The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia.

BACKGROUND: Kangaroo mother care has been highlighted as an effective intervention package to address high neonatal mortality pertaining to preterm births and low birth weight. However, KMC uptake and service coverage have not progressed well in many countries. The aim of this case study was to understand the institutionalisation processes of facility-based KMC services in three Asian countries (India, Indonesia and the Philippines) and the reasons for the slow uptake of KMC in these countries. METHODS: Three main data sources were available: background documents providing insight in the state of implementation of KMC in the three countries; visits to a selection of health facilities to gauge their progress with KMC implementation; and data from interviews and meetings with key stakeholders. RESULTS: The establishment of KMC services at individual facilities began many years before official prioritisation for scale-up. Three major themes were identified: pioneers of facility-based KMC; patterns of KMC knowledge and skills dissemination; and uptake and expansion of KMC services in relation to global trends and national policies. Pioneers of facility-based KMC were introduced to the concept in the 1990s and established the practice in a few individual tertiary or teaching hospitals, without further spread. A training method beneficial to the initial establishment of KMC services in a country was to send institutional health-professional teams to learn abroad, notably in Colombia. Further in-country cascading took place afterwards and still later on KMC was integrated into newborn and obstetric care programs. The patchy uptake and expansion of KMC services took place in three phases aligned with global trends of the time: the pioneer phase with individual champions while the global focus was on child survival (1998-2006); the newborn-care phase (2007-2012); and lastly the current phase where small babies are also included in action plans. CONCLUSIONS: This paper illustrates the complexities of implementing a new healthcare intervention. Although preterm care is currently in the limelight, clear and concerted country-led KMC scale-up strategies with associated operational plans and budgets are essential for successful scale-up.

Kangaroo mother care for low birth weight infants: a randomized controlled trial.

OBJECTIVE: To compare the effect of Kangaroo mother care (KMC) and conventional methods of care (CMC) on growth in LBW babies (> 2000 g). STUDY DESIGN: Randomized controlled trial. SETTING: Level III NICU of a teaching institution in western India. SUBJECTS: 206 neonates with birth weight < 2000 g. INTERVENTION: The subjects were randomized into two groups: the intervention group (KMC-103) received Kangaroo mother care. The control group (CMC: 103) received conventional care. OUTCOME MEASURES: Growth, as measured by average daily weight gain and by other anthropometrical parameters at 40 weeks postmenstrual age in preterm babies and at 2500 g in term SGA infants was assessed. RESULTS: The KMC babies had better average weight gain per day (KMC: 23.99 g vs CMC: 15.58 g, P< 0.0001). The weekly increments in head circumference (KMC: 0.75 cm vs CMC: 0.49 cm, P = 0.02) and length (KMC: 0.99 cm vs CMC: 0.7 cm, P = 0.008) were higher in the KMC group. A significantly higher number of babies in the CMC group suffered from hypothermia, hypoglycemia, and sepsis. There was no effect on time to discharge. More KMC babies were exclusively breastfed at the end of the study (98% vs 76%). KMC was acceptable to most mothers and families at home. CONCLUSION: Kangaroo mother care improves growth and reduces morbidities in low birth weight infants. It is simple, acceptable to mothers and can be continued at home.

Fanconi's anemia in newborn.

Fanconi's anemia (FA) is a paradigm for congenital anomalies, aplastic anemia and predisposition to malignancies. Identification of the disease at birth is based on characteristic physical malformations, as hematologic manifestations at birth are extremely rare. We report a case of FA in a newborn who presented with anophthalmia, unilateral radial ray defect, hemivertebrae and thrombocytopenia.

Fluconazole prophylaxis against fungal colonization and invasive fungal infection in very low birth weight infants.

BACKGROUND: Fungal infections are common cause of morbidity and mortality in very low birth weight Infants OBJECTIVES: To evaluate the efficacy of prophylactic Fluconazole in preventing fungal colonization and invasive fungal infection in VLBW infants. DESIGN: Prospective, randomized, double blind placebo controlled clinical trial. SETTING: Tertiary level Neonatal intensive care unit. SUBJECTS: 120 preterm infants with birth Weight < 1500 g. INTERVENTION: Infants were randomly assigned during first three days to receive either Fluconazole or placebo till 28 days or less if, discharged or died earlier. Weekly surveillance cultures from groin, oropharynx, rectum and blood were collected in all patients. Fungal isolates were typed based on standard microbiologic techniques. Liver enzymes were monitored. RESULTS: Baseline risk factors for fungal infection in Fluconazole and Placebo groups were similar. Fungal colonization was seen in 30 infants (50%) in the placebo group and 11 infants (19%) in the Fluconazole group (P <0.001). Fungal colonization at rectum, groin and oropharynx was less in fluconazole groups. Fluconazole group showed significantly lower colonizations with Candida albicans but not with C. glabrata. Invasive infection was seen in 15 (25%) infants in Placebo group and 16 (26.7%) infants in Fluconazole group (P = 0.835). Various non-albicans Candida were responsible for 96.8% cases of invasive fungal infection (Candida glabrata 71%, C. parapsilosis 14.7% and C. tropicalis 9.6%). No significant hepatotoxicity was noticed during Fluconazole therapy. CONCLUSION: Prophylactic fluconazole during the first four weeks of life is effective in reducing fungal colonization but not invasive infection in VLBW infants.

Sirenomelia apus with vestigial tail.

Sirenomelia is an exceptionally rare congenital malformation characterized by complete or near complete fusion of lower limbs. A newborn with clinical features of sirenomelia including fused lower limbs in medial position, absent fibula, anal atresia, complete absence of urogenital system (bilateral renal agenesis, absent ureters, urinary bladder, absent internal and external genitalia), a single umbilical artery and a vestigial tail is reported. Association of vestigial tail with sirenomelia is not described in the literature.

Room air vs. 100 per cent oxygen for neonatal resuscitation: a controlled clinical trial.

The aim of the study was to determine whether neonates resuscitated with room air compared with 100 per cent oxygen in the delivery room were less likely to have hypoxic ischemic encephalopathy and/or death before discharge. A controlled clinical trial was carried out at a tertiary care institute. All newborns weighing 1000 g or more with apnea or gasping respiration and/or heart rate less than 100 beats/min requiring positive pressure ventilation after initial steps of resuscitation were included. All eligible neonates were randomized to receive room air or 100 per cent oxygen for the first 90 s after birth if they required positive pressure ventilation. The composite primary outcome variable was hypoxic ischemic encephalopathy (HIE) and/or death before discharge. A total of 204 neonates fulfilling the inclusion criteria were enrolled. Of these, 107 neonates received room air and 97 neonates received 100 per cent oxygen for resuscitation. The composite primary outcome occurred in 41.1 per cent of the neonates assigned to receive room air and 43.3 per cent of those in the 100 per cent oxygen group (odds ratio in the group assigned to room air, 0.92; 95 per cent confidence interval, 0.52-1.60). Resuscitation of a newborn baby with room air instead of the current practice of 100 per cent oxygen does not confer a benefit in terms of reduced HIE and/or mortality. Significantly, there is no increase in adverse outcome with the use of room air, which can be recommended for resuscitation if oxygen is not available.

Analgesic effect of oral glucose in preterm infants during venipuncture--a double-blind, randomized, controlled trial.

The aim of the present study was to evaluate the effect of different concentrations of glucose on measures of neonatal pain during venipuncture. A randomized, double-blind, placebo controlled trial was carried out at the neonatal intensive care unit at the King Edward Memorial Hospital. Sixty healthy preterm infants of gestation age 28-37 weeks and postnatal age 2-28 days were randomized to receive 2 ml of one of three solutions (sterile water, 10 per cent wt/vol. glucose and 25 per cent wt/vol. glucose) in the mouth 2 min before venipuncture. There was a significant reduction in duration of first cry in the babies given 25 per cent glucose compared with controls and those given 10 per cent glucose. There was no significant effect on heart rate, respiratory rate or oxygen saturation. It is concluded that concentrated glucose solution seems to reduce pain and may be a useful and safe analgesic for minor procedures in neonates.