Investigation of infant deaths associated with critical congenital heart diseases; 2018-2021, Türkiye.

BACKGROUND: The aim of this study was to examine the characteristics of infant mortality associated with critical congenital heart disease (CCHD). METHODS: In a cross-sectional study, data for the study were obtained through Death Notification System, Birth Notification System and Turkish Statistical Institute birth statistics. RESULTS: Of all infant deaths, 9.8% (4083) were associated with CCHD, and the infant mortality rate specific to CCHD was 8.8 per 10,000 live births. CCHD-related infant deaths accounted for 8.0% of all neonatal deaths, while the CCHD specific neonatal death rate was 4.6 per 10,000 live births. Of the deaths 21.7% occurred in the early neonatal, 30.3% in the late neonatal and 48.0% in the post neonatal period. Group 1 diseases accounted for 59.1% (n = 2415) of CCHD related infant deaths, 40.5% (n = 1652) were in Group 2 and 0.4% (n = 16) were in the unspecified group. Hypoplastic left heart syndrome was the most common CCHD among infant deaths (n = 1012; 24.8%). The highest CCHD related mortality rate was found in infants with preterm birth and low birth-weight while multiparity, maternal age ≥ 35 years, twin/triplet pregnancy, male gender, maternal education in secondary school and below, and cesarean delivery were also associated with higher CCHD related infant mortality rate. There was at least one non-cardiac congenital anomaly/genetic disorder in 26.1% of all cases. CONCLUSION: CCHD holds a significant role in neonatal and infant mortality in Türkiye. To mitigate CCHD-related mortality rates, it is crucial to enhance prenatal diagnosis rates and promote widespread screening for neonatal CCHD.

Evaluation of critical congenital heart disease from 2018 to 2020 in Turkey: a retrospective cohort study.

BACKGROUND: The aim of this study is to examine the features of critical congenital heart disease (CCHD). METHODS: The study was planned as a retrospective cohort study. Data for the study were obtained through national data collection systems and 2018-2020 CCHD cohort was established. In this study, we divided the patients into two groups: Group 1 included seven primary target diseases of the newborn CCHD screening program and Group 2 included secondary target diseases. RESULTS: There were 9884 CCHD cases, with a prevalence of 27.8 per 10,000 live births. Of the cases 44.4% were in Group 1 (12.3 per 10,000) and 54.8% were in Group 2 (15.2 per 10,000). Of all cases 55.5% were male and the female/male ratio was 1/1.2. While 21.8% of the cases were premature, 23.0% were babies with low birth weight (LBW), 4.8% were born from multiple pregnancies. The highest prevalence of CCHD was found in LBW (84.8 per 10,000), premature infants (57.8 per 10,000) (p < 0.001). The fatality rate in the cohort was 16.6% in the neonatal period, 31.6% in the first year of life respectively. The mean estimated survival time in the birth cohort was 40.0 months (95% CI: 39.5-40.6). The mean survival time for Group 1 diseases was 33.4 months (95% CI: 32.5-34.2), while it was 45.4 months (95% CI: 44.7-46.0) for Group 2 diseases (p < 0.001). Preterm birth, LBW, maternal age and region were evaluated as factors associated with mortality risk. CONCLUSION: This study showed that CCHDs are common in Turkey and mortality rates are high. There are regional differences in CCHD both prevalence and survival. Improving prenatal diagnosis rates and expanding neonatal CCHD screening are of key importance.

Baby-friendly hospitals in Turkey: evaluation of adherence to the Ten Steps to Successful Breastfeeding.

Background: The Baby-Friendly Hospital Initiative (BFHI) is a World Health Organization and United Nations Children's Fund joint global programme to protect, promote and support breastfeeding. Sustainability of the BFHI standards is important for health facilities and country-level implementation. Aims: To analyse the 2018-2019 external reassessment results of baby-friendly hospitals (BFHs) in Turkey. Methods: We included 414 BFHs. The Ten Steps to Successful Breastfeeding were divided into 2 groups: critical management procedures (Steps 1 and 2) and key clinical practices (Steps 3-10). Results: All 10 steps were fulfilled by 60.1% of the hospitals. Steps 3 and 2 had the lowest compliance rates (81.6% and 85.7%), and Steps 7 and 8 had the highest rates (97.1% and 98.1%). Caesarean section rates in the fourth quartile were associated with significantly lower adherence to Steps 3 and 10. The presence of another external reassessment within 5 years was associated with a significantly higher adherence rate to Step 3, and a significantly higher full implementation rate for the clinical practices. Hospitals that fully implemented management procedures had a significantly higher fulfilment percentage for all clinical practices. The western region had higher adherence rates for all the clinical practices than other regions. Conclusion: Reassessments seem useful for sustainability. Full compliance with Steps 1 and 2 is important for higher adherence to the clinical steps. Regional variations should be taken into account in the implementation of the programme.

Evaluation of neural tube defects from 2014 to 2019 in Turkey.

OBJECTIVE: The aim of this study is to determine the frequency of neural tube defects (NTDs) and to examine the epidemiological characteristics of NTD related deaths in Turkey. METHODS: This nationwide descriptive study was included NTD related infant deaths, termination of pregnancy for fetal anomaly (ToPFA) and stillbirth cases registered in Death Notification System between 2014 and 2019, and patients diagnosed with NTD in the 2018 birth cohort. FINDINGS: In the 2018 birth cohort, there were 3475 cases of NTD at birth (27.5 per 10,000). The fatality rates for live-born babies with NTD in this cohort were 13.5% at first year, and 15.6% at the end of March, 2022. NTDs were associated with 11.7% of ToPFA cases, 2.5% of stillbirths and 2.8% of infant deaths in 2014-2019. NTD related stillbirth rate was 1.74 per 10,000 births, while NTD related ToPFA rate and infant mortality rate were 0.61 and 2.70 per 10,000 live births respectively. NTD-related stillbirth and infant mortality rate were highest in the Eastern region (3.64 per 10,000 births; 4.65 per 10,000 live births respectively), while ToPFA rate was highest in the North and West regions (1.17 and 0.79 per 10,000 live births respectively) (p < 0.05). Prematurity and low birth weight were the variables with the highest NTD related rates for stillbirths (11.26 and 16.80 per 10,000 birth), ToPFA (9.25 and 12.74) per 10,000 live birth), and infant deaths (13.91 and 20.11 per 10,000 live birth) (p < 0.05). CONCLUSION: NTDs are common and have an important place among the mortality causes in Turkey. Primary prevention through mandatory folic acid fortification should be considered both to reduce the frequency of NTD and related mortality rates.

Effect of Maternal Subclinical Hypothyroidism on Congenital Hypothyroidism Screening Results: A Retrospective Cohort Study.

OBJECTIVES: This study aimed to evaluate the results of congenital hypothyroidism screening (CHS) in neonates born to women with subclinical hypothyroidism (SHT) during pregnancy and to identify maternal and neonatal characteristics associated with recall rate in CHS. STUDY DESIGN: This retrospective cohort study included nonrefugee pregnant women and newborn pairs who underwent thyroid function tests during prenatal follow-up between 2014 and 2017 and had neonatal CHS records. The women were evaluated overall and divided into euthyroidism (ET) and SHT groups according to their thyroid function tests. The groups were compared in terms of CHS results. Neonates with thyroid-stimulating hormone (TSH) levels <5.5 mIU/L were considered "normal," while those with values ≥5.5 mIU/L were "recall." RESULTS: The antenatal thyroid function data of a total of 22,383 pregnant women were analyzed. Of these, 71.6% were ET and 16.3% were diagnosed as SHT. Overall, the recall rate accounted for 5.34% of all CHS results and the recall rate was higher in the SHT group (7.10%) compared with the ET group (5.54%; p = 0.001). Being low birth weight (LBW) or large for gestation age (LGA), maternal TSH above the 97.5th percentile, and cesarean delivery increased the risk of recall in CHS (p ˂ 0.05). CONCLUSION: The recall rate was higher among the neonates of mothers with SHT. Being LBW or LGA, maternal TSH above the 97.5th percentile and cesarean delivery increased the risk of recall in CHS. KEY POINTS: · SHT is the most common form of hypothyroidism in pregnancy.. · TSH elevation is higher among the neonates of mothers with SHT.. · Being LBW or LGA, and cesarean delivery also increase the risk of TSH elevation in infants..

Effects of the COVID-19 pandemic on perinatal outcomes: a retrospective cohort study from Turkey.

BACKGROUND: Lockdowns, pregnant women's fear from hospitalization in addition to uncertainties about appropriate birthing practices at the beginning of the pandemic may have affected the health outcomes of mother-infant couples. We aimed to explore whether pregnancy outcomes including the rates of cesarean delivery (CS), preterm, and low birth weight (LBW) births have changed during the pandemic period compared with the pre-pandemic period. METHODS: We applied a population-based retrospective cohort, before-after approach in 2020 vs. similar calendar months in 2019 for five periods [Jan-Feb (pre-pandemic); March-May (1st wave and lockdown); June-August; September-October; November-December (2nd wave and lockdown)]. The data was modelled through multiple logistic regressions using key outcomes; CS, preterm, and LBW births as the dependent variables, and adjustments were made for independent variables in SPSS software. We evaluated the modification of years by periods by adding interaction term (yearXperiod) to the model. RESULTS: The rate of CS in hospital births increased from 57.7% in 2019 to 60.2% in 2020. CS rates were significantly increased during the 3rd and 4th periods. The overall preterm rate was 11%. When singleton pregnancies were considered, adjusted multivariable analyses showed a decrease in preterm proportions during all time periods with respect to the pre-pandemic period. The percentage of LBW was 7.7% during the pandemic period and was found to be significantly reduced compared to the pre-pandemic period. There was a significant reduction in LBW rates in all periods except the second lockdown period. CONCLUSIONS: Our findings suggested significant reductions in preterm and LBW births possibly due to the indirect effects of the pandemic. Moreover, strategies need to be considered to address the increased CS rates and shifting of maternity service utilization to private facilities.

Cystic fibrosis newborn screening: Five-year experience from a tertiary care center.

BACKGROUND: Newborn screening (NBS) for cystic fibrosis (CF) was implemented in our country on January 1, 2015, based on immunoreactive trypsinogen tests (IRT/IRT). Here, we aimed to evaluate the diagnoses of patients and follow-up process within the first 5 years of NBS from a tertiary care center. METHODS: This retrospective cohort study was conducted on patients who were admitted to our pediatric pulmonology department for sweat test (ST) via NBS. Patients with CF with negative NBS results and those with CF with positive NBS and joined our follow-up were also investigated. Clinical outcome measures were compared between patients with CF with positive and negative NBS. RESULTS: Six hundred sixty infants who were referred for ST via NBS were included. Across the entire study population (n = 683), 11.4% of patients had CF (14.1% of had negative NBS in this CF group). The sensitivity of NBS was found as 84.9% and the positive predictive value (PPV) was 9.4%. The median age at diagnosis was older (p < 0.001), reluctance for feeding and Pseudobartter syndrome (PBS) were significantly higher at presentation in the negative NBS group. There was no statistically significant difference between the groups regarding weight-for-age (p = 0.899) and height-for-age (p = 0.491) in the first 2 years' follow-ups. CONCLUSIONS: Our findings showed the low sensitivity and PPV of NBS; therefore, further studies based on all patients in our country are necessary for new cut-off values. PBS and reluctance for feeding should be alarm symptoms for CF even if the infants had negative NBS. Additionally, later diagnosis of patients who had negative NBS did not affect the nutritional outcomes; we need large-scale prospective studies to optimize nutritional benefits for all infants diagnosed via NBS.

Immigration and screening programs for hemoglobinopathies in Italy, Spain and Turkey.

Sickle cell disease (SCD) and thalassemias are the most common monogenic diseases in the world. The number of migrants and refugees in Europe and Turkey, in the past decade, has increased dramatically due to war, violence or prosecutions in their homeland. Prevention and management of haemoglobin disorders is well established and managed in countries where these conditions were traditionally endemic or in countries that have a longstanding tradition of receiving migrants. Therefore, preventive and diagnostic programmes regarding hemoglobinopathies in immigrant populations have been implemented. The purpose of this paper it to report a summary of the experience gained in Italy, Spain and Turkey in migrants, asylum seekers and refugees.

Neonatal Screening in Europe Revisited: An ISNS Perspective on the Current State and Developments Since 2010.

Neonatal screening (NBS) was initiated in Europe during the 1960s with the screening for phenylketonuria. The panel of screened disorders ("conditions") then gradually expanded, with a boost in the late 1990s with the introduction of tandem mass spectrometry (MS/MS), making it possible to screen for 40-50 conditions using a single blood spot. The most recent additions to screening programmes (screening for cystic fibrosis, severe combined immunodeficiency and spinal muscular atrophy) were assisted by or realised through the introduction of molecular technologies. For this survey, we collected data from 51 European countries. We report the developments between 2010 and 2020 and highlight the achievements reached with the progress made in this period. We also identify areas where further progress can be made, mainly by exchanging knowledge and learning from experiences in neighbouring countries. Between 2010 and 2020, most NBS programmes in geographical Europe matured considerably, both in terms of methodology (modernised) and with regard to the panel of conditions screened (expanded). These developments indicate that more collaboration in Europe through European organisations is gaining momentum. We can only accomplish the timely detection of newborn infants potentially suffering from one of the many rare diseases and take appropriate action by working together.

Evaluation of injury-related under-five mortality in Turkey between 2014-2017.

BACKGROUND: Injury is the most common cause of preventable morbidity and mortality among children. The aim of this study was to determine the epidemiological characteristics and trends of injury-related mortality in children under five and to provide evidence for future preventive strategies. METHODS: Our study was designed as a descriptive cross-sectional study. National under-five mortality data from the Death Notification System database, entered between January 1st, 2014, and December 31th, 2017, was included in the study. RESULTS: Among all under-five deaths registered in the system, 2,560 injury-related death cases were included in the study. Overall, deaths related to injuries accounted for 4.1% of all deaths in children under five years old. Of all injury deaths, 59.9% of cases were male, 52.7% occurred at home or its close vicinity, and 80.3% were children aged 12-59 months. Injury-related under-five deaths were mainly attributed to traffic injuries (36.5%), falls (12.0%), and suffocation (10.2%). Traffic injuries were the most common cause of injury-related deaths both in infants 0-11 months and children 12-59 months old. The second and third most common causes of injury-related deaths among infants 0-11 months were suffocation and falls, while these were falls and drowning in children aged 12-59 months, respectively. The injury-related under-five mortality rate dropped from 11.3 per hundred thousand in 2014 to 9.1 in 2017. Causes of all unintentional injury-related deaths were associated with season except for other unintentional injuries and exposure to mechanical forces (p < 0.001). CONCLUSIONS: The injury-related mortality rate among children under five years declined from 2014 to 2017, however it is still high. To prevent injuries in children under five, it is important to raise awareness and increase the supervision of children by their caregivers. At the national level, multisectorial cooperation with a holistic approach will be of key importance.

Neonatal Screening for Congenital Adrenal Hyperplasia in Turkey: Outcomes of Extended Pilot Study in 241,083 Infants

Objective: Turkish Directorate of Public Health introduced the first pilot screening program for congenital adrenal hyperplasia (CAH) in four Turkish cities in 2017, and in 2018 extended the program, with a slight change in screening strategy, to fourteen cities. To evaluate the performance of the extended study and update previously reported outcomes. Methods: Retrospective, descriptive study. Neonates of ≥32 gestational weeks and ≥1500 gr birth weight from fourteen cities, born between May-December 2018, were included. Screening protocol included one sample, two-tier testing as applied in the previous pilot study. In the first step, 17α-hydroxyprogesterone (17-OHP) was measured by fluoroimmunoassay in dried blood spots (DBS) obtained at 3-5 days of life. Cases with positive initial screening underwent second tier testing by steroid profiling in DBS using liquid chromatographyt-andem mass spectrometry to measure 17-OHP, 21-deoxycortisol (21-S), cortisol (F), 11-deoxycortisol and androstenedione. The babies with a steroid ratio (21-S+17-OHP)/F of ≥0.7 (increased from ≥0.5 in the earlier pilot study) were referred to pediatric endocrinology clinics for diagnostic assessment. Results: In the evaluated period, 241,083 newborns were screened. 12,321 (5.11%) required second-tier testing and 880 (0.36%) were referred for clinical assessment, twenty of whom were diagnosed with CAH (10 females, 10 males). Sixteen were diagnosed as classical 21-hydroxylase deficiency (21-OHD) CAH (12 with salt-wasting and four with simple virilising CAH), and four cases were identified with 11ß-OHD CAH. No case of salt-wasting CAH was missed by neonatal screening (sensitivity was 100%). The incidence of classical 21-OHD and 11ß-OHD in the screened population was 1:15,067 and 1:60,270, respectively. Conclusion: Turkish neonatal CAH screening effectively led to earlier diagnosis of 21-OHD and 11ß-OHD, using steroid profiling as a second-tier test. This will result in improved care of these patients in the future.

Neonatal Screening for Congenital Adrenal Hyperplasia in Turkey: A Pilot Study with 38,935 Infants

Objective: Congenital adrenal hyperplasia (CAH) is the most common form of primary adrenal insufficiency in children. Neonatal screening for CAH is effective in detecting the salt-wasting (SW) form and in reducing mortality. In this study, our aim was to estimate the incidence of CAH in Turkey and to assess the characteristics and efficacy of the adopted newborn CAH screening strategy. Methods: A pilot newborn CAH screening study was carried out under the authority of the Turkish Directorate of Public Health. Newborn babies of ≥32 gestational weeks and ≥1500 gr birth weight from four cities, born between March 27-September 15, 2017 were included in the study. Screening protocol included one sample two-tier testing. In the first step, 17α-hydroxyprogesterone (17-OHP) was measured by fluoroimmunoassay in dried blood spots (DBS) obtained at 3-5 days of life. The cases with positive initial screening were tested by steroid profiling in DBS using a liquid chromatography-tandem mass spectrometry method to measure 17-OHP, 21-deoxycortisol (21-S), cortisol (F), 11-deoxycortisol and androstenedione as a second-tier test. The babies with a steroid ratio (21-S+17-OHP)/F of ≥0.5 were referred to pediatric endocrinology clinics for diagnostic assessment. Results: 38,935 infants were tested, 2265 (5.82%) required second-tier testing and 212 (0.54%) were referred for clinical assessment, six of whom were diagnosed with CAH (four males, two females). Four cases were identified as SW 21-hydroxylase deficiency (21-OHD) (two males, two females). One male baby had simple virilizing 21-OHD and one male baby had 11-OHD CAH. The incidence of classical 21-OHD in the screened population was 1:7,787. Conclusion: The incidence of CAH due to classical 21-OHD is higher in Turkey compared to previous reports. We, therefore, suggest that CAH be added to the newborn screening panel in Turkey. The use of steroid profiling as a second-tier test was found to improve the efficacy of the screening and reduce the number of false-positives.

Recent Declines in Infant and Neonatal Mortality in Turkey from 2007 to 2012: Impact of Improvements in Health Policies.

BACKGROUND: Infant mortality rate (IMR) and neonatal mortality rate (NMR) are accepted as good indicators to measure the health status of a nation. This report describes recent declines in IMR and NMR in Turkey. METHODS: Data on infants who died before 12 months of life were obtained from the Infant Mortality Monitoring System of Ministry of Health of Turkey between 2007 and 2012. A total of 94,038 infant deaths were evaluated. RESULTS: Turkey IMR and NMR exhibited a marked decline from 2007 (16.4 and 12.2) to 2010 (10.1 and 6.6) and then plateaued in 2012 (9.7 and 6.3), despite regional differences. Prematurity, congenital anomalies and congenital heart diseases (CHD) were the three most common causes of infant deaths between 2007 and 2012. While the rates of respiratory distress syndrome (RDS), sudden infant death syndrome (SIDS), and metabolic diseases increased, the rates of congenital anomalies and birth injuries decreased. IMR and NMR significantly increased with the number of infants per paediatrician, per doctor, and per midwife, while was decreasing with the increased rate of hospital birth, caesarean delivery, antenatal care, infant follow-up, and staff trained within the Neonatal Resuscitation Programme (NRP). CONCLUSION: From 2007-2012, Turkey showed remarkable encouraging advances in reducing IMR and NMR. Any interventions aimed at further reductions in IMR and NMR should target the common causes of death and defined risk factors especially in socioeconomically disadvantaged regions.

Neonatal Thyroid-Stimulating Hormone Screening as a Monitoring Tool for Iodine Deficiency in Turkey.

OBJECTIVE: Thyroid-stimulating hormone (TSH) level in neonates is recommended as an indicator for presence of iodine deficiency (ID) at a population level and as a monitoring tool in programs of iodine supplementation. The purpose of this study, based on data from the National Newborn Screening Program (NNSP) for congenital hypothyroidism (CH) in 2014, was to analyze neonatal TSH levels to predict the current status of iodine nutrition in Turkey. METHODS: According to screening methodology, heel-prick blood samples of newborns were collected on filter paper cards usually on day 3-5 after birth (or shortly before discharge). Results of samples collected >48 h after birth were analyzed. The degree of severity of ID was assessed by using the epidemiologic criteria of the World Health Organization (WHO). Elevated TSH levels (>5 mIU/L) were processed and classified according to province, region, birth season, and sampling time. RESULTS: A total of 1,298531 newborns were registered in the NNSP for the CH database. Of those, 1,270311 newborns had screening results collected >48 h after birth and were included in the statistical analyses. The national prevalence of elevated TSH was 7.2%. While the Gaziantep sub-region had the highest TSH elevation rate (15.9%), the Tekirdag sub-region had the lowest rate (4.0%; p<0.001). Seasonal variations were also significant, and the elevated TSH prevalence rate was highest in winter (7.4%; p<0.001). CONCLUSION: National CH screening results suggest that Turkey may still be mildly iodine deficient. Nationwide studies should be performed for direct assessment and monitoring of iodine status in vulnerable populations to confirm accuracy of our results.

Complementary Feeding Practices of Children Aged 12-23 Months in Turkey.

AIM: This study was conducted to determine the breastfeeding and complementary feeding attitudes and practices of women with children aged 12-23 months in three different regions in Turkey. METHODS: From 12 geographical regions (Nomenclature of Territorial Units for Statistics - NUTS 1), 3 regions were selected depending on the Turkish Demographic Health Survey 2003 (TDHS) results of nutritional status of children. Then, a weighted, multistage, stratified cluster sampling was used. In total, 1,486 children aged 12-23 months and mother pairs were enrolled. Mothers were face-to-face interviewed with trained health workers to collect information on breastfeeding practices, amount and types of complementary foods introduced and potentially related factors and demographic data filled in a questionnaire. RESULTS: The percentage of ever breastfeeding was 98.7%, no differences were determined among regions for ever breastfeeding (p>0.05). Duration of exclusive breastfeeding was 5.1±2.4 months. The shortest duration of exclusive breastfeeding was found in the good nutritional status region as 4.8±2.4 months (p<0.05). Yogurt, bread, pasta, fruits and vegetables were the foods introduced to the majority of the children. Red meat, poultry and fish were introduced to children in later ages in the low nutritional status region compared to middle and good nutritional status regions. Complementary feeding is introduced earlier than 6 months of age. CONCLUSIONS: Raising awareness on appropriate infant and young child feeding practices should be a priority. Enhancing of mothers knowledge, attitudes and practices on breastfeeding and complementary feeding is needed.

The development and organization of newborn screening programs in Turkey.

BACKGROUND: Newborn screening tests have been designed to identify infants with severe disorders that are relatively prevalent and treatable or controllable. Comparing to other countries, the incidence of these diseases are very high in Turkey where the rate of consanguineous marriage is high. METHODS: In this article, it is aimed to evaluate the development and organization of newborn screening programs in Turkey which include phenylketonuria, congenital hypothyroidism and biotinidase deficiency screenings. The point reached today, limitations of the program, expectations and projects for the future are discussed. RESULTS: Today, the point reached in screening programs of the country is appreciable. While the screening rate of the live born babies was 4,7% in 1987, this rate reached to 95% by 2008. Predicted target for newborn screening program at the strategic plan of Ministry of Health for 2010-2014 was to enhance this rate above 95% by the end of 2012. It seems that the envisaged goal has been reached. CONCLUSION: National newborn screening program appears to be conducted successfully and extensively as a result of political determination and performance of health care workers who are in charge of this program. Nevertheless, limited numbers of the nutrition and metabolism clinics and specialists on these branches have caused some access difficulties, waste of time, and financial loss. Therefore, special planning to improve quality and the number of the clinics would be useful.

Changes and determinants in under-five mortality rate in Turkey since 1988.

Child survival is the focus of the fourth Millenium Developmental Goal (MDG4). This paper describes levels, trends, and differentials in Under-Five Mortality Rate (U5MR) and also summarizes state programmes in Turkey between 1988 and 2010. Turkey is among only a few countries that have already surpassed MDG4 and have reduced their under-five mortality rate by more than two-thirds. In 2010, 13 out of every 1,000 children died before their fifth birthday. Low birth weight, high-birth order, short birth intervals, rural residence, low level of maternal education and lowest wealth quintile have affected negatively children's chances of survival. Expanding the scope of free vaccination programmes for children, improving screening and disease prevention schemes aimed at children, encouraging breastfeeding, implementing an emergency obstetric care programme, improving the services provided to newborns (a newborn intensive care programme) have brought about a significant decrease in the rate of infant and under-five mortality. The implementation of state and region specific action plans should be necessary to increase the chance of an access to the Continuum of Care for each mother and infant and to surpass MDG4.

A community-based iron supplementation program, "Iron-Like Turkey", and the following prevalence of anemia among infants aged 12-23 months.

During the second year of the "Iron-like Turkey" Project, in which all children aged 4-6 months in Turkey receive iron supplementation for 5 months, we aimed to assess the utilization of iron supplementation in the field, as well as the prevalence of anemia in healthy infants aged 12-23 months, while determining a variety of sociodemographic and nutritional factors for anemia in three of the 12 NUTS (Nomenclature of Territorial Units for Statistics) regions (regions with the highest, lowest and middle under-5 malnutrition levels). In a community-based, cross-sectional survey using a multi-staged, weighted, cluster-selected sample, children aged 12-23 months with birthweight ≥2500 g, no chronic illness, no history of blood disease, and from term and singleton pregnancy were enrolled; 1589 children met the criteria. The mean±SD age of children surveyed was 17.8±3.6 months. Of the parents, 72.4% claimed that their physician had recommended iron supplementation, and 68.8% had given supplementation to their children. Overall prevalence of anemia was 7.3%. Multivariate analysis revealed that the frequency of anemia decreased significantly in older infants, when supplementation was recommended by health providers, when an infant was breastfed longer than 6 months, and when the mother received iron supplementation during pregnancy. However, anemia prevalence increased when the infant received iron supplementation at a later age (³9 months), lived in a crowded family (³6 persons), and when the mother had a history of iron deficiency anemia. Anemic infants had significantly lower z scores of weight for age than non-anemic ones. This survey suggests that iron supplementation during pregnancy, initiation of iron supplementation in infants at 4-6 months of age, effective counseling on supplementation, subsequent compliance, support of breastfeeding, and effective training of health care personnel are effective strategies for prevention of anemia in the community.

Resuscitation skills of pediatric residents and effects of Neonatal Resuscitation Program training.

BACKGROUND: The Neonatal Resuscitation Program (NRP) is an effective tool in decreasing mortality and morbidity due to birth asphyxia. The aim of the study was to assess the skill and knowledge level of pediatric residents in a teaching hospital and the effects of NRP training. METHODS: Subjects consisted of pediatric residents of Dr Behcet Uz Hospital, Izmir, Turkey. They were assessed on practice exam scenarios and NRP provider course flow charts. Teams with two members were formed randomly. Each resident was evaluated on a 100 point scale covering all resuscitation steps and interventions. Exam scores were analyzed for two major parameters: resident participation in NRP training (never, within the last 6 months, and ≥6 months previously) and being a senior (>18 months residency). RESULTS: A total of 49 residents enrolled in the study (94.2% of the target group). Twenty-one residents had NRP training (42.9%). Junior residents comprised 46.9% of the study group. The mean skill score was 72.1, and it was significantly higher for senior residents and residents who attended the NRP course (P < 0.05). Although there was no difference between the members within a team, residents who had not attended the NRP course performed better when paired with a resident with NRP certification. CONCLUSIONS: NRP training significantly increases the resuscitation knowledge and skill of pediatric residents, although this can be achieved by being a senior. Residents should undergo training as soon as possible to achieve a higher level of quality in resuscitating babies.

Rapid decrease of neonatal mortality in Turkey.

Our aim was to assess trends in neonatal mortality in 2009, evaluate advances in health policy, determine new goals to preserve a higher quality health service, and to prevent neonatal deaths. Data were gathered from the system of the General Directorate of Mother and Child and Family Planning. Maternal age, birth weight, gestational week, delivery at a health center, delivery by trained assistant, antenatal visits, and cause of death were evaluated. The neonatal mortality rate was 10/1,000 in Turkey in 2009, significantly better than rates of 26 in 1998, 17 in 2003, and 13 in 2008. The percentage of pregnant women making a minimum of four antenatal visits was around 80 %. Most deaths were attributable to prematurity and its complications, including 47.2 % of early neonatal mortality (ENM) and 36.1 % of late neonatal mortality (LNM). In ENM, the next-most common causes of death were congenital anomalies other than heart and genetic disorders (17.5 %), infections (6.5 %), asphyxia (6.1 %), and congenital heart disease (4.0 %), whereas in LNM, they were infections (19.9 %), congenital anomalies other than heart and genetic disorders (13.1 %), congenital heart disease (7.7 %), and asphyxia (3.8 %). Neonatal mortality in Turkey has declined within 8 years to level similar to that reached by Organisation for Economic Co-operation and Development countries over 30 years. Our findings show that each of the major causes of the neonatal death can be prevented by available interventions. Interventions to prevent prematurity, early diagnosis of congenital anomalies, and the prevention of infections would contribute to further reductions in neonatal mortality in Turkey.