Sustainable decline in mortality among severely malnourished children with local resources.

Sustainability of survival among malnourished children is a challenge. Over a period of four years, we achieved a significant decline in mortality, using locally available food, medicines and simple protocols.

Antiretroviral therapy in children: Indian experience.

BACKGROUND: There is a paucity of reports on Highly Active Antiretroviral therapy (HAART) in children. We studied feasibility and effectiveness fixed dose combination (FDC) of lamivudine, nevirapine and stavudine in HIV infected children. DESIGN: Interventional study. SETTING: A Tertiary care center. SUBJECTS: Twenty five consecutive HIV positive antiretroviral naive children older than 18 months. METHODS: The study subjects were started on weight-appropriate doses of the FDC and followed up for 6 months. Weight, CD4 counts, absolute lymphocyte count (ALC) and number of episodes of illness were assessed before and after HAART. Adherence and barriers to adherence were studied. RESULTS: Mean weight increased from 15.2 to 16.8 kg (P < 0.001) while mean CD4 counts increased from 488/cmm to 765/cmm (P < 0.001). Only 2 cases of drug associated adverse event were encountered. Improvement in Center for Disease Control (CDC) immunological classification of the subjects was significant while that in World Health Organization (WHO) clinical staging was not statistically significant. Follow up visits were 95% of the expected 175 visits. The average distance traveled by the patient for every visit was 72 km (one way). CONCLUSIONS: Use of FDC in weight specific dosages is feasible and effective for treatment of Pediatric HIV in resource scarce setting. These preliminary results need to be tested in a different setting.

Declining seroprevalence of HIV infection among paediatric inpatients.

An unlinked anonymous testing for HIV infection among consecutive paediatric admissions at Cama and Albless Hospital, Mumbai, was performed in 1998-99 and again in 2003-04. The seroprevalence declined from 5.5% (24/535) to 2.2% (10/447). Greater awareness, enhanced antenatal detection and measures taken to prevent mother-to-child transmission (MTCT) seem to have contributed to the declining seroprevalence. We believe that paediatric inpatients reflect the extent of MTCT in the community.

Hodgkins lymphoma with HIV infection.

The association between Hodgkins Lymphoma (HL) with HIV is common in adults but rare in children. A 5 year old boy, known case of HIV on antiretroviral therapy, presented with prolonged fever, multiple enlarged lymph nodes along with hepatosplenomegaly. A diagnosis of Hodgkins lymphoma was entertained on histopathological examination; further subtyping was done by immunohistochemistry.

Anganwadi worker's participation in rural newborn care.

Anganwadi worker was involved in rural newborn care as a link between a dai and a health worker. She was trained to ensure that, (i) borderline LBW/preterm baby was kept warm at home and (ii) a very small baby was referred to hospital. The training was conducted during routine monthly meetings and cost of equipping each anganwadi worked out to be Rs 110. Newborn survival, infant survivals and overall MCH performance improved. Thus, newborn care formed an ideal entry point into MCH activities.

PIP: The Rural Neonatal Care Program was initiated in January 1988 in Ganjad Primary Health Center, Dahanu, India, with the training of dais in care of the newborn. Later in the year training was conducted for anganwadi workers, who would follow-up newborn care until the child was 6 years of age. The anganwadi worker was a link between the dai and health worker and the health center. Home visits were made on the day of birth. The infant was measured and an health assessment made. If the infant was preterm or low birth weight and with a foot length of between 6.5 and 7 cm, repeat home visits were made to assess the breast feeding progress, the infant activity level, and general signs of health, as reflected in warm and pink feet. Training was conducted at monthly meetings at the block level, at the primary health care level, and during field visits to show how to care for hypothermic babies. A training manual and record book were developed and used. Footprints were made, and referrals were made to the hospital for those with feet under 6.5 to 7 cm. General observations were that birth registration improved, and infants were more easily identified for immunization. Newborn referral improved, and infant mortality declined. There was an important role for the anganwadi worker in providing continuity of care, identification of referrals, and training in the home for how to keep a baby warm. The number of referrals averaged 1-2 per month and 1-2 with special home attention. The training of the anganwadi worker in newborn care was included in the normal course of training and cost about Rs. 110 per worker.

Non-sucrose sweetener for pain relief in sick newborns.

A prospective controlled blind study was carried out in the Special Care Unit for Newborns to assess the effect of commercially available sweetener on pain relief in newborns. Response to intramuscular injection and the pain stimulus was studied in twenty-five sick newborns, 13 preterm and 12 term, in a blinded fashion. Pain score, duration of cry, heart rate and oxygen saturations were studied. Basal response, responses with sterile water or sweetener were recorded in each baby. Responses to sweetener versus no solution and sweetener versus sterile water were compared by applying paired t-test. The reduction in pain score with sweetener was significant when compared with no solution. The difference was not significant when compared with sterile water. Similarly, duration of cry and heart rate with sweetener were significantly less when compared to sterile water or to no solution. However, the difference in oxygen saturation was not significantly different. Sweetener has an analgesic effect in sick babies. This can minimise adverse effects associated with painful procedures.

Neonatal care during a residents' strike.

Medical officers from a primary health centre and rural hospital were posted at our neonatal care unit during the residents' strike that lasted 69 days. They were trained in labour room care and in special care of high-risk babies. Four weeks later they were to be first-on-call. During the pre-strike, strike and post-strike period, there was no significant difference in the number of high-risk deliveries and admissions and deaths at the special care unit (SCU). The low-tech neonatal care that we followed, can be practised at the first referral centre in rural areas of developing countries by the team led by a medical officer.

Leptospirosis in children.

Leptospirosis has a broad spectrum of clinical manifestations varying, from inapparent influenza like illness to fulminant fatal disease with hepato-renal dysfunction and hemorrhagic phenomena. Our cases had fever, puffiness, respiratory distress and bleeding diathesis as leading manifestations. Leptospirosis was suspected in view of epidemic situation prevailing in the city. We report four cases here, three of which survived and one died.

Intraosseous access using butterfly needle.

Butterfly needle (18 G) was used for intraosseous administration of fluids and drugs in 22 children with shock. All except one patient could be stabilized successfully. Fifteen children had severe dehydration because of diarrhoea. The intraosseous route needs to be popularized as an option for rehydration in areas, where diarrhoeal dehydration continues to be an important cause of child mortality.

Oropharyngeal delivery of oxygen to children.

Oropharyngeal oxygen was administered to 13 patients with rapid breathing and hypoxaemia, six of whom were newborns. Feeding tube, No. 8F, was used in newborns for delivery of oxygen and No. 1 OF for others. Oxygen flow rate, 0.5 litre/min for four newborns and 1 litre/min, for the rest, was adequate to maintain oxygen saturations 90% and above. There were no instances of tube blockage or displacement.

Adequacy of solar energy to keep babies warm.

OBJECTIVE: Solar energy could be used as an alternate energy source for keeping neonates warm especially in tropical countries. The present study investigated the efficacy of solar powered room heating system. SETTING: Referral center for neonatal care. INTERVENTION: A fluid system heated by solar panels and circulated into a room was used to maintain room temperature. A servocontrolled heating device was used to regulate and maintain desired room temperature. MAIN OUTCOME MEASURES: Neonatal rectal temperature and room temperature. RESULT: Infants between 1750-2250 g were observed to require a mean room temperature of 32.5 degrees C to maintain normothermia. In 85 infants less than 1500 g, of the 5050 infant temperature records, only 3% showed a record less than 36 degrees C. CONCLUSIONS: Solar powered room heating is effective in maintaining infant temperature and is cost-effective as compared to the existing warming devices.

Clinical profile of severe birth asphyxia.

In this retrospective analysis, 56 babies with Apgar score 3 and less were studied. In 33, successful bag-mask ventilation was carried out. Seventeen babies received endotracheal IPPV. In 9 out of them bag-mask ventilation was never tried whereas in 8 bag-mask ventilation had failed. In 6 babies physical stimulation and blast of oxygen on the face was adequate. Following this experience, in the subsequent years, endotracheal intubation was required mainly in extremely low birth weight babies or babies with Apgar score 0 at birth. During the study period, drugs were used in about 50% babies. In subsequent years this figure has come down to 10%, that too in special situations. This study helped us to evolve a policy in resuscitations severely asphyxiated babies. Bag-mask ventilation is the first choice. Failure to achieve progressively improving Apgar score by 1 minute, usually 4-5, is an indication for endotracheal intubation. Drugs are required in special situations only.

Rural neonatal care: Dahanu experience.

The Rural Neonatal Care Project, started by the Government of Maharashtra in the Ganjad Primary Health Centre, Dahanu block in Maharashtra, had the TBA as the sheet anchor for delivery of neonatal care. Maintenance of "warm chain" and resuscitation of an asphyxiated baby were recognized as the most important interventions besides detection of a very low birth weight/preterm baby and safe transportation of such a baby. Foot length measurement from foot print was used as a surrogate to birth weight as an indicator for referral. Neonatal and perinatal mortality rates dropped appreciably over 3 years and the antenatal registration went up by 30%. The cost of this programme is affordable and the programme itself was acceptable to the community and the TBAs because of its simplicity.

Basic care reduces neonatal hyperbilirubinaemia.

We studied the frequency of jaundice, bilirubin estimations, phototherapy administration and exchange transfusions performed at 5 year intervals (1981, 1986 and 1991) among babies admitted to special care unit and those managed in postnatal ward, showing a decline which was significant except for the number of exchange transfusions performed. The number of term babies with serum bilirubin > 15 mg/dl and preterm babies with serum bilirubin > 10 mg/dl also declined significantly without prophylactic phototherapy or pharmacotherapy.

PIP: An examination of the case records of infants admitted to the Institute of Child Health in Bombay, India, in 1981, 1986, and 1991 reveals a significant decline over time in the numbers of infants with jaundice and those requiring serum bilirubin estimation and phototherapy. Cases of jaundice totalled 341 in 1981, 156 in 1986, and 109 in 1991. Bilirubin estimations were required in 166, 13, and 27 infants, respectively, while phototherapy was administered in 125, 7, and 1 cases, respectively. Nine infants received exchange transfusion in 1981 compared with 2 in 1986 and none in 1991. Also recorded were significant declines in serum bilirubin values exceeding 15 mg/dl in term babies and 10 mg/dl in preterm infants. These changes, which occurred without prophylactic use of phototherapy or pharmacotherapy, are considered to reflect a renewed emphasis on provision of warmth, early institution of breast milk feeds, and improved care in the labor room. Although modest physiologic levels of bilirubin during the neonatal period may not be harmful, the bilirubin concentration at which the risk of brain damage exceeds the risk of treatment remains unclear.

Training of traditional birth attendants in newborn care.

PIP: Appropriate training of traditional birth attendants (TBAs) can both increase the proportion of births attended by trained persons and enhance linkages between rural communities and modern health services. Described is a TBA training program in newborn care developed by the Rural Neonatal Care Project in Maharashtra State, India. To improve attendance, a sub-center was established for TBAs from the northern part of the primary health care area. In addition, an effort was made to train women who assist the TBAs (usually a close relative). Two training sessions per month were held for 6 months, then the frequency was reduced to once a month. TBAs received 5 rupees for attending a training session and an additional 5 rupees for each registered birth. The training, delivered by lady health visitors and auxiliary nurse midwives, used photographs and dolls to communicate information about keeping the newborn warm, resuscitating a depressed baby, identifying very small infants, and safely transporting at-risk infants to the primary health care center. Also addressed were immunization, management of diarrhea, and referral of acute respiratory infection cases. Program evaluation highlighted the importance of brief, task-oriented sessions that use demonstrations, case histories, oral questioning, and reviews of material presented in earlier sessions. Since TBAs have extensive experience in deliveries in village conditions, they should be regarded by trainers as equal partners.^ieng

Special care for newborns at a community hospital: a 5-year experience.

A workable model for the special care of newborns has been developed at a community hospital in a predominantly tribal block. Adequate warmth, prompt resuscitation, proper feeding and oxygen administration, when necessary, formed the key interventions. This facility was developed with existing staff and infrastructure and with minimal material inputs. Neonatal survivals were 61.5% in the 1000-1500 g category and 92.5% in the 1520-2000 g category during a five year period. We believe that this model is both replicable and affordable. It has the potential for developing horizontal links with perinatal care and child survival programmes.

Orogastric versus nasogastric feeding of newborn babies.

Oxygen saturations were compared, 10 min before and 10, 20 and 30 min after orogastric and nasogastric feeds, in 10 stable newborns. The mean saturations were significantly lower with mere passage of nasogastric tube and continued to be so during feeds. There was no difficulty in securing the orogastric tube and no baby aspirated milk.