Market mechanisms for newborn health in Nepal.

BACKGROUND: In Nepal, hypothermia is a major risk factor for newborn survival, but the country's public health care sector has insufficient capacity to improve newborn survival given the burden imposed by distance to health facilities and cost. Low-cost technology to provide newborn thermal care in resource-limited environments exists, but lacks effective distribution channels. This study aims to develop a private sector distribution model for dedicated newborn thermal care technology to ensure equitable access to thermal protection and ultimately improve newborn health in Nepal. METHODS: We conducted a document analysis of newborn health policy in Nepal and a scoping literature review of approaches to newborn hypothermia in the region, followed by qualitative interviews with key stakeholders of newborn health in Nepal. RESULTS: Current solutions addressing newborn hypothermia range from high-technology, high-cost incubators to low-cost behavioral interventions such as skin-to-skin care. However, none of these interventions  are currently implemented at scale. A distribution model that provides incentives for community health volunteers and existing public health services in Nepal can deliver existing low-cost infant warmers to disadvantaged mothers where and when needed. Newborn technology can serve as an adjunct to skin-to-skin care and potentially create demand for newborn care practices. CONCLUSION: Harnessing market forces could promote public health by raising awareness of newborn challenges, such as newborn hypothermia, and triggering demand for appropriate health technology and related health promotion behaviors. Market approaches to promoting public health have been somewhat neglected, especially in economically disadvantaged and vulnerable populations, and deserve greater attention in Nepal and other settings with limited public health service delivery capacity.

The recent fall in postperinatal mortality in New Zealand and the Safe Sleep programme.

AIM: Postneonatal mortality rates changed very little from 2000 until recently. There has been a decrease in mortality in New Zealand from 2009 to 2015. This study describes an infant Safe Sleep programme and postulates it is the cause for the recent decrease in deaths. METHODS: The Safe Sleep programme involved as follows: a focus on preventing accidental suffocation, a 'blitz' approach to SUDI education, the targeted provision of portable infant Safe Sleep devices (ISSD) and the development of Safe Sleep policy across all district health boards (DHBs). RESULTS: Participation in the education 'blitz' by health professionals exceeded one in 23 live births, distribution of Safe Sleep leaflets exceeded two for every live birth, and over 16 500 ISSDs have been distributed to vulnerable infants. Postperinatal mortality fell 29% from 2009 to 2015 (2.8 to 2.0/1000 live births). The fall has been greatest for Maori and in regions with the most intensive programmes. CONCLUSION: The recent fall in postperinatal mortality has not happened by chance. It is likely that the components of end-stage prevention strategy, a focus on preventing accidental suffocation, the education 'blitz', the targeted supply of ISSDs and strengthened health policy, have all contributed to varying degrees.

Securing the safety of our most precious cargo: SAFE KIDS.

There are staggering and tragic statistics involving children, car seats, and motor vehicle accidents. According to the Centers for Disease Control and Prevention, motor vehicle injuries are the leading cause of death among children from 0 to 15 years of age, and in the United States during 2005, 1,335 children ages 14 years and younger died as occupants in motor vehicle accidents; approximately 184,000 were injured. That is an average of 4 deaths and 504 injuries each day. National Highway Traffic Safety Administration (NHTSA) statistics show that nearly one-half of deaths and injuries in children occurred because they were not properly restrained. Child safety seats and safety belts, when installed and used properly, can prevent injuries and save lives. Among children under age 5, an estimated 425 lives were saved in 2006 by child restraint use. Research on the effectiveness of child safety seats has found them to reduce fatal injury by 71% for infants, and by 54% for toddlers in passenger cars. This article discusses the need for increased education of parents and healthcare professionals about selection and installation of car safety restraints, and the importance of developing a child safety restraint program.

Medicaid-based child restraint system disbursement and education and the vaccines for children program: comparative cost-effectiveness.

OBJECTIVE: Low-income children are disproportionately at risk for preventable motor-vehicle injury. Many of these children are covered by Medicaid programs placing substantial economic burden on states. Child restraint systems (CRSs) have demonstrated efficacy in preventing death and injury among children in crashes but remain underutilized because of poor access and education. The objective of this study was to evaluate the cost-effectiveness of Medicaid-based reimbursement for CRS disbursement and education for low-income children and compare it with vaccinations covered under the Vaccines For Children (VFC) program. METHODS: A cost-effectiveness analysis was performed of Medicaid reimbursement for CRS disbursement/education for low-income children based on data from public and private databases. Primary outcomes measured include cost per life-year saved, death, serious injury, and minor injury averted, as well as medical, parental work loss, and future productivity loss costs averted. Cost-effectiveness calculations were compared with published cost-effectiveness data for vaccinations covered under the VFC program. RESULTS: The adoption of a CRS disbursement/education program could prevent up to 2 deaths, 12 serious injuries, and 51 minor injuries per 100,000 low-income children annually. When fully implemented, the program could save Medicaid over $1 million per 100,000 children in direct medical costs while costing $13 per child per year after all 8 years of benefit. From the perspective of Medicaid, the program would cost $17,000 per life-year saved, $60,000 per serious injury prevented, and $560,000 per death averted. The program would be cost saving from a societal perspective. These data are similar to published vaccination cost-effectiveness data. CONCLUSION: Implementation of a Medicaid-funded CRS disbursement/education program was comparable in cost-effectiveness with federal vaccination programs targeted toward similar populations and represents an important potential strategy for addressing injury disparities among low-income children.

Car seat safety for high-risk infants.

Most neonates discharged from the hospital are able to go home in a standard car safety seat. Some infants, though, require special devices to ensure their safe travel. NICU nurses must have the knowledge and skills to comfortably and competently give vital information to parents preparing to take their infant home. This article is intended to increase awareness among NICU nurses of the potential dangers babies face when placed in a car seat. It provides a basic overview of car seat safety for infants being discharged home from an NICU and includes references for those who seek further information on this topic.

Child and family safety device affordability by country income level: an 18 country comparison.

OBJECTIVE: To compare availability, urban price, and affordability of child/family safety devices between 18 economically diverse countries. DESIGN: Descriptive: urban price surveys by local safety organisations or shoppers. SETTING: Retail stores and internet vendors. MAIN OUTCOME MEASURES: Prices expressed in US dollars, and affordability measured by hours of factory work needed to buy a child safety seat, a belt-positioning booster seat, a child bicycle helmet, and a smoke alarm. RESULTS: Prices of child and family safety devices varied widely between countries but the variation for child safety seats and bicycle helmets did not relate strongly to country income. Safety devices were expensive, often prohibitively so, in lower income countries. Far more hours of factory work were required to earn a child safety device in lower income than middle income, and middle income than higher income, countries. A bicycle helmet, for example, cost 10 hours of factory work in lower income countries but less than an hour in higher income countries. Smoke alarms and booster seats were not available in many lower income countries. CONCLUSIONS: Bicycles and two-axle motor vehicles were numerous in lower and middle income countries, but corresponding child safety devices were often unaffordable and sometimes not readily available. The apparent market distortions and their causes merit investigation. Advocacy, social marketing, local device production, lowering of tariffs, and mandatory use legislation might stimulate market growth. Arguably, a moral obligation exists to offer subsidies that give all children a fair chance of surviving to adulthood.

Increasing the use of child restraints in motor vehicles in a Hispanic neighborhood.

The use of restraints in motor vehicles is less common in minority and low-income populations than in the general population. A preliminary survey of Hispanic preschool-aged children in west Dallas, Tex, conducted in 1997 showed much lower child restraint use (19% of those surveyed) than among preschool children of all races in the rest of the city (62%). Because there are few reports of successful programs to increase child restraint use among Hispanics, we undertook to implement and evaluate such a program. The program was conducted by bilingual staff and was tailored for this community. It was successful in increasing both child restraint use and driver seat belt use.

Effects of improved access to safety counseling, products, and home visits on parents' safety practices: results of a randomized trial.

OBJECTIVE: To present the results of an intervention trial to enhance parents' home-safety practices through pediatric safety counseling, home visits, and an on-site children's safety center where parents receive personalized education and can purchase reduced-cost products. DESIGN: Pediatricians were randomized to a standard- or an enhanced-intervention group. Parents of their patients were enrolled when the patient was 6 months or younger and observed until 12 to 18 months of age. SETTING: A hospital-based pediatric resident continuity clinic that serves families living in low-income, inner-city neighborhoods. PARTICIPANTS: First- and second-year pediatric residents and their patient-parent dyads. INTERVENTIONS: Parents in the standard-intervention group received safety counseling and referral to the children's safety center from their pediatrician. Parents in the enhanced-intervention group received the standard services plus a home-safety visit by a community health worker. OUTCOMES: Home observers assessed the following safety practices: reduction of hot-water temperature, poison storage, and presence of smoke alarms, safety gates for stairs, and ipecac syrup. RESULTS: The prevalence of safety practices ranged from 11% of parents who stored poisons safely to 82% who had a working smoke alarm. No significant differences in safety practices were found between study groups. However, families who visited the children's safety center compared with those who did not had a significantly greater number of safety practices (34% vs 17% had > or 3). CONCLUSIONS: Home visiting was not effective in improving parents' safety practices. Counseling coupled with convenient access to reduced-cost products appears to be an effective strategy for promoting children's home safety.

Child restraint systems: an update for physicians.

During the past decade, many advances have been made in motor vehicle safety restraint systems, and these advancements have brought changes in the recommendations for child passenger safety. In spite of these advances, a high morbidity and mortality rate continues to be attributed to improper or absent child restraint use. Child transportation safety is a complex issue. Lack of public awareness and incomplete laws contribute to the confusion. The solution involves professional and public education, further technological advances, and advocacy for improved legislation and regulation. Physicians have a unique opportunity to incorporate advice about proper restraint use into their daily practice; however, that requires a clear understanding of the current recommendations. Both the age and weight of the child determine the appropriate child restraint system. Understanding, practicing, and promoting these recommendations will save lives. This article reviews the current recommendations for proper child restraint while traveling in a motor vehicle.

Developing a special needs restraint loaner program for transporting medically fragile children.

Pediatric orthopaedic patients require special consideration for their transportation needs. A hospital-based program to fulfill these needs promotes patient safety and allows accessibility of needed devices to elective and nonelective patients. Nurses can be an integral part of this process. This article presents the process of establishing a special needs restraint program including the legalities, acquisition of equipment, and training of appropriate personnel.

Use of seating devices in infants too young to sit.

OBJECTIVES: To determine how frequently seating devices are available in homes with small infants and how often they are used for infants who are too young to sit erect and unsupported. DESIGN: Observational study using a questionnaire administered to a cohort of parents of well infants younger than 5 months. SETTING: Well-Baby Clinic, Department of Pediatrics, Tripler Army Medical Center, a tertiary care center serving the population of military dependents on the island of Oahu, Hawaii. RESULTS: Infant seating devices were available in the homes of all of the infants whose parents completed the questionnaire during the study. Of 187 infants, 176 (94%) spent 30 minutes or longer in seating devices each day. The mean (tSD) time spent each day in seating devices was 5.7 +/- 3.5 hours and ranged from 0 to 16 hours. CONCLUSIONS: Seating devices were widely available for use in the care of the infants. Car seats that double as infant carriers and infant seats likely are being used extensively outside of automobiles. Prolonged use of infant seating devices with infants who are too young to sit unsupported may have several potential adverse consequences.