NEONATOLOGY
Does India need a better NICU care?
Preterm birth is the world’s number one cause of new-born deaths, causing almost 30 percent of neonatal deaths worldwide.
Emilie Moulard Anand
Burden of prematurity (deaths caused) in India
According to WHO, In India, out of 27 million babies born every year (2010 data), 3.5 million babies born are premature. Preterm birth is the world’s number one cause of new-born deaths, causing almost 30 percent of neonatal deaths worldwide. Infant respiratory distress syndrome, in turn, is the leading cause of death in preterm infants, affecting about 1% of new born infants. India however has the highest number of first day deaths and stillbirths at598,038 per year - a quarter of the 2.2 million lost lives.
Challenges contributing to the burden of premature deaths
Lack of infrastructure: In India there are only about 18,000 estimated number of NICU beds available. Additionally, overcrowded, lack of hygiene, poor resource, lack of staff, restricted entry for the mother are other problems that add on to the burden.
Comparison: Indian NICU care v/s Western NICU care
@Palliative care provision in the Indian NICU settings is almost non-existent at present. The principal causes of neonatal mortality in India are sepsis, perinatal asphyxia, and prematurity
@Basis an assessment of infrastructure, staffing, equipment, patient profile and their involvement in research and training, Majority of the units were well staffed and led by neonatologists trained in India and abroad. All had facilities for mechanical ventilation and were equipped with sophisticated imported equipment.
@Yet, availability of in-house blood gas and X-ray, microbiology facility, invasive blood pressure monitoring and support of ophthalmologist was not universal.
@More than half had published papers in scientific journals and were having recognized training programs in neonatology. Though tremendous progress is visible since the last surveys, the number of NICUs is still grossly insufficient. The current and future gap in trained manpower is however daunting, and intensive efforts for expanding the in-service training programs and innovative approaches to training are required.
Establishing role/importance of mother’s milk in combating premature deaths
Late initiation of breast-feeding is associated with a higher risk of neonatal mortality. Emphasis on breast-feeding promotion programs in low-resource settings of India where early initiation is low could significantly reduce neonatal mortality. The Government enforced Millennium Goals of reducing under 5 mortality rates to 26/1000 children by 2015, India only managed to reach 50/1000 children and infant mortality rate, targeted at 39/1000 reached41/1000. Though there was a significant decrease in the mortality rates, it wasn't enough. It is now understood that improving access to mother’s milk for premature infant is key to further decrease these rates.
New estimates as per the WHO published in “The Lancet” reveal that increasing breastfeeding to near-universal levels could save more than 800 000lives every year, the majority being children under 6 months. In addition, nearly half of all diarrhoeal diseases and one-third of all respiratory infections in children in low- and middle-income countries such as India, could be prevented with increased rates of breastfeeding.
The American Academy of Paediatrics (AAP) recommends breast milk as the best nutrition for infants. It provides natural antibodies that help the infant resist illnesses, such as ear infections. It's usually more easily digested than formula.
The way forward
@While The government has launched initiatives such as MAA (mothers' absolute affection) to spread awareness on benefits of breastfeeding
@Need to invest in policies and programmes that support women's breastfeeding
@The focus must move forward from simply survival till discharge; to intact complete life survival;. Simultaneously, the NICU care has to stay available and affordable for the less affording people.
@Highlight a system with 2 speeds and challenges. High level of care in private hospitals with a focus on infection control that often keep the baby away from the mother. Less number of beds in government hospitals which can not refuse people and often don’t have enough staff and look for ways to provide the best care possible.
@Need for infrastructure to allow the mother to be closed to the baby (cf Mac Donald foundation in the US). And for milk management to make sure that even if the mother doesn’t stay in the hospital she can get the milk production going and making sure that the infant receives it.
@Need of NGOs with a focus on the topic. Need more initiative like the Preemie event(you can explain what it was) to raise awareness. Need of support programmes for parents of premature babies.
-Emilie Moulard Anand Managing Director, Medela India Private Limited
(https://health.economictimes.indiatimes.com/health-files/author/926/emilie-moulard-anand )
Sex Differences in Mortality and Morbidity of Infants Born at Less Than 30 Weeks’ Gestation
OBJECTIVE: To examine whether changes in mortality and morbidities have benefited male more than female infants.
METHODS: Infants of gestational ages 22 to 29 weeks born between January 2006 and December 2016 at a Vermont Oxford Network center in the United States were studied. We examined mortality and morbidity rate differences and 95% confidence intervals by sex and birth year. We tested temporal differences in mortality and morbidity rates between boys and girls by means of a likelihood ratio test (LRT) on nested binomial regression models with log links.
RESULTS: A total of 205 750 infants were studied; 97 048 (47.2%) infants were girls. The rate for mortality and chronic lung disease decreased over time faster for boys than for girls (LRT P < .001 for mortality; P = .006 for lung disease). Restricting to centers that remained throughout the entire study period did not change all the above but additionally revealed a significant year-sex interaction for respiratory distress syndrome, with a faster decline among boys (LRT P = .04). Morbidities, including patent ductus arteriosus, necrotizing enterocolitis, early-onset sepsis, late-onset sepsis, severe intraventricular hemorrhage, severe retinopathy of prematurity, and pneumothorax, revealed a constant rate difference between boys and girls over time.
CONCLUSIONS:Compared with girls, male infants born at <30 weeks' gestation experienced faster declines in mortality, respiratory distress syndrome, and chronic lung disease over an 11-year period. Future research should investigate which causes of death declined among boys and whether their improved survival has been accompanied by a change in their neurodevelopmental impairment rate.
(Reference: Pediatrics. 2018 Dec;142(6). pii: e20182352. doi: 10.1542/peds.2018-2352).