Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022.

The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.

Cost implication of CPAP use in low resource settings, surmounting the oxygen administration challenge.

PURPOSE: Newborn respiratory support using Bubble Continuous positive airway pressure (bCPAP) has become acceptable in Nigeria as many centers are increasingly reporting its usefulness. There is increasing access to CPAP devices although the use of 100% oxygen for bCPAP administration is on the rise as oxygen/air blenders are not commonly available or insufficient. The cost of oxygen has become a significant contributor to hospital bills. The oxygen concentrator driven bCPAP device with blending capacity is expected to save lives and reduce cost of care. OBJECTIVE: To compare the cost saving benefit of the use of oxygen concentrator bCPAP devices for CPAP administration to oxygen based devices in a resource limited setting. METHODS: This prospective cross sectional study was done between February and December 2019. The oxygen use by CPAP devices-Improvised (IbCPAP), Fisher and Paykel and T-piece were quantified, costed, documented and compared with the same duration of use of concentrator CPAP-Diamedica. RESULTS: CPAP services was accessed by 357 babies, 154 males and 203 females of GA range from 22 to 42 weeks and Birthweights range from 264 to 4400 grams. The main indication for CPAP was respiratory distress syndrome 201(56.3%). Oxygen supply were by oxygen pipeline 250 (70%), cylinders 39 (10.9%), concentrator CPAP 44 (12.3%) mixed source 24 (6.7%). Mean duration on the CPAP devices was 5.4 days, mean cost ₦37,645 ($104) or ₦6,971 ($20)/day, highest with IbCPAP, non-existent with concentrator bCPAP. CONCLUSION: The high running cost implication of CPAP use in low resource settings could deter transitioning to quality devices hence the need for non-oxygen dependent devices.

A new low-cost commercial bubble CPAP (bCPAP) machine compared with a traditional bCPAP device in Nigeria.

Background: The bubble continuous positive airway pressure (bCPAP) technique is widely applied in neonatal respiratory support. Commercial bCPAP brands are expensive in Nigeria and this has driven Nigerian paediatricians to use potentially risky improvised devices (IbCPAP). Aim: This study aimed to design, produce and trial an appropriate low-cost bCPAP machine which is functionally effective and safe. Methods: Questionnaires were distributed to assess the need for a new bCPAP design for use in Nigeria, leading to the development of a new system (politeCPAP) which was functionally and clinically validated in three Nigerian hospitals. Six months of clinical data on the new device of sufficient comparative quality were generated from one of the hospitals and compared with control data on the IbCPAP. The hospitals (n = 3) submitted data on 71 patients on IbCPAP or politeCPAP; 14 were disqualified on the basis of the elimination criteria. The infants were classified into two birthweight categories: <1000 g (extremely low birthweight, ELBW, n = 15) and 1000 g (n = 42). Results: Six ELBW neonates on politeCPAP survived; there were no ELBW survivors in the IbCPAP group (n = 9). The IbCPAP device delivered an average 90% O2-gas ratio (FiO2) whereas the politeCPAP required only 47%. Many heavier neonates in the IbCPAP group survived (23 of 26); however, supplementary warming was required for all of them whereas none of the politeCPAP infants required warming. The politeCPAP costs around US$2000 whereas standard commercial CPAP brands in Nigeria range from US$5000 to US$18,000. High oxygen requirement and iatrogenic hypothermia were serious adverse features of IbCPAP. Conclusions: The study has narrowed the gap between relatively low-cost, risky devices (e.g. IbCPAP) and high-cost commercial machines. The politeCPAP is a feasible alternative to the IbCPAP in cost-constrained settings. Abbreviations: bCPAP: bubble continuous positive airway pressure; CPAP: continuous positive airway pressure; ELBW: extremely low birthweight; FiO2: ratio of oxygen content in gas flow (%); IbCPAP: improvised bubble continuous positive airway pressure device; LBW: low birthweight; NNU: neonatal unit; PEEP: positive end expiratory pressure; politeCPAP: the newly developed commercial bCPAP machine; RDS: respiratory distress syndrome; SpO2, oxygen saturation level (%).

Effect of HIV-1 Serostatus on the Prevalence of Asymptomatic Plasmodium falciparum Parasitemia Among Children Less Than 5 Years of Age in Benin City, Nigeria.

BACKGROUND: Human immunodeficiency virus (HIV) infection and Plasmodium falciparum malaria are 2 of the gravest health threats in sub-Saharan Africa. Multiple repeat infections with the malaria parasite as seen in endemic areas are necessary to develop specific malaria immunity. HIV is an immunosuppressive virus and in children aged <5 years, development of malaria-specific immunity may be impaired and malaria parasite clearance in theory will be delayed; hence the predisposition to increased incidence of asymptomatic malaria or severe malaria. This cross-sectional study was carried out to examine associations between immunosuppression and asymptomatic malaria parasitemia (ASMP) in HIV-infected children aged <5 years in Benin City. METHODS: One hundred seventy-nine asymptomatic HIV-1-positive and 179 age- and sex-matched HIV-1-negative children aged <5 years were recruited. The malaria parasite was determined by Giemsa-stained blood film by certified microscopy while concomitant CD4(+) count was estimated in the HIV-infected children. RESULTS: The prevalence of ASMP in those who were HIV-infected of 34.1% was significantly higher than 17.3% in the HIV uninfected (P = .001). The prevalence of ASMP was highest (59.3%) among subjects who were severely immunosuppressed (CDC immunologic category 3). The prevalence of ASMP significantly increased with advanced immune disease in the subjects (P = .011). Severe (World Health Organization) clinical staging was also significantly associated with increased prevalence of ASMP (P = .031). The prevalence of ASMP is significantly higher among subjects not receiving cotrimoxazole, associated with threefold risk of having ASMP (P = .003: odds ratio = 3.5). CONCLUSIONS: ASMP is more common in HIV-positive children aged <5 years and is significantly associated with declining CD4(+) T-cell count and severe clinical disease. There is a need for integration of HIV- and malaria-control programs for stronger case management. Malaria-control programs may consider malaria prevention interventions and cotrimoxazole prophylaxis for preschool children who are HIV-infected and living in malaria-endemic regions.