A Rapid Assessment of the Quality of Neonatal Healthcare in Kilimanjaro Region, Northeast Tanzania.

While child mortality is declining in Africa there has been no evidence of a comparable reduction in neonatal mortality. The quality of inpatient neonatal care is likely a contributing factor but data from resource limited settings are few. The objective of this study was to assess the quality of neonatal care in the district hospitals of the Kilimanjaro region of Tanzania. Clinical records were reviewed for ill or premature neonates admitted to 13 inpatient health facilities in the Kilimanjaro region; staffing and equipment levels were also assessed. Among the 82 neonates reviewed, key health information was missing from a substantial proportion of records: on maternal antenatal cards, blood group was recorded for 52 (63.4%) mothers, Rhesus (Rh) factor for 39 (47.6%), VDRL for 59 (71.9%) and HIV status for 77 (93.1%). From neonatal clinical records, heart rate was recorded for3 (3.7%) neonates, respiratory rate in 14, (17.1%) and temperature in 33 (40.2%). None of 13 facilities had a functioning premature unit despite calculated gestational age <36 weeks in 45.6% of evaluated neonates. Intravenous fluids and oxygen were available in 9 out of 13 of facilities, while antibiotics and essential basic equipment were available in more than two thirds. Medication dosing errors were common; under-dosage for ampicillin, gentamicin and cloxacillin was found in 44.0%, 37.9% and 50% of cases, respectively, while over-dosage was found in 20.0%, 24.2% and 19.9%, respectively. Physician or assistant physician staffing levels by the WHO indicator levels (WISN) were generally low. Key aspects of neonatal care were found to be poorly documented or incorrectly implemented in this appraisal of neonatal care in Kilimanjaro. Efforts towards quality assurance and enhanced motivation of staff may improve outcomes for this vulnerable group

Pilot randomized trial of therapeutic hypothermia with serial cranial ultrasound and 18-22 month follow-up for neonatal encephalopathy in a low resource hospital setting in Uganda: study protocol

Background: There is now convincing evidence that in industrialized countries therapeutic hypothermia for perinatal asphyxial encephalopathy increases survival with normal neurological function. However, the greatest burden of perinatal asphyxia falls in low and mid-resource settings where it is unclear whether therapeutic hypothermia is safe and effective.Aims: Under the UCL Uganda Women's Health Initiative, a pilot randomized controlled trial in infants with perinatal asphyxia was set up in the special care baby unit in Mulago Hospital, a large public hospital with similar to 20,000 births in Kampala, Uganda to determine:(i) The feasibility of achieving consent, neurological assessment, randomization and whole body cooling to a core temperature 33-34 degrees C using water bottles(ii) The temperature profile of encephalopathic infants with standard care(iii) The pattern, severity and evolution of brain tissue injury as seen on cranial ultrasound and relation with outcome(iv) The feasibility of neurodevelopmental follow-up at 18-22 months of ageMethods/Design: Ethical approval was obtained from Makerere University and Mulago Hospital. All infants were in-born. Parental consent for entry into the trial was obtained. Thirty-six infants were randomized either to standard care plus cooling (target rectal temperature of 33-34 degrees C for 72 hrs, started within 3 h of birth) or standard care alone. All other aspects of management were the same. Cooling was performed using water bottles filled with tepid tap water (25 degrees C). Rectal, axillary, ambient and surface water bottle temperatures were monitored continuously for the first 80 h. Encephalopathy scoring was performed on days 1-4, a structured, scorable neurological examination and head circumference were performed on days 7 and 17. Cranial ultrasound was performed on days 1, 3 and 7 and scored. Griffiths developmental quotient, head circumference, neurological examination and assessment of gross motor function were obtained at 18-22 months.Discussion: We will highlight differences in neonatal care and infrastructure that need to be taken into account when considering a large safety and efficacy RCT of therapeutic hypothermia in low and mid resource settings in the future

Massage-like stroking boosts the immune system in mice

Recent clinical evidence suggests that the therapeutic effect of massage involves the immune system and that this can be exploited as an adjunct therapy together with standard drug-based approaches. In this study, we investigated the mechanisms behind these effects exploring the immunomodulatory function of stroking as a surrogate of massage-like therapy in mice. C57/BL6 mice were stroked daily for 8 days either with a soft brush or directly with a gloved hand and then analysed for differences in their immune repertoire compared to control non-stroked mice. Our results show that hand-but not brush-stroked mice demonstrated a significant increase in thymic and splenic T cell number (p lt 0.05; p lt 0.01). These effects were not associated with significant changes in CD4/CD8 lineage commitment or activation profile. The boosting effects on T cell repertoire of massage-like therapy were associated with a decreased noradrenergic innervation of lymphoid organs and counteracted the immunosuppressive effect of hydrocortisone in vivo. Together our results in mice support the hypothesis that massage-like therapies might be of therapeutic value in the treatment of immunodeficiencies and related disorders and suggest a reduction of the inhibitory noradrenergic tone in lymphoid organs as one of the possible explanations for their immunomodulatory function

Neonatal Handling Affects Durably Bonding and Social Development

The neonatal period in humans and in most mammals is characterized by intense mother-young interactions favoring pair bonding and the adaptation of neonates to their new environment. However, in many post-delivery procedures, human babies commonly experience combined maternal separation and intense handling for about one hour post-birth. Currently, the effects of such disturbances on later attachment and on the development of newborns are still debated: clearly, further investigations are required. As animals present good models for controlled experimentation, we chose domestic horses to investigate this issue. Horses, like humans, are characterized by single births, long lactating periods and selective mother-infant bonds. Routine postnatal procedures for foals, as for human babies, also involve intense handling and maternal separation. In the present study, we monitored the behavior of foals from early stages of development to “adolescence”, in a normal ecological context (social groups with adults and peers). Experimental foals, separated from their mothers and handled for only 1 hour post-birth, were compared to control foals, left undisturbed after birth. Our results revealed short- and long-term effects of this unique neonatal experience on attachment and subsequent social competences. Thus, experimental foals presented patterns of insecure attachment to their mothers (strong dependence on their mothers, little play) and impaired social competences (social withdrawal, aggressiveness) at all ages. We discuss these results in terms of mother-young interactions, timing of interactions and relationships between bonding and subsequent social competences. Our results indicate that this ungulate species could become an interesting animal model. To our knowledge, this is the first clear demonstration that intervention just after birth affects bonding and subsequent social competences (at least until “adolescence”). It opens new research directions for studies on both humans and other animals

Risk factors and outcomes for neonatal hypoglycaemia and neonatal hyperbilirubinaemia in pregnancies complicated by gestational diabetes mellitus : a single centre retrospective 3-year review

Aim To determine risk factors associated with neonatal hypoglycaemia and hyperbilirubinaemia, and assess their impact on neonatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM). Methods Retrospective review investigating all pregnancies complicated by GDM at Campbelltown Hospital (Sydney, Australia) between 1 January 2013 and 31 December 2015. Main outcomes measured were neonatal hypoglycaemia (capillary glucose levels 0.6; 97.1, 95% CI 38.9-241.5, P < 0.001). Conclusions Neonatal hypoglycaemia and hyperbilirubinaemia largely occur in different pregnancies. Both are associated with earlier GDM diagnosis; however, hypoglycaemia is more associated with maternal glycaemia and its sequelae, and hyperbilirubinaemia is associated with polycythaemia

Cranial ultrasound findings in well newborn Ugandan infants

Apparently well term-born Ugandan infants frequently have abnormalities on cUS. These are mainly increased WM echogenicity, SEP and CPC. These may relate to the reported high incidence of congenital infections in this population but this remains to be confirmed. The observations provide baseline data for comparison with scans from sick infants from similar communities and are also important for studies in which cUS will be used to assess progress

Cerebral measurements made using cranial ultrasound in term Ugandan newborns

These data provide reliable reference values for linear measurements of many cerebral structures made using cUS. The data agree well with those from other populations suggesting that cerebral size is similar in different ethnic groups

Neonatal neurological examination in well newborn term Ugandan infants.

BACKGROUND: Newborn neurological examinations have mostly been developed in high-resource settings with cohorts comprising predominantly white Caucasian infants. No comparison has been made with different populations. AIMS: To (i) establish the range of neurological findings in apparently well newborn term Ugandan infants, (ii) compare these findings to published data for equivalent term UK infants and (iii) correlate the neurological findings with perinatal characteristics and cranial ultrasound (cUS) imaging. METHODS: Low-risk term Ugandan infants were recruited from the postnatal ward at Mulago Hospital, Kampala, Uganda. Neurological examination (1) and cUS were performed. The raw data and neurological optimality scores were compared to published data from UK infants (1). Gestational age, postnatal age, sex, maternal parity and HIV status, mode of delivery, birth weight and head circumference were correlated with raw scores. RESULTS: Ugandan infants showed significantly stronger palmar grasp, better auditory and visual orientation, less irritability and less need for consoling but had poorer tone, poorer quality of spontaneous movements and more abnormal signs than UK infants. No correlation was found between raw scores and cUS findings, gestational age, sex, birth weight and head circumference. Significantly fewer Ugandan infants had optimal scores based on the UK data. CONCLUSION: The neurological status of low-risk hospital-born term Ugandan infants differs from that of low-risk UK infants. The study findings have implications for assessing normality in Ugandan infants and raise concerns about the use of this UK "optimality" score in other research settings. Further work is needed to understand fully the reasons for the differences