g who were admitted to NICU between August 2018 and 2019 Had major congenital malformations Never received enteral feeding because of their clinical conditions (due to GI surgical intervention) Died before initiation of enteral feeds Records with missing or wrong data on all the predictors The sample size was calculated by using G* power and the following assumption were made while calculating the sample size. The degree of precision or margin of error chosen to be 0.05 with the reliability coefficient of 1.96 certainties (Z = 1.96), 80% power of the study, and 0.2 minimum effect size were taken. Then the final sample size was calculated to be 273 . Public hospitals that are found in Hawassa city administration, Adare general hospital, and Hawassa university comprehensive specialized hospital (HUCSH) were included in the study because of the service they had in NICU during the specified period. Study inclusion criteria were used to select the study subject from the admission registration book of the two hospitals. Records from August 2018 to August 2019 were reviewed. The sample size was proportionally allocated for the two hospitals depending on the caseload assessed from the registration book for the year before this study. Simple random sampling was employed to draw the final sample size from the two hospitals as it permits a high degree of accuracy due to the limited area of operations of the neonatal ICU “ ”. Fig 1 Lost to follow-up: subjects drop out of a study for a reason unrelated to the study, such as infants moving or referred from the NICU, leaving against medical advice, and disappearing without leaving an address during the survival period Incomplete card: when a variable could not be registered or missed on neonatal ICU feeding chart, internal referral paper, and infant medical card Survival time: Time in day that subjects (infants) spent since the start of trophic until full enteral feeding achieved Censored: Where subjects died after enteral feeding started, lost to follow-up (drop out), and failed to achieve full enteral feeding before 14 days of follow-up Event (Failure): The time when infants with a birth weight of 1000-2000g neonates reached full enteral feeding A retrospective cohort enrollment was completed for infants who were admitted to NICU. The study follow-up period was 14 days. This time is considered the average time when low birth-weight infants started to regain their birth weight, and it is also considered the time when early full enteral feeding should be achieved [ 14 – 16 ]. The data was collected using a checklist that was developed in English. Subjects were screened from the registration book by using a medical record number. Four NICU nurses who had a BSc degree in nursing and trained in NICU nurse’s training extracted data using the checklist; two medical doctors who have been working in NICU supervised the data collection. Data collectors were trained for one day about the whole course of data extraction, including familiarizing them with the tool, proper data handling, and organizing collected data. A pre-test was done on 10% of the study sample size in Yirgalem hospital neonatal ICU, which is closer but outside the proposed study area. The pre-test was used to test the clarity and understandability of the checklist. The variables and their definitions used for this study are listed below: Early-onset neonatal sepsis: Early-onset infections are acquired before or during delivery from birth to 7 days usually less than 72 hrs and diagnosed with Complete Blood Count with differential. Concern for sepsis if total WBC is abnormal (<5,000 or >20,000) and differential with granulocytes >70%. Antenatal steroid: Antenatal corticosteroids (at least 24–48 hrs. before delivery) given to pregnant women < 34 weeks of gestational period. A complete course of antenatal steroids is diagnosed if a full dose (4 doses of dexamethasone 6mg and 2 doses of betamethasone 12mg) is taken and if a single dose of these drugs is missed, this refers to incomplete. Gestational age: was estimated by using the last normal menstrual period (LNMP) if the mother can recall her last cycle. If not, an ultrasound supported by Ballard scores is used to assess the physical and neuromuscular maturity of the newborn shortly after birth. This helps to make consistent decisions on gestational age. Weight for gestational age (WFGA): was determined based on the International Newborn Size Standard charts and categorized the newborns as small for gestational age (SGA) whose weight for gestational age less than the 10 th percentile, appropriate for gestational age (AGA) those who are between the 10 th and 90 th percentile and large for gestational age (LGA) those greater than 90th percentile. Maintenance fluid: Immediately after birth, following admission, intravenous fluid (80–100 ml/kg/day) composed of 10% dextrose and water started as parenteral nutrition. This has to be advanced by 20 ml/kg/day for the next consecutive days depending on the hydration status of the infant. After the second day of life, other electrolytes like sodium chloride are considered in addition to glucose. Enteral nutrition: After 24–48 hours of postnatal age, enteral feeding started bilaterally with intravenous fluid as trophic. A small amount of expressed human breast milk or formula milk- 10-20ml/kg/day with a frequency of 3 to 4 times a day is introduced to stimulate and enhance gut function. Daily evaluation of feeding status done by a senior physician every morning and decision made on the way feeding progresses (progressive feeding). This includes escalating the feed by 10–20 ml/kg/day for the date, holding the feed, or keeping it at nothing per os (NPO). As the level of tolerance of the gut increases the need for intravenous fluid becomes less important. This results in reaching full enteral feeding, where intravenous fluid is discontinued and keep the feeding at the volume of 140–150 ml/kg/day or calories of 110–120 kcal/kg/day. Feeding intolerance (FI): is diagnosed when infants develop either one or more of the following abdominal conditions: vomiting more than 3 times in 24 hours, gastric residual more than 50% before the next feeding, altered aspiration on NGT or OGT (bloody, green, bilious, etc.) and abdominal distension with visible bowel (abdominal girth>2 cm since the last assessment). Necrotizing enterocolitis (NEC): this is considered if feeding intolerance progress in a worsened form and this may be supported by the unstable vital sign plus or minus abnormal abdominal radiography. The data was checked from the checklist for completeness and entered Epi. data version 3.1. The data was then exported to SPSS (Statistical Package for Social Science) version 20 for analysis. Data were cleaned, recorded, categorized, and sorted to facilitate the analysis. Demographic, obstetrics, and clinical characteristics of the study subjects were summarized using descriptive statistics. The Kaplan-Meier estimator was used to calculate the median time to achieve full enteral feeding. Variance inflation factor (VIF) <10 and tolerance statistics > 0.1, were used to conduct a Collinearity diagnostic test to check for the existence of multi-collinearity among the explanatory variables. A bivariate cox-proportional hazard regression model was used to analyze the association of factors with the time at which full enteral feeding was achieved. Variables that were associated with time to full enteral feeding at 0.25 significant levels in the bivariate model were included in the final multivariable model [ 17 ]. Multivariable Cox-proportional hazard models were fitted to assess the association of the time at achieving full enteral feeding with factors. Adjusted hazard ratios with their 95% Confidence Interval (CI) were estimated and P-value less than 0.05 was used to declare the presence of a significant association. Log (-log (st)) plot was used to check the proportional hazard model assumptions. The ethical approval letter, with a reference number of IRB/270/12, was obtained from the Institutional Review Board (IRB) of the College of Medicine and Health Sciences, Hawassa University. The research involves minimal risk, as the review of subjects’ medical records is for limited information. Moreover, the information is not sensitive, and the data are derived from routine, clinically indicated procedures. The need for informed consent was waived or not required as we were doing a retrospective cohort study, and official permission was obtained from HUCSH and Adare general hospital ethical issue concerned bodies. Information that was collected was kept confidential through coding and omitting personal identification. The data were used for research purposes only. The study was conducted per the World Medical Association Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects. Of the 1017 medical records, (n = 5) were excluded due to major congenital malformations, (n = 192) due to records with missing data, (n = 215) due to death before initiation of enteral feeding, (n = 2) due to newborns never received enteral feeding because of surgical intervention. Among the eligible (603) medical records, 273 of them were extracted for the final analysis. Almost all (93.8%) of the mothers of infants were married; 39.6% of mothers were aged 21–25 years, and 49.1% were null parity. Six percent (5.5%) of the mothers did not have any ANC follow-up for the current pregnancy. More than half (55.3%) of the neonates were born by cesarean section (CS) and 19.8% of pregnancies resulted in multiple pregnancy outcomes. Among mothers of LBW infants, 50.2% of mothers had pregnancy-induced hypertension, and 26.4% of them had severe pre-eclampsia. About 40.3% of the mothers who were expecting preterm delivery received antenatal steroid prophylaxis. Among those who received antenatal steroid prophylaxis, only 23.1% of them completed the full course of the treatment. Furthermore, 12.5% of the mothers had a history of prolonged rupture of the membrane. However, only 3.2% of them developed complications and had chorioamnionitis “ ”. Table 1 As shown in “ out of 273 infants, 55.7% were male. The mean (SD) of gestational age (GA) and birth weight was 33.8 (1.3) weeks and 1578 (245.9) grams, respectively. Infants with a birth weight of 1000-2000g in this cohort, those whose birth weight is between 1000-1500g less likely to achieve full enteral feeding earlier than 1500-2000g with a mean value of 7.31 vs 5.72days, respectively “ Table 2 ” Among those infants who were included in this study, 20.5% were small for their gestational age (SGA) (less than the 10th percentile). Of the neonates, 30.4% were treated for clinical sepsis (early-onset neonatal sepsis). The Apgar score, determined in the 1st and 5th minutes, was low for 53.1% and 20.5% of infants, respectively. Respiratory distress syndrome was also diagnosed in more than half of low-birth-weight infants (53.2%). Of the participants, 7 (2.6%) and 9 (3.3%) were fed on formula and mixed types of milk, respectively “ Fig 2 ”. ”. Table 2 Follow-up and full enteral feeding attainment patterns of the cohort, as shown in the figure below, from those who were in this cohort, 100(36.6%) were censored due to: death 83 (30.4%), losses to follow-up 6(2.2%), and not experiencing full enteral feeding attainment before the study end 11(4.02%). Of those who are in this cohort, 30.4% of them were dead after enteral feeding had started this is due to RDS, EONS, low Apgar score, etc. The mean (SD) of age when an enteral feed (trophic feeding) was first commenced was 2.13(1.373) days, and 63.4% of the neonates achieved full enteral feeding within 14 days. The median (IQR) time of attainment of full enteral feeding was 8 (7–10) days. The total person-time that the cohort yields in this study were 1,838 person-days (5.04 infant-years) of follow-up. The incidence rate of full enteral feeding achievement was calculated to be 9.4 per 100 person-day. As shown in “ , about 194 and 54 infants were likely to achieve full enteral feeding achievement on the 5th and 10th days of the follow-up, respectively. Fig 3 ” To determine which variables, determine the full enteral feeding achievement, maternal and neonatal clinical and obstetrics characteristics were assessed for their association with full enteral feeding achievement using cox regression. Variables that passed the bivariate analysis and multi-collinearity test were included in the multivariate analysis. Variables such as sex, marital status, pregnancy-induced hypertension, multiple pregnancies, antenatal steroid prophylaxis, Apgar score (at 1st and 5th min), mode of delivery, birth weight, type of milk, and resuscitation at birth failed to pass bivariate analysis at p-value less than 0.25 " Table 3 ”. Whereas gestational age, prolonged rupture of membrane (PROM), weight for gestational age (WGA), early-onset neonatal sepsis (EONS), respiratory distress syndrome (RDS), and neonatal hyperbilirubinemia were included in the final model. In the multivariate analysis, only gestational age and weight for gestational age were significantly associated with the time to full enteral feeding achievement. GA and WFGA were negatively associated with the time to full enteral feeding achievement. After adjustment for RDS, PROM, EONS and neonatal hyperbilirubinemia, GA reduces the time to full enteral feeding by 18.8%, GA (AHR = 0.812, 95%CI = (0.708–0.931, p-value = 0.003)). Being small for gestational age (SGA) reduced the time to full enteral feeding achievement by 70.4% as compared to appropriate for gestational age (AGA) (HR = 0.296,95%CI = (0.187–0.467), p-value = <0.001). A subgroup analysis between AGA and SGA shows Test Statistics (TS) = -5.134, and p-value = <0.001 “ ”. However, PROM, EONS, RDS, and neonatal hyperbilirubinemia were not statistically significant even if they were included in the last model “ Fig 4 ”. Table 4 HR: hazard ratio; CI: confidence interval **: p-value <0.01, Log (-log (survival)) plot used to test proportional hazards assumption for covariates Ref = Reference The present study explored the time that infants with a birth weight of 1000-2000g spend in NICU to achieve full enteral feeding. This study found that more than sixty percent of infants with a birth weight of 1000-2000g achieved full enteral feeding within 14 days of the follow-up period. They demonstrate a shorter time to achieve full enteral feeding as compared to other studies. The median time to reach full enteral feeding was 8 days with IQR (7–10 days), and the mean GA was 33.8 weeks. This is much lower than that was reported from Italy but higher from India, 13 days IQR (7–24 days) with a mean GA of 29+1 week and 7 days IQR (7–9.5 days) with a mean GA of 30.8 weeks, respectively [ 13 , 18 ]. There are also studies whose median time is slightly higher than that of the current findings from Italy, India, and the UK: 11 days IQR (7–20 days) with a mean GA of 29 weeks; 9.5 days with a mean GA of 35.5 weeks; and 11 days IQR (8–13 days) with median GA of 26 weeks, respectively [ 6 , 19 , 20 ]. This may be due to the difference in the mean gestational age between the two populations. The mean gestational age of the population in the current study was relatively higher than in the earlier study in Italy, India, and the UK. However, another multicenter study from UK was in line with the current finding, with a median time to achieve full enteral feeding of 8 days IQR (6–11 days) with the median gestational age of 32+2 weeks, provided that there is gestational age and clinical setup difference between the two populations [ 21 ]. As expected, higher gestational age was a predictor for the fastest achievement of full enteral feeding. As GA increases in a week, the time to achieve full enteral feeding decreases by 18.8%. This is slightly lower than a study from Italy, which was 15.5%, even though it is difficult to compare up-front with the current study regardless of issues like patterns of low birth weight and clinical variability [ 13 ]. There is evidence that as the gestational age increases, the time needed to reach full enteral feeding becomes shorter. This could be due to a well-developed and matured gastrointestinal system they have. Moreover, a well-developed and matured gastrointestinal tract abides by a minute and progressive volume of milk given as a treatment, which also determines the tolerance level of the feeding [ 2 , 13 , 22 ]. This in turn reduces the time that the neonates spend on trophic feeding and hospital stay, and reaches full enteral feeding earlier than those who are with small GA. Weight for gestational age (WFGA) was statistically significant, with full enteral feeding achievement. According to the result of this study, being small for gestational age (SGA) is protective- it reduces the time to full enteral feeding by 70.4% more than that of appropriate for gestational age (AGA). As previously mentioned, this may also be due to the gestational age difference in the category that increases gut development and maturation as gestational gets higher. Moreover, this could be due to failure in early initiation of enteral nutrition and advancement to full in infants with birth weight 1000-2000g with small GA, which is important in rapid maturation of the gastrointestinal system and lesserfeeding intolerance. There are a few similar studies that correlate being small for gestational age (SGA) with GI maturation. According to Patwardhan et al. [ 2 ], the time to full enteral feeding achievement was negatively affected by being SGA or not in the group. Furthermore, this study also concludes that SGA shows a reduction in time to full enteral feeding achievement as compared to AGA. This is also due to the difference in mean gestational age in these two groups, and mean GA being 30 weeks was compared with 32.9 weeks maturity in AGA and SGA, respectively. However, subgroup analysis between AGA and SGA shows Test Statistics (TS) = -5.134, and p-value = <0.001. Mihatsch et al. [ 23 ], also show that SGA with abnormal umbilical artery Doppler ultrasound and not SGA has no difference in reaching full enteral feeding. This study tried to compare very-low-birth-weight infants with SGA whose umbilical artery blood flow has resistance on Doppler ultrasound (placental insufficiency) and infants with a normal weight for gestational age. Therefore, more than 65.5% of SGA infants had abnormal doppler or a history of Pregnancy-induced hypertension. Attempts should have been designed to address limited practices of parenteral and enteral nutrition in infants who are admitted to the NICU. This study finding may be used as evidence to improve enteral feeding practices that are needed to reduce the risk of short and long-term adverse outcomes for infants due to extended periods of hospital stay. Variable that has possible confounder effects were early-onset neonatal sepsis and respiratory distress syndrome this may be adjusted in a model of multivariate cox regression. The major limitation of this study is a high percentage of attrition and missing data as a result of being a retrospective study. Furthermore, the study is limited to some clinical variables which need an advanced clinical setup to find out participants’ characteristics. According to this study, the time that the neonate takes to achieve full enteral feeding was relatively short. Gestational age and weight for gestational were the determinants for time to full enteral feeding achievement. Further research needs to be conducted to explore further, in addition to current findings. First of all, I would like to express my deepest gratitude and appreciation to Hawassa University, College of Agriculture, School of Nutrition, Food Science and Technology. We would like to extend our deepest gratitude and appreciation to Adare General Hospital and Hawassa University Comprehensive Specialized Hospital staff and administrative body for their invaluable support and guidance during data collection. Appropriate for Gestational Age Caesarian Section Expressed Breast Milk Early Onset Neonatal Sepsis Feeding Intolerance Gestational Age Hawassa University Comprehensive Specialized Hospital Low Birth Weight Neonatal Intensive Care Unit Necrotizing Enterocolitis Pregnancy Induced Hypertension Small for Gestational Age Southern Nations Nationality Peoples Region Spontaneous Vaginal Delivery Very Low Birth Weight World Health Organization Determinants of time to full enteral feeding achievement among infants with birth weight 1000-2000g admitted to the neonatal intensive care unit of public hospitals in Hawassa city, Sidama region Ethiopian, 2019: A retrospective cohort study Factors Associated with Time to Full Feeds in Preterm Very Low Birth Weight Infants Early Aggressive Nutrition in the Neonate In resource-limited areas complete enteral feed in stable very low birth weight infants (1000–1500 g) started within 24 h of life can improve nutritional outcomes Scientifically Based Strategies for Enteral Feeding in Premature Infants Delayed introduction of progressive enteral feeds to prevent necrotizing enterocolitis in very low birth weight infants Prevention of postnatal growth restriction by the implementation of an evidence-based premature infant feeding bundle Delayed initiation of enteral feeds is associated with postnatal growth failure among preterm infants managed at a rural hospital in Uganda Early Total Enteral Feeding in Stable Very Low Birth Weight Infants: A Before and After Study A prospective randomized trial of feeding methods in very low birth weight infants Predictors of Full Enteral Feeding Achievement in Very Low Birth Weight Infants Very early feeding in stable small for gestational age preterm infants: a randomized clinical trial ଝ Low Birthweight Neonates: Aspects of Feeding in Resource-limited Settings Postnatal weight gain patterns in preterm very-low-birth-weight infants born in a tertiary care center in South India Survival Analysis of Under-Five Mortality of Children and its Associated Risk Factors in Ethiopia Slow versus rapid enteral feeding advancement in preterm newborn infants 1000–1499 g: a randomized controlled trial Feeding Practices in Very Preterm and Very Low Birth Weight Infants in an Area Where a Network of Human Milk Banks Is in Place Early progressive feeding in extremely preterm infants: A randomized trial Multicentre prospective observational study of feeding practices in 30–33 weeks preterm infants (AGA) as compared to those small for gestational age (SGA) Early feeding advancement in very-low-birth-weight infants with intrauterine growth retardation and increased umbilical artery resistance |
Answer the following medical question. | What does research say about Predictors of neonatal mortality among neonates admitted to the neonatal intensive care unit at Hawassa University Comprehensive Specialized Hospital, Sidama regional state, Ethiopia.? | Despite promising efforts, substantial deaths occurred during the neonatal period. According to estimates from the World Health Organization (WHO), Ethiopia is among the top 10 nations with the highest number of neonatal deaths in 2020 alone. This staggering amount makes it difficult to achieve the SDG (Sustainable Development Goals) target that calls for all nations to work hard to meet a neonatal mortality rate target of ≤ 12 deaths per 1,000 live births by 2030. We evaluated neonatal mortality and it’s contributing factors among newborns admitted to the Neonatal Intensive Care Unit (NICU) at Hawassa University Comprehensive Specialized Hospital (HUCSH). A hospital-based retrospective cross-sectional study on neonates admitted to the NICU from May 2021 to April 2022 was carried out at Hawassa University Comprehensive Specialized Hospital. From the admitted 1044 cases over the study period, 225 babies were sampled using a systematic random sampling procedure. The relationship between variables was determined using bivariate and multivariable analyses, and statistically significant relations were indicated at p-values less than 0.05. The magnitude of neonatal death was 14.2% (95% CI: 0.099–0.195). The most common causes of neonatal death were prematurity 14 (43.8%), sepsis 9 (28.1%), Perinatal asphyxia 6 (18.8%), and congenital malformations 3 (9.4%). The overall neonatal mortality rate was 28 per 1000 neonate days. Neonates who had birth asphyxia were 7.28 times more probable (AOR = 7.28; 95% CI: 2.367, 9.02) to die. Newborns who encountered infection within the NICU were 8.17 times more likely (AOR = 8.17; 95% CI: 1.84, 36.23) to die. The prevalence of newborn death is excessively high. The most common causes of mortality identified were prematurity, sepsis, perinatal asphyxia and congenital anomalies. To avert these causes, we demand that antenatal care services be implemented appropriately, delivery care quality be improved, and appropriate neonatal care and treatment be made available. The neonatal mortality rate (NMR), which is the number of neonatal deaths per 1,000 live births in a given year, is a crucial sign of population health [ 1 – 5 ]. Around the moment of delivery, there is a heightened risk of mortality and severe morbidity. Perinatal mortality is the term used to describe the deaths of babies that occur between the weeks of gestation 28 and birth, including stillbirths and early neonatal deaths [ 2 ]. The first 28 days of life, or the neonatal phase, are a very vulnerable time for the baby as they complete several physiological changes needed for extrauterine existence [ 6 , 7 ]. The neonatal intensive care unit (NICU), which uses advanced equipment and skilled staff to effectively offer specialized care for neonates, admits newborns who require immediate medical attention [ 8 ]. The result of the intricate interactions between neonatal, maternal, and healthcare-related factors is neonatal mortality. Neonatal mortality can be decreased by recognizing and comprehending aspects such as prenatal care, birth methods, and labor. Neonatal mortality continues to play a significant role despite the fact that significant efforts have been made and improvements in the under-five mortality rate have been observed. Neonatal deaths made up around half of the 5.3 million deaths of children under five worldwide [ 9 ]. The target 3.2 of the Sustainable Development Goals (SDGs) of reducing newborn mortality to at least 12 per 1,000 live births must be achieved in just around seven years [ 10 ]. According to the Ethiopian Mini-Demographic Health Survey (Mini-EDHS) study, newborn mortality is likely to increase, rising from 29 per 1,000 live births in 2016 to 33 per 1,000 live births in 2019 [ 11 ]. Notably, newborn deaths account for 56% of the under-five mortality rate in Ethiopia [ 11 ]. If maximum wide-ranging implementation tactics are not used to reduce neonatal death, Ethiopia risks missing SDG target 3.2. In order to prevent neonatal deaths and track the effectiveness of public health initiatives, it is crucial to establish the cause and contributing factors of mortality. Knowing the disease patterns and causes in the Neonatal Intensive Care Unit (NICU), as well as the disease-specific mortality rate, can help guide the necessary efforts to reduce morbidity and mortality. There are no published documents that address this topic to our knowledge, so the goal of this study was to document the burden of neonatal death and to identify the predictors of neonatal death among admitted newborns at Hawassa University Comprehensive Specialized Hospital’s NICU (HUCSH). This study was aimed at assessing neonatal deaths and evaluating predictors of death in neonates admitted to the NICU of HUCSH. The study area was Hawassa City, which was located in the Sidama region on the shore of Lake Hawassa in the Great Rift Valley, 273 km south of Addis Ababa. Our research has been conducted at Hawassa University’s comprehensive specialized hospital, which was established 16 years ago by the Regional Health Bureau. The hospital was intended to serve the 3.5–5 million total population at the beginning and now serves the whole Sidama region, Southern Nations Nationalities and Peoples Region (SNNPR), and part of the Oromia region. HUCSH has a total of seven departments and fourteen units. Pediatrics and child health is one of the departments, where around 15,000 pediatric patients are treated per year. The HUCSH NICU, inaugurated in 2014, has 35 beds equipped with advanced technologies for neonatal care. It is supported by multidisciplinary care and provides level III neonatal care. There are a total of 28 nurses assigned to the NICU. A consultant neonatologist, trained nurses, and pediatricians, together with pediatric residents and medical interns, provide services 24/7. It has four main classes: preterm, term, Kangaroo Mother Care (KMC), and backside. It is located near the hospital’s obstetric ward to receive high-risk newborns from this ward as quickly as possible. Apart from the hospital’s obstetric ward, the unit also receives neonates referred from other health facilities and homes. The unit has 14 radiant warmers, 4 Continuous Positive Airway Pressure (CPAP), phototherapy, and oxygen concentrator machines. The unit provides outpatient and inpatient services, with estimated admissions of 100–150 newborns per month for inborn neonates as well as referred babies from surrounding provinces. Annual admissions at the NICU during the study period were 1044. A facility-based retrospective cross-sectional study of chart review was performed for the assessment of neonatal death ,and searching for predictors of death at HURH NICU over the past year prior to the study period(May 2021 to the end of April 2022), and the study period was from May 2022 to August 2022. All neonates who were admitted to NICU of HUCSH, Hawassa, Ethiopia during the study period. All systematically selected neonates that fulfilled the inclusion criteria who were admitted to the NICU of HUCSH, Hawassa, Ethiopia during the study period. All neonates who were admitted in the NICU of HUCSH and registered as died or alive within the first 28 days during the study period. All neonates who were admitted in the NICU of HUCSH and registered as died or alive within the first 28 days during the study period. Medical records with incomplete information for the outcome variables. Medical records with incomplete information for the outcome variables. Neonatal mortality- which was dichotomized as 1 if neonates had died and 0 if not. Neonatal mortality- which was dichotomized as 1 if neonates had died and 0 if not. Socio-demographic characteristics of the mother and the newborn Socio-demographic characteristics of the mother and the newborn Maternal Age Residence Ethnicity Occupation and income ANC follow up Maternal Age Residence Ethnicity Occupation and income ANC follow up Age Residence Ethnicity Occupation and income ANC follow up Neonatal Sex Age Neonatal Sex Age Sex Age 2. Obstetric factors Obstetric factors Birth weight Mode of delivery Gestational age Apgar/immediate crying Resuscitation at delivery Duration of labor Duration of rupture of the membrane Maternal fever Parity Prior pregnancy loss Birth weight Mode of delivery Gestational age Apgar/immediate crying Resuscitation at delivery Duration of labor Duration of rupture of the membrane Maternal fever Parity Prior pregnancy loss 3. Neonatal inpatient conditions Neonatal inpatient conditions Evidence of sepsis Length of stay before discharge (alive/death) Time during death date Evidence of sepsis Length of stay before discharge (alive/death) Time during death date Neonatal mortality is the death of the newborn during the first 28 completed days after live birth (days 0–27) after admission to the NICU and before discharge, as confirmed and recorded on the chart. Early neonatal death is a death during the first 7 completed days after live birth (days 0–6). Antenatal care visit: any history of visit or follow-up during the current or index pregnancy at any health institution for a checkup of pregnancy and designated or recorded on a chart. Intrapartum complications are complications that occur after the onset of labor, including intrapartum bleeding, obstructed labor, prolonged labor, eclampsia, chorioamnionitis, and others. Congenital malformation is a body deformity or deformities, structural or functional anomalies, that occur during intrauterine life and can be identified prenatally, at birth, or sometimes only later in infancy, and that is believed to have an impact on the health of the baby. It is diagnosed and recorded on charts by professionals on admission. Hypoglycemia is a measure of low blood glucose (40 mg/dl) that was diagnosed and recorded on charts by professionals on admission. Hypothermia is a low-body temperature measurement (< 36.5 °C), diagnosed and recorded on or during admission of neonates. Birth asphyxia is diagnosed whenever a neonate has an APGAR score of 6 in the 5th minute and/or if he or she does not cry immediately after birth, has respiratory distress, floppiness, loss of consciousness, the presence of convulsions, and a loss of neonatal reflexes. Birth weight is classified using the WHO weight classification: very low birth weight is any child with a birth weight of 1,500 g, while low birth weight is any child with a birth weight of 2,500 g. Premature rupture of membranes (PROM) is the spontaneous leakage of amniotic fluid from the amniotic sac, occurring after 28 weeks of gestation and before the onset of labor. It was diagnosed and recorded on charts by professionals on admission. Prolonged rupture of membranes (PROM) is considered when the duration of the leakage is more than 18 h before delivery. The sample size was calculated by using a single population proportion formula with assumptions of a confidence level of 95% = 1.96, a margin of error (d) = 0.05, and the magnitude of neonatal death ( p = 0.23) from a previous study conducted at the NICU of Gondar Referral Hospital [ 15 ].Considering a 10% incompleteness rate, the final sample size was 235. The study participants were selected by systematic random sampling using the registration numbers of the neonates. Among a total of 1044 neonatal registration numbers, every fifth participant was selected. The first study unit was selected using the lottery method. Estimation of neonatal mortality rate (NMR): The median follow-up period of selected risky neonates for the study was determined. The product of the number of days of the median follow-up period and the total number of neonates followed gives neonate-days. The overall incidence of neonatal mortality was calculated as a ratio of neonatal deaths to neonate days per 1000 neonate days. A data extraction checklist that was modified and adjusted from various literary works was used to review the medical records and collect the data [ 15 , 16 ]. The following variables were included in the data using the data collection tool: the clinical diagnosis at admission, sex, maternal and neonatal age, complications during pregnancy, gestational age, antenatal care visits, birth weight, place of birth (HUSCH, other, or home), the neonate’s body temperature, random blood sugar at admission, the mode of delivery, the outcome (survival or death) at discharge, and the length of stay prior to discharge. The International Classification of Diseases in its tenth iteration (International Statistical Classification of Diseases and Related Health Problems, ICD-10-WHO, version 2015) was used to classify clinical diagnoses (congenital deformity, prematurity, birth asphyxia, infection). A data-gathering tool that was properly designed and structured was used. During data collection and data input, data collectors were trained and strictly supervised. The data collectors were medical interns and residents undergoing training to improve their comprehension and interpretation of patient medical charts. The lead investigator cross-checked 10% of the gathered data with medical records and ensured its consistency after data collection. At the end of each day, the data were reviewed for completeness and consistency. It was cleaned, modified, programmed, and entered into EpiData software version 4.6. The data were then exported into SPSS 25 for statistical analysis. During the analysis, the frequency distribution and percentage of various variables were computed to describe and summarize the respondents’ basic socio-demographic characteristics. To provide an overview of the variables, the findings were presented in the form of frequency tables, pie charts, and graphs. Neonatal survival (lived or died within the neonatal period of 28 days) was defined as the binary outcome for bivariate and multivariate studies examining risk factors. Binary regression analysis was used to first look into the bivariate relationship between each independent variable and the result. To reduce the impact of confounding variables and pinpoint the primary causes of inpatient neonatal death, the variables with a p-value of 0.20 during the bivariate analysis were used as candidate variables for a multivariate logistic regression analysis model. Neonatal mortality was determined using an adjusted odds ratio (AOR) at a 95% confidence interval (CI) to demonstrate the strength of the link, and statistical significance was deemed to exist at a p-value of 0.05. The Chi square and Fisher’s exact tests were used to determine the statistical significance of the differences between the groups. The median follow-up time for the study’s risky neonates was established. Neonatal days are calculated as the median follow-up period divided by the total number of neonates followed. The ratio of neonatal fatalities to neonatal days per 1,000 neonatal days, which represents the total incidence of neonatal mortality. During the most recent one-year study period, a total of 1044 neonates admitted to the NICU were registered in the HIMS registry book. Of these, 225 neonates’ charts were reviewed and included in the study. Out of the 235 newborns who were chosen, 10 had medical records that were incomplete; therefore, 225 cases were chosen with an overall review rate of 96%. In the 225-person sampled retrospective survey study group, 127 (56.4%) of the babies were boys born to mothers who were between the ages of 18 and 45. The median age of the neonatal mothers, who made up 84% of the population, was 26 years old. Within the first 24 h of life, 154 neonates (68.4%) were admitted, and between one and seven days, 42 newborns (18.7%) were admitted, making up roughly two thirds of the total. Additionally, with a median of 5.0 days and an interquartile range of 9 days, the average length of stay in neonatal critical care units was 8.1 days. (Table 1 ). Table 1 Socio-demographic characteristics of neonates and mothers of the neonates admitted at the NICU of the HUCSH, Southern Ethiopia, 2022 Variable Categories Neonatal Outcome p -value Death Survival Maternal age in years < 20 1 (9.1%) 10 (90.9%) 0.317 20–34 25 (13.2%) 164 (86.8%) Reference ≥ 35 6 (24.0%) 19 (76.0%) 0.157 Sex of Neonates Female 15 (15.3%) 83 (84.7%) Reference Male 17 (13.4%) 110 (86.6%) 0.683 Age of neonates at admission in day/s < 1 25 (16.2%) 129 (83.8%) Reference 1–6 5 (11.9%) 37 (88.1%) 0.209 ≥ 7 2 (6.9%) 27 (93.1%) 0.492 Socio-demographic characteristics of neonates and mothers of the neonates admitted at the NICU of the HUCSH, Southern Ethiopia, 2022 About a quarter, 54 (24%) of mothers of neonates, had suboptimal, less than four Antenatal Care (ANC), follow-up visits before the delivery of the current newborns. Ten (4.4%) of the mothers had no ANC follow-up. There were 8 (3.6%) mothers who gave birth at their homes. The majority, 204 (90.7%) of mothers, had singleton deliveries. In this study, ninety-eight (43.6%) of mothers were primiparous. Sixty-three (28%) of the mothers had delivered for the second time; a single mother (0.9) was found to have a total of nine delivery histories. One-fifth, or 46 (20.4%), of mothers of neonates encountered index pregnancy complications like preeclampsia (16), chorioamnionitis (8), antepartum hemorrhage (7), eclampsia (5), and others (diabetes mellitus, obstructed labor, poly/oligohydramnios) (10). Thirty-eight (17.5%) of the mothers faced intraprtum complications like prolonged rupture of the membrane (PROM) before the onset of labor, which occurred in 20 (8.9%) of the mothers, while non-reassuring heart rate pattern (NRHRP) with bradycardia or tachycardia secondary to meconium-stained amniotic fluid was documented in 12 (5.3%) of the parturient mothers. The proportion of neonates directly transferred from the obstetric ward of HUCSH was 71.6% (161), greater than referred cases, 28.4% (64).) (Table 2 ). Table 2 Maternal obstetric characteristics of neonates admitted to the NICU of the HUCSH, Southern Ethiopia, 2022 Variable Categories Neonatal Outcome p -value Death Survival Number of ANC ≥ 4 visits 19(13.2%) 152(13.2%) Reference 1–3 visits 9 (20.5%) 35(79.5%) 0.015 No single visit 4 (40.0%) 6 (60.0%) 0.106 Place of delivery Health institution 30 (13.8%) 187 (86.2%) Reference Home 2 (25.0%) 6 (75.0%) 0.384 Type of pregnancy Singleton 28 (13.7%) 176 (86.3%) Reference Multiple 4 (19.0%) 17 (81.0%) 0.508 Parity < 2 12 (12.2%) 86 (87.8%) Reference 2–4 15 (13.6%) 95 (86.4%) 0.766 > 4 5 (29.4%) 12 (70.6%) 0.075 Index pregnancy complications No 24(13.4%) 155 (88.6%) Reference Yes 8 (17.4%) 38 (82.6%) 0.491 Intrapartum complications No 23 (12.8%) 156 (87.2%) Reference Yes 9 (23.7%) 29 (76.3%) 0.092 Duration of PROM < 18 h 27 (13.2%) 178 (86.8%) Reference ≥ 18 h 5 (25.0% ) 15 (75.0%) 0.157 Admission status Transferred 24 (14.9%) 137 (85.1%) Reference Referred in 8 (12.5%) 56 (87.5%) 0.641 Maternal obstetric characteristics of neonates admitted to the NICU of the HUCSH, Southern Ethiopia, 2022 About a quarter of the newborns, 55 (24.4%), were less than 37 weeks of gestational age. One neonate (0.4%) was born post term. However, 59 (26.2%), 14 (6.2%), and 2 (0.9%) of the hospitalized neonates were LBW, VLBW, and ELBW, respectively. Regarding the major vital signs of neonates at admission, the respiratory rate was normal for 119 (52%) neonates; approximately one-third, 68 (30.2) and 43 (19.1%), were hypothermic and febrile, respectively. Hypoglycemia was found in 14 (6.2%) of the infants. Perinatal asphyxia was observed in 25 (11.1%) of the neonates, as shown by either failure to cry shortly after birth, necessitating resuscitation, a low Apgar score, or both. 122 (54.2%) of the neonates were admitted with the diagnosis of early or late-onset sepsis or infection inside the NICU setting. Hospital-acquired infection (HAI) was found in 11 (4.9%) of the newborns who died in the NICU. The 37 (16.4%) newborns were found to have a variety of congenital abnormalities. Meningomyelocele (MMC) was the commonest (12, 5.5%) malformation, followed by anorectal malformations (3), Hirschsprung’s disease (3), small intestinal atresia (3), congenital heart disease (2), choanal atresia (2), bladder extrophy (2), cleft lip and palate (2), and others (tracheoesophageal fistula, hypospadias, encephalocele, Aqueductal stenosis, Edward syndrome, Down syndrome) (1 each). After admission, fifty eight (25.7%) neonates either presented with or developed neonatal hyperbilirubinemia or jaundice. (Table 3 ). Table 3 Neonatal-related characteristics of neonates admitted to the neonate intensive care unit (NICU) of the HUCSH, Southern Ethiopia, 2022 Variable Categories Neonatal Outcome p -value Death Survival GA (wks) ≥ 37 12 (7.1%) 158 (92.9%) Reference < 37 20(36.4%) 35 (63.6%) 0.001 Birth (g) 2500–3999 9 (6.4%) 131 (93.6%) Reference < 2500 23 (30.7%) 52 (69.3%) 0.001 Respiratory rate ( breath/min) 31–60 13 (10.9%) 106 (89.1%) Reference ≥ 61 16 (15.7%) 86 (84.3%) 0.019 ≤ 30 3 (75.0%) 1 (25.0%) 0.007 Body temperature( O C) 36.5–37.5 11 (9.6%) 103 (90.4%) Reference ≥ 37.6 4 (9.3%) 39 (90.7%) 0.048 < 36.5 17 (25.0%) 51 (75.0%) 0.007 Hypoglycemia No 27 (12.8%) 184 (87.2%) Reference Yes 5 (35.7% ) 9 (64.3%) 0.025 Perinatal asphyxia No 24 (12.0%) 176 (88.0%) Reference Yes 8 (32.0%) 17 (68.0%) 0.010 Sepsis No 13 (12.6%) 90(87.4%) Reference Yes 19 (15.6%) 103 (84.4%) 0.570 Hospital acquired infection No 21 (10.9%) 172 (89.1%) Reference Yes 11 (34.4%) 21 (65.6%) 0.001 Congenital malformations No 20 (13.2%) 132 (86.8%) Reference Yes 7 (18.9%) 30 (81.1%) 0.372 Jaundice No 24 (14.4% ) 143 (85.6%) Reference Yes 8 (13.8%) 50 (86.2%) 0.914 Neonatal-related characteristics of neonates admitted to the neonate intensive care unit (NICU) of the HUCSH, Southern Ethiopia, 2022 Respiratory rate ( breath/min) The majority of the neonates admitted to the HUCSH NICU, 193 (85.8%), were discharged alive, while 32 (14.2%) died before discharge. As a result, the prevalence of newborn death was 14.2% (95% confidence interval: 0.099–0.195). The average hospital stay for the 225 hospitalized neonates was 5 days, accounting for 1,125 neonate-days in the study. Taking 32 neonatal fatalities over the follow-up period into account, the overall neonatal mortality rate was 28 per 1000 neonate days. The majority, 23 (71.9%) of neonates perished before their first seven days of life, and three (9.4%) died on the first day of life. Prematurity (14, 43.8%), sepsis (9, 28.1%), prenatal asphyxia (6, 18.8%), and congenital abnormalities (3, 9.4%) were the most frequent causes of newborn death. Six (42.9%) of the newborns with sepsis were also diagnosed with prematurity as their direct cause of death. Despite birth asphyxia being listed as the initial cause of death, two (33.3%) of the neonates additionally developed sepsis. Additionally, sepsis was present in 2/3 (66.6%) of neonatal deaths that were attributed to congenital deformity as the direct cause of death. Two (14.3%) of the newborns who died from asphyxia were preterm. Numerous factors, including the number of ANC visits, parity, intrapartum complications, premature rupture of the membranes (PROM), neonatal gestational age (GA), neonatal birth weight, hypothermia, hypoglycemia, perinatal asphyxia, and hospital-acquired infection (HAI), were taken into consideration for multivariate binary logistic regression analysis to control the effect of confounders of binary logistic regression. Multivariate logistic regression research revealed significant relationships between variables such as neonatal gestational age, birth weight, hypothermia, hypoglycemia, perinatal hypoxia, HAI, and neonatal death. Neonatal mortality was more than 4 times more likely to occur in preterm neonates compared to those whose GA was at least 37 weeks (AOR = 4.21; 95% CI: 2.43, 8.69). Neonates with low birth weights were 5.12 times more likely to die from neonatal causes than infants with normal birth weights (AOR = 5.125; 95% CI: 1.56, 10.06). Neonatal mortality was 1.66 and 4.16 times more likely to happen in hypothermic and hypoglycemia neonates than in neonates without the conditions (AOR = 1.66; 95% CI: 1.56, 6.84) and correspondingly (AOR = 4.16; 95% CI: 1.80, 6.04). The odds of a neonate dying during their newborn period were 7.28 times higher for those who suffered birth asphyxia (AOR = 7.28; 95% CI: 2.367, 9.02) than for those who did not. When a newborn was infected in the NICU, neonatal mortality was 8.17 times more likely to occur (AOR = 8.17; 95% CI: 1.84, 36.23). (Table 4 ). Table 4 Factors affecting neonatal mortality at the NICU of the HUCSH, Southern Ethiopia, 2022 Variable Categories Neonatal Outcome COR with 95% CI AOR with 95% CI p -value Death Survival Number of ANC visits ≥ 4 19 (13.2%) 152 (13.2%) 1 1 Ref. 1–3 9 (20.5%) 35 (79.5%) 5.33 (1.38–20.62 2.36 (0.35–9.04) 0.381 No 4 (40.0%) 6 (60.0%) 2.59 (0.60–9.19) 2.18 (0.27–17.53) 0.465 Parity < 2 12 (12.2%) 86 (87.8%) 1 1 2–4 15 (13.6%) 95 (86.4%) 0.88 (0.39–1.99) 0.20 (0.42–11.28) 0.194 > 4 5 (29.4%) 12 (70.6%) 0.34 (0.10–1.12) 0.13 (0.41–12.53) 0.125 Intrapartumcomplications No 23 (12.8%) 156 (87.2%) 1 1 Ref. Yes 9 (23.7%) 29 (76.3%) 0.48 (0.20–1.13) 1.68 (0.40–7.05) 0.478 Duration of PROM < 12 h 27 (13.2%) 178 (86.8%) 1 1 Ref. ≥ 12 h 5 (25.0%) 15 (75.0%) 0.46 (0.15–1.35) 1.64 (0.29–9.31) 0.575 GA in weeks ≥ 37 12 (7.1%) 158 (92.9%) 1 1 Ref. < 37 20 (36.4%) 35 (63.6%) 7.52 (3.37–9.81) 4.21(2.43–8.69) 0.048 * Birth weight in grams ≥ 2500 9 (6.0%) 141 (94.0%) 1 1 Ref. < 2500 23 (30.7%) 52 (69.3%) 34.47 (9.84–12.74) 5.12 (4.01–12.34) 0.01* Hypother mia No 11 (9.6%) 103 (90.4%) 1 1 Ref. Yes 4 (9.3%) 39 (90.7%) 2.49 (1.15–5.38) 1.66 (1.56–6.84) 0.038 * Hypogly-cemia No 27 (12.8%) 184 (87.2%) 1 1 Ref. Yes 5 (35.7% ) 9 (64.3%) 3.78 (1.18–12.14) 4.16 (1.80–6.04) 0.03 * Perinatal asphyxia No 24 (12.0%) 176 (88.0%) 1 1 Ref. Yes 8 (32.0%) 17 (68.0%) 3.45 (1.34–8.85) 7.28 (2.367–9.02) 0.001 ** HAI No 21 (10.9%) 172 (89.1%) 1 1 Ref. Yes 11 (34.4%) 21 (65.6%) 4.29 (1.82–10.13) 8.17 (1.84–36.23) 0.02 * P * < 0.05, p * < 0.01, COR- Crude odds ratio, AOR-Adjusted odds ratio, CI-Confidence interval Factors affecting neonatal mortality at the NICU of the HUCSH, Southern Ethiopia, 2022 GA in weeks Birth weight in grams Hypother mia P * < 0.05, p * < 0.01, COR- Crude odds ratio, AOR-Adjusted odds ratio, CI-Confidence interval This study was done retrospectively on neonates admitted to NICU where intensive care is required to save the lives of newborns with critical clinical conditions and struggling to adapt to the new environment. In the developing world: poor quality of care during antenatal, intrapartum, and postpartum periods contributes most to neonatal mortality. Hence, continuous assessment is needed as neonatal mortality has not declined, rather, the mortality has continued to contribute a huge share (47%) of the overall under-5 mortality. According to the current study, the overall neonatal death rate was 28 per 1000 neonate days, and the proportion of neonatal loss was 14.2% (95% CI: 0.099–0.195). Studies conducted in Hiwot Fana Specialized University Hospital, Eastern Ethiopia, at 14.3% infant mortality rates were found to be congruent with this 14.2% neonatal death magnitude [ 17 ];Jimma University Medical Center, Southwest Ethiopia at 13.3% [ 18 ] and Dire Dawa city, Ethiopia at11.4% [ 19 ].But the finding was lower compared with studies conducted in Ghana at 20.2% (17); Debre Markos, Northwest Ethiopia, at 21.3% (18); Mizan Tepi University Teaching Hospital, Southwest Ethiopia, at 22.8% (19); and Gondar Referral Hospital, Northwest Ethiopia, at 23.1% (13). However, the prevalence of neonatal death was much higher than studies conducted in the Somali Region, Ethiopia, at 5.7% (20); the North Gondar Zone, Ethiopia, at 4.4% (21); and the East Wollega Zone, Ethiopia, at 6.6% (22). The neonatal hospital mortality rate of 28 per 1000 neonates-days was highly consistent with a similar study done in Wolaita Sodo, Ethiopia, at 27 per 1000 neonates-days (23). However, the finding was higher than the mortality rate determined in Hadiya zone, southern Ethiopia, at 25 per 1000 neonates-days(24).The discrepancy might be due to differences in sample sizes, in sociocultural and socioeconomic aspects, in health service utilization, including giving birth at health institutions by skilled care providers and health seeking for sick neonates, the variation in health institution setup, and economic disparities among study participants (19, 25, 26). As per this study, which is in line with many others, neonates delivered before 37 weeks of gestational age (GA) were measured as having a statistically significant association with the episode of neonatal mortality that was over 4 times more likely (AOR = 4.21; 95% CI: 2.43, 8.69) when compared to neonatal mortality in neonates with GA of 37 weeks and above. According to a study conducted in Rwanda, newborns born at gestational age (GA) less than 37 weeks had a 3.1-times higher mortality rate than newborns born at GA of 37 weeks or higher [ 20 ]. In addition, a study in Kenya found that the risk of newborn death attributable to prematurity is more than 7.0 times higher when compared to controls with a GA of 37 weeks and above [ 21 ]. Preterm babies are more likely to die than mature neonates by 3.3 and 2.5 times, respectively, according to research done in Adama and Dilla, Ethiopia [ 22 , 23 ]. Prematurity may lead to poor neonatal outcomes due to the immaturity of the respiratory and circulatory systems, susceptibility to infection, hypothermia, and failure to adjust to the external environment [ 24 – 27 ]. Newborns with low birth weights had a neonatal death rate that was 5.12 times higher than that of infants with normal birth weights (AOR = 5.125; 95% CI: 1.56, 10.06). According to reports, newborns with low birth weight (LBW) were 1.54 times more likely to die in hospitals than newborns with birth weights of 2500 g and higher. This relationship between low birth weight and neonatal mortality events was significant, according to the report of a study from Jimma, Ethiopia [ 18 ]; which is consistent with reports of studies from Adama, Ethiopia [ 22 ]and Dilla, Ethiopia [ 23 ] measuring 1.6 and 2.44 times more likely deaths to LBW neonates as compared to neonates with birth weight ≥ 2500 g. In keeping with a study from Wolaita, Ethiopia, neonates with low birth weights have a nine-fold higher risk of dying than those with normal birth weights [ 28 ]. Due to metabolic, hematologic, and immunological functions, low birth weight may increase the risk of infection and hypothermia [ 29 , 30 ]. Neonatal death was 1.66 times more likely in hypothermic newborns (AOR = 1.66; 95% CI: 1.56, 684) compared to neonates who were not hypothermic. The results were similar to a study in Dire Dawa, Ethiopia, that found babies with hypothermia had a 2.5 likelihood of neonatal death [ 16 ]. The association between hypothermia and conditions like hypotension, hypoxia, hypoglycemia, bradycardia, disseminated intravascular coagulation, irregular and sluggish breathing, and shock is one reason that has been proposed [ 31 ], which, in turn, increase the likelihood of death. Compared to neonates who were normoglycemic, neonates with neonatal hypoglycemia had an odds ratio of 4.16 (AOR = 4.16; 95% CI: 1.80, 6.04) for neonatal death. The prevalence is higher than the reported value from Macedonia, which was 2.38% [ 31 ]. The fact that hypoglycemia causes neurological impairment, bradycardia, irregular and slow breathing, and apnea may be an explanation for the substantial mortality rate in hypoglycemic neonates [ 32 ]. Birth asphyxia, defined as failing to breathe immediately after birth, requiring resuscitation after birth, or having a poor APGAR score, was associated with a 7.28 times greater likelihood (AOR = 7.28; 95%CI: 2.367, 9.02) of dying during the newborn period than those who were not asphyxiated. According to a study conducted in the Amhara area of Ethiopia, the prevalence of birth asphyxia was reported to be 22.6% [95% CI 19.2% − 26.4%] in the first minute of birth [ 33 ]; strongly linked with primipara, prolonged labor, and Prolonged membrane rupture. The prevalence of perinatal asphyxia in a report from Northwest Ethiopia (31) was 19.8% (95% CI: 15.9, 24.2), which was significantly associated with the absence of maternal formal education (AOR = 4.09, 95% CI: 1.25, 13.38), pregnancy-induced hypertension (AOR = 4.07, 95% CI: 1.76, 9.40), antepartum hemorrhage (AOR = 6.35, 95% CI: 1.68, 23.97), prolonged duration of labor (AOR = 3.69, 95% CI: 1.68, 8.10), instrumental delivery (AOR = 3.17, 95% CI: 2.19, 9.26), and meconium-stained amniotic fluid (AOR = 4.50, 95% CI: 2.19, 9.26). Neonatal sepsis is the main factor in neonatal morbidity and mortality on a global scale. According to this study, newborns who tested positive for a hospital-acquired illness were 8.17 times more likely to pass away than newborns who did not have HAI (AOR = 8.17, 95% CI: 1.84, 36.23). In various investigations, neonatal sepsis has been identified as a substantial risk factor for newborn mortality. The results of a study from Dilla, Ethiopia, showed that newborns with sepsis were 2.45 times more likely to die prematurely than neonates without sepsis [ 23 ]; which is similar to the report of a study in Adama, Ethiopia (19), which revealed neonates with sepsis were 2.4 times more likely to face death when compared to neonates who were not having sepsis. According to a report from a study conducted in Eastern Ethiopia, the total prevalence of sepsis was 45.8%, and it was strongly linked to things like prolonged membrane rupture, prelacteal feeding, and a low APGAR score [ 34 ]. A smaller sample size could reduce the representativeness of the source population, and the data was secondary, with the potential for incompleteness. The fact that we used glucose 40 mg/dl for defining hypoglycemia might have resulted in underdiagnoses especially on the first day of admission. Furthermore, because the study was cross-sectional, a cause-and-effect relationship might not be demonstrated. The prevalence of newborn death is excessively high. The most common causes of mortality identified were prematurity, sepsis, perinatal asphyxia and congenital anomalies. To avert these causes, and to remedy the disparities that have been identified, we demand that antenatal care services be implemented appropriately, delivery care quality be improved, and appropriate neonatal care and treatment be made available. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. All data collectors are greatly valued; however, a special gratitude goes out to the HUCSH consultant Neonatologist (Dr Fitsum Belay) for her exemplary dedication in improving the quality of the unit, and all the neonatology nurses in the NICU for availing the necessary data for this paperwork. KT, YK and DT conceived and designed the study. WK drafted the manuscript. KT, YK, and DT meticulously reviewed the manuscript and incorporated needed input. All authors read, provided feedback, and approved the final version of this article. All authors reviewed the manuscript. Hawassa University provided funding for this study as a requirement for the accomplishment of the Specialty in Pediatrics and Child Health, but the sponsor had no input into the study’s conception, analysis, or interpretation. The correspondent author will provide additional data of this article upon reasonable request. The institutional review board of Hawassa University Comprehensive Specialized Hospital (HUCSH) gave approval (ID: PGPediR/0014/12) for the study to proceed ethically. Additional approval for the use of medical records was received from the HURH medical director and the department head of pediatrics. As the information regarding this paper was collected by reviewing the patient’s file, the HUCSH ethics committee waived the requirement for informed consent. All along the procedure, the privacy of the data acquired was guaranteed. Not applicable (N/A). We, the paper’s authors, hereby declare that there are no existing or potential competing interests relating to the publication of this article. 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Answer the following medical question. | What does research say about A national retrospective review of neonatal critical care transfers in dedicated critical care transport services in the private sector.? | South Africa (SA) has a shortage of dedicated neonatal critical care services, which are mostly concentrated in urban areas, thus illustrating the need for neonatal critical care transport (CCT) services. Neonates who are transported by teams without the requisite experience and knowledge in neonatal care are at risk of severe adverse events during transport. This has led to the development of dedicated CCT teams by some emergency medical services. There is a paucity of national literature describing the neonatal population who undergo CCT in dedicated services. To describe a sample of neonates who underwent CCT transfer by dedicated CCT services in the private sector in SA. This observational cohort study with a retrospective descriptive design sampled all neonatal transfers completed during 1 year (1 January 2017 - 31 December 2017) from the dedicated CCT of the two largest national emergency medical services in SA. Data were extracted from patient report forms by trained data extractors, and subjected to descriptive analysis. A total of 444 neonates were transferred between the two services. A total of 760 diagnoses were recorded, yielding an average of ~2 diagnoses per patient. The most prevalent diagnosis was respiratory distress syndrome (n=139, 31%), followed by congenital heart defects (n=123, 28%) and prematurity (n=81, 18%). Patients had an average of ~4 attachments, with the most prevalent being patient monitoring (n=677, 152%). Just under half (n=182, 41%) of patients required ventilatory support. A total of 422 medications were required during transport, yielding a rate of ~1 medication or infusion per neonate transported. The most common infusion was maintenance (n=199, 45%), while almost 1 in 10 neonates required inotropic support (n=33, 7%). This study provides insight into the demographics, most prevalent diagnoses, and interfacility transfer monitoring needs of neonates being transported in SA by two private dedicated CCT services. The results of this study should be used to inform future specialised neonatal CCT courses and qualifications, as well as the scopes of practice of providers transporting neonates. |
Answer the following medical question. | What does research say about Neonatal end-of-life spiritual support care.? | The death of an infant is a profound loss that may complicate, disrupt, or end relationships between parents; and lead to maladaptive grieving, long-term decreased quality of life, and symptoms related to psychological morbidity. Facing neonatal loss is frequently experienced as traumatic assault on parents' spiritual and existential world of meaning. This article highlights the importance of supporting parents through loss by providing comprehensive care that focuses not only on the neonate's physical needs, but also addresses parents' and families' spiritual, religious, and existential needs. Our objective is to increase practitioners' awareness of spiritual and existential distress and to provide strategies to address such needs, particularly at the end of life. |
Answer the following medical question. | What does research say about Neonatal nosocomial infections.? | Nosocomial acquisition of infection is now the most common mode of transmission of infection in neonatal intensive care units (NICUs). Surveillance studies have shown rates of infection in the NICU of 15% to 20%, which are as high as those in adult medical or surgical ICUs and higher than those in most pediatric ICUs. Studies of NICU nosocomial infections have pinpointed the use of indwelling vascular catheters, high-calorie hyperalimentation infusions, assisted ventilation, and prior use of antibiotics as significant risk factors for infection. Strategies to reduce nosocomial infections with the use of prophylactic antibiotics, immunoglobulins, and physical barriers have been unsuccessful. New methods of reducing risk factors and enhancing the neonate's resistance to infection are badly needed. |
Answer the following medical question. | What does research say about Randomized clinical trial of the effect of the onset time of skin-to-skin contact at birth, immediate compared to early, on the duration of breastfeeding in full term newborns.? | Skin-to-skin contact (SSC) compared to separation at birth has a positive effect on breastfeeding. However, separation at birth is common with negative impact on breastfeeding. The aim was to determine the effect of immediate SSC compared to early SSC on the duration of exclusive breastfeeding. A randomized multicentre parallel clinical trial was conducted in two hospitals in Cundinamarca (Colombia) between November 2018 and January 2020. Low-risk full term newborns at birth were included. Neonates were assigned to immediate (in the first minute after birth) or early onset (start exactly at 60 min of life) skin to skin contact. Monthly follow-up was performed until 6 months of age. The primary outcome was the percentage of exclusively breastfed infants at 6 months (time in months with human milk as the only source of food). Secondary outcomes were the percentage of infants with exclusive breastfeeding at 3 months, duration in months of exclusive breastfeeding, neonate’s breastfeeding ability, percentage of weight change between birth and the first week of life and hospitalization in the neonatal unit in the first week. A bivariate analysis was performed to determine the variables associated with exclusive breastfeeding at 6 months. A survival analysis was performed to evaluate the effect of the onset of SSC on exclusive breastfeeding duration. A total of 297 newborns were included: 49.8% ( n = 148) in the immediate SSC group, and 50.2% ( n = 149) in the early SSC group. The mean duration of exclusive breastfeeding in both groups was 5 months. There were no differences between the groups in the percentage of exclusive breastfeeding at 6 months (relative risk [RR] 1.06, 95% CI 0.72, 1.58) or in the duration of exclusive breastfeeding (hazard ratio [HR] 0.98, 95% CI 0.74, 1.28). The percentage of infants and the duration of exclusive breastfeeding in the first 6 months of age were the same between the two groups of SSC interventions. Given the current barriers to its implementation, the results of this study could positively impact the use of SSC at birth and standardize the intervention and improve breastfeeding indicators. ClinicalTrials.gov NCT02687685 . Skin-to-skin contact (SSC) at birth between mother and child consists of placing the naked newborn in the prone position on the naked thorax of the mother between her breasts at the time of birth [ 1 ]. It is part of the set of essential newborn care interventions that has a positive impact on the health of the mother and newborn [ 2 , 3 ]. In fact, SSC, compared with mother-child separation at birth, improves breastfeeding indicators (early onset, prevalence and duration of exclusive breastfeeding), physiological stability during immediate adaptation, risk of hospitalization prior to discharge from the maternity ward and the mother-child bond and attachment [ 4 , 5 ]. The main effect of SSC on the health of newborns and infants is derived from the consequences of breastfeeding [ 6 – 8 ]. Exclusive breastfeeding in the first 6 months of life is a strategy that reduces infant morbidity and mortality [ 9 , 10 ]. However, the prevalence of exclusive breastfeeding in the world is 37% [ 9 ], and in Colombia, 36.1% of children under 6 months received exclusive breastfeeding [ 11 ]. Increasing the prevalence of exclusive breastfeeding is a priority in all nations, with the goal of increasing it by at least 50% by 2025 [ 12 ]. The prevalence of SSC in the care of the mother-infant dyad during birth is very variable among different regions of the world, with its prevalence being much lower than ideal [ 13 , 14 ]. The situation is similar in Colombia, where mother-child separation is frequent [ 15 , 16 ]. Some identified barriers to achieving its broad and general use in the care of the mother-child dyads are the perception by health professionals of interfering with the care routines of the mother and child at birth, limited time availability and personnel to carry out the intervention, lack of knowledge of the technique and its benefits, fear of complications and absence of guidelines and standardization of the practice [ 17 – 19 ]. The time of onset of SSC can be categorized as immediate, beginning in the first 10 min after birth, and as early, beginning in the first hour of life [ 1 , 4 ]. However, the time of onset is very heterogeneous in studies on SSC, making it difficult to interpret the results and standardize the intervention [ 4 , 13 ]. Moreover, there are no studies that compare the effect of onset in the first 10 min versus in the first hour [ 4 , 13 ]. It is thus necessary to standardize the technique in regard to the time of onset and duration [ 13 ]. Given the positive effects of SSC, expanding its use in the care of the mother-child dyads would contribute to the objectives of improving the prevalence of exclusive breastfeeding and reducing neonatal and infant mortality. Knowing the existing barriers and the lack of standardization of the procedure, evaluating the two onset times of SSC and their effects on neonatal health and breastfeeding could help overcome such barriers and improve the evidence-based guidelines that recommend the best technique for performing the intervention while maintaining its effects on health. The objective of this study was to determine the effect of immediate SSC compared to early SSC on the duration of exclusive breastfeeding in full term and healthy newborns. The hypothesis that there is a difference in the percentage of full term newborns who receive exclusive breastfeeding for 3 months or more between the immediate and early SSC at birth groups was evaluated. The study protocol was registered in the clinicaltrials.gov clinical trials database under identification number NCT02687685 , and the study protocol has been previously published [ 20 ]. A randomized multicentre parallel clinical trial was conducted in two second-level reference hospitals in the Sabana Centro Cundinamarca region (Hospital El Salvador de Ubaté and Hospital Universitario de La Samaritana – Unidad Funcional de Zipaquirá) between November 2018 and January 2020. The study protocol was approved by the ethics committee of Universidad de La Sabana (N° 70–2018) and Hospital Universitario de La Samaritana (N° 0302–18). The parents of the neonates signed an informed consent for inclusion in the study prior to the start of and/or in the latent phase of labour and before randomization. There was a data monitoring and security committee headquartered at the Contract Research Organization (CRO). The researchers were planned an interim analysis from the protocol when completing 50% of the sample size (150 newborns) followed up to 3 months. Full term newborns with appropriate weight for gestational age, born from single gestation and by vaginal birth, with spontaneous neonatal adaptation, stable at birth, with indication for maternity and whose mother expressed desire to breastfeed were included. Neonates with congenital malformations, mothers with perinatal complications, patients with indication for separation of the mother-child pair at the time of birth and mother-child dyads with known contraindications for breastfeeding were excluded. The primary outcome was the percentage of neonates with exclusive breastfeeding at 6 months. Secondary outcomes were the percentage of infants with exclusive breastfeeding at 3 months, duration in months of exclusive breastfeeding, neonate’s breastfeeding ability evaluated by the Infant Breastfeeding Assessment Tool (IBFAT) in the first 24 h and/or before discharge and categorized into effective vigorous breastfeeding (IBFAT score ≥ 10) and non-effective breastfeeding (moderately effective and weak sucking and/or no feeding; IBFAT score < 10) [ 21 , 22 ], percentage of weight change between birth and the first week of life (less than or equal to 7% and greater than 7%), and hospitalization in the neonatal unit in the first week. For the primary outcome, a survey was applied at the follow-ups with the neonates developed according to WHO recommendations for breastfeeding practices [ 23 ]. The type of foods and supplements given to the infant during the past month was asked, categorizing the feeding practice into [ 24 ]: exclusive breastfeeding, predominant breastfeeding, partial breastfeeding and complementary feeding. Last, based on this information, the results were categorized into exclusive breastfeeding and non-exclusive breastfeeding. Exclusive breastfeeding was considered the time in months with human milk as the only source of food with no other liquids or solid foods given [ 23 ]. For the application of the IBFAT, prior to the start of recruitment an educational strategy and a pilot test were performed to standardize the use of the instrument. The weight change in the first week was evaluated in the face-to-face follow-up in the first week of life, and it was measured on the same electronic scale used at birth. The need for hospitalization was investigated at this same follow-up; when the mother reported hospitalization, the event was reviewed and documented with the medical record. The mother-child dyads were randomly allocated to one of two study groups, immediate SSC and early SSC, through a computer-generated process centralized in the CRO and with a strategy of permuted blocks with size of six. The allocation numbers were kept hidden in opaque and sealed envelopes; they were only consecutively revealed in the final expulsion phase of labour by the study monitor assigned to the centre. Due to the characteristics of the study intervention, blinding was only applied to the group of researchers who analysed the data. SSC between mother and child was defined as placing the naked newborn in the prone position, wearing a diaper and cap, on the mother’s naked thorax (between the breasts), with both covered by a warm blanket [ 1 ]; the duration of SSC in both groups was established as 1 h (60 min). Immediate SSC was defined as the intervention initiated in the first minute after birth, with performance of the immediate neonatal adaptation manoeuvres (thermoregulation, umbilical cord clamping and immediate neonate assessments) during SSC but postponing subsequent manoeuvres (neonate evaluations and screenings) until the end of the SSC duration. Early SSC was defined as the intervention that began exactly at 60 min of life of the newborn. In this group, thermoregulation and umbilical cord clamping were performed according to the protocol of the health institution, after which the neonate was placed under a radiant warmer to complete the neonatal adaptation interventions; once these were completed, the neonate was dressed and placed next to the mother, initiating the SSC at 60 min of life. In both study groups, during the SSC, the neonate was monitored with a pulse oximeter, three-lead EKG, axillary temperature measurement and continuous medical surveillance, recording these data at the beginning and end of the intervention. Mothers were advised and supported to initiate early breastfeeding (first hour of life) in both groups. The neonates were followed-up for a total period of 6 months. The first follow-up was performed at discharge from the maternity ward, when the IBFAT score was evaluated. The second follow-up was performed in the first week of life (between five to 7 days of life) in person in the doctor’s office. The weight and need for hospitalization during the first week of life were recorded. Subsequently, monthly follow-ups were conducted by telephone by applying the survey to evaluate the practice of breastfeeding. The sample size was calculated considering a baseline risk of exclusive breastfeeding at 6 months for Colombia of 24% [ 25 ], and considering that we found no studies evaluating the two onset times of SSC, the data in Moore et al. were used [ 26 ], who reported that SSC compared to separation at birth increases exclusive breastfeeding between three and 6 months of age (relative risk [RR] 1.97, 95% CI 1.37, 2.83), for a power of 80% and a Type I error probability of 5% with expected losses to follow-up of 30%. Thus, a total sample size of 300 neonates was estimated (150 in each group). Descriptive data analyses were performed using measures of central tendency, position and dispersion for the continuous variables and absolute and relative frequencies for the categorical variables. The assumption of normality was evaluated with the Shapiro-Wilk test. The association between the time of onset of SSC and categorical variables (exclusive breastfeeding at six and 3 months, percentage of weight change, hospitalization in the first week of life and newborn’s breastfeeding behaviours) were evaluated by constructing contingency tables and evaluating the independence between variables with the Chi 2 test and/or Fisher’s exact test according to the assumption of number of cases per cell. The RR was calculated as a measure of effect along with its 95% confidence interval (95% CI). A survival analysis was performed to evaluate whether the time of onset of SSC has an effect on the duration of exclusive breastfeeding. For the analysis, the final event was the absence of exclusive breastfeeding. The event time was defined from the time of onset of the intervention until the month that exclusive breastfeeding was documented. In participants who were lost to follow-up, this time was censored until the last follow-up in which exclusive breastfeeding was documented. Survival functions were constructed using the non-parametric Kaplan-Meier method for the total cohort and by SSC onset time group. Survival functions were compared using the log-rank test. A Cox proportional hazards analysis was performed to estimate the hazard ratio (HR) with the 95% CI of exclusive breastfeeding suspension. Subgroup analyses were also performed for variables considered to possibly interact with the evaluated interventions (early breastfeeding, newborn breastfeeding behaviours, hospitalization in the first week of life and receiving breastfeeding education at discharge from the maternity ward). The proportionality assumption was confirmed by Cox regression models. For data collection, input and management, the electronic data capture tool REDCap (Research Electronic Data Capture) housed at the Institute for the Evaluation of Health Care Quality (Instituto para la Evaluación de la Calidad y Atención en Salud - IECAS) was used. Data analysis was performed in STATA version 14. Because an interim analysis was planned from the protocol, the p - value was adjusted for multiple analyses, defining a value of p < 0.025 as the level of significance. A total of 297 newborns were included, 148 (49.8%) in the immediate SSC group and 149 (50.2%) in the early SSC group (Fig. 1 ). There was loss to follow-up for the primary outcome of exclusive breastfeeding at 6 months of nine participants, five in the immediate SSC group and four in the early SSC group, with no differences in baseline characteristics. Fig. 1 Flowchart Flowchart The two study groups were similar, especially regarding confounding variables such as maternal obesity, working and parity (Table 1 ). No differences were observed between the groups in the percentage of exclusive breastfeeding at 6 months (SSC immediate 27.3% vs SSC early 25.5%; RR 1.06, 95% CI 0.72, 1.58) or at 3 months (SSC immediate 79.9% vs SSC early 80.1%; RR 0.99, 95% CI 0.88, 1.11). Table 1 Sociodemographic and clinical characteristics of the mother-child dyads by group skin-to-skin contact Immediate skin-to-skin contact ( = 148) n Early skin-to-skin contact ( = 149) n Maternal Characteristics Age, years (median - IQR) 23 (21–29) 24 (20–25) Marital status n (%) Domestic partnership 112 (75.7) 109 (73.2) Separated/divorced 0 1 (0.67) Married 14 (9.5) 11 (7.4) Single 22 (14.9) 28 (18.8) Educational level n (%) Primary education 12 (8.1) 19 (12.7) Secondary education 95 (64.2) 85 (57.0) Higher education 16 (10.8) 20 (13.4) Graduate education 2 (1.3) 1 (0.67) Technical, professional and/or technological education 22 (14.9) 17 (11.4) University or equivalent 1 (0.68) 7 (4.7) Specialization 0 0 Doctorate 0 0 Working mother n (%) Yes 107 (72.3) 109 (73.1) No 41 (27.7) 40 (26.8) Socio-economic stratum n (%) 1 91 (61.5) 100 (67.1) 2 53 (35.8) 47 (31.5) 3 2 (1.3) 2 (1.34) 4 1 (0.68) 5 1 (0.68) Primiparous n (%) Yes 79 (53.4) 81 (54.4) No 69 (46 .6) 68 (45.6) Previous breastfeeding n (%) Yes 75 (94.9) 77 (95.1) No 4 (5.1) 4 (4.9) Smoking n (%) Yes 1 (0.68) 1 (0.67) No 147 (99.3) 148 (99.3) Antenatal appointments, median (IQR) 8 (6–9) 7 (5–9) BMI classification at the beginning of pregnancy n (%) Low weight 4 (2.7) 10 (6.7) Normal 105 (70.9) 95 (63.8) Overweight 26 (17.6) 32 (21.5) Obesity 13 (8.8) 12 (8.0) Newborn characteristics Birthweight (grams) median (IQR) 3085 (2805–3340) 3130 (2920–3400) Gestational age (Weeks - Ballard) median (IQR) 39 (38–40) 39 (38–39) Sex n (%) Male 66 (44.6) 71 (47.6) Female 82 (55.4) 78 (52.3) Immediate skin-to-skin contact: intervention initiated in the first minute after birth Early skin-to-skin contact: intervention that began exactly at 60 min of life of the newborn Sociodemographic and clinical characteristics of the mother-child dyads by group skin-to-skin contact Immediate skin-to-skin contact: intervention initiated in the first minute after birth Early skin-to-skin contact: intervention that began exactly at 60 min of life of the newborn Similarly, no differences were found in the breastfeeding behaviours of the newborns at discharge from the maternity ward (IBFAT score), hospitalization in the first week of life and/or the weight change percentage between birth and the first week of life (Table 2 ). Table 2 Time of onset of skin-to-skin contact and health outcomes Immediate skin-to-skin contact (%) n Early skin-to-skin contact (%) n RR (95% CI) a Exclusive breastfeeding b to 6 months 1.06 (0.72, 1.58) Yes 39 (27.3) 37 (25.5) No 104 (72.7) 108 (74.5) Exclusive breastfeeding b to 3 months 0.99 (0.88, 1.11) Yes 115 (79.9) 117 (80.1) No 29 (20.1) 29 (19.9) IBFAT c score at discharge 1.02 (0.94, 1.10) Effective 134 (90.5) 132 (88.6) Not Effective 14 (9.7) 17 (11.4) Weight loss during the first week of life 0.82 (0.45, 1.49) > 7% 17 (11.7) 21 (24.3) ≤ 7% 128 (88.9) 126 (85.7) Hospitalization in the first week of life 0.6 (0.22, 1.63) Yes 6 (4.1) 10 (6.8) No 139 (95.7) 137 (93.2) a RR = Relative risk comparing immediate SSC versus early SSC b Exclusive breastfeeding: was considered the time in months with human milk as the only source of food with no other liquids or solid foods given c IBFAT Instrument Breastfeeding Assessment Tool Time of onset of skin-to-skin contact and health outcomes a RR = Relative risk comparing immediate SSC versus early SSC b Exclusive breastfeeding: was considered the time in months with human milk as the only source of food with no other liquids or solid foods given c IBFAT Instrument Breastfeeding Assessment Tool Figure 2 a and b shows the survival function for the total cohort and for the SSC onset time groups, respectively. The median exclusive breastfeeding duration was 5 months for the total cohort and for both groups. The Cox proportional hazards model showed no differences in the duration of exclusive breastfeeding between the two study groups (HR 0.98, 95% CI 0.74, 1.28). In the subgroup analysis (breastfeeding education, hospitalization, IBFAT score, breastfeeding in the first hour), no differences were observed in exclusive breastfeeding duration (Fig. 3 ). Fig. 2 Kaplan-Meier plot of exclusive breastfeeding. a - Kaplan-Meier plot of exclusive breastfeeding for the total cohort. b - Kaplan-Meier plot of exclusive breastfeeding for the cohort by group. p = Long-rank test . SSC = Skin-to-skin contact Fig. 3 Subgroup survival analyses Kaplan-Meier plot of exclusive breastfeeding. a - Kaplan-Meier plot of exclusive breastfeeding for the total cohort. b - Kaplan-Meier plot of exclusive breastfeeding for the cohort by group. p = Long-rank test . SSC = Skin-to-skin contact Subgroup survival analyses Our trial evaluated the effect of the time of onset of SSC, immediate versus early, on exclusive breastfeeding in the first 6 months of age. The results indicate that placing low risk newborns in SSC for one continuous hour immediately after birth (in the first minute after birth) and/or after performing routine newborn and maternal care practices (at 60 min of life) is the same in the two SSC study groups in the percentage of infants on exclusive breastfeeding at the three and 6 months of life and in the duration of exclusive breastfeeding. Similarly, no differences were observed between the groups in relation to the behaviour of newborns towards breastfeeding, weight loss and hospitalization in the first week. Compared to separation at birth, SSC is effective in different areas of mother-child health, especially in improving indicators and prevalence of breastfeeding in infants under 6 months [ 27 , 28 ]. Specifically, it increases the percentage of infants on exclusive breastfeeding at 3 months and 6 months. Karimi et al. [ 28 ] showed an effect of SSC started in the first 10 min of life compared to separation in improving the duration of exclusive breastfeeding for 3 months (odds ratio [OR] 2.47, 95% CI 1.73, 3.48) and for 6 months (OR 1.71, 95% CI 1.05, 2.78). Likewise, Moore et al. [ 4 ] showed that SSC started immediately compared to separation increases the duration of breastfeeding by 3 months or more (RR 1.97, 95% CI 1.37, 2.83). However, there was a question about the effect of the onset of SSC on breastfeeding and the need to standardize the strategy to improve its recommendation and applicability [ 4 , 13 ]. In the study, the median duration of exclusive breastfeeding in both groups was 5 months and the rates of exclusive breastfeeding in the trial were higher than in rates reported for the country. Where the main decrease in exclusive breastfeeding is observed in the first month of life, where 51.6% of infants receive exclusive breastfeeding [ 11 ] and the percentage of infants with exclusive breastfeeding in our trial was 89.6% (immediate SSC 87.6% and early SSC 91.6%). The duration of exclusive breastfeeding in Colombia is approximately 2 months [ 25 ]. Our trial show that in a group of low-risk neonates, SSC, regardless of the time of onset, improves the percentage of exclusively breastfed infants and is an effective intervention that aims at increasing the number of neonates exclusively breastfed in the first 6 months by 50%. The results of the present study are relevant since the barriers to performing SSC are the perception of interference with the newborn care routines and the availability of time and personnel during birth and immediate neonatal adaptation [ 17 , 19 ]. The strategy of initiating SSC once the mother and child are stabilized and the newborn interventions are finished, could positively impact the use of SSC at birth without compromising exclusive breastfeeding. The results of the present study also show no differences between the time of onset of SSC groups in hospitalization in the first week of life or in the newborn behaviours evaluated by the IBFAT. Again, this is important given that previous studies have shown that separation at birth compared to SSC negatively impacts these parameters. Agudelo et al. [ 5 ] reported that SSC initiated in the first 10 min of life and maintained for 45 continuous minutes decreased the risk of hospitalization prior to discharge from the maternity ward (13.8% vs. 26.4%; OR 0.46, 95% CI 0.29, 0.71). Khadivzadeh et al. [ 29 ] found that the success of the first breastfeeding evaluated by the IBFAT was significantly higher in the group with SSC immediately after birth (first 10 min) compared to the group that adapted under a radiant warmer. Moore et al. [ 4 ] showed that the group exposed to SSC compared to separation had a higher IBFAT score (mean difference 2.28, 95% CI 1.41, 3.15). Some of the main risk factors for non-exclusive breastfeeding are maternal obesity, working and smoking [ 30 – 33 ]. In addition, for Colombia, one of the main causes of non-exclusive breastfeeding is a sick/hospitalized child and maternal return to work [ 11 ]. We did not find differences in the duration of exclusive breastfeeding in the subgroups of obese, working and smoking mothers and neonate hospitalization in the first week of life. It is important to emphasize that during the study, in both interventions, mothers were encouraged and supported to perform early onset (first hour of life) breastfeeding and educational support was provided to all mothers. A small loss to follow-up percentage and 100% adherence to the interventions and follow-ups established are strengths of this study. One of its limitations are the lack of a separation group at birth. However, we do not consider it feasible from an ethical point of view to have this group since offering SSC at birth is the currently recommended management for the care of the mother-child dyads and not offering it has ethical limitations. The percentage of infants and the duration of exclusive breastfeeding in the first 6 months of age were the same between the two groups of SSC interventions. Given the low prevalence of the use of SSC at birth and the current barriers to its implementation, the results of the present study may contribute to increase the prevalence of the use of SSC and to standardize the intervention by supporting the development of guidelines for the technique. Increasing the prevalence of Skin-to-Skin Contact would improve exclusive breastfeeding. Contract Research Organization Infant Breastfeeding Assessment Tool Research Electronic Data Capture Skin-to-Skin Contact Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The authors would like to thank all the mothers and newborn who participated in this study and the Hospital Universitario de La Samaritana – Unidad Funcional de Zipaquirá and Hospital El Salvador de Ubaté. SAP: conception and design of the work, analysis, and interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. OGG, EAR, LA, SB, JG, MJ, MV: design of the work, acquisition, analysis and interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MLP, NG, EO, FR : design of the work, drafting the work or revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The author(s) read and approved the final manuscript. SAP: Professor and Researcher at the Faculty of Medicine at the Universidad de La Sabana. Head of the Department of Pediatrics, Universidad de La Sabana. Pediatrician, Perinatologist and Neonatologist. Currently a doctoral student in Health Sciences at the CES University of Medellin, Colombia. OGG: Doctor, Statistician. Master’s in Economics. Researcher in Health Economics and Public Policy. EAR: Pediatrician. Head of the Pediatrics Department of Hospital Universitario de La Samaritana – Unidad Funcional de Zipaquirá. Professor of Chair at Universidad de La Sabana, Faculty of Medicine. FR: Pediatrician, epidemiologist. Master’s in Public Health. Professor of Chair at Universidad de La Sabana, Faculty of Medicine. Research funded by the Administrative Department of Science, Technology and Innovation (Departamento Administrativo de Ciencia, Tecnología e Innovación - COLCIENCIAS) (777–2017). Registration code 58068. Contract number 829 of 2017. The datasets generated and/or analyzed during the current study are available in the electronic data capture tool REDCap (Research Electronic Data Capture) housed at the Institute for the Evaluation of Health Care Quality (Instituto para la Evaluación de la Calidad y Atención en Salud - IECAS). The datasets generated are not publicly available due the confidentiality and information of the participating minors requested by the health institutions but are available from the corresponding author on reasonable request. The study protocol was approved by the ethics committee of Universidad de La Sabana and Hospital Universitario de La Samaritana. The parents of the neonates signed an informed consent for inclusion. The authors declare that they have no competing interests. Randomized clinical trial of the effect of the onset time of skin-to-skin contact at birth, immediate compared to early, on the duration of breastfeeding in full term newborns Early essential newborn care is associated with reduced adverse neonatal outcomes in a tertiary hospital in Da Nang, Viet Nam: a pre- post- intervention study Early skin-to-skin contact for mothers and their healthy newborn infants Effect of skin-to-skin contact at birth on early neonatal hospitalization Effect of immediate and continuous mother-infant skin-to-skin contact on breastfeeding self-efficacy of primiparous women: a randomised control trial The effects of skin-to-skin contact on temperature and breastfeeding successfulness in full-term newborns after cesarean delivery World Health Organization Baby-Friendly Hospital Initiative Guideline and 2018 Implementation Guidance Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect Breastfeeding: a smart investment in people and in economies Worldwide prevalence of mother-infant skin-to-skin contact after vaginal birth: a systematic review Contato pele a pele ao nascer: um desafio para a promoção do aleitamento materno em maternidade pública no Nordeste brasileiro com o título de Hospital Amigo da Criança [Skin-to-skin contact at birth: a challenge to promote breastfeeding in a public maternity hospital in Northeastern Brazil with the title of Baby Friendly Hospital] Uso de prácticas clínicas durante el embarazo, parto, puerperio y recién nacido, en hospitales públicos de Manizales-Colombia, 2005 [Use of clinical practices during pregnancy, childbirth, puerperium and newborn, in public hospitals of Manizales-Colombia, 2005] Prácticas clínicas en el cuidado de gestantes y recién nacidos en algunos hospitales de Bogotá, Colombia [Clinical practices in the care of pregnant women and newborns in some hospitals in Bogotá, Colombia] Observational study found that skin-to-skin contact was not common after vaginal birth in Saudi Arabia Clinical practices in the hospital care of healthy newborn infant in Brazil Barriers and enablers to skin-to-skin contact at birth in healthy neonates - a qualitative study The effect of skin-to-skin contact at birth, early versus immediate, on the duration of exclusive human lactancy in full-term newborns treated at the Clínica Universidad de La Sabana: study protocol for a randomized clinical trial Developing an instrument to assess infant breastfeeding behaviour in the early neonatal period Assessment tools for evaluation of oral feeding in infants younger than 6 months Toward consistency in breastfeeding definitions Early skin-to-skin contact for mothers and their healthy newborn infants A randomised trial of continuous skin-to-skin contact after preterm birth and the effects on salivary cortisol, parental stress, depression, and breastfeeding The effect of mother-infant skin-to-skin contact immediately after birth on exclusive breastfeeding: a systematic review and meta-analysis The effects of post-birth mother-infant skin to skin contact on first breastfeeding Sociodemographic, physical, mental and social factors in the cessation of breastfeeding before 6 months: a systematic review Breastfeeding and weaning practices among Hong Kong mothers: a prospective study Maternal prepregnancy body mass index and initiation and duration of breastfeeding: a review of the literature Duration of breastfeeding and risk of overweight: a meta-analysis |
Answer the following medical question. | What does research say about Neonatal anesthesia with limited resources.? | Neonates are the most vulnerable age group in terms of anesthetic risk and perioperative mortality, especially in the developing world. Prematurity, malnutrition, delays in presentation, and sepsis contribute to this risk. Lack of healthcare workers, poorly maintained equipment, limited drug supplies, absence of postoperative intensive care, unreliable water supplies, or electricity are further contributory factors. Trained anesthesiologists with the skills required for pediatric and neonatal anesthesia as well as basic monitoring equipment such as pulse oximetry will go a long way to improve the unacceptably high anesthetic mortality. |
Answer the following medical question. | What does research say about Impact of advanced maternal age on neonatal morbidity: a systematic review.? | This systematic review aimed to understand the impact of advanced maternal age (AMA) on the neonatal morbidity, based on the available scientific evidence. A systematic search was conducted on 22 November 2021, using the PubMed and Scopus databases to identify studies that compared the morbidity of neonates delivered to AMA mothers with that of neonates delivered to non-AMA mothers. Sixteen studies that evaluated the effect of AMA on the neonatal morbidity were included in this review. Nine of these studies found some association between AMA and increased neonatal morbidity (with two of them only reporting an increase in asymptomatic hypoglycemia, and one only reporting an association in twins), six found no association between AMA and neonatal morbidity and one study found a decrease in morbidity in preterm neonates. The studies that found an increase in overall neonatal morbidity with AMA considered older ages for the definition of AMA, particularly ≥40 and ≥45 years. The current evidence seems to support a lack of association between AMA and the neonatal morbidity of the delivered neonates. However, more studies focusing on the neonatal outcomes of AMA pregnancies are needed to better understand this topic. |
Answer the following medical question. | What does research say about Neonatal ventilation.? | Preventing ventilation-induced lung injury and bronchopulmonary dysplasia is an important goal in the care of ventilated neonates. Recently, there have been tremendous efforts to improve ventilation strategies, which aim at ventilating with a 'protective' and 'open-lung' strategy. Several different ventilation modes are now available, but it is important to note that, with regard to the neonatal pulmonary and neural outcome, there is still no clear evidence as to the superiority of one ventilation mode over another. Clinicians should bear in mind that any ventilation mode used to ventilate a neonate should be accompanied by real-time pulmonary monitoring to continuously adapt the ventilation strategy to the sudden changes in the respiratory mechanical properties of the lung. This article will describe the different ventilation modes available for neonates and highlight the importance of using a protective and open-lung ventilation strategy, even in the operating room. |
Answer the following medical question. | What does research say about Nasal High-Frequency Ventilation.? | Noninvasive high-frequency oscillatory (NHFOV) and percussive (NHFPV) ventilation represent 2 nonconventional techniques that may be useful in selected neonatal patients. We offer here a comprehensive review of physiology, mechanics, and biology for both techniques. As NHFOV is the technique with the wider experience, we also provided a meta-analysis of available clinical trials, suggested ventilatory parameters boundaries, and proposed a physiology-based clinical protocol to use NHFOV. |
Answer the following medical question. | What does research say about Neonatal hypertension: diagnosis and management.? | Hypertension in the term or preterm neonate may be seen in up to 2% of all infants cared for in the modern neonatal intensive care unit. Although the definition of hypertension in this age group has not been completely standardized, recent studies have provided new normative data that may be used to facilitate identification of such infants. Common causes of hypertension in neonates include thromboembolic events related to umbilical catheterization, congenital problems such as aortic coarctation, structural renal malformations and renovascular disease, as well as acquired renal disease and certain medications. A careful history and physical examination will usually identify the probable cause in most cases without the need for extensive laboratory or radiologic testing. Therapy of neonatal hypertension should be tailored to the severity of the blood pressure elevation, and to the underlying cause of hypertension as appropriate. A wide range of therapeutic agents are now available for management of neonatal hypertension in both the acute and chronic settings. In most cases hypertension will resolve, but some infants may require prolonged treatment. |
Answer the following medical question. | What does research say about Understanding neonatal ventilation: strategies for decision making in the NICU.? | Neonatal ventilation is an integral component of care delivered in the neonatal unit. The aim of any ventilation strategy is to support the neonate's respiratory system during compromise while limiting any long-term damage to the lungs. Understanding the principles behind neonatal ventilation is essential so that health professionals caring for sick neonates and families have the necessary knowledge to understand best practice. Given the range of existing ventilation modes and parameters available, these require explanation and clarification in the context of current evidence. Many factors can influence clinical decision making on both an individual level and within the wider perspective of neonatal care. |
Answer the following medical question. | What does research say about The effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm infant admitted to neonatal intensive care units: a randomized controlled crossover study.? | Neonates in the neonatal intensive care unit are frequently subjected to painful procedures. Non-pharmacological pain control techniques are useful for reducing procedural pain. Touch as one of the aspects of developmental care used to reduce neonatal pain. The purpose of this study was to determine the effect of gentle human touch during endotracheal suctioning on procedural pain response in preterm neonates. This was a clinical trial study with a crossover design. The study was conducted in a level III NICU in a hospital, affiliated to Iran University of Medical Sciences. Thirty-four neonates were enrolled in this study based on inclusion criteria. The samples were randomly received a sequence of suctioning with/without or suctioning without/with gentle human touch. Preterm Infant Pain Profile (PIPP) was used to collect the data. SPSS version 22 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. 85.3% of neonates experienced moderate and 8.8% severe pain during suctioning without intervention, and only 64.7% of them experienced moderate and 2.9% severe pain during suctioning with intervention. The results of the paired Results from this study showed that the pain due to suctioning procedure is considerably reduced by applying Gentle Human Touch. And nurses can use this method as one of the non-pharmacological methods of pain management. |
Answer the following medical question. | What does research say about Cutaneous fungal infection in a neonatal intensive care unit patient: a case report and literature review.? | Fungal skin infections are not uncommon in healthy, premature or immunocompromised newborns. Healthy neonates usually develop fungal skin infections caused by dermatophytes, Candida and Malassezia species, whereas immunocompromised neonates are more susceptible to skin infections with opportunistic pathogens (Aspergilus, Zygomycetes). Therefore neonatal fungal skin infections can range from generally benign superficial lesions to potentially fatal, deep, necrotic forms with dissemination. We present the case of a premature neonate twin with cutaneous fungal infection in a neonatal intensive care unit. Because there were doubts concerning the correspondence of the clinical features with the cultured species in the newborn, a literature review was performed searching for similar clinical cases. |
Answer the following medical question. | What does research say about Neonatal hematological parameters: the translational aspect of developmental hematopoiesis.? | Hematopoiesis is a process constantly evolving from fetal life through adulthood. Neonates present with qualitative and quantitative differences in hematological parameters compared to older children and adults, reflecting developmental changes in hematopoiesis correlated with gestational age. Such differences are more intense for preterm and small-for-gestational-age neonates or neonates with intrauterine growth restriction. This review article is aimed at describing the hematologic differences among neonatal subgroups and the major underlying pathogenic mechanisms. Issues that should be taken into account when interpreting neonatal hematological parameters are also highlighted. |
Answer the following medical question. | What does research say about Neonatal acute kidney injury: a case-based approach.? | Neonatal acute kidney injury (AKI) is increasingly recognized as a common complication in critically ill neonates. Over the last 5-10 years, there have been significant advancements which have improved our understanding and ability to care for neonates with kidney disease. A variety of factors contribute to an increased risk of AKI in neonates, including decreased nephron mass and immature tubular function. Multiple factors complicate the diagnosis of AKI including low glomerular filtration rate at birth and challenges with serum creatinine as a marker of kidney function in newborns. AKI in neonates is often multifactorial, but the cause can be identified with careful diagnostic evaluation. The best approach to treatment in such patients may include diuretic therapies or kidney support therapy. Data for long-term outcomes are limited but suggest an increased risk of chronic kidney disease (CKD) and hypertension in these infants. We use a case-based approach throughout this review to illustrate these concepts and highlight important evidence gaps in the diagnosis and management of neonatal AKI. |
Answer the following medical question. | What does research say about End-of-life care in the neonatal intensive care unit: applying comfort theory.? | The provision of quality end-of-life care is essential when a neonate is dying. End-of-life care delivered in a neonatal intensive care unit (NICU) must consider the needs of both the newborn and their family. The purpose of this paper is to demonstrate how comfort theory and its associated taxonomic structure can be used as a conceptual framework for nurses and midwives providing end-of-life care to neonates and their families. Comfort theory and its taxonomic structure are presented and issues related to end-of-life care in the NICU are highlighted. A case study is used to illustrate the application of comfort theory and issues related to implementation are discussed. The delivery of end-of-life care in the NICU can be improved through the application of comfort. |
Answer the following medical question. | What does research say about Pain assessment practices in Swedish and Norwegian neonatal care units.? | The use of measurement scales to assess pain in neonates is considered a prerequisite for effective management of pain, but these scales are still underutilised in clinical practice. The aim of this study was to describe and compare pain assessment practices including the use of pain measurement scales in Norwegian and Swedish neonatal care units. A unit survey investigating practices regarding pain assessment and the use of pain measurement scales was sent to all neonatal units in Sweden and Norway (n = 55). All Norwegian and 92% of Swedish units responded. A majority of the participating units (86.5%) assessed pain. Swedish units assessed and documented pain and used pain measurement scales more frequently than Norwegian units. The most frequently used scales were different versions of Astrid Lindgren's Pain Scale (ALPS) in Sweden and Echelle Douleur Inconfort Noveau-Ne (EDIN), ALPS and Premature Infant Pain Profile (PIPP) in Norway. Norwegian head nurses had more confidence in their pain assessment method and found the use of pain measurement scales more important than their Swedish colleagues. The persisting difference between Swedish and Norwegian units in pain assessment and the use of pain measurement scales are not easily explained. However, the reported increased availability and reported use of pain measurement scales in neonatal care units in both countries may be seen as a contribution towards better awareness and recognition of pain, better pain management and potentially less suffering for vulnerable neonates. |
Answer the following medical question. | What does research say about Wound care considerations in neonates.? | Wound care management is a complex issue when caring for the neonate. An understanding of the anatomy and physiology of neonatal skin is necessary to recognise and prevent any potential problems. Effective wound care is a dynamic process based on accurate assessment and the setting of realistic goals. Knowledge of the specific characteristics of neonatal skin and the wound healing process is required when determining appropriate treatment and selecting wound care products. |
Answer the following medical question. | What does research say about Neonatal Head Ultrasound: A Review and Update-Part 1: Techniques and Evaluation of the Premature Neonate.? | Ultrasound of the infant brain has proven to be an important diagnostic tool in the evaluation of neonatal brain morphology and pathology since its introduction in the late 1970s and early 1980s. It is a relatively inexpensive examination that can be performed in the isolette in the neonatal intensive care unit. There is no radiation exposure and no need for sedation. This article will discuss gray scale and Doppler techniques and findings in normal head ultrasounds of premature neonates. It will discuss intracranial pathologies noted in such neonates and their neurodevelopmental outcome. |
Answer the following medical question. | What does research say about Costs and cost-effectiveness of periviable care.? | With increasing concerns regarding rapidly expanding healthcare costs, cost-effectiveness analysis allows assessment of whether marginal gains from new technology are worth the increased costs. Particular methodologic issues related to cost and cost-effectiveness analysis in the area of neonatal and periviable care include how costs are estimated, such as the use of charges and whether long-term costs are included; the challenges of measuring utilities; and whether to use a maternal, neonatal, or dual perspective in such analyses. A number of studies over the past three decades have examined the costs and the cost-effectiveness of neonatal and periviable care. Broadly, while neonatal care is costly, it is also cost effective as it produces both life-years and quality-adjusted life-years (QALYs). However, as the gestational age of the neonate decreases, the costs increase and the cost-effectiveness threshold is harder to achieve. In the periviable range of gestational age (22-24 weeks of gestation), whether the care is cost effective is questionable and is dependent on the perspective. Understanding the methodology and salient issues of cost-effectiveness analysis is critical for researchers, editors, and clinicians to accurately interpret results of the growing body of cost-effectiveness studies related to the care of periviable pregnancies and neonates. |
Answer the following medical question. | What does research say about Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia.? | Newborn Brain Society, PO Box 200783, Roxbury Crossing, MA 02120. [email protected] Ensuring comfort for neonates undergoing therapeutic hypothermia (TH) after neonatal encephalopathy (NE) exemplifies a vital facet of neonatal neurocritical care. Physiologic markers of stress are frequently present in these neonates. Non-pharmacologic comfort measures form the foundation of care, benefitting both the neonate and parents. Pharmacological sedatives may also be indicated, yet have the potential to both mitigate and intensify the neurotoxicity of a hypoxic-ischemic insult. Morphine represents current standard of care with a history of utilization and extensive pharmacokinetic data to guide safe and effective dosing. Dexmedetomidine, as an alternative to morphine, has several appealing characteristics, including neuroprotective effects in animal models; robust pharmacokinetic studies in neonates with NE treated with TH are required to ensure a safe and effective standard dosing approach. Future studies in neonates treated with TH must address comfort, adverse events, and long-term outcomes in the context of specific sedation practices. Management of comfort and sedation in neonates with neonatal encephalopathy treated with therapeutic hypothermia |
Answer the following medical question. | What does research say about Identifying Aspiration Among Infants in Neonatal Intensive Care Units Through Occupational Therapy Feeding Evaluations.? | Importance: When a neonate’s sucking, swallowing, and breathing are disorganized, oropharyngeal aspiration often occurs and results in illness, developmental problems, and even death. Occupational therapists who work in the neonatal intensive care unit (NICU) need to identify neonates who are at risk for aspirating so they can provide appropriate treatment. Objective: To ascertain whether client factors and performance skills of infants ages 0–6 mo during occupational therapy feeding evaluations are related to results of videofluoroscopic swallowing studies (VFSSs). Design: Retrospective chart reviews. Setting: 187-bed NICU in a nonprofit teaching hospital. Participants: A purposive sample of 334 infants ages 0–6 mo, ≥33 wk gestational age at birth, admitted to a Level II, III, or IV NICU as defined by the American Academy of Pediatrics. Outcomes and Measures: Neonates were administered a feeding evaluation by an occupational therapist and a VFSS by a speech-language pathologist, which yielded information about client factors and performance skills. Results: Signs and symptoms of aspiration on the evaluations were significantly associated with VFSS results. Of 310 patients, 79 had silent aspiration. Of 55 infants who demonstrated no aspiration symptoms during the feeding evaluation, 45% demonstrated aspiration symptoms on the VFSS, and 55% aspirated on the VFSS but demonstrated no symptoms of aspiration. Conclusions and Relevance: Aspiration among infants occurs inconsistently and depends on client factors, contexts, and environments. Occupational therapists are encouraged to assess an infant’s feeding over several sessions to obtain a more accurate picture of the infant’s feeding status. What This Article Adds: This study provides information that helps occupational therapists identify infants at risk for aspiration and make optimal recommendations regarding safe feeding practices and appropriate referrals for a VFSS. Making appropriate referrals for VFSS is also important in preventing unnecessary exposure to radiation for preterm infants. Identifying Aspiration Among Infants in Neonatal Intensive Care Units Through Occupational Therapy Feeding Evaluations |
Answer the following medical question. | What does research say about Neonatal disseminated intravascular coagulation.? | Bleeding in the neonate can be a life-threatening emergency. Quick action is necessary to determine the cause of bleeding, which determines how the infant will be treated. Disseminated intravascular coagulation (DIC) is uncontrolled, simultaneous bleeding and clotting occurring as a secondary disorder in sick neonates. Knowledge of the complex physiologic mechanisms at work to maintain hemostasis contributes to the proper nursing care of infants at risk for DIC and better outcomes. |
Answer the following medical question. | What does research say about A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants.? | Despite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards. We retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher’s exact or Wilcoxon rank-sum tests at the α = 0.05 significance level. A total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates ( n = 965/1168) and 93.4% ( n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% ( n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days. Our results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries. Despite efforts to reduce neonatal mortality globally, in 2015, nearly half of the 5.9 million under-five deaths occurred in the first 28 days of life [ 1 ] and eight of the 10 countries with the highest neonatal mortality rates are in sub-Saharan Africa (SSA) [ 2 ]. The main clinical causes of death include prematurity, infection, inadequate management of complications of pregnancy and delivery, and lack of quality care immediately after birth [ 1 – 4 ]. The majority of these deaths are preventable through evidence-based clinical interventions, such as antibiotic administration [ 5 ], oxygen therapy, continuous positive airway pressure [ 6 ] and caffeine treatment [ 7 , 8 ]. However, implementing these interventions in resource-limited settings can be challenging due to health system constraints, including limited equipment, lack of standardized protocols to guide neonatal management, insufficient training and support for clinical staff, and the shortage of pediatricians and neonatologists [ 9 , 10 ]. In Rwanda, there has been a tremendous reduction in under-five mortality, which fell from 196 per 1000 live births in 2000 to 50 per 1000 live births in 2015, making the country one of the few in SSA to achieve the Millennium Development Goals for child mortality [ 11 – 14 ]. In addition, the neonatal mortality rate significantly declined from 41 per 1000 live births in 1990 to 17 per 1000 live births in 2016 [ 2 ]. Although national surveillance systems are able to provide population level data on neonatal survival [ 15 ], little data exists on the treatment and quality of care provided to high-risk newborns at health facilities, as well as predictors of clinical success in Rwanda or other countries in SSA. One study conducted in a rural Rwandan district hospital reported that over 60% of neonatal deaths occurred at presentation or shortly after admission and could be attributed in part to the lack of trained staff and lack of standard care practice supported by protocols [ 16 ]. Subsequently, the researchers identified the need for training staff and establishing protocols as vital for improving neonatal care. The Rwanda Ministry of Health (MOH) developed a national neonatal care protocol and standards in partnership with a number of organizations, including Partners In Health/Inshuti Mu Buzima (PIH/IMB) - an international non-profit organization committed to improving health services in impoverished communities - and specialists from Boston Children’s Hospital in Boston, USA. The neonatal care package was nationally adopted in 2012 with the goal of providing quality care to sick and preterm/low birth weight infants in rural district hospitals which lack specialist physicians [ 17 , 18 ]. The protocol was initially implemented and tested in the neonatal units of two rural PIH/IMB supported MOH district hospitals in 2010–2011. Details on the development and implementation of the newborn medicine program have been reported previously in Hansen et al’s 2015 study [ 18 ]. The protocol implementation included roll-out of standardized medical records, quality indicators, and corresponding training materials. Here, we describe the presentation, clinical management, and outcomes of neonates after approximately 2 years of implementation of the neonatal care package. Neonates admitted between January 2013 and December 2014 to the neonatal units of the two rural district hospitals where the care package was first introduced were included. We also compared outcomes between low birth weight (LBW) and normal birth weight (NBW) neonates to detect any differences that may exist in the delivery of care to these patients. We aimed to highlight successes and gaps in the implementation of the national neonatal care package that could support quality care provision for neonates in Rwanda and similar settings. This retrospective cross-sectional study included neonates admitted to the neonatal units of PIH/IMB supported MOH Rwinkwavu and Kirehe District Hospitals (RDH, KDH). Both hospitals are located in rural areas of the Eastern Province of Rwanda and serve a total population of approximately 550,000 [ 19 ]. The initial roll-out involved international neonatal physician and nurse specialist support. After introduction, routine technical support has included support for training and ongoing mentorship of general practitioners and nurses working in the neonatal units by PIH/IMB-employed Rwandan nurse mentors. Visiting specialist physicians supporting PIH/IMB’s medical education mission provided intermittent support. Additionally, PIH/IMB provided targeted support for essential equipment and consumables as part of health system strengthening. At either of these two district hospitals, about 2700 to 2800 deliveries per year are recorded and roughly over 90% are referrals from health centers in the district hospitals’ catchment areas. The average facility delivery rate in the Eastern Province is 88.8% [ 15 ]. When neonates are born in clinical distress or exhibit risk factors such as LBW, prematurity, sepsis or birth asphyxia, they are transferred to a neonatal unit for ongoing clinical management. At the time of this study, seven to ten certified nurses or midwives staffed each neonatal unit. During the day shift, two nurses/midwives worked in the neonatology unit and one general practitioner (GP) supervised both the pediatric and neonatal units. Overnight, one to two GPs staffed the hospital and nurses/midwives in the neonatal units called them if in need of assistance. On average, there were 10 to 15 neonates in the neonatal unit at each hospital per day. Training and on-site mentorship were provided intermittently throughout the study period by an expert physician and nurse trainers to the physicians and nurses staffing the units. Available equipment in the neonatal units included beds for kangaroo mother/skin-to-skin care, syringe pumps, incubators, radiant warmers and phototherapy units since 2011 and bubble continuous positive airway pressure (bCPAP) machines had recently been introduced in January 2013. All neonates aged 0 to 28 days and admitted to the hospitals between January 1, 2013, and December 31, 2014 were included in our analysis. Data was extracted from patients’ medical files using a standardized neonatal data collection form and entered into an electronic database by hired and trained non-clinical data officers supporting hospital monitoring and evaluation. Before data collection the officers completed a two-day orientation and training that focused on specific clinical terms used in the neonatal units and how to read patients’ medical files and abstract data from the file to the data collection form. The data were extracted over a one-month period of time. We analyzed a subset of data that contained neonatal demographic and clinical characteristics, clinical management and outcome information. The clinical management variables are based on the quality indicators, which were originally drafted for the protocol according to expert opinion and literature review and later modified to address topics identified as challenging by hospital clinical staff. The indicators aim to monitor key aspects of neonatal care provision per protocol, with a focus on the needs of sick, LBW and preterm neonates [ 17 , 18 ]. The indicators tracked the monitoring of vital signs, thermoregulation, hypoglycemia, administration of antibiotics for infectious diseases, fluid electrolytes and nutrition, and respiratory distress and included targets for high quality (Table 1 ). Cut-off point for hypoglycemia changed during the study period. Originally, low blood sugar was defined as less than 40 mg/dl. The definition was eventually changed to be less than 45 mg/dl in order to support more cautious clinical management. It took time for the new definition to be applied, so for the purposes of our analysis we used the range of less than 40 or less than 45 mg/dl to define low blood sugar. Table 1 Quality indicators definitions and targets Category Indicator Definitions Targets Vital signs Percent of patient records in which vital signs are documented on average every 3 h within the first 48 h of admission 15 (every 3 h × 48 h with possibility of one less on day of admission) per patient and 80% overall. Thermoregulation Percent of neonates who have first temperature documented within 30 min of admission to neonatal unit 80% Percent of neonates with documented first temperature after admission < 36.0 °C having temperature improve to > 36.0 °C in ≤2 h 80% Hypoglycemia a Percent of neonates with documented blood sugar < 40- < 45 mg/dL who had blood sugar level improve to > 40- > 45 mg/dL within 1 h 80% Infectious disease Percent of neonates who received antibiotics (ampicillin and gentamicin) at correct dose and interval for first 24 h of therapy 80% Fluid electrolytes and nutrition Percent of neonates admitted to neonatal unit within first 48 h of life and remain in unit until at least 2 weeks of age who regain their birth weight by < 2 weeks of age 80% Respiratory Percent of neonates with BW < 1.5 kg or GA < 33 weeks for whom methylxanthine treatment (caffeine or aminophylline) is prescribed 80% Percent of preterm/LBW neonates eligible for CPAP who are started on CPAP within 2 h of life (eligibility criteria: BW < 2 kg or GA < 33 weeks and any degree of respiratory distress - O 2 saturation ≤ 90% oxygen requirement and/or RR ≥50 and/or grunting/flaring/retractions) 90% o C degrees centigrade, mg/dL milligrams per deciliter, BW birth weight, LBW low birth weight, kg kilogram, GA gestational age, O2 Oxygen, RR respiratory rate, CPAP continuous positive airway pressure a Cut-off point for hypoglycemia changed during the study period. Originally, low blood sugar was defined as less than 40 mg/dl. The definition was eventually changed to be less than 45 mg/dl. It took time for the new definition to be applied, so for the purposes of our analysis we used the range of less than 40 or less than 45 mg/dl to define low blood sugar Quality indicators definitions and targets o C degrees centigrade, mg/dL milligrams per deciliter, BW birth weight, LBW low birth weight, kg kilogram, GA gestational age, O2 Oxygen, RR respiratory rate, CPAP continuous positive airway pressure a Cut-off point for hypoglycemia changed during the study period. Originally, low blood sugar was defined as less than 40 mg/dl. The definition was eventually changed to be less than 45 mg/dl. It took time for the new definition to be applied, so for the purposes of our analysis we used the range of less than 40 or less than 45 mg/dl to define low blood sugar For this study, the antibiotic indicator is limited to antibiotics provided in the first 24 h of therapy. For routine monitoring and evaluation, it was most feasible to assess all charts with antibiotic provision, rather than algorithmic exclusions of those who were ruled out within 72 h. Additionally, medication safety is a critical issue, particularly when introducing treatments in a neonatal population which can require dilution calculations. Therefore, the routinely monitored indicator was adapted to the version included here. Correct dose and interval for the first 24 h of therapy was determined according to the national neonatal protocol [ 17 ]. The actual dose administered was compared to the calculated correct dose using the neonate’s birth weight, and administration interval was calculated using the time of medication administration as documented. In the two participating hospitals, the quality indicators were reviewed quarterly to monitor progress and inform quality improvement initiatives. All extracted data was verified for accuracy and completeness during routine audits performed by the MOH’s and PIH/IMB’s monitoring and evaluation teams. We report demographic and clinical characteristics, clinical management and outcome variables using frequencies and proportions for categorical data and medians with interquartile ranges (IQR) for continuous data. We stratified the data by birth weight and used Fisher’s exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables to compare clinical management and outcomes variables between LBW and NBW neonates at the α = 0.05 significance level. NBW included neonates with a birth weight of ≥2500 g. LBW included neonates with a birth weight < 2500 g, with the sub-categories of extremely LBW neonates (< 1000 g), very LBW neonates (1000 to 1499 g) and LBW neonates (1500 to 2499 g). Although not used for stratification, gestational age is reported for some variables and was categorized as term (≥37 weeks) and preterm (<37 weeks). Outcomes included the number of neonates discharged, transferred, absconded (defined as leaving against medical advice) and deceased at the end of the study period, as well as weight at discharge and length of stay in the neonatal unit. Missing data were analyzed using a pairwise deletion for the missing data at random. Data were analyzed using Stata v13 (College Station, TX: StataCorp LP). A total of 1723 neonates were admitted to the two district hospital neonatology units; 49.7% ( n = 856) to Kirehe and 50.3% ( n = 867) to Rwinkwavu (Table 2 ), respectively. Admission age was recorded for 1684 neonates; 88.7% ( n = 1493) were admitted within the first 48 h of life and 58.4% ( n = 949 of 1624) were males. Birth weight was recorded for 1518 neonates and gestational age recorded for 1528; 46.2% ( n = 501) were LBW and 53.8% ( n = 817) were NBW, and 36.4% ( n = 556) were preterm and 63.6% ( n = 972) were term. The top three primary diagnoses (among the 1663 neonates with recorded diagnoses) were prematurity (27.8%, n = 463), neonatal infection (23.6%, n = 392), and asphyxia (20.2%, n = 336). Table 2 Socio-demographic and clinical characteristics of neonates admitted to neonatology units at two rural district hospitals in Rwanda ( N = 1723) n % Hospital Kirehe 856 49.7 Rwinkwavu 867 50.3 Age at admission (days) N = 1621 < 1 1140 70.3 1–3 310 19.1 4–7 54 3.3 8–28 117 7.2 Admitted in first 48 h of life N = 1684 Yes 1493 88.7 No 191 11.3 Gender N = 1624 Male 949 58.4 Female 675 41.6 Birth weight (grams) N = 1518 Low birth weight (< 2500) 701 46.2 LBW (≥1500- < 2500) 528 34.8 Very LBW (≥1000- < 1500) 139 9.2 Extremely LBW (< 1000) 34 2.2 Normal birth weight (≥2500) 817 53.8 Gestational age (weeks) N = 1528 Preterm (<37) 556 36.4 Preterm (≥33 to < 37) 391 25.6 Very preterm (< 33) 165 10.8 Term (≥37) 972 63.6 Primary diagnosis N = 1663 Prematurity 463 27.8 Neonatal infection 392 23.6 Asphyxia at birth/low APGAR score/HIE 336 20.2 Respiratory distress/apnea 113 6.8 Low birth weight 95 5.7 Poor feeding 51 3.1 Malformation 36 2.2 Convulsion 28 1.7 Pneumonia 21 1.3 Jaundice 13 0.8 Hypothermia 10 0.6 Hypoglycemia 8 0.5 Others 97 5.8 LBW Low birth weight, APGAR A measurement of Appearance, Pulsation, Grimace, Activity and Respiration, HIE Hypoxic Ischemic Encephalopathy Socio-demographic and clinical characteristics of neonates admitted to neonatology units at two rural district hospitals in Rwanda ( N = 1723) LBW Low birth weight, APGAR A measurement of Appearance, Pulsation, Grimace, Activity and Respiration, HIE Hypoxic Ischemic Encephalopathy For clinical management during a hospital stay, 82.6% ( n = 965 of 1168) of neonates had their vital signs checked and documented at least 15 times within the first 48 h of their hospital admission (Table 3 ). For thermoregulation, 55.0% ( n = 812 of 1476) of neonates had their initial temperature measured within 30 min of admission; 29.4% ( n = 435 of 1480) had an initial temperature below 36 °C recorded, and 38.8% ( n = 156 of 402) had an initial temperature below 36 °C improve to be greater than 36 °C within 2 h of the time the initial temperature was taken. Hypoglycemia was also assessed; 3.6% (31 of 871) of neonates had low blood sugar levels (either < 40 or < 45 mg/dl) and 16.7% ( n = 2 of 12) neonates with low blood sugar improved to have a blood sugar measurement of either > 40 or > 45 mg/dl documented within the hour. Table 3 Clinical management and interim outcomes of neonates with birth weight recorded upon admission to neonatology units at two rural district hospitals in Rwanda ( N = 1518) All neonates ( N = 1518) Low birth weight (< 2500 g) ( N = 701) Normal birth weight (≥2500 g) ( N = 817) p -value n % n % n % Vital signs Vital signs checked every 3 h for the first 48 h of admission N = 1168 N = 556 N = 612 Yes (≥15 times) 965 82.6 478 86.0 487 79.6 0.004 No (< 15 times) 203 17.4 78 14.0 125 20.4 Thermoregulation Initial temperature measured within 30 min of admission N = 1476 N = 683 N = 793 Yes 812 55.0 367 53.7 445 56.1 0.373 No 664 45.0 316 46.3 348 43.9 Initial temperature < 36 °C N = 1480 N = 684 N = 796 Yes 435 29.4 249 36.4 186 23.4 < 0.001 No 1045 70.6 435 63.6 610 76.6 If initial temperature < 36 °C, temperature improved from < 36 °C to > 36 °C within 2 h N = 402 N = 234 N = 168 Yes 156 38.8 99 42.3 57 33.9 0.097 No 246 61.2 135 57.7 111 66.1 Hypoglycemia Low blood sugar (< 40/< 45 mg/dl) N = 871 N = 418 N = 453 Yes 31 3.6 21 5.0 10 2.2 0.028 No 840 96.4 397 95.0 443 97.8 If blood sugar low, improved to > 40/> 45 mg/dl within 1 h N = 12 N = 7 N = 5 Yes 2 16.7 1 14.3 1 20 > 0.999 No 10 83.3 6 85.7 4 80 Infectious diseases Received antibiotics (ampicillin and gentamicin) a N = 334 N = 69 N = 265 Yes 312 93.4 68 98.6 244 92.1 0.053 No 22 6.6 1 1.4 21 7.9 Ampicillin received at correct dose and interval N = 301 N = 66 N = 235 Yes 204 67.8 36 54.6 168 71.5 0.009 No 97 32.2 30 45.4 67 28.5 Gentamicin received at correct does and interval N = 286 N = 64 N = 222 Yes 146 51.0 23 35.9 123 55.4 0.006 No 140 49.0 41 64.1 99 44.6 Fluid electrolytes and nutrition Regained birth weight within 2 weeks b N = 225 N = 169 N = 56 Yes 126 56.0 88 52.1 38 67.9 0.044 No 99 44.0 81 47.9 18 32.1 Respiratory distress Received caffeine c N = 548 Yes 206 37.6 No 342 62.4 Received oxygen therapy N = 1491 N = 690 N = 801 Yes 603 40.4 278 40.3 325 40.6 0.916 No 888 59.6 412 59.7 476 59.4 Method of oxygen therapy N = 540 N = 247 N = 293 Mask/nasal cannula 449 83.1 185 74.9 264 90.1 < 0.001 bCPAP 91 16.9 62 25.1 29 9.9 If eligible, received bCPAP d N = 107 Yes 13 12.2 No 94 87.8 Duration of oxygen therapy in hours Median IQR Median IQR Median IQR Mask/nasal cannula 24 20, 96 48 24, 120 24 14, 72 0.050 bCPAP 60 24, 120 72 24, 144 48 24, 72 0.093 a For neonates with primary diagnosis of infection; b Restricted to neonates that were hospitalized for at least 2 weeks; c Restricted to preterm neonates (< 33 weeks) or LBW (< 1500 g); d Restricted to preterm (< 33 weeks) or LBW (< 1500 g) neonates with any sign of respiratory distress o C degrees centigrade, gm/dl grams per decilitre, bCPAP bubble continuous positive airway pressure, IQR inter-quartile range Clinical management and interim outcomes of neonates with birth weight recorded upon admission to neonatology units at two rural district hospitals in Rwanda ( N = 1518) a For neonates with primary diagnosis of infection; b Restricted to neonates that were hospitalized for at least 2 weeks; c Restricted to preterm neonates (< 33 weeks) or LBW (< 1500 g); d Restricted to preterm (< 33 weeks) or LBW (< 1500 g) neonates with any sign of respiratory distress o C degrees centigrade, gm/dl grams per decilitre, bCPAP bubble continuous positive airway pressure, IQR inter-quartile range Of the 334 neonates with a primary diagnosis of infection, 93.4% ( n = 312) received antibiotics. Among the 301 neonates who had data recorded on ampicillin administration and the 286 neonates who had data recorded on gentamicin administration, 67.8% ( n = 204) and 51.0% ( n = 146) received the correct dose at the correct time interval, respectively. Of 225 neonates who stayed in the hospital for at least 14 days, 56.0% ( n = 126) regained their birth weight within the 2 weeks. With regard to respiratory support, 40.4% ( n = 603) of 1491 neonates received oxygen therapy. Of 540 neonates with oxygen therapy method documented, 83.1% ( n = 449) received mask or nasal cannula and 16.9% ( n = 91) received bCPAP. Of the 107 preterm/low birth weight neonates meeting eligibility criteria for bCPAP (born < 1500 g or < 33 weeks and showing any signs of respiratory distress), 12.2% ( n = 13) received bCPAP. Among the 548 neonates born < 1500 g or < 33 weeks (meeting eligibility criteria), 37.6% ( n = 206) received caffeine citrate. When results were stratified by birth weight, there was no evidence of differences in clinical management between LBW and NBW neonates for the following variables: initial temperature measured within 30 min of admission ( p = 0.373), improvement in initial temperature from < 36 °C to > 36 °C ( p = 0.097), improvement in low blood sugar levels to normal levels ( p > 0.999), and administration of oxygen therapy ( p = 0.916) (Table 3 ). However, we observed significant differences in the clinical management of LBW and NBW neonates for a number of variables. Vital signs were checked at least 15 times within the first 48 h of admission for 86.0% ( n = 478 of 556) of LBW neonates and 79.6% ( n = 487 of 612) of NBW neonates ( p = 0.004). Antibiotics were administered to 98.6% ( n = 68 or 69) of LBW neonates with infection and 92.1% ( n = 244 of 265) of NBW neonates with infection ( p = 0.053). Correct dosage and interval of ampicillin was provided to 54.6% ( n = 36 of 66) LBW neonates and 71.5% ( n = 168 of 235) NBW neonates ( p = 0.009), and to 35.9% ( n = 23 of 64) LBW neonates and 55.4% ( n = 123 of 222) NBW neonates for gentamicin ( p = 0.006). Approximately half (52.1%, n = 88 of 169) of LBW neonates regained birth weight within 2 weeks, compared to 67.9% ( n = 38 of 56) of NBW neonates ( p = 0.044). For method of oxygen therapy, LBW neonates were more likely to receive bCPAP compared to NBW neonates (25.1%, n = 62 of 247 and 9.9%, n = 29 of 293, respectively, p < 0.001). LBW neonates received oxygen for a longer duration, whether on mask/nasal cannula (median = 48 h, IQR: 24–120, p = 0.050) or bCPAP (media n = 72 h, IQR: 24–144, p = 0.093) compared to NBW neonates, who used mask/nasal cannula for a median of 24 h (IQR 14–72) and bCPAP for a median of 48 h (IQR 24–72, p = 0.093). Overall, 83.3% ( n = 1162) of the neonates were discharged, 13.3% ( n = 185) died, 2.3% ( n = 32) transferred and 0.5% (n = 7) absconded (Table 4 ). The top three primary diagnoses among the 183 deceased neonates with primary diagnosis recorded were asphyxia (36.1%, n = 66), prematurity (29.5%, n = 54), and respiratory distress (13.1%, n = 24). There was no evidence of differences in outcomes between LBW and NBW neonates ( p = 0.131). The overall median length of stay in the neonatal unit was 5 days (IQR: 2–10). The length of stay was significantly longer for LBW neonates (median = 7 days, IQR: 2–14) compared to NBW neonates (median = 4 days, IQR: 2–7, p < 0.001). This remained true when stratified by those who survived to discharge (median = 8 days, IQR: 3–18 vs. median = 5, IQR: 2–8, p < 0.001) and those who did not (median = 2 days, IQR: 0–2 vs median = 1 day, IQR: 0–2, p = 0.003). Of the neonates who were discharged, 477 were low birthweight at admission, and 94.1% ( n = 449) remained under 2500 g when they were discharged, while of the 536 neonates of normal birthweight at admission, 12.3% ( n = 66) were under 2500 g at discharge ( p < 0.001). Table 4 Outcomes of neonates with birth weight recorded upon admission to neonatology units at two rural district hospitals in Rwanda ( N = 1518) All neonates ( N = 1518) Low birth weight (< 2500 g) ( N = 701) Normal birth weight (≥2500 g) ( N = 817) p -value n % n % n % Outcome N = 1386 N = 626 N = 760 Discharged 1162 83.3 522 83.4 640 84.2 0.131 Transferred 32 2.3 11 1.8 21 2.8 Absconded 7 0.5 1 0.2 6 0.8 Died 185 13.3 92 14.7 93 12.2 Length of stay a Median IQR Median IQR Median IQR All neonates 5 2, 10 7 2, 14 4 2, 7 < 0.001 Discharged 6 2, 11 8 3, 18 5 2, 8 < 0.001 Transferred 3 0.5, 9.5 3.5 0, 11 2.5 0.5, 7.5 0.722 Absconded 7 1, 15 21 21, 21 5 1, 8 0.134 Died 1 0, 3 2 1, 4 1 0, 2 0.003 Weight at discharge (grams) b N = 1013 N = 477 N = 536 < 2500 515 50.8 449 94.1 66 12.3 < 0.001 ≥ 2500 498 49.2 28 5.9 470 87.7 a Only reported for neonates that had an admission date and outcome date or age at admission and age at discharge; b Limited to neonates who were discharged Outcomes of neonates with birth weight recorded upon admission to neonatology units at two rural district hospitals in Rwanda ( N = 1518) a Only reported for neonates that had an admission date and outcome date or age at admission and age at discharge; b Limited to neonates who were discharged Neonatal care provision in rural resource-limited settings is a challenge for many countries in SSA and in the early stages of introduction [ 18 – 25 ]. Hansen et al. (2015) showed that while neonatal care may be considered a specialized clinical service, it can be standardized and implemented in rural district hospitals in Rwanda [ 18 ]. Here, we show clinical management and quality of neonatal care in two rural district hospitals that were guided by this neonatal care package. Our study had a number of key results. First, we found that the demographic and clinical characteristics of our neonatal sample were similar to those reported in other studies. Consistent with studies showing higher and earlier hospital admission rates for neonates within the first 7 days of birth and higher morbidity rates among male neonates [ 2 , 20 , 26 , 27 ], most neonates in our study were admitted to the neonatal units within the first 48 h after birth and were males. Prematurity, infection and asphyxia were the top three causes of infant illnesses, mirroring findings reported in other parts of SSA [ 1 , 20 , 27 , 28 ]. These patterns show that more research into the underlying causes of neonatal illness in resource-limited settings is needed, as are interventions that can address these persistent challenges. Second, our assessment of clinical management and outcome variables shows that it is possible to provide care to high-risk neonates in this setting with reasonable patient outcomes, particularly when compared to those of other countries in the region [ 27 ]. A study on the use of medicines in 104 developing and transitional countries from 1990 to 2009 found that the percentage of patients receiving antibiotics increased from 45 to 54% over this 20-year period [ 29 ] and the management of prematurity-related complications using antibiotics was only 50% [ 27 ]. Additionally, the majority of LBW neonates, who are at the highest risk of morbidity, were more likely to receive care according to protocol compared to NBW neonates in a number of clinical domains, including close monitoring (vital sign measurement) and duration on oxygen therapy, which are important interventions to reduce clinical deterioration in this population [ 5 , 30 ]. LBW neonates also stand to gain the greatest impact from bCPAP for the treatment of respiratory distress syndrome [ 5 , 21 ] and their higher rates of bCPAP use and longer duration on oxygen therapy showed possible prioritization of their needs by health care workers, particularly in a staff-constrained environment. The transfer rate for neonates was low and impressively similar to a study conducted at a Rwandan provincial hospital (which is supposed to have a higher level of care than district hospitals) which reported a drop-in neonate transfer rates from 50 to 2% in 1 year after a series of quality improvement interventions were implemented, including introduction of standardized treatment procedures [ 16 ]. Finally, and most importantly, the overall neonatal unit survival rate for both LBW and NBW neonates was higher than results reported from similar settings and did not differ across birth weight categories [ 23 , 26 , 31 ]. This study is descriptive and limits any assessment of causality; however, given that no standardized care for sick and preterm infants was provided before the establishment of the neonatal care unit and these infants were previously being referred to the one national referral hospital in the country, it demonstrates that neonatal care can be provided in a decentralized manner with the appropriate investment in neonatal unit establishment, vastly improving population access to this essential service. Availability and ease of protocol use, presence of essential equipment and medications, along with intermittent training and mentorship for providers likely influenced the quality of care for high-risk neonates in these hospitals [ 32 , 33 ]. Asphyxia was a leading diagnosis among those who died, which could indicate a greater need to target improvement efforts during delivery and immediately after birth and underscore the need for interdepartmental coordination within the hospital across maternity, delivery, and neonatal units. Further research assessing the impact of the neonatal care package on population level neonatal mortality, as well as assessment of the optimal content and level of complexity for rural district hospitals is warranted. Despite these successes, there is still a need to improve treatment practices to meet quality indicator targets and further improve neonatal outcomes. These targets were intentionally set high to serve as a goal for quality improvement efforts. Based on our results, management of vital signs measurement, weight gain, administration of antibiotics and thermoregulation measurement of temperature within the first 30 min of admission were close to the targets, while other indicators, such as improved temperature within 2 h of admission, caffeine administration, improved blood sugar levels and weight gain were not. These results can be used to inform the design and goals of quality improvement initiatives so they can be most effective. For example, while LBW infants had relatively strong outcomes, a low percentage of the bCPAP-eligible LBW/preterm neonates received bCPAP therapy, indicating further potential gains in neonatal outcomes that could be made. While this gap could be exaggerated due to the fact that bCPAP was introduced in first month of the study period and may have improved with increasing health care worker comfort and practice over time during the study period, a gap in bCPAP implementation was also noted by a second bCPAP-focused study from an overlapping time period [ 34 ]. Therefore, this area has been targeted for quality improvement since the completion of this study. In addition, while antibiotics were administered to neonates diagnosed with infections, there is room for improvement in the timing and dosage of these antibiotics. As these data were used for quarterly data review with the clinical teams, quality improvement problem analyses found a number of challenges with hospital level neonatal antibiotic administration. The dose has to be selected based on gestational age/birth weight and a weight-based dose had to be correctly calculated. Some providers new to neonatal care, or not providing neonatal care routinely, found this selection challenging, and more NBW neonates received correct administration of gentamicin. Staff shortages and high patient volume could be challenges to administering antibiotics on-time. There is also room for improvement around documentation and recordkeeping. Further exploration into the issue should be pursued by asking the neonatal nurses about the documentation processes they follow and challenges they face. Observation of documentation practices can also be done if possible. Strategies for improving documentation should be designed and implemented as a collaborative effort between nurses and researchers to better support uptake and sustainability. Our results also show that quality improvement efforts need to be directed at NBW neonates as well. We found that 12% of neonates admitted to the hospital with a normal birthweight were discharged weighing less than 2500 g. While this could be focused among neonates born just above the LBW cut-off experiencing normal weight loss in the first few days of life with short-course hospitalizations, this may indicate that supporting neonatal growth and nutrition was challenging. Taking the full context into consideration, this may be due to a family’s inability to pay for the costs of hospitalization or because parents are unable to leave other children at home or be absent from work to be in the hospital. Therefore, this finding warrants further investigation into how to support families comprehensively, and more interventions, such as social support packages that can address financial challenges, are needed to ensure these high-risk vulnerable neonates get the treatment they need to thrive. Health systems challenges may have also influenced the ability to reach certain indicator targets. Not being able to apply to full protocol due to staffing shortages, high turnover of trained staff, misaligned rotations where providers not trained in neonatal care are assigned to the neonatal unit and stock outs of drug and laboratory reagents may have impacted the quality of care provided in the neonatal units [ 4 , 28 ]. We recommend implementation of quality improvement projects that target the national indicators, accurate and timely documentation of management and outcomes, revision of the rotation system to ensure the nurses staffing the neonatal unit have necessary training and skills for neonatal management and harmonizing internal transfers of neonates to ensure continuity of care as activities that can address the challenges we see in our neonatal units [ 35 ]. It is important to note that the care protocol was not introduced as an isolated document – when first introduced, it was paired with medical record introduction, quality indicators, and institutionalized training and mentorship. More broadly, will-building across hospital leadership and health care providers to establish a neonatal unit with designated physician and nursing staff and management was critical to providing a setting in which this introduction could have any measure of success. The district hospitals have both adopted district-based quality improvement initiatives in response to these data which were reviewed quarterly, including projects aimed at accurate and timely documentation of management and outcomes, revision of the rotation system to ensure the nurses staffing the neonatal unit have necessary training and skills for neonatal management, and coordination of internal transfer processes of neonates to ensure continuity of care [ 36 ]. This study has several limitations. First, as a retrospective cross-sectional study over a two-year time period, we were unable to assess variations in quality across time and potential relationships with intervening variables such as those related to constrained health systems and timing of introduction of new initiatives such as bCPAP listed previously. We do not have data for year-to-year variations in the indicators. Data variation over a longer period would have to take issues like staffing and policy changes into consideration, which were outside the scope of this study. Along the same vein, we chose not to examine trends in performance on the quality indicators because we chose to focus on the current level of performance. Trends in performance in relation to specific quality improvement interventions could be the subject of future studies. Additionally, some of the diagnoses, such as infection and asphyxia, require laboratory evaluations for definitive diagnosis that were not available at this district hospital level [ 22 ]. However, we believe the clinical management to be appropriate if the provider closely followed the guidance for clinical management of a given suspected diagnosis, as they are designed to leverage the diagnostic resources available in these low-resource settings. Finally, another limitation was missing data, which we believe was due to the high documentation burden placed on the nurses and physicians staffing the neonatal units. Approximately 12% of the records were missing data and not included in the analysis of clinical management and interim outcomes shown in Table 3 . Results were reported only for neonates who had a birth weight recorded upon admission to the neonatology unit. While missing data limited the ability to which we were able to generalize our study findings, we are still able to present outcomes and discuss our experiences of treating small and sick neonates in accordance with a national neonatal care package. Periodic data quality checks and training with an emphasis on the importance of proper documentation in clinical charts could improve data quality. In addition, future plans to implement electronic medical record systems in the hospital units could also help address these data quality gaps. This study demonstrates the feasibility of specialized neonatal care in resource-limited settings supported by a standardized national package of services including infrastructure, training and supplies, as well as the implementation of a national neonatal protocol. LBW neonates received higher quality care compared to NBW and overall mortality rates were lower or comparable to other urban and tertiary hospital settings among both categories. However, gaps in care management remain that should be addressed in order to achieve further gains in morbidity and mortality. We recommend quality improvement efforts to address lagging indicators as well as continuous training and mentorship to ensure new providers are empowered with the tools necessary to provide high quality care to these vulnerable newborns and families. Bubble continuous positive airway pressure General practitioner Interquartile range Kirehe District Hospital Low birth weight Normal birth weight Degrees centigrade Partners In Health/ Inshuti Mu Buzima Rwinkwavu District Hospital Ministry of Health Sub-Saharan Africa This study was developed under the Partners In Health/Inshuti Mu Buzima Intermediate Operational Research Training Program, developed and facilitated by Bethany Hedt-Gauthier and Neil Gupta. We thank Hari Iyer, Evariste Bigirimana and Jackline Odhiambo for their support in the data cleaning, analysis and manuscript editing. We also thank Janet Umuhoza and Liliose Mukantaganzwa for their help with data collection. We would like to acknowledge the Rwanda Ministry of Health for its leadership, and the doctors and nurses at Kirehe and Rwinkwavu District Hospitals who work tirelessly to improve the lives of newborns in their communities. We acknowledge Partners In Health/Inshuti Mu Buzima and the IMB Innovation Grants for the support of this work. We acknowledge the PIH/IMB Doris Duke Charitable Foundation funds that supported data collection. The funding used for data collection for this study was part of a larger support by the Doris Duke Charitable Foundation. The funder had no direct role in any technical or intellectual aspect of this work. The data that support the findings of this study are available from Partners In Health/Inshuti Mu Buzima but restrictions apply to the availability of these data, which were used under license for the current study, and are not publicly available. Data are available from the corresponding author upon reasonable request and with permission of Partners In Health/Inshuti Mu Buzima and the Rwandan Ministry of Health. MN led all aspects of the study from study design, data analysis and interpretation of results, and manuscript writing. BHG, NG and RB supported study design, analysis, and results interpretation and critically reviewed the manuscript. EN, WI, FN, FB, ChM, FM, ClM, ML and AH supported study design, and critically reviewed manuscript. HM supervised the study and supported design, results interpretation, and provided constructive feedback on the manuscript. All authors approved the final manuscript. The study received technical approval from the PIH/IMB Research Committee and the Rwanda National Health Research Committee and ethical approval from the Rwanda National Ethics Committee and the Institutional Review Board of Brigham and Women’s Hospital, Boston, MA, USA. The study was completed using de-identified routinely collected program data; therefore, no informed consent was required. Not applicable. The authors declare that they have no competing interests. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the sustainable development goals Population based trends in mortality, morbidity and treatment for very preterm- and very low birth weight neonates over 12 years Sub-Saharan Africa’s mothers, newborns, and children: where and why do they die? 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Answer the following medical question. | What does research say about [Challenges in neonatal dermatology : An introduction].? | In order to support dermatologists' interest for the fascinating area of neonatal dermatology, we provide (1) an introduction to the specifics of skin barrier in premature and full-term neonates as well as their clinical implications and (2) an example of age-dependent differential diagnoses and approach to a facial vascular stain in a neonate. Das Ziel der aktuellen Übersichtsarbeit ist, das Interesse der Dermatologen für die faszinierende Mikrowelt der neonatalen Dermatologie durch die folgenden Themenbereiche zu wecken: (1) Besonderheiten der Hautbarriere bei reifen Neugeborenen und Frühgeborenen – Konsequenzen für die Klinik und Hautpflege; (2) „Ein Neugeborenes mit rötlichen Effloreszenzen im Gesicht“ als Beispiel für die Altersspezifität der Differenzialdiagnosen und Vorgehensweisen. |
Answer the following medical question. | What does research say about The challenges of neonatal magnetic resonance imaging.? | Improved neonatal survival rates and antenatal diagnostic imaging is generating a growing demand for postnatal MRI examinations. Neonatal brain MRI is now becoming standard clinical care in many settings, but with the exception of some research centres, the technique has not been optimised for imaging neonates and small children. Here, we review some of the challenges involved in neonatal MRI, including recent advances in overall MR practicality and nursing practice, to address some of the ways in which the MR experience could be made more neonate-friendly. |
Answer the following medical question. | What does research say about Improvised Neonatal Care-Realizing the Gaps in a Disaster Zone.? | The treatment of newborns in a disaster zone can be extremely challenging. The effects of the disaster combine with local health care disparity to give these neonates little chance of survival in the event of even minor complications. Rescue teams arriving at such locations must be prepared to handle and to aid these difficult situations using improvisation and ingenuity to overcome many of the unexpected hurdles. A discussion of the difficulties faced in the Philippines following a typhoon and recommendations for future teams are presented. |
Answer the following medical question. | What does research say about Thermoregulation of the Extremely Low Birth Weight Neonate.? | The birth of an extremely low birth weight (ELBW) neonate is complex because of their immaturity. Respiratory and hemodynamic stabilization often takes precedence in the immediate delivery period. While establishing effective breathing and circulation is vital to the survival of the neonate, it is crucial to understand that other adverse outcomes can occur during the resuscitation and transport of the ELBW neonate. Impaired thermoregulation is one of the most detrimental adverse outcomes during the golden hour period and later in the neonatal intensive care unit. Hypothermia is an independent risk factor for increased morbidity and mortality and can impact multiple body systems, making management even more challenging. This article discusses the physiology of thermoregulation while exploring interventions to maintain normothermia in the ELBW neonate, ultimately improving long-term outcomes. |
Answer the following medical question. | What does research say about Nurse-Guided Maternal Interventional Package for Neonatal Stress - A Randomized Controlled Trial.? | To assess the role of nurse-guided maternal interventional package for reducing stress behaviour among preterm neonates admitted in neonatal intensive care unit (NICU). A randomized controlled trial was conducted among 100 mothers and their newborns delivered preterm and admitted consecutively in the NICU over 4 months. Mothers in the intervention group (n = 50) received education and demonstration regarding the use of maternal touch, facilitated tucking, kangaroo mother care (KMC), non-nutritive sucking (NNS), nesting and maternal voice alongwith a handout in local language for five consecutive days, while those in the control group (n = 50) received routine care including KMC and NNS for five consecutive days. Neonates were assessed before and five days after enrolment or intervention by using modified Infant Positioning Assessment Tool (IPAT), Neonatal Stress Scale and Preterm Neonate's Behaviour Assessment Scale. The mean (SD) score of positioning was significantly higher in the intervention group as compared to control group [9.62 (1.17) vs 6.58 (1.72), P < 0.001]. The median (IQR) score of stress was significantly lower in the intervention group compared to the control group [7 (7,10) vs 11(8,12.75), P = 0.004]. The mean (SD) scores for the autonomic and visceral subsystem behavioral response were significantly higher in the intervention group [5.28 (1.4) vs 3.25 (1.0), P < 0.001]. Mean (SD) attention interaction subsystem behavioral response score in the intervention group was significantly higher compared to the control group [2.96 (1.2) vs 1.85 (0.9), P = 0.001]. Mothers can be guided by nurses on neonatal stress behaviour and how to handle neonates in NICU, which significantly improves positioning and behavioral scores and reduces stress scores. |
Answer the following medical question. | What does research say about Neonatal Anthropometric Measures and Peripherally Inserted Central Catheter Depth.? | Peripherally inserted central catheters (PICCs) are used routinely in neonatal care. Measures of surface anatomy have been used to estimate appropriate PICC depth in neonates since 1973. However, prior PICC research using anthropometric measures to estimate proper PICC insertion depth has been limited to pediatric and adult literature. The purpose of this study was to explore the relationships among a neonate's anthropometric measures and the appropriate PICC insertion depth. Neonates requiring PICC insertion at Nationwide Children's Hospital were enrolled between January and September 2018. Standard PICC procedures were followed. The research group corroborated appropriate PICC tip position of enrolled infants. Multivariable linear regression with robust standard errors was used to evaluate linear relationships between PICC insertion depth and current weight, current length, and PICC insertion site. Demographics of enrolled infants included gestational ages of 23 to 39 weeks, weights of 510 to 3870 g, and lengths of 31 to 54 cm. Of the 56 infants considered, final statistical analysis included 49 neonates (14 ankle, 16 knee, and 19 antecubital insertions). Current neonatal weight was associated with PICC depth at all sites (all Ps < .0001). Current neonatal length was associated with PICC depth at all sites (all Ps < .0001). Preprocedure surface measurement was also strongly associated with PICC insertion depth (P < .0001). This investigation demonstrated a relationship for both neonatal weight and length that may be an anthropometric model for neonatal PICC insertion depth. A more robust sample size could more precisely define the anthropometric model. |
Answer the following medical question. | What does research say about Neonatal Iron: Factors Influencing its Level and Associated Complications - a Review Article.? | Iron is an essential micronutrient which plays a significant role, particularly vital for early brain growth and function. Maternal iron condition influences the iron status of neonates since iron transferred from the mother is the only source for fetal iron. A depletion in iron as a result of rapid growth leads to iron deficiency which is common in neonates. Although there are inconsistencies with regard to the normal reference ranges for neonatal iron level, the current review summarized literature to provide compressive information about neonatal iron status and factors that influence its level. This is a narrative review on the basis of relevant literatures mainly on neonatal iron from peer-reviewed journals. Electronic databases such as PubMed, PMC, Scopus, Science Direct, Google scholar, Google, and Yahoo were used to retrieve relevant literatures using key terms like "newborn iron, neonatal iron, iron overload, maternal factors, complication, iron level and neonates" separately and in combination. Several factors had been postulated as factors associated with neonatal iron status. The current review figured out that maternal obesity, gestational diabetes mellitus, preterm delivery, placental transferrin receptor, inappropriate iron supplementation, use of iron fortified formula, uses of recombinant erythropoietin therapy, smoking, maternal iron deficiency anemia, umbilical cord clamping, and transfusion are the major factors which can influence neonatal iron level. These factors may have either positive or negative effects on neonatal iron level. Both iron deficiency and iron overload at some stage in the fetal development or at early stage of neonatal development cause abnormal functions of multiple organ system of neonates and subsequently contributed to neonatal and childhood morbidity and mortality. By one and other means insufficient, late and extra maternal iron supplementation, early and delayed umbilical cord clamping have negative effects on the iron level of neonates. Therefore, careful prenatal and antenatal follow-up need to be strengthened with due emphasis for maternal iron assessment. |
Answer the following medical question. | What does research say about Systemic Hypertension in Infants with Bronchopulmonary Dysplasia.? | Neonatal hypertension is increasingly recognized as improvements in neonatal intensive care have led to increased survival of premature infants. Among infants with bronchopulmonary dysplasia (BPD), the rates of hypertension are much higher than the general neonatal population. However, the etiology and pathophysiology of this increased risk of hypertension in neonates with lung disease remain unclear. Among infants with bronchopulmonary dysplasia, the rates of hypertension are much higher than the general neonatal population. New studies suggest outcomes in neonates with BPD with hypertension are usually good, with resolution of hypertension in most infants with lung disease. Several potential mechanisms of hypertension in this patient population have been recently proposed. This review focuses on the recent epidemiologic data on prevalence of hypertension in neonates with bronchopulmonary dysplasia, reviews the typical clinical course, and discusses available strategies for management of infants with bronchopulmonary dysplasia that develop hypertension. |
Answer the following medical question. | What does research say about Oral Care with Mother's Own Milk in Sick and Preterm Neonates: A Quality Improvement Initiative.? | Oral care with mother's own milk (OC-MOM) in sick and preterm neonates provides immune protection, improves feed tolerance and helps in earlier achievement of full enteral nutrition. This quality improvement (QI) initiative was undertaken when authors documented scanty awareness regarding neonatal oral care practices among care-givers in their neonatal unit. The project aimed to improve the proportion of OC-MOM in sick and preterm neonates from the baseline of 5.9% to 80%. The QI project was designed as per Point of Care Quality Improvement (POCQI) model and conducted over 6 mo (January 14, 2019 to July 12, 2019). Preterm and sick term neonates on enteral fasting or gavage feeding were included. Neonates with major congenital malformation and whose MOM was not available were excluded. An OC-MOM team was formed and baseline data were collected. Flow charts and fish-bone diagrams were used to analyse the problem and identify the key issues. Mouth assessment tool (MAT) was customized and adapted as one of the outcome measures. An OC-MOM protocol was designed and implemented as a part of routine neonatal care. Four Plan-Do-Study-Act (PDSA) cycles were conducted to achieve the target. After successful implementation of OC-MOM protocol, proportion of neonates receiving OC-MOM increased to 83.3% from a baseline of 5.9% and proportion of neonates having MAT score "0" improved to 94.4% from a baseline of 24.4%. This QI initiative using POCQI model resulted in a significant and sustained improvement in the proportion of neonatal oral care with MOM using locally available resources. |
Answer the following medical question. | What does research say about The Effect of Mindfulness-Based Stress Reduction on Posttraumatic Stress of Mothers With Premature Neonates Admitted to a Neonatal Intensive Care Unit.? | Mothers experience posttraumatic stress disorder with the birth of a premature neonate. The purpose of this study was to determine the effect of mindfulness-based stress reduction on posttraumatic stress of mothers with premature neonates in Iran. Sixty mothers with premature neonates were selected by using convenience sampling and stratified random allocation. Mindfulness-based stress reduction was trained and mean posttraumatic stress disorder was measured. Mean posttraumatic stress scores of the 2 groups were statistically significant immediately and 1 month after the intervention (independent t test, P < .05). Posttraumatic stress of both groups reduced over time, but this reduction was more significant in the intervention group (repeated-measures analysis of variance, P < .05). Concerning the positive role of mindfulness-based stress reduction in posttraumatic stress disorder of mothers, it is recommended to use this approach in care programs of mothers with premature neonates. |
Answer the following medical question. | What does research say about Safety of neonatal phototherapy lamp exposure.? | A routine review of light exposure within a neonatal intensive care unit is described following the introduction of a new model of neonatal phototherapy lamp. Spectral measurements were undertaken using a Bentham Dmc150 spectroradiometer system. Safety assessments were undertaken based on likely exposure of parents at the cot side, neonates in adjacent cots and the effectiveness of eye protection for neonates with direct phototherapy. An aphakic eye response was used for assessment of neonatal risk and the blue-light response for estimation of adult exposure using current ICNIRP guidelines. Such estimations indicated exposure levels of parents at the cot side and neonates in adjacent cots were within current established safe limits. The level of light blocking provided by the available neonatal eye protection was estimated to be entirely adequate and presented no hazard to the infant when correctly positioned over the neonate. It is likely, however, that an increased safety factor is potentially present for the neonate due to the fact that the neonate's eyes will typically be shut for over 50% of the time. It is identified, however, that the aphakic response is essentially associated with mature adult retinal cells, and that the maturing cells of the neonate may exhibit additional light sensitivity, especially in the case of premature infants. Changes in neonatal physiology associated with neonatal phototherapy are discussed, which may influence mechanisms of light-induced retinal damage. |
Answer the following medical question. | What does research say about Trends in neonatal emergency transport in the last two decades.? | Although maternal antenatal transfer is the preferred option, some infants inevitably need urgent transport to a tertiary neonatal care facility after birth. This study aimed to investigate trends over time in patient characteristics and respiratory management in a large series of neonatal emergency transfers, in order to provide health caregivers an up-to-date profile of such patients and their therapeutic needs. Trends in patient characteristics and respiratory management were evaluated in 3337 transfers by the Eastern Veneto Neonatal Emergency Transport Service in 2000-2019. Joinpoint regression analysis was performed to evaluate trends and to estimate annual percentage changes (APCs). Proportions of preterm neonates increased (APC |
Answer the following medical question. | What does research say about Diagnosis and Management of Seizures in the Preterm Infant.? | The risk of seizure is increased in premature neonates compared to full term infants, with a distinct profile of etiologies, timing and character. Despite improvements in neonatal care, preterm infants with seizure continue to have higher risk of abnormal neurodevelopmental outcomes when compared to preterm infants without seizures, or to full term infants with seizures. Very limited evidence guides the care of this challenging population, therefore, management of the preterm neonate with seizure is largely extrapolated from the care of full-term neonates. A critical need exists for well-designed clinical trials investigating and validating the safety, efficacy, and outcomes of seizure management in this vulnerable population. |
Answer the following medical question. | What does research say about Optimal timing of extubation in preterm infants.? | In neonatal intensive care, endotracheal intubation is usually performed as an urgent or semi-urgent procedure in infants with critical or unstable conditions related to progressive respiratory failure. Extubation is not. Patients undergoing extubation are typically stable, with improved respiratory function. The key elements to facilitating extubation are to recognize improvement in respiratory status, promote weaning of mechanical ventilation, and accurately identify readiness for removal of the endotracheal tube. Therefore, extubation should be a planned and well-organized procedure. In this review, we will appraise the evidence for existing predictors of extubation readiness and provide patient-specific, pathophysiology-derived strategies to optimize the timing and success of extubation in neonates, with a focus on extremely preterm infants. |
Answer the following medical question. | What does research say about Out of pocket expenditure and its associated factors in neonates admitted to neonatal intensive care unit of tertiary care government hospital of Agra District, Uttar Pradesh.? | Neonatal health remains a thrust area of public health, and an increased out-of-pocket expenditure (OOPE) may hamper efforts toward universal health coverage. Public spending on health remains low and insurance schemes few, thereby forcing impoverishment upon individuals already close to poverty line. To determine catastrophic health expenditure (CHE) in neonates admitted to the government neonatal intensive care unit (NICU) and factors associated with of out-of-pocket expenditure. This cross-sectional study was conducted in a governmental NICU at Agra from May 2017 to April 2018. A sample of 450 neonatal admissions was studied. Respondents were interviewed for required data. OOPE included costs at NICU, intervening health facilities, and transport as well. SPSS version (23.0 Trial) and Epi Info were used for analysis. Of the 450 neonates analyzed, the median total OOPE was Rs. 3000. CHE was found among 55.8% of cases with 22% spending more than their household monthly income. On binary logistic regression, a higher total OOPE of Rs. 3000 or more was found to be significantly associated with higher odds of residing outside Agra (adjusted odds ratio [AOR] = 1.829), delay in first cry (AOR = 1.623), referral points ≥3 (AOR = 3.449), private sector as first referral (AOR = 2.476), and when treatment was accorded during transport (AOR = 1.972). OOPE on neonates amounts to a substantial figure and is more than the country average. This needs to be addressed sufficiently and comprehensively through government schemes, private enterprises, and public-private partnerships. |
Answer the following medical question. | What does research say about Oxidative stress in neonatology: a review.? | Free radicals are highly reactive oxidizing agents containing one or more unpaired electrons. Both in human and veterinary neonathology, it is generally accepted that oxidative stress functions as an important catalysator of neonatal disease. Soon after birth, many sudden physiological and environmental conditions make the newborn vulnerable for the negative effects of oxidative stress, which potentially can impair neonatal vitality. As a clinician, it is important to have in depth knowledge about factors affecting maternal/neonatal oxidative status and the cascades of events that enrol when the neonate is subjected to oxidative stress. This report aims at providing clinicians with an up-to-date review about oxidative stress in neonates across animal species. It will be emphasized which handlings and treatments that are applied during neonatal care or resuscitation can actually impose oxidative stress upon the neonate. Views and opinions about maternal and/or neonatal antioxydative therapy will be shared. |
Answer the following medical question. | What does research say about Fathers' Involvement in a Surgical Neonatal Intensive Care Unit: A Prospective Cohort Study.? | To date, studies exploring patterns of fathers' involvement in their neonate's care in the neonatal intensive care unit (NICU) and barriers to involvement have utilised qualitative approaches, which can be time- and resource-consuming. This study aimed to explore the fathers' involvement in a surgical NICU using a novel tool along with identifying potential facilitators and barriers to fathers' involvement in their neonate's care. This single-centre prospective cohort study was conducted at a surgical NICU (SNICU). A novel questionnaire, Fathers' Involvement Questionnaire: Neonatal Intensive Care Unit (FIQ:NICU) comprising four sections, was developed based on current evidence and expert consensus. Study data were collected and managed using REDCap electronic data capture tools. Involvement scores are reported for individual items, subscales (Physical contact, Verbal Interaction, During Procedures, Cares/Feeding, Participation in rounds), and total score (possible range 0-92). Associations between subscales and total FIQ scores and confidence levels were explored using bivariate correlation (Pearson's r). Thirty-two fathers participated. Total FIQ:NICU scores ranged from 20 to 74, mean score 55.1 (95% confidence interval 49.9-60.2), SD 14.24. Fathers reported the highest level of involvement in 'During Procedures' subscale (M = 2.88, SD = 1.00) and the lowest involvement in 'Cares/Feeding' (M = 1.67, SD = 0.83). All fathers reported support from their partner (100%) as a facilitator, followed by support from nurses (71.9%). The most frequently reported barrier was lines and tubes on their neonate (46.9%), followed by work/job commitments (34.4%). Support from healthcare professionals, psychologists and peers can increase father's involvement in their neonate's care in SNICU. |
Answer the following medical question. | What does research say about Lorazepam.? | The nurse administering any BZD--especially lorazepam--to a neonate must be knowledgeable about the drug's effects and risks and must remember that BZDs do not provide analgesia. The sedative effects of lorazepam will increase with concomitant use of opioids. The nurse must be alert for adverse reactions (Table 1). Close monitoring of the neonate's respiratory effort and blood pressure is important. Because of the various reported cases of myoclonus in neonates after lorazepam administration, close observation for seizure activity is imperative. Although lorazepam use may be beneficial in specific instances, administration should be approached with caution in the neonate (especially in the preterm neonate) and other agents considered. |
Answer the following medical question. | What does research say about Factors related to passing the safety fast test among neonates with hypoglycaemia in the neonatal intensive care unit.? | To investigate the success rates and predictors of safety fast test among neonates admitted to the neonatal intensive care unit for hypoglycaemia. A retrospective review of neonates transferred from the newborn nursery unit to the neonatal intensive care unit for intravenous dextrose therapy for hypoglycaemia from January 2016 to June 2019. Neonatal clinical and demographic variables were abstracted from the medical records. A successful safety fast test was defined by blood glucose >60 mg/dL (3.3 mmol/L) at 3, 4, 5 and 6 h after a feed. Of the 76 neonates who had a safety fast test, 80% passed on their first attempt. Neonates who passed the safety fast test were less likely to be premature/small for gestational age (54.1% vs. 92.9%, P = 0.03), required less maximum glucose infusion rate (median 6 vs. 7 mg/kg/min; P = 0.04), and were younger at fasting challenge (median 5 vs. 9 days; P = 0.02), required lower overall intravenous glucose load (median 12 vs. 24 g/kg; P = 0.006). Safety fast test may be a useful tool evaluating discharge readiness of neonates with persistent hypoglycaemia. |
Answer the following medical question. | What does research say about Age-Appropriate Formulations Including Pharmaceutical Excipients in Neonatal Medicines.? | The development of appropriate pharmaceutical formulations for routine neonatal practice is challenging because of the developmental characteristics and the need for it to be specifically ageappropriate. This has led to wide use of extemporaneous formulations, which lack standardized procedures that can result in medication errors in clinical practice resulting in suboptimal efficacy and safety concerns. We have reviewed the most recent literature on formulations and pharmaceutical excipients. We present the issues related with the lack of age-appropriate formulations, discuss the importance and extent of exposure to pharmaceutical excipients known to be harmful to neonates, indicate ways that can reduce exposure to excipients of concern, and review challenges of the design of age-appropriate drug formulations and dosage forms/drug delivery systems for neonates. Finally, we summarize novel approaches regarding drug delivery for neonates. Novel approaches in age-appropriate drug delivery should overcome the present obstacles and improve the quality of medicines, thus avoiding errors in treatment and improving the management of neonates. Further basic researches on discovering new technologies and modern formulations, using in vitro testing systems as well as preclinical and clinical trials, are needed to improve the feasibility, practicality and safety of new formulations, including research on pharmaceutical excipients. |
Answer the following medical question. | What does research say about Interventions for reducing late-onset sepsis in neonates: an umbrella review.? | Neonatal sepsis is one of the leading causes of neonatal deaths in neonatal intensive care units. Hence, it is essential to review the evidence from systematic reviews on interventions for reducing late-onset sepsis (LOS) in neonates. PubMed and the Cochrane Central were searched from inception through August 2020 without any language restriction. Cochrane reviews of randomized clinical trials (RCTs) assessing any intervention in the neonatal period and including one or more RCTs reporting LOS. Two authors independently performed screening, data extraction, assessed the quality of evidence using Cochrane Grading of Recommendations Assessment, Development and Evaluation, and assessed the quality of reviews using a measurement tool to assess of multiple systematic reviews 2 tool. A total of 101 high-quality Cochrane reviews involving 612 RCTs and 193,713 neonates, evaluating 141 interventions were included. High-quality evidence showed a reduction in any or culture-proven LOS using antibiotic lock therapy for neonates with central venous catheters (CVC). Moderate-quality evidence showed a decrease in any LOS with antibiotic prophylaxis or vancomycin prophylaxis for neonates with CVC, chlorhexidine for skin or cord care, and kangaroo care for low birth weight babies. Similarly, moderate-quality evidence showed reduced culture-proven LOS with intravenous immunoglobulin prophylaxis for preterm infants and probiotic supplementation for very low birth weight (VLBW) infants. Lastly, moderate-quality evidence showed a reduction in fungal LOS with the use of systemic antifungal prophylaxis in VLBW infants. The overview summarizes the evidence from the Cochrane reviews assessing interventions for reducing LOS in neonates, and can be utilized by clinicians, researchers, policymakers, and consumers for decision-making and translating evidence into clinical practice. |
Answer the following medical question. | What does research say about Assessment of pain in the neonate.? | Accurate pain assessment in preterm and term neonates in the neonatal intensive care unit (NICU) is of vital importance because of the high prevalence of painful experiences in this population, including both daily procedural pain and postoperative pain. Over 40 tools have been developed to assess pain in neonates, and each NICU should choose a limited number of pain assessment tools for different populations and contexts. Only two pain assessment tools have a metric adjustment to account for differences of pain assessment in prematurity. Preterm neonates do not display behavior and physiologic indicators of pain as reliably and specifically as full term infants, and preterm infants are vulnerable to long term sequelae of painful experiences. "Brain-oriented" approaches for more objective measurement of pain in neonates may become available in the future. In the meantime, neonatal pain assessment tools need to be taught, implemented, and their ongoing use optimized to form a consistent, reproducible basis for the safe and effective treatment of neonatal pain. |
Answer the following medical question. | What does research say about The nursing care of the surgical neonate.? | In the last two decades, advancement in neonatal surgery, anesthesia, and intensive care have improved the outcome not only for neonates with complex surgical conditions but also for those preterm infants with combined medical and surgical issues. Infants with surgical problems may remain in the neonatal care setting for weeks or months, and providing ongoing nursing care can be challenging but rewarding. In this article, the authors outline the immediate preoperative management, stabilization, and subsequent postoperative nursing care of the surgical neonate. |
Answer the following medical question. | What does research say about End-of-life Decisions at Neonatal Intensive Care Units: Jordanian Nurses Attitudes and Viewpoints of Who, When, and How.? | To explore factors predicting neonatal nurses' attitude towards end-of-life decisions in neonates, and to describe the nurses' viewpoints on end-of-life decisions; barriers to end-of-life decision making; parents', nurses', and ethical committees' involvement in the process of end-of-life decision making; and who should regulate end-of-life decisions regarding neonates. A cross-sectional descriptive correlational design was applied. Sample included 279 neonatal nurses working in 24 neonatal intensive care units across Jordan. Data were collected using internationally-accepted questionnaires. Descriptive and inferential statistics were applied in data analysis. Most nurses perceived that everything possible should be done to ensure a neonate's survival, even when they suffer severe prognosis (80%) and irrespective of the burden of the child's disability on the family (75%). Almost all nurses (96%) were against administering drugs with the purpose of ending the neonate's life and 63% were against continuing current treatment without adding others. The nurses' perceived effect of end-of-life decisions on their everyday life, and the importance of religious values to the nurses' personal lives, significantly predicted pro-life attitude scores. According to 80% of the nurses, legal constraints were the most significant barriers to end-of-life decision making. The majority of nurses (84%) indicated that non-religious bodies should establish end-of-life regulations for neonates. Generally, nurses' attitude was supportive of life saving decisions at end-of-life, regardless of the survival odds and the probable health outcomes of the neonates. Neonates' end-of-life care, and parents' bereavement care, should be standard practices in every NICU, worldwide. |
Answer the following medical question. | What does research say about High-Frequency Jet Ventilation in Neonatal and Pediatric Subjects: A Narrative Review.? | High-frequency ventilation is commonly utilized with neonates and with children with severe respiratory failure. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) are used extensively in neonates. HFJV can also be used in older, larger children. The purpose of this narrative review is to discuss the physiologic principles behind HFJV, examine the evidence supporting its use in neonatal and pediatric ICUs, give meaningful guidance for clinical application, and highlight potential areas for future research. |
Answer the following medical question. | What does research say about Early Fluid and Nutritional Management of Extremely Preterm Newborns During the Fetal-To-Neonatal Transition.? | During the fetal-to-neonatal transitional period, extremely preterm newborns undergo significant intrabody fluid shifts and resulting weight loss due to increased insensible fluid losses due to immature skin, kidneys, among other factors. These ongoing physiologic changes make fluid and nutritional management complex in the neonatal-to-fetal transitional time period for extremely premature newborns. However, limited literature exists to guide optimal practices for providers caring for this population. Here, we review the evidence on optimal fluid and nutritional management during the fetal-to-neonatal transition of extremely preterm newborns. |
Answer the following medical question. | What does research say about Experiences of the mothers of infants hospitalized in the neonatal intensive care unit (NICU).? | The mother-newborn relationship is more important in neonates hospitalized in the NICU than in healthy neonates. This study was conducted to explore the experiences of the mothers of infants hospitalized in the NICU. This qualitative study was done in 2016 by adopting a conventional content analysis approach. Thirty-five mothers in the NICUs, Imam Hossein Hospital and Fatemieh Hospital were selected. Their experiences were assessed using in-depth individual semi-structured interviews. Sampling was purposive and was continued until reaching data saturation. Two hundred and nine primary codes were extracted. After removing duplicates and overlaps, 95 primary codes were categorized in 8 subcategories, 2 accessory categories and 1 main category based on their appropriateness, agreement, and similarity. The accessory categories of "mothers' worries" and "mothers' hopes" were merged into a more general, abstract category named "dual feelings about the baby". The nurses' awareness of the mothers' experiences can help design interventions to promote the quality of care for mothers and infants in the critical period of the NICU admission. |
Answer the following medical question. | What does research say about Assessment of sickness severity of illness in neonates: review of various neonatal illness scoring systems.? | Sickness severity scores are widely used for neonates admitted to neonatal intensive care units to predict severity of illness and risk of mortality and long-term outcome. These scores are also used frequently for quality assessment among various neonatal intensive care unit and hospital. Accurate and reliable measures of severity of illness are required for unbiased and reliable comparisons especially for benchmarking or comparative quality improvement care studies. These scores also serve to control for population differences when performing studies such as clinical trials, outcome evaluations, and evaluation of resource utilisation. Although presently there are multiple scores designed for neonates' sickness assessment but none of the score is ideal. Each score has its own advantages and disadvantages. We did literature search for identifying all neonatal sickness severity score and in this review article, we discuss these scores along with their merits and demerits. |
Answer the following medical question. | What does research say about Gabapentin Use for Hospitalized Neonates.? | Declarations of interest: none. Despite some clinician advocacy for the use of gabapentin to treat neonatal irritability of presumed neurologic origin, the extent of gabapentin administration to hospitalized neonates is unknown. We aimed to identify trends in gabapentin utilization among infants hospitalized in neonatal intensive care units (NICUs) across the United States (US) and to evaluate the associations between clinical diagnoses and gabapentin treatment. We analyzed NICU admitted neonates within the 2005–2016 Pediatric Health Information System to measure treatment timing, duration, and frequency. We used a modified Poisson regression with a robust between-cluster variance estimator to calculate a probability (adjusted relative risk) for gabapentin administration. Of 278,403 neonates, 374 were administered gabapentin treatment (0.13%). The median treatment duration was 16 days (25th-75th%: 8–40). Gabapentin use increased from 0% in 2005 to 0.39% in 2016. Treatment was prescribed to neonates at 31 of 48 studied hospitals; 73% of total treated infants localized to 5 NICUs. Term (0.16%) and ≤28-weeks gestation preterm infants (0.22%) were most likely to receive gabapentin. Varying by gestational age, a diagnosis of chromosomal abnormalities, severe bronchopulmonary dysplasia (BPD), hemorrhagic stroke, and neonatal abstinence syndrome (NAS) were associated with higher treatment with gabapentin. The majority (88.8%) of treated infants did not have a seizure diagnosis. Gabapentin use in US NICUs increased in recent years and varies markedly between institutions. Term infants, ≤28-weeks gestation preterm infants, and neonates with chronic genetic, neurologic, and gastrointestinal diagnoses were more likely to receive gabapentin. Gabapentin Use for Hospitalized Neonates |
Answer the following medical question. | What does research say about Point-of-care ultrasound (POCUS) protocol for systematic assessment of the crashing neonate-expert consensus statement of the international crashing neonate working group.? | Communicated by Piet Leroy. Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a “crashing” neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention. Conclusion : To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained “crashing” neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion. Point-of-care ultrasound (POCUS) refers to ultrasonography done at the bedside by the clinician caring for the patient [ 1 ]. It is performed in real time, with serial assessments longitudinally as required, to monitor disease progress and evaluate the response to interventions [ 2 ]. POCUS is a clinical tool applied to answer a practical specific question and guide critical care interventions, rather than a substitute for medical imaging performed and interpreted by diagnostic specialists (such as pediatric radiologists or cardiologists) [ 3 ]. A Crashing Neonate Ultrasound Protocol (CNP) could be used to assess any newborn needing or likely to need critical care, especially if the underlying cause is unknown. The routine use of POCUS has been suggested in clinical situations where the underlying mechanism of deterioration is unclear [ 3 ], and some authors have already proposed an algorithm for assessing life-threatening events in neonates admitted to the neonatal intensive care unit (NICU) such as SAFE/SAFER (Sonographic Assessment of Life-Threatening Events-Revised) protocol [ 4 , 5 ]. A specific international working group of experts in POCUS was created to develop a screening protocol incorporating a quick bedside multiorgan ultrasound evaluation to understand the underlying mechanism of deterioration in a critically unwell newborn. The CNP protocol represents an expert consensus by POCUS key leaders, built on appropriate methodology, for the use of POCUS applications in the critically ill or crashing neonate in NICU. The proposed CNP is specifically designed for use in neonatal emergencies leading to significant cardiorespiratory instability and can be used in both term and pre-term neonates who are either “crashed” (needing resuscitation) or “crashing” (likely to need resuscitation if not stabilized soon) infants. CNP proposes a stepwise systematic targeted assessment with simple basic ultrasound views which are easily reproducible and can be learnt with a focused training, similar to the already established SAFE/SAFER in the newborn [ 5 ]. The CNP introduces a new approach with pre-defined steps focusing at assessing the underlying etiology for unresponsiveness to resuscitation, a sudden deterioration for unknown reason, or acute unexplained anemia/blood loss [ 6 ]. This protocol provides neonatal practitioners an opportunity to understand the ongoing multiorgan pathophysiology in real time as compared to the conventional blind “guessing” approach that often occurs in the absence of direct physiologic information. The CNP is focused on the evaluation of four vital organs most often compromised in the unstable neonate, as well as an assessment of central line-related complications. The protocol includes (a) Lung-POCUS assessment of pulmonary emergencies (pneumothorax, pleural effusion, or lung atelectasis); (b) Cardiac-POCUS assessment of shock and hemodynamic instability; (c) Cranial-POCUS assessment for acute brain hemorrhage; (d) Abdominal-POCUS assessment of peritoneal or subcapsular bleeding, gut injury, or bowel ischemia; and (e) assessment of central line-related complications by Central-Line POCUS [ 3 , 7 ]. We applied the following six steps in developing the consensus statement, as summarized in Fig. 1 : Fig. 1 The flow diagram summarizing the six steps applied to reach the consensus agreement The flow diagram summarizing the six steps applied to reach the consensus agreement Step 1: Three lead expert authors in POCUS (YE, YS, and MGA) identified 5 subsection expert leaders (AM: Lung-POCUS, MK: Cardiac-POCUS, NB: Abdominal-POCUS, JA: Cranial-POCUS, MF: Central line-POCUS). Step 2: The lead authors performed a literature review in the six main domains (general indications of CNP, Lung-POCUS, Cardiac-POCUS, Abdominal-POCUS, Cranial-POCUS, and central line-related complications). The level of evidence was assessed according to the published guidelines (GRADE) [ 8 , 9 ]. Step 3: The lead authors together with the subsection leaders identified another 6 expert neonatologists who have significantly contributed with institutional guidelines and publications in the field of POCUS and/or developed POCUS training courses in the last 10 years. The selected experts were from Europe, USA, Canada, Asia, and Australia (DD, NY, SB, PS, AH, AK) and together formed a group of 14 panelists. Step 4: The lead authors and subsection’ leaders selected 20 recommendations for voting. The first 6 recommendations are general indications of the CNP protocol, 4 Lung-POCUS recommendations, 5 Cardiac-POCUS recommendations, 2 Abdominal-POCUS recommendations, one recommendation for each of Cranial and central line-related complications, and one related to the whole algorithm itself. Step 5: Step 5 : We applied a modified anonymous electronic Delphi strategy for the online voting process [ 10 ]. The Delphi method of voting was among the 14 panelists, each recommendation was graded to 5 grades of agreement: strongly agree, agree, neutral, disagree, and strongly disagree as described in RAND/ULCA published methodology of consensus agreement [ 11 – 13 ]. Step 6: The final step was an open anonymous survey to an international group of 251 neonatologists who are members of the “point of care ultrasound in neonatology association” (pocusneo.org) with a variable degree of experience in utilization of POCUS. The statement recommendations have been prepared according to the international Appraisal of Guidelines, Research and Evaluation (AGREE). Each recommendation is intended to be applied only in the neonatal population with unexplained deterioration as detailed in the protocol [ 14 ]. Three lead expert authors in POCUS (YE, YS, and MGA) identified 5 subsection expert leaders (AM: Lung-POCUS, MK: Cardiac-POCUS, NB: Abdominal-POCUS, JA: Cranial-POCUS, MF: Central line-POCUS). The lead authors performed a literature review in the six main domains (general indications of CNP, Lung-POCUS, Cardiac-POCUS, Abdominal-POCUS, Cranial-POCUS, and central line-related complications). The level of evidence was assessed according to the published guidelines (GRADE) [ 8 , 9 ]. The lead authors together with the subsection leaders identified another 6 expert neonatologists who have significantly contributed with institutional guidelines and publications in the field of POCUS and/or developed POCUS training courses in the last 10 years. The selected experts were from Europe, USA, Canada, Asia, and Australia (DD, NY, SB, PS, AH, AK) and together formed a group of 14 panelists. The lead authors and subsection’ leaders selected 20 recommendations for voting. The first 6 recommendations are general indications of the CNP protocol, 4 Lung-POCUS recommendations, 5 Cardiac-POCUS recommendations, 2 Abdominal-POCUS recommendations, one recommendation for each of Cranial and central line-related complications, and one related to the whole algorithm itself. Step 5 : We applied a modified anonymous electronic Delphi strategy for the online voting process [ 10 ]. The Delphi method of voting was among the 14 panelists, each recommendation was graded to 5 grades of agreement: strongly agree, agree, neutral, disagree, and strongly disagree as described in RAND/ULCA published methodology of consensus agreement [ 11 – 13 ]. The final step was an open anonymous survey to an international group of 251 neonatologists who are members of the “point of care ultrasound in neonatology association” (pocusneo.org) with a variable degree of experience in utilization of POCUS. The statement recommendations have been prepared according to the international Appraisal of Guidelines, Research and Evaluation (AGREE). Each recommendation is intended to be applied only in the neonatal population with unexplained deterioration as detailed in the protocol [ 14 ]. The three lead experts met with the subsections leaders and developed the CNP considering the priority steps for assessment of neonate, parallel to neonatal resuscitation program (NRP) [ 15 ]. CNP starts with identifying the indication of the protocol as stated in the consensus agreement. The first priority of the NRP is assessment of adequate ventilation and the underlying lung pathology by Lung POCUS and then assessment of circulation by Cardiac POCUS [ 16 , 17 – 21 ]. The next step is assessment of cranial hemorrhage by Cranial POCUS [ 22 ] followed by abdominal hemorrhage and gut injury on Abdominal POCUS [ 1 , 23 ]. Then assessment of central line-related complication by Central line POCUS is recommended [ 24 ]. The algorithm of the CNP was refined many times before approving the final algorithm described in Fig. 2 by consensus agreement among all authors. Fig. 2 Algorithm for multiorgan systematic assessment by ultrasound for any neonate not responding to the standard steps of resuscitation after birth or any time during NICU admission. The sequence and start point may be different according to the clinical presentation of the crashed or the crashing neonate Algorithm for multiorgan systematic assessment by ultrasound for any neonate not responding to the standard steps of resuscitation after birth or any time during NICU admission. The sequence and start point may be different according to the clinical presentation of the crashed or the crashing neonate A total of 20 recommendations on the use of POCUS in the crashing neonate were assessed. There was strong agreement among all the panelists on 16 recommendations and agreement on 4 recommendations, as detailed in Table 1 . We included results of both the Delphi method of voting among the 14 expert panelists and the survey of POCUSNEO members (all members are practicing neonatologists and utilize POCUS in their clinical practice with variable expertise). Table 1 Summary of recommendations for the Crashing Neonate Protocol with levels of agreements and quality of published evidence POCUS section Recommendation Level of agreement Quality of evidence (GRADE) Experts in POCUS N = 14 Neonatologists N = 251 General-1 POCUS can provide helpful information when a neonate is not responding to the initial steps of resuscitation Agree Strongly agree C General-2 POCUS is helpful in evaluating neonates with unexplained circulatory shock Strongly agree Strongly agree C General-3 POCUS is helpful in evaluating neonates with unexplained lactic acidosis Strongly agree Strongly agree C General-4 POCUS evaluation is helpful in evaluation of worsening acute hypoxemia unresponsive to routine support Strongly agree Strongly agree C General-5 POCUS is helpful in assessing neonates with compromised peripheral perfusion, with decreased perfusion index or prolonged capillary refill time Strongly agree Strongly agree C General-6 POCUS is helpful in localizing a source of hemorrhage when there is an unexplained drop in hematocrit or hemoglobin Strongly agree Strongly agree C Lung-1 Lung POCUS is helpful to diagnose pneumothorax accurately in the crashing neonate Strongly agree Agree B Lung-2 Lung POCUS is helpful in diagnosis of pleural effusion in the crashing neonate Strongly agree Strongly agree B Lung-3 Lung POCUS is helpful in semi quantifying pleural effusion in the crashing neonate Strongly agree Strongly agree D Lung-4 Lung POCUS is helpful in diagnosis of lung consolidation in the crashing neonate Strongly agree Agree B Cardiac-1 Cardiac POCUS is helpful in diagnosis of pericardial effusion and pericardial tamponade in the crashing neonate Strongly agree Strongly agree B Cardiac-2 Cardiac POCUS is helpful in semi-quantification of pericardial effusion in the crashing neonate Agree Agree C Cardiac-3 Cardiac POCUS is helpful for rapid recognition of poor contractility in the crashing neonate Agree Agree D Cardiac-4 Cardiac POCUS is helpful in recognition of underfilling of the heart in the crashing neonate Strongly agree Strongly agree D Cardiac-5 Cardiac POCUS is helpful in recognition of pulmonary hypertension in the crashing neonate Strongly agree Agree B Cranial Cranial POCUS is helpful in the assessment of intracranial hemorrhage in neonates with rapidly progressing anemia Strongly agree Strongly agree A Abdomen-1 Abdominal POCUS is helpful in the diagnosis of ascites or abdominal bleeding in the crashing neonate Strongly agree Agree C Abdomen-2 Abdominal POCUS is helpful in the diagnosis of gut injury in the crashing neonate Agree Agree B Line -POCUS POCUS is helpful in identifying complications related to central lines in the crashing neonate Strongly agree Agree C Algorithm Multiorgan assessment (Lung POCUS, Cardiac POCUS, Abdominal POCUS, Cranial POCUS, and Central Line POCUS) as one integrated algorithm is helpful in assessment of the crashing neonate with unknown etiology Strongly agree Strongly agree C Summary of recommendations for the Crashing Neonate Protocol with levels of agreements and quality of published evidence POCUS can provide helpful information when a neonate is not responding to the initial steps of resuscitation—agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : When a newborn is not responding to the initial steps of resuscitation (heart rate < 100, low arterial oxygen saturation (SpO2) < 85% after effective positive pressure ventilation adequate oxygen therapy) with no identifiable cause clinically, the underlying cause is secondary to the cardiorespiratory systems in most of the cases as detailed in the next 2 Sects. [ 10 – 12 ]. POCUS is helpful in evaluating infants with unexplained circulatory shock—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : In the presence of circulatory shock, defined as blood pressure less than the lower limit for corrected gestational age, POCUS is helpful in understanding the cause and mechanism of shock [ 26 – 28 ]. POCUS is helpful in evaluating infants with unexplained lactic acidosis—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : Lactic acidosis is a marker of decreased oxygen delivery which could be due to hemodynamic instability, acute anemia, or severe hypoxia. Identifying the underlying cause can be a challenge without detailed multiorgan assessment using POCUS [ 25 , 28 , 29 ]. POCUS evaluation is helpful in evaluation of worsening acute hypoxemia unresponsive to routine respiratory support—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C): Worsening hypoxemia unresponsive to routine respiratory support and positive pressure ventilation could be secondary to multiple pathophysiologic mechanisms related to parenchymal lung disease and/or cardiac conditions, which may be difficult to diagnose without a detailed assessment using POCUS as explained in lung-POCUS subsection [ 4 , 6 , 7 ]. POCUS is helpful in assessing infants with compromised peripheral perfusion, with decreased perfusion index or prolonged capillary refill time—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : Compromised peripheral perfusion can be an early sign of worsening hemodynamic instability or shock, and routine clinical examination has limitations in its ability to diagnose the underlying mechanism [ 28 ]. POCUS is helpful in localizing a source of hemorrhage when there is an unexplained drop in hematocrit or hemoglobin—strong agreement by the panelist and strong agreement by the neonatologists (quality of evidence C) : Perinatal hemorrhage could be secondary to birth trauma, intraventricular hemorrhage in preterm infants, or spontaneous hemorrhage secondary to coagulopathy. Localizing the hemorrhage by ultrasonography is critical for planning medical intervention and is a time-sensitive indication [ 8 – 10 ]. POCUS can provide helpful information when a neonate is not responding to the initial steps of resuscitation—agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : When a newborn is not responding to the initial steps of resuscitation (heart rate < 100, low arterial oxygen saturation (SpO2) < 85% after effective positive pressure ventilation adequate oxygen therapy) with no identifiable cause clinically, the underlying cause is secondary to the cardiorespiratory systems in most of the cases as detailed in the next 2 Sects. [ 10 – 12 ]. POCUS is helpful in evaluating infants with unexplained circulatory shock—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : In the presence of circulatory shock, defined as blood pressure less than the lower limit for corrected gestational age, POCUS is helpful in understanding the cause and mechanism of shock [ 26 – 28 ]. POCUS is helpful in evaluating infants with unexplained lactic acidosis—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : Lactic acidosis is a marker of decreased oxygen delivery which could be due to hemodynamic instability, acute anemia, or severe hypoxia. Identifying the underlying cause can be a challenge without detailed multiorgan assessment using POCUS [ 25 , 28 , 29 ]. POCUS evaluation is helpful in evaluation of worsening acute hypoxemia unresponsive to routine respiratory support—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C): Worsening hypoxemia unresponsive to routine respiratory support and positive pressure ventilation could be secondary to multiple pathophysiologic mechanisms related to parenchymal lung disease and/or cardiac conditions, which may be difficult to diagnose without a detailed assessment using POCUS as explained in lung-POCUS subsection [ 4 , 6 , 7 ]. POCUS is helpful in assessing infants with compromised peripheral perfusion, with decreased perfusion index or prolonged capillary refill time—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : Compromised peripheral perfusion can be an early sign of worsening hemodynamic instability or shock, and routine clinical examination has limitations in its ability to diagnose the underlying mechanism [ 28 ]. POCUS is helpful in localizing a source of hemorrhage when there is an unexplained drop in hematocrit or hemoglobin—strong agreement by the panelist and strong agreement by the neonatologists (quality of evidence C) : Perinatal hemorrhage could be secondary to birth trauma, intraventricular hemorrhage in preterm infants, or spontaneous hemorrhage secondary to coagulopathy. Localizing the hemorrhage by ultrasonography is critical for planning medical intervention and is a time-sensitive indication [ 8 – 10 ]. The use of lung ultrasound (LUS) in neonatal and pediatric intensive care has seen rapid growth over the past few years, both for clinical and research purposes [ 32 , 33 ]. The recently published international guidelines on the use of POCUS provided evidence-based recommendations for diagnosis and monitoring of various lung conditions in critically ill children and neonates [ 1 ]. Lung POCUS is an ideal tool for use in emergency situations since it is quick, portable, repeatable, accurate, non-invasive, and radiation free and thereby offers a number of advantages for the clinician when compared with the chest X-ray (CXR) [ 34 ]. Lung POCUS is helpful to diagnose pneumothorax accurately in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : Evidence from the adult, pediatric, and neonatal literature has shown that LUS has higher diagnostic accuracy (91% sensitivity and 98% specificity) when compared to CXR in detecting pneumothorax, and time to make the diagnosis is shorter [ 35 – 37 ]. Visualization of the following combined LUS patterns can accurately diagnose pneumothorax: (1) absence of “lung sliding sign” of the pleural line, (2) complete absence of B lines, i.e., only A-lines, (3) presence of a “lung point,” and (4) presence of a stratosphere sign on M-mode imaging (Table 2 B) [ 38 ]. Of note, evidence of pneumothorax on LUS should always be interpreted in the clinical context. Assessment of the lung point, which is the point of separation of the pleural leaflets and is seen at the point where normal sliding pleura meets the non-sliding segment, is specific of pneumothorax and can help in predicting pneumothorax size [ 36 ]. Lung POCUS is helpful in diagnosis of pleural effusion in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence B) : In a newborn with congenital effusion(s), such as those with congenital hydrothorax or chylothorax, may comprise ventilation, and a timely drainage of the effusion is often essential to allow expansion of the lung. Pleural effusion is also an uncommon, but serious complication of central lines, which are one of the mainstays of neonatal critical care in delivering infusions [ 39 ]. Lung POCUS provides a quick and reliable information regarding presence of pleural fluid and has a high diagnostic accuracy, close to that of a CT scan and superior to CXR, with a 93% sensitivity and 96% specificity [ 40 , 41 ]. The presence of effusion on lung POCUS is seen as a hypoechoic area between the pleural leaflets at the dependent costophrenic angle. Lung POCUS is helpful in semi-quantifying pleural effusion in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence D) : Lung POCUS is an excellent tool to rule out or to detect large pleural effusion that may lead to acute decompensation or compromise resuscitation efforts [ 32 , 42 , 43 ]. Although it is easier to diagnose pleural effusion by ultrasound as compared to CXR, the quality of evidence is low on quantifying the volume of pleural effusion in neonates. Hence, for the clinical decision-making, it is better semi-quantified using categories of minimal, small, moderate, or large volume. It is estimated by measuring the distance at the site of maximum collection [ 40 ]. Lung POCUS is helpful in diagnosis of lung consolidation in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : Lung consolidation is characterized by the presence of a non-aerated area or lung parenchyma filled with fluid [ 44 , 45 ]. The most common causes are atelectasis, inflammatory processes, severe pulmonary edema, or acute pulmonary hemorrhage [ 46 ]. The sonographic appearance of a consolidated lung usually looks like an area with an abnormal pleural line and bronchograms (figure in Table 2 A) [ 30 , 47 ]. Meta-analysis of LUS studies on diagnosis of lung consolidation has shown a high sensitivity and specificity of 96% and 93%, respectively. LUS is superior to both CXR and laboratory tests, even when combined together [ 48 ]. In a crashing infant, lung POCUS may help in rapidly diagnosing consolidation and/or atelectasis, which looks like a solid organ-like resembling liver [ 49 , 50 ]. Table 2 Case scenarios of crashing neonates with the ultrasound images and their interpretation and subsequent interventions Lung POCUS is helpful to diagnose pneumothorax accurately in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : Evidence from the adult, pediatric, and neonatal literature has shown that LUS has higher diagnostic accuracy (91% sensitivity and 98% specificity) when compared to CXR in detecting pneumothorax, and time to make the diagnosis is shorter [ 35 – 37 ]. Visualization of the following combined LUS patterns can accurately diagnose pneumothorax: (1) absence of “lung sliding sign” of the pleural line, (2) complete absence of B lines, i.e., only A-lines, (3) presence of a “lung point,” and (4) presence of a stratosphere sign on M-mode imaging (Table 2 B) [ 38 ]. Of note, evidence of pneumothorax on LUS should always be interpreted in the clinical context. Assessment of the lung point, which is the point of separation of the pleural leaflets and is seen at the point where normal sliding pleura meets the non-sliding segment, is specific of pneumothorax and can help in predicting pneumothorax size [ 36 ]. Lung POCUS is helpful in diagnosis of pleural effusion in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence B) : In a newborn with congenital effusion(s), such as those with congenital hydrothorax or chylothorax, may comprise ventilation, and a timely drainage of the effusion is often essential to allow expansion of the lung. Pleural effusion is also an uncommon, but serious complication of central lines, which are one of the mainstays of neonatal critical care in delivering infusions [ 39 ]. Lung POCUS provides a quick and reliable information regarding presence of pleural fluid and has a high diagnostic accuracy, close to that of a CT scan and superior to CXR, with a 93% sensitivity and 96% specificity [ 40 , 41 ]. The presence of effusion on lung POCUS is seen as a hypoechoic area between the pleural leaflets at the dependent costophrenic angle. Lung POCUS is helpful in semi-quantifying pleural effusion in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence D) : Lung POCUS is an excellent tool to rule out or to detect large pleural effusion that may lead to acute decompensation or compromise resuscitation efforts [ 32 , 42 , 43 ]. Although it is easier to diagnose pleural effusion by ultrasound as compared to CXR, the quality of evidence is low on quantifying the volume of pleural effusion in neonates. Hence, for the clinical decision-making, it is better semi-quantified using categories of minimal, small, moderate, or large volume. It is estimated by measuring the distance at the site of maximum collection [ 40 ]. Lung POCUS is helpful in diagnosis of lung consolidation in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : Lung consolidation is characterized by the presence of a non-aerated area or lung parenchyma filled with fluid [ 44 , 45 ]. The most common causes are atelectasis, inflammatory processes, severe pulmonary edema, or acute pulmonary hemorrhage [ 46 ]. The sonographic appearance of a consolidated lung usually looks like an area with an abnormal pleural line and bronchograms (figure in Table 2 A) [ 30 , 47 ]. Meta-analysis of LUS studies on diagnosis of lung consolidation has shown a high sensitivity and specificity of 96% and 93%, respectively. LUS is superior to both CXR and laboratory tests, even when combined together [ 48 ]. In a crashing infant, lung POCUS may help in rapidly diagnosing consolidation and/or atelectasis, which looks like a solid organ-like resembling liver [ 49 , 50 ]. Case scenarios of crashing neonates with the ultrasound images and their interpretation and subsequent interventions Cardiac POCUS was first described in the 1980s as a readily available, rapid, limited bedside examination performed by emergency physicians to enhance diagnostic capabilities and direct theraphy [ 51 ]. In the event of acute decompensation, the goal of cardiac POCUS is to assess cardiac filling and function, pericardial effusion, and ventricular symmetry [ 52 – 54 ]. Cardiac POCUS is not intended to be used as a screening tool for detection of congenital heart diseases (CHD) [ 52 ]. However, when clinical urgency precludes a comprehensive echocardiographic assessment in a critically ill infant, utilization of standardized protocols by clinicians trained in cardiac POCUS may aid in recognition of abnormalities and help them in consulting a cardiac specialist earlier [ 1 , 7 , 55 , 56 ]. CHD, such as outflow tract obstruction, may manifest as poor cardiac function, and recognition of an abnormal cardiac ultrasound may direct management and expedite a comprehensive cardiac evaluation [ 47 ]. Cardiac POCUS is helpful in diagnosis of pericardial effusion and cardiac tamponade in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence B) : One of the most immediate applications of cardiac POCUS in a crashing neonate is to rule out cardiac tamponade or a large pericardial effusion leading to cardiovascular instability [ 56 , 58 , 59 ]. Pericardial effusion can reliably be seen on cardiac POCUS by using multiple echocardiographic views. When cardiac tamponade is detected, POCUS can be used to guide pericardiocentesis, and ultrasound-guided pericardiocentesis is associated with a lower complication rate compared to the traditional landmark technique (figure in Table 2 F) [ 59 – 61 ]. Cardiac POCUS is helpful in semi-quantification of pericardial effusion in the crashing neonate — agreement by the panelists and agreement by the neonatologists (quality of evidence C) : The decision to treat pericardial effusion should be made based upon the clinical significance, and ultrasound findings should be interpreted in the clinical context. Nagdev et al. assessed the importance of evaluating the movement of the right ventricle free wall and IVC size during respiratory cycle, and they reported a collapse of right ventricle free wall and absence of inspiratory collapse of IVC as reliable markers to diagnose significant pericardial effusion prior to development of shock [ 58 ]. Cardiac POCUS can be used for rapid recognition of poor contractility in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : International expert consensus statements highlighted the use of cardiac POCUS in pediatrics for assessment of cardiac function and filling [ 1 ]. The ability to rapidly identify and address cardiogenic shock can help in earlier initiation of appropriate treatment [ 62 – 65 ]. Qualitative assessment, rather than quantitative measurement of cardiac function from multiple views, including parasternal long and short axes and apical 4-chamber and subcostal view, is one of the primary goals of cardiac POCUS [ 52 ]. The use of cardiac POCUS in the hands of non-cardiologist clinicians trained in cardiac ultrasound enables them to differentiate normal and impaired contractility, with good interobserver correlation with cardiologists [ 66 ]. Cardiac POCUS is helpful in recognition of underfilling of the heart in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : The use of clinical findings to guide fluid resuscitation in the neonate is challenging. The traditional markers such as capillary refill, central venous pressure, and tachycardia do not provide a definitive picture of fluid status [ 67 ]. The use of cardiac POCUS to evaluate volume status in a critically ill pediatric patient is recommended; however, in the mechanically ventilated neonates, recognition of preload can be challenging, and the findings should be interpreted in the clinical context. Assessment of the difference between end systolic and end diastolic volumes in the apical 4-chamber and parasternal long and short axis views by eyeballing for the filling volumes on 2D and M-Mode is useful for determining the need of fluid resuscitation (Table 2 D) [ 1 , 68 ]. Cardiac POCUS is helpful in recognition of pulmonary hypertension in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : In a crashing infant, cardiac POCUS can be used to suspect or rule out moderate to severe pulmonary hypertension [ 69 , 70 ]. While a detailed assessment of pulmonary hypertension or right ventricular function is out of the scope of cardiac POCUS, it can be utilized for the recognition and a focused evaluation of pulmonary hypertension and assessment of right ventricular function utilizing visual inspection and semi-quantitative assessment [ 54 , 71 ]. Cardiac POCUS is helpful in diagnosis of pericardial effusion and cardiac tamponade in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence B) : One of the most immediate applications of cardiac POCUS in a crashing neonate is to rule out cardiac tamponade or a large pericardial effusion leading to cardiovascular instability [ 56 , 58 , 59 ]. Pericardial effusion can reliably be seen on cardiac POCUS by using multiple echocardiographic views. When cardiac tamponade is detected, POCUS can be used to guide pericardiocentesis, and ultrasound-guided pericardiocentesis is associated with a lower complication rate compared to the traditional landmark technique (figure in Table 2 F) [ 59 – 61 ]. Cardiac POCUS is helpful in semi-quantification of pericardial effusion in the crashing neonate — agreement by the panelists and agreement by the neonatologists (quality of evidence C) : The decision to treat pericardial effusion should be made based upon the clinical significance, and ultrasound findings should be interpreted in the clinical context. Nagdev et al. assessed the importance of evaluating the movement of the right ventricle free wall and IVC size during respiratory cycle, and they reported a collapse of right ventricle free wall and absence of inspiratory collapse of IVC as reliable markers to diagnose significant pericardial effusion prior to development of shock [ 58 ]. Cardiac POCUS can be used for rapid recognition of poor contractility in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : International expert consensus statements highlighted the use of cardiac POCUS in pediatrics for assessment of cardiac function and filling [ 1 ]. The ability to rapidly identify and address cardiogenic shock can help in earlier initiation of appropriate treatment [ 62 – 65 ]. Qualitative assessment, rather than quantitative measurement of cardiac function from multiple views, including parasternal long and short axes and apical 4-chamber and subcostal view, is one of the primary goals of cardiac POCUS [ 52 ]. The use of cardiac POCUS in the hands of non-cardiologist clinicians trained in cardiac ultrasound enables them to differentiate normal and impaired contractility, with good interobserver correlation with cardiologists [ 66 ]. Cardiac POCUS is helpful in recognition of underfilling of the heart in the crashing neonate—strong agreement by the panelists and strong agreement by the neonatologists (quality of evidence C) : The use of clinical findings to guide fluid resuscitation in the neonate is challenging. The traditional markers such as capillary refill, central venous pressure, and tachycardia do not provide a definitive picture of fluid status [ 67 ]. The use of cardiac POCUS to evaluate volume status in a critically ill pediatric patient is recommended; however, in the mechanically ventilated neonates, recognition of preload can be challenging, and the findings should be interpreted in the clinical context. Assessment of the difference between end systolic and end diastolic volumes in the apical 4-chamber and parasternal long and short axis views by eyeballing for the filling volumes on 2D and M-Mode is useful for determining the need of fluid resuscitation (Table 2 D) [ 1 , 68 ]. Cardiac POCUS is helpful in recognition of pulmonary hypertension in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence B) : In a crashing infant, cardiac POCUS can be used to suspect or rule out moderate to severe pulmonary hypertension [ 69 , 70 ]. While a detailed assessment of pulmonary hypertension or right ventricular function is out of the scope of cardiac POCUS, it can be utilized for the recognition and a focused evaluation of pulmonary hypertension and assessment of right ventricular function utilizing visual inspection and semi-quantitative assessment [ 54 , 71 ]. In a crashing infant, pulmonary hypertension can be suspected when there is right ventricular hypertrophy and/or dilation in the presence of clinical suspicion such as persistent hypoxia and significant pre- and post-ductal saturation difference. In the presence of tricuspid regurgitation, pulmonary artery systolic pressure can be reliably estimated using cardiac POCUS [ 72 , 73 ]. In the absence of tricuspid regurgitation, POCUS can be used for semi-quantitative assessment of pulmonary hypertension by evaluating the interventricular septal position and movement at the end of systole and by assessing the flow direction and velocities across a patent ductus arteriosus and/or foramen ovale (figure in Table 2 E) [ 69 ]. As stated previously, cardiac POCUS is not a screening tool for CHD, and recognition of abnormality warrants comprehensive cardiac evaluation to ensure a normal structured heart. Infants with suspected or established pulmonary hypertension should have a comprehensive echocardiographic evaluation by the specialist pediatric cardiologist or a neonatologist trained in performing targeted neonatal echocardiography. Cranial POCUS is helpful in assessment of intracranial hemorrhage in neonates with rapidly progressing anemia—strong agreement by the panelists, and strong agreement by the neonatologists (quality of evidence B) : Cranial POCUS is the most common neuroimaging modality used in the NICU [ 62 , 63 ]. In a crashing neonate, cranial POCUS enables the diagnosis of intraventricular, parenchymal, or large cerebellar hemorrhages. Cranial POCUS is usually performed through anterior fontanelle window; however, adding the mastoid fontanelle increases its reliability for diagnosing posterior fossa hemorrhages [ 74 , 75 ]. Intraventricular hemorrhage (IVH) affects 20–40% of very preterm infants (born before 33 weeks’ gestation) [ 65 , 76 ]. Extensive IVH or parenchymal hemorrhage may present as a catastrophic event with apnea/bradycardia, hypotension, metabolic acidosis, a rapidly falling hematocrit, or seizures [ 66 , 78 ]. Cranial POCUS can help in rapidly detecting IVH as per the Volpe or modified Papile classification (figure in Table 2 I) [ 67 , 77 ]. Abdominal POCUS is helpful in the diagnosis of ascites or abdominal bleeding in the crashing neonate—agreement by the panelists, and agreement by the neonatologists (quality of evidence C) : Ultrasound has a high sensitivity in assessing and localizing abdominal bleeding. While ultrasound cannot differentiate the nature of the fluid, free peritoneal or subcapsular fluid can represent blood in a patient with unexplained anemia or abdominal trauma [ 31 ]. Ultrasound can provide information regarding presence of blood in real time and can aid in therapeutic intervention such as ultrasound-guided abdominal paracentesis, making it an excellent tool for use in neonatal emergencies [ 79 , 80 ]. Abdominal POCUS is helpful in the diagnosis of gut injury in the crashing neonate—agreement by the panelists, agreement by the radiologists, and agreement by the neonatologists (quality of evidence C) : Ultrasound has been proven as an excellent imaging modality with a high sensitivity in assessing intestinal emergencies including gut ischemia secondary to shock [ 81 , 82 ]. We recommend assessment of intestinal ischemic injury in any case of shock with unknown cause (figure in Table 2 G) [ 1 , 57 ]. In addition to gut ischemia, abdominal ultrasound can be performed in any infant suspected of having anemic shock due to traumatic abdominal bleeding (figure in Table 2 H) [ 81 ]. Abdominal POCUS is helpful in the diagnosis of ascites or abdominal bleeding in the crashing neonate—agreement by the panelists, and agreement by the neonatologists (quality of evidence C) : Ultrasound has a high sensitivity in assessing and localizing abdominal bleeding. While ultrasound cannot differentiate the nature of the fluid, free peritoneal or subcapsular fluid can represent blood in a patient with unexplained anemia or abdominal trauma [ 31 ]. Ultrasound can provide information regarding presence of blood in real time and can aid in therapeutic intervention such as ultrasound-guided abdominal paracentesis, making it an excellent tool for use in neonatal emergencies [ 79 , 80 ]. Abdominal POCUS is helpful in the diagnosis of gut injury in the crashing neonate—agreement by the panelists, agreement by the radiologists, and agreement by the neonatologists (quality of evidence C) : Ultrasound has been proven as an excellent imaging modality with a high sensitivity in assessing intestinal emergencies including gut ischemia secondary to shock [ 81 , 82 ]. We recommend assessment of intestinal ischemic injury in any case of shock with unknown cause (figure in Table 2 G) [ 1 , 57 ]. In addition to gut ischemia, abdominal ultrasound can be performed in any infant suspected of having anemic shock due to traumatic abdominal bleeding (figure in Table 2 H) [ 81 ]. POCUS is helpful in identifying complications related to central lines in the crashing neonate—strong agreement by the panelists and agreement by the neonatologists (quality of evidence C) : Several studies have questioned the accuracy of X-rays in assessing the line position accurately, reporting a discordance of 20–40% when compared to ultrasound assessment [ 83 ]. The anatomical position of the line can be viewed by X-ray, but identifying the intravascular position versus extravascular migration of the line needs either contrast study or ultrasound evaluation. With the available evidence, POCUS may be considered a standard of care for revealing central line tip position and catheter migration [ 84 ]. Furthermore, in neonates with acute clinical decompensation with impending cardiac arrest, where pericardial or pleural effusion are suspected due to central line malposition, radiological assessment is insufficient, and POCUS can reliably provide additional information in real time [ 60 , 85 , 86 ]. Multiorgan assessment (Lung POCUS, Cardiac POCUS, Abdominal POCUS, Cranial POCUS, and Central Line POCUS) as one integrated algorithm is helpful in assessment of the crashing neonate with unknown etiology—strong agreement by the panelists, and strong agreement by the neonatologists (B) : The proposed protocol introduces a comprehensive approach using POCUS with pre-defined steps focused on the assessment of mechanisms of unresponsiveness to resuscitation, unexplained acute decompensation, or acute unexplained anemia/blood loss. CNP recommends using only focused ultrasound views, which are relatively easy to practice and are reproducible, to detect specific pathologies [ 5 ]. Use of a POCUS-guided protocol in evaluation of a sick neonate provides an important opportunity for neonatal practitioners to identify the underlying pathophysiology in a crashing neonate in real time, replacing the empiric approach based upon clinical assessment [ 84 ]. This stepwise systematic assessment of the crashing neonate can be applied in any setting such as in the resuscitation room and NICU [ 5 ]. However, the sequence and the priority of the organ to be assessed might be different according to the clinical presentation [ 28 ]. Although this is the first consensus agreement statement on using POCUS to guide neonatal resuscitation, the practice in using POCUS during adult resuscitation is well established [ 5 , 16 ]. If there is no response to resuscitation as per the neonatal resuscitation guidelines, we recommend using POCUS to identify the underlying pathology which may explain the reason for unresponsiveness to conventional measures, as demonstrated in the flow diagram (Fig. 2 ). This stepwise approach encompasses moving from organ to organ, considering the organ priorities as per the Neonatal Resuscitation Program (NRP) [ 5 ]. First , lung assessment includes assessing lung inflation for optimum ventilation and evaluation for the underlying pathologies such as lung collapse, pneumothorax, effusions [ 19 , 45 , 87 , 88 ]. Second , cardiac assessment includes underfilling, poor contractility, pulmonary hypertension, and pericardial effusion [ 58 , 89 , 90 ]. If there is associated anemia or severe pallor, or suspicion of line migration, then cranial and abdominal POCUS should also be performed. We acknowledge the limitations of POCUS-guided proposed protocol including the following: (1) Ultrasound is operator dependent, and the reliability of the images depends on the training and competency of the operator, quality of images, and the machine; (2) the operator needs to be trained in multiorgan assessment with completion of acceptable training in each module, so a clear institutional protocol for training and guidelines for practice should be considered; (3) CNP is time-sensitive and ideally needs a trained person being available in the NICU at any time; and (4) the level of evidence supporting the crashing neonate protocol is low to intermediate level (mostly B to C grade), and most studies supporting POCUS use are either observational or retrospective analysis type. An important next step would be to formally study the learning curve needed to apply the CNP protocol as a whole and/or each organ section. The newly proposed protocol for the crashing neonate can be used as an adjunct to the current recommendations for neonatal resuscitation. The CNP protocol is proposed based upon preidentified steps focused on gaining information regarding pathophysiology in infants with unexplained clinical deterioration or those not responding to the standard resuscitation. In comparison to the currently used diagnostic aids, POCUS can provide valuable information in real time to answer a specific question relating to diagnosis or ruling out potential causes of deterioration. It can help in early diagnosis and facilitates targeting of specific intervention based upon the underlying pathophysiology in neonates, similar to the well-established application in pediatric and adult clinical practice. Abdominal X-ray Congenital heart disease Crashing Neonate Protocol Chest X-ray Lung ultrasound Neonatal intensive care unit Point-of-care ultrasound Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. The authors acknowledge the help of Dr. Shivani Shankar-Aguilera in designing Figure 2 . All authors made a substantial contribution to the manuscript and the design of the work. YS and YE conceptualized the idea; all authors contributed in developing the protocol and writing the manuscript. All authors critically reviewed the manuscript for important intellectual content, edited, and approved it in its final version. All data and original material are available for transparency. Not applicable. No ethical approval was needed for this manuscript. Not applicable. Not applicable. The authors declare no competing interests. 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Answer the following medical question. | What does research say about Position statement on neonatal follow-up care of the high risk neonate. National Association of Neonatal Nurses.? | It is the position of the National Association of Neonatal Nurses that an essential component of early discharge of the high risk neonate must be neonatal follow-up care. Broad guidelines for neonatal follow-up care have been outlined. Neonatal follow-up care must be performed by qualified health professionals and experienced neonatal registered nurses knowledgeable in the specialized needs of the high risk neonate. If follow-up care is an unavailable service of the unit, the neonate's care after discharge should be coordinated with the nearest existing program. Successful follow-up care will result in improved neonatal and family outcomes. |
Answer the following medical question. | What does research say about Neonatal surgery: intensive care unit versus operating room.? | The critically ill neonate with a surgical condition requires transfer to an operating room (OR), a process which may be associated with significant morbidity. In an effort to reduce such morbidity, we performed surgery on critically ill neonates in a designated area of our neonatal intensive care unit (NICU) over the past 4 years and have compared the outcome for infants operated on within the NICU with infants operated on in the OR over the same period. There were 81 procedures performed in the NICU compared with 112 in the OR. Infants operated on in the NICU had lower birthweights (1,758 g v 2,457 g), lower gestational ages (31.3 weeks v 35.8 weeks), and lower presurgical weights (2,118 g v 2,922 g) (all P < .0001). In addition, infants operated on in the NICU had a greater severity of illness with 78% requiring mechanical ventilation versus 26% for the OR group (P < .0001) with a higher presurgical FiO2 (.43 v .31, P = .005), and a higher presurgical mean airway pressure (8.0 cm H2O v 6.2 cm H2O) for infants requiring mechanical ventilation. The overall mortality was higher in the NICU group (14% v 2%), reflecting their underlying prematurity, illness, and anomalies. There was only one surgically related death, which occurred in the NICU group. There was no significant difference in culture-proven sepsis, length of surgery, change in weight, temperature, blood pressure, heart rate, FiO2, mean airway pressure, or oxygen index associated with surgery, but there was a significantly higher incidence of hyperthermia with a temperature of greater than 37.5 degrees C in the OR group (17.8% v 3.7%, P = .002). Our experience suggests that surgical procedures can be performed in the NICU for the unstable critically ill neonate with a morbidity comparable to that seen in the OR. Further experience is needed to compare the risks and benefits of this approach. |
Answer the following medical question. | What does research say about An Observational Cohort Study Examining the Effect of the Duration of Skin-to-Skin Contact on the Physiological Parameters of the Neonate in a Neonatal Intensive Special Care Unit.? | Focus on skin-to-skin contact (SSC) as a family-centered care intervention in Neonatal Intensive Special Care (NISC) Units continues to increase. Previously, SSC has been shown to improve neonatal physiological stability, support brain development, and promote bonding and attachment. Limited research exists investigating SSC duration and neonatal physiological responses. This study examined the relationship between SSC duration and the neonate's oxygen saturation, heart rate (HR), respiratory rate (RR), and temperature. An observational cohort study was conducted at The Royal Women's Hospital NISC Unit in Melbourne, Australia. For each neonate participant, 1 SSC with their parent was studied (parent convenience) and neonatal physiological parameters recorded, with a bivariate correlation used to explore the relationship between the duration of SSC and the percentage of time during SSC that the neonate's physiological variables remained within a target range. No correlation existed between the duration of SSC and the neonatal physiological variables of oxygen saturation, HR, RR, and temperature. However, neonatal oxygen requirement was more often reduced across the duration of SSC. Due to previously documented benefits to neonates physiologically from SSC, and our supportive finding that SSC reduces neonatal oxygen requirement, we believe that this study adds to the evidence to support promotion of SSC in NISC Units. The duration of SSC does not appear to negatively impact the physiological effects to the neonate. Thus, SSC should be encouraged in all NISC Units to be conducted for the length of time the parent is able. This study should be repeated with a larger sample size. |
Answer the following medical question. | What does research say about Therapeutic Hypothermia for Birth Asphyxia in Neonates.? | India contributes to the highest neonatal mortality globally. Birth asphyxia is one of the leading causes of neonatal mortality in India. A large number of neonates who suffer from birth asphyxia progress to Hypoxic Ischemic Encephalopathy (HIE). The risk of a neonate progressing to severe form of HIE is many times higher in the low and middle income countries (LMICs) with ill developed health infrastructure. Till date LMICs have had a low institutional delivery rate, poor regionalization of care, lack of adequate transport facilities and ill equipped neonatal intensive care facilities. This has lead to a tremendous burden on the health care systems with a cohort of developmentally challenged neonates surviving into adulthood. Recently, Therapeutic Hypothermia (TH) has emerged as an evidence based intervention to reduce mortality and neurodevelopmental disability associated with asphyxia induced encephalopathy. TH has become the gold standard in the management of such cases in the western world. Extension of this knowledge to the LMICs and countries like India require a better understanding of the unique sociocultural issues associated with asphyxial brain injury in neonates. The high incidence of sepsis and presence of economic constraints make this problem more complex in such countries. The current review has tried to address these issues and looked at the basics of this complex topic from the perspective of a general pediatrician. |
Answer the following medical question. | What does research say about Neonatal incubator or artificial womb? Distinguishing ectogestation and ectogenesis using the metaphysics of pregnancy.? | A 2017 Nature report was widely touted as hailing the arrival of the artificial womb. But the scientists involved claim their technology is merely an improvement in neonatal care. This raises an under-considered question: what differentiates neonatal incubation from artificial womb technology? Considering the nature of gestation-or metaphysics of pregnancy-(a) identifies more profound differences between fetuses and neonates/babies than their location (in or outside the maternal body) alone: fetuses and neonates have different physiological and physical characteristics; (b) characterizes birth as a physiological, mereological and topological transformation as well as a (morally relevant) change of location; and (c) delivers a clear distinction between neonatal incubation and ectogestation: the former supports neonatal physiology; the latter preserves fetal physiology. This allows a detailed conceptual classification of ectogenetive and ectogestative technologies according to which the 2017 system is not just improved neonatal incubation, but genuine ectogestation. But it is not an artificial womb, which is a term that is better put to rest. The analysis reveals that any ethical discussion involving ectogestation must always involve considerations of possible risks to the mother as well as her autonomy and rights. It also adds a third and potentially important dimension to debates in reproductive ethics: the physiological transition from fetus/gestateling to baby/neonate. |
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