Kate Milner, Centre for International Child Health, University of Melbourne
Beyond survival: Improving long-‐term outcomes for survivors of serious newborn illness in Asia and the Paciﬁc Dr Kate Milner Centre for Interna?onal Child Health Department of Paediatrics University of Melbourne April 12 2013 Courtesy Graham Crumb. 2012
Outline • Background -‐Global newborn morbidity data gap -‐Importance of long-‐term outcomes data • Measuring long-‐term outcomes -‐Important outcomes in resource-‐limited seLngs -‐Available literature on neurodevelopmental outcomes • Interven?ons for ‘high risk’ newborns in resource-‐limited seLngs • Regional research -‐Fiji Newborn Integrated Care Ini?a?ve
Child survival context 3.1 million newborn deaths 134.6 million live births Ref: Liu L et al. Lancet 2012.
Newborn morbidity data gap 3.1 million newborn deaths ~14 million preterm survivors • Survivors of intrapartum related events (‘birth asphyxia’)? • Survivors of serious infecAons? World Health Organisa?on. Born too soon: the global ac?on report on preterm birth. C.P Howson, Kinney M.V, Lawn J.E, Editor 2012: Geneva 134.6 million live births
Newborn Morbidity Data Gap “Few more important health issues exist for which so li5le complete and reliable knowledge about the worldwide extent of the problem is available.” Morken, NH. Lancet 2012.
Coun?ng survivors -‐ challenges • Lack of vital registra?on • Deﬁning and measuring key outcomes • Resources
Importance of long-‐term outcome data “What gets measured gets done.” Dr Margaret Chan, Director-‐ General of the World Health Organiza?on
Importance of long-‐term outcome data • To improve: -‐maternal and newborn care -‐follow-‐up care and early interven?on for newborns who survive serious illness • To advocate for broader considera?ons of newborn health in regional public health and policy arena
Hearing loss • Permanent congenital or early onset hearing loss (PCHL) 6/1000 live births in resource-‐ limited seLngs • 737, 000 children worldwide Olusanya BO. Archives of Disease in Childhood. 2012
CondiAon Hearing loss – median % (IQR) Sepsis 12.4 (11.1-‐14.9) Meningi?s 8.6 (2.6-‐13.1) Hypoxic ischaemic encephalopathy 10.0 (5-‐11.6) Preterm birth 2.9 (12-‐8.7) Jaundice 10.5 (3.7-‐14.4) Cytomegalovirus 24.3 (11.4-‐35.8) Herpes 29.9 (20.0-‐39.1) Overall 13.4% (5.0-‐28.6) Adapted from Mwaniki MK et al. Long-‐term neurodevelopmental outcomes aler intrauterine and neonatal insults: a systema?c review. Lancet. 379(9814):445-‐52, 2012
Risk factors for early onset and congenital hearing loss Known factors (40-‐62%) Primary prevenAon opAons Prenatal Parental counselling re gene?cs (e.g. consanguinity) -‐Gene?c syndromic Rubella vaccina?on -‐Gene?c non-‐syndromic Maternal health educa?on and antenatal care -‐Acquired congenital infec?ons Natal -‐Lack of skilled birth amendant Maternal educa?on, improved obstetric and neonatal -‐Mode of delivery care -‐Maternal hypertensive disorders in pregnancy -‐Birth trauma -‐Birth asphyxia -‐Prematurity/Low birth weight Postnatal -‐Neonatal sepsis Improved obstetric care -‐Neonatal meningi?s Improved neonatal care (e.g. ra?onal use ototoxics, -‐Neonatal jaundice management of jaundice) -‐Ototoxicity (e.g. aminoglycosides) Vaccina?on (especially in at risk popula?on) -‐Undernutri?on Early detec?on and interven?on Early nutri?onal interven?ons Unknown factors (38-‐60%) Early detec?on and interven?on Adapted from Olusanya, B. O. "Neonatal hearing screening and intervenAon in resource-‐limited sengs:
Hearing loss – early detec?on and interven?on • WHO ‘guiding principles’ for Newborn Hearing Screening Programs (NHSP) in resource-‐limited seLngs (2010) • Documented NHSP in a number of low and middle income countries • Early detec?on and interven?on facilitate op?mal speech and language outcomes • Beneﬁts extend well beyond op?mal speech and language outcomes Olusanya, B. O. Archives of Disease in Childhood. 2012.
Vision impairment • Overall risk of visual impairment 12.9% (3.5-‐33.4) among survivors of perinatal or neonatal insult globally^ • 3rd epidemic of re?nopathy of prematurity* – Predominant cause of childhood blindness in some resource limited seLngs (e.g. La?n America, South Asia) – 50,000 children globally ^Mwaniki MK et al. Lancet 2012. *Courtright P et al. Arch Dis Child. 2011; Gilbert C. Early Human Development. 2008
Propor?on of blindness due to re?nopathy of prematurity % blindness due to ROP Infant mortality rate/1000 live births (1999) Reference: Gilbert C. Re?nopathy of prematurity: a global perspec?ve of the epidemics, popula?on of babies at risk and implica?ons for control. Early Human Development. 84(2):77-‐82.
Vision impairment • Similari?es to hearing impairment – Antenatal and postnatal risk factors – Important opportuni?es for primary and secondary preven?on of vision impairment and disability
‘Early interven?on’ for ‘high-‐risk’ newborns
Early interven?on – resource limited seLngs • Robust evidence of beneﬁt for systema?c investment in early childhood development • A range of interven?ons can improve children’s cogni?ve, psychosocial development and schooling outcomes • Eﬀects are generally largest in the most disadvantaged popula?ons • Returns on investment in Early Child Development are substan?al Engle PL, Lancet 2007, Engle PL, Lancet 2011.
Early interven?on – resource limited seLngs • Eﬀec?ve interven?ons -‐S?mula?on combined with nutri?on and health programmes -‐Improving food intake, reducing stun?ng, reducing iodine deﬁciency and iron deﬁciency anaemia • Few studies of models of early interven?on for children with developmental disabili?es Engle PL, Lancet 2007; Engle PL, Lancet 2011.
Early interven?on for ‘high-‐risk’ newborns Jamaica LBW study – 24 month home based interven?on – 6 years – beneﬁts in performance IQ, memory and behaviour Walker SP, Dev Med Child Neurol. 2010.
Early interven?on for ‘high-‐risk’ newborns Brain Research to Ameliorate Impaired Neurodevelopment Home Interven?on Trial • Mul?country trial • Linked with First Breath Trial • RCT of home based interven?on in infants requiring bag/mask ven?la?on in home and facility seLngs • 12 month results (n=78 in interven?on arm) -‐no diﬀerence in developmental outcomes -‐ 16% of resuscitated group severe neurodevelopmental impairment -‐ Small numbers, mild-‐moderate hypoxic ischaemic encephalopathy Carlo WA. J Pediatr. 2012.
Background • Newborn health in Fiji • Colonial War Memorial • Hospital • Current follow-‐up
Aim: • To assess the medium term health and developmental outcomes and unmet health needs for a cohort of neonatal intensive care pa?ents, compared with controls.
Objec?ves: To assess: • Prevalence of neurodevelopmental impairment at age 2-‐4 years. • Prevalence of stun?ng, was?ng, anaemia, immunisa?on rates, feeding prac?ces To explore: • Nurse-‐administered developmental screening compared with a gold standard developmental assessment.
Progress: team building Sr Lanieta Koyamaibole and Dr Rakei Kaarira Colonial War Memorial Hospital
Conclusions • Long-‐term morbidity amongst newborns who survive serious illness is an increasing public health issue in resource-‐limited seLngs. • More quality, community-‐based data is required. • Improving outcomes requires improved maternal and newborn care and early detec?on and interven?on when complica?ons arise. • Support from global health community is required for advocacy, capacity building and further research in this area.
Thank you Dr Joseph Kado & Paediatric Team Colonial War Memorial Hospital Suva Lanieta Koyamaibole Dr Rakei Kaarira Dr Raina Prasad Mere Gunaivalu Dr Anne Miller Kathryn O’Heir Dr Sue Woolfenden University of Melbourne Audiology Carabez Ear Clinic Suva Prof Trevor Duke, Dr Gehan Roberts, Dr Andrew Steer Centre for Interna?onal Child Health AusAID Women and Children’s Knowledge Hub For Health CureKids Fiji Knowledge Hubs for Health are a strategic partnership initiative funded by the Australian Agency for International Development!