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Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015

Newborn survival and perinatal health in resource-constrained settings in Asia and the Pacific: Applying Global Evidence to Priorities Beyond 2015
12 April 2013

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    Kate Milner, Centre for International Child Health, University of Melbourne Kate Milner, Centre for International Child Health, University of Melbourne Presentation Transcript

    • 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    
    • Defining  and  measuring  long-­‐term   outcomes  
    • Long-­‐term  morbidity  in  resource-­‐limited   seLngs…  •  Post  neonatal  mortality  •  Growth  and  nutri?on  •  Infec?ous    and  respiratory  morbidity  •  Neurodevelopmental  outcomes  •  Hospitalisa?on  •  Outcomes  in  adolescence  and  adulthood  •  Others  -­‐  Impact  on  families,  economic   implica?ons  
    • Neurodevelopmental  outcomes  Mwaniki  et  al,  Lancet  2012  
    •   Neurodevelopmental  outcomes   (Mwaniki  et  al,  Lancet  2012)                                                                153  studies                                          22,161  survivors                39.4%  one  sequela                        (18.5%  severe)    Cogni?ve,  learning,   Cerebral   Hearing   Vision   Seizures  Developmental  delay   palsy  
    • 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.  
    • Fiji  Newborn  Integrated   Care  Ini?a?ve  
    • 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:  developmental  clinics  
    • Progress:  hearing  clinics  
    • Progress:  logis?cs  
    • 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!