Early outcomes of preterm neonates with respiratory distress syndrome admitted at Muhimbili National Hospital, a prospective study

BMC Pediatrics, Volume 22, No. 1, Year 2022

Interpretation

Background: Respiratory distress syndrome (RDS) is one of the commonest complication preterm neonates suffer and accounts for a significant morbidity and mortality in low and middle income countries (LMICs). Addressing RDS is therefore crucial in reducing the under 5 mortality in LMICs. This study aimed at describing early outcomes (death/survival) of preterm neonates with RDS and identify factors associated with the outcomes among neonates admitted at Muhimbili national hospital, Tanzania. Methods: Between October 2019 and January 2020 we conducted a prospective study on 246 preterm neonates with RDS at Muhimbili National Hospital. These were followed up for 7 days. We generated Kaplan–Meier survival curve to demonstrate time to death. We performed a cox regression analysis to ascertain factors associated with outcomes. The risk of mortality was analyzed and presented with hazard ratio. Confidence interval of 95% and P-value less than 0.05 were considered as significant. Results: Of the 246 study participants 51.6% were male. The median birth weight and gestational age of participants (Inter-Quartile range) was 1.3 kg (1.0, 1.7) and 31 weeks (29, 32) respectively. Majority (60%) of study participants were inborn. Only 11.4% of mothers of study participants received steroids. Of the study participants 49 (20%) received surfactant. By day 7 of age 77/246 (31.3%) study participants had died while the majority of those alive 109/169 (64.5%) continued to need some respiratory support. Factors independently associated with mortality by day 7 included birth weight of < 1500 g (AHR = 2.11 (1.16–3.85), CI95%; p = 0.015), lack of antenatal steroids (AHR = 4.59 (1.11–18.9), CI95%; p = 0.035), 5th minute APGAR score of < 7 (AHR = 2.18 (1.33–3.56), CI95%; p = 0.002) and oxygen saturation < 90% at 6 hours post admission (AHR = 4.45 (1.68–11.7), CI95%; p = 0.003). Conclusion: Our study reports that there was high mortality among preterm neonates admitted with RDS mainly occurring within the first week of life. Preterm neonates with very low birth weight (VLBW), whose mother did not receive antenatal steroid, who scored < 7 at 5th minute and whose saturation was < 90% at 6 hours were at higher risk of dying. There is need to scale up antenatal corticosteroids, neonatal resuscitation training and saturation monitoring among preterm neonates with RDS. A prospective study was conducted at the newborn intensive care unit (NICU) of Muhimbili National Hospital (MNH), Dar-es-Salaam, Tanzania. MNH is a national tertiary level referral hospital for Tanzania and a teaching hospital for Muhimbili University of Health and Allied Sciences. Neonatal unit is located at the maternity block, second floor, it has two wards one for preterm (ward 37) and another for term babies (ward 36). In preterm ward there are 4 cubes, with a total bed capacity of 60 beds. At the time of the study the unit has wall mounted oxygen, 3 mechanical ventilators, 5 radiant warmers, 5 wall cardiac monitors, 5 diamedic continuous positive airway pressure (CPAP), 10 high flow CPAP and 20 infusion pumps. It has well trained staffs for premature care, 7 specialist, 3 registered medical officers, 3–5 Paediatric resident’s, minimum of 4 intern medical doctors and well-trained nurses. MNH has approximately 10,000 neonates born per year both term and preterm. Admissions in preterm unit is approximately 4–10 babies per day with monthly admission rate of 120–280 neonates and an annual admission rate of 1440–3360 neonates, of which RDS is one of the admission diagnoses. MNH neonatal unit therefore was selected purposively because most preterm infants with RDS are admitted here. Inborn preterm neonates are received by midwives in the delivery rooms and transferred immediately to NICU. Delayed cord clamping is hardly observed for preterm infants and no CPAP is provided in the delivery rooms. Preterm neonates receive intravenous fluids, antibiotics, and aminophylline. They are cared for on open radiant warmers with on many occasions one warmer hosting 2-3infants. Preterm neonates with SAS score of > 3 are commenced on CPAP with blended oxygen but not with heated air. Infants needing < 30% oxygen with SAS score < 3 are transitioned to nasal prong oxygen 2 l/min and gradually weaned off. Surfactant is given to infants with severe distress whose parents can purchase. Tanzania is a lower-middle-income country, it has an estimated population of about 60 million people. Health services in the United Republic of Tanzania are delivered through a decentralized system. Access to health care in Tanzania is still a challenge especially in women. Health insurance coverage is still low approximately 32%. All preterm neonates < 24 hours old with clinical signs of RDS. Clinical signs of RDS which starts in < 6 hours after birth were tachypnea, nasal flaring, expiratory grunting, intercostal, subcostal, and subxiphoid retractions, and cyanosis. The outcome for this study was Death or Survival at 7 days of life. In this study, maternal and Preterm neonates variables were considered. Antenatal steroid, Place of delivery, Mode of delivery, pPROM> 18 hours, maternal fever. Gestational age, Birth weight, Sex, APGAR score at 5th minute, Age at admission, SAS at admission and 6 hours, Oxygen saturation at commence of care and at 6 hours, Body temperature, random blood sugar, Surfactant. Between October 2019 and January 2020, all preterm neonates < 24 hours of age whose respiratory distress commenced < 6 hours after birth were enrolled. New Ballard score [26] was used to determine gestational age and then preterm neonates were categorized in two groups for analysis (< 32 weeks and > 32 weeks), while Silverman Andersen score (SAS) [27] was used to grade the severity of RDS. Neonates with major anomalies and those with severe birth asphyxia (APGAR score < 4 at 5 min) were excluded. All study variables were obtained from maternal history, antenatal cards and NICU records. These were entered in the data sheet. Daily follow-up was done, vital signs and oxygen saturations were observed daily or obtained from the nursing charts. The data was analysed using SPSS software packages version 23.0. Frequency distribution and Kaplan–Meier survival curves were used to show pattern of death in 7 days for birth weight and gestational age. Independent and adjusted relationships of different predictors with preterm neonates’ survival were assessed with Cox regression model. Factors associated with mortality in crude model with a p value < 0.05 were entered in the multivariable Cox regression model to identify and quantify predictors of deaths while controlling for potential confounder. The risk of mortality was explored and presented with hazard ratio and 95% confidence interval. P-value less than 0.05 was considered as significant.

AI Digest

Study Justification:

– Respiratory distress syndrome (RDS) is a common complication among preterm neonates and contributes to high morbidity and mortality rates in low and middle income countries (LMICs).
– Addressing RDS is crucial in reducing under 5 mortality in LMICs.
– This study aimed to describe the early outcomes (death/survival) of preterm neonates with RDS and identify factors associated with these outcomes at Muhimbili National Hospital in Tanzania.

Study Highlights:

– The study included 246 preterm neonates with RDS who were followed up for 7 days.
– The majority of study participants were inborn and had a median birth weight of 1.3 kg and gestational age of 31 weeks.
– Only 11.4% of mothers received antenatal steroids, and 20% of neonates received surfactant.
– By day 7, 31.3% of study participants had died, and 64.5% of those alive still required respiratory support.
– Factors independently associated with mortality included birth weight < 1500 g, lack of antenatal steroids, 5th minute APGAR score < 7, and oxygen saturation < 90% at 6 hours post admission.

Study Recommendations:

– Scale up the use of antenatal corticosteroids to improve outcomes for preterm neonates with RDS.
– Provide neonatal resuscitation training to healthcare providers to ensure timely and effective interventions.
– Implement saturation monitoring for preterm neonates with RDS to identify those at higher risk of mortality.

Key Role Players:

– Healthcare providers: Specialists, registered medical officers, pediatric residents, intern medical doctors, and well-trained nurses.
– Hospital administration: Responsible for allocating resources and implementing changes in protocols and training.
– Policy makers: Involved in developing and implementing policies related to neonatal care and access to healthcare services.

Cost Items for Planning Recommendations:

– Training programs for healthcare providers on neonatal resuscitation and saturation monitoring.
– Procurement of antenatal corticosteroids and surfactant.
– Equipment and supplies for saturation monitoring.
– Staffing and personnel costs for additional training and implementation.

Please note that the cost items provided are general examples and may vary depending on the specific context and resources available.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study was conducted prospectively and included a relatively large sample size of 246 preterm neonates with respiratory distress syndrome. The study used appropriate statistical analysis methods to identify factors associated with outcomes. However, the study could be improved by providing more details on the methodology, such as the inclusion and exclusion criteria, data collection process, and potential limitations. Additionally, the abstract could benefit from including specific recommendations for action based on the study findings, such as scaling up antenatal corticosteroids and neonatal resuscitation training.

Abstract

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Telemedicine: Implementing telemedicine services can allow healthcare providers to remotely monitor and provide consultations to pregnant women, especially those in remote or underserved areas. This can help improve access to prenatal care and reduce the need for travel.

2. Mobile health (mHealth) applications: Developing mobile applications that provide educational resources, appointment reminders, and personalized health information can empower pregnant women to take control of their own health. These apps can also facilitate communication between healthcare providers and patients, ensuring timely access to care.

3. Community health workers: Training and deploying community health workers who can provide basic prenatal care, education, and support to pregnant women in their communities can help bridge the gap in access to maternal health services, particularly in rural or low-resource settings.

4. Maternal health clinics: Establishing dedicated maternal health clinics that offer comprehensive prenatal care, including screenings, vaccinations, and counseling, can ensure that pregnant women receive the specialized care they need in a timely manner.

5. Mobile clinics: Setting up mobile clinics that travel to remote or underserved areas can bring essential maternal health services directly to the communities that need them most. These clinics can provide prenatal check-ups, screenings, and basic treatments.

6. Health financing schemes: Implementing health financing schemes, such as health insurance or subsidized healthcare, can help reduce financial barriers to accessing maternal health services. This can ensure that pregnant women can afford the necessary care without facing financial hardship.

7. Maternal health education programs: Developing and implementing educational programs that focus on maternal health, including prenatal care, nutrition, and birth preparedness, can empower women with knowledge and skills to make informed decisions about their health and the health of their babies.

8. Partnerships with non-governmental organizations (NGOs): Collaborating with NGOs that specialize in maternal health can help expand access to services and resources. These partnerships can provide additional funding, expertise, and support to improve maternal health outcomes.

It’s important to note that these recommendations are general and may need to be tailored to the specific context and needs of the community or country in question.

AI Innovations Description

Based on the information provided, here is a recommendation that can be developed into an innovation to improve access to maternal health:

1. Scale up antenatal corticosteroids: The study found that only 11.4% of mothers of preterm neonates received antenatal steroids, which are known to improve lung maturity and reduce the risk of respiratory distress syndrome (RDS). Scaling up the use of antenatal corticosteroids can help improve access to maternal health by ensuring that more mothers receive this important intervention.

Innovation: Develop and implement a comprehensive antenatal care program that includes routine administration of antenatal corticosteroids to pregnant women at risk of preterm birth. This can be done through training healthcare providers, raising awareness among pregnant women, and ensuring the availability of corticosteroids in healthcare facilities.

By implementing this innovation, more mothers will have access to antenatal corticosteroids, leading to improved lung maturity in preterm neonates and a reduced risk of RDS.

Note: It’s important to consider the local context and resources available when implementing any innovation. Collaboration with relevant stakeholders, such as healthcare providers, policymakers, and community members, is crucial for successful implementation.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Increase availability and accessibility of antenatal corticosteroids: Antenatal corticosteroids have been shown to reduce the risk of respiratory distress syndrome (RDS) in preterm neonates. Scaling up the availability and accessibility of antenatal corticosteroids can help improve maternal health outcomes and reduce the incidence of RDS.

2. Strengthen neonatal resuscitation training: Enhancing the training of healthcare providers in neonatal resuscitation techniques can improve the immediate care provided to preterm neonates with RDS. This can include training on proper ventilation techniques, oxygen administration, and other essential resuscitation skills.

3. Implement saturation monitoring for preterm neonates with RDS: Continuous monitoring of oxygen saturation levels in preterm neonates with RDS can help identify those at higher risk of mortality. Implementing saturation monitoring protocols and providing the necessary equipment can ensure timely interventions and improve outcomes.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Determine the specific population that will be affected by the recommendations, such as pregnant women in low and middle-income countries (LMICs) or a specific region or healthcare facility.

2. Collect baseline data: Gather data on the current access to maternal health services, including the availability of antenatal corticosteroids, the level of neonatal resuscitation training among healthcare providers, and the use of saturation monitoring for preterm neonates with RDS.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and simulates the impact of the recommendations on improving access to maternal health. This model can take into account factors such as the number of pregnant women, the coverage of antenatal corticosteroids, the level of neonatal resuscitation training, and the implementation of saturation monitoring.

4. Run the simulation: Use the simulation model to run scenarios that reflect the implementation of the recommendations. This can involve adjusting variables such as the coverage of antenatal corticosteroids, the level of neonatal resuscitation training, and the utilization of saturation monitoring. The simulation will provide estimates of the potential impact on access to maternal health.

5. Analyze the results: Evaluate the results of the simulation to assess the potential improvements in access to maternal health. This can include analyzing changes in maternal health outcomes, such as the reduction in RDS cases and associated mortality, as well as the increase in the availability and utilization of maternal health services.

6. Refine and validate the model: Refine the simulation model based on feedback and validation from experts in the field of maternal health. This can involve adjusting the model parameters, incorporating additional data sources, and conducting sensitivity analyses to assess the robustness of the results.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of implementing these recommendations and make informed decisions to improve access to maternal health.

Author

Dima Health

Identifiers:

DOI: 10.1186/s12887-022-03731-2

Research Areas:

Disparities, Environmental, Health System and Policy, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Workforce

Study Countries:

Tanzania

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female