Factors associated with mortality of pediatric sepsis patients at the pediatric intensive care unit in a low-resource setting.

BACKGROUND: Sepsis is the leading cause of death worldwide in pediatric populations. Studies in low-resource settings showed that the majority of pediatric patients with sepsis still have a high mortality rate. METHODS: We retrospectively collected records from 2014 to 2019 of patients who had been diagnosed with sepsis and admitted to PICU in our tertiary hospital. Cox proportional hazard regression modeling was used to evaluate associations between patient characteristics and mortality. RESULTS: Overall, 665 patients were enrolled in this study, with 364 (54.7%) boys and 301 (46.3%) girls. As many as 385 patients (57.9%) died during the study period. The median age of patients admitted to PICU were 1.8 years old with interquartile range (IQR) ±8.36 years and the median length of stay was 144 h (1-1896 h). More than half 391 patients (58.8%) had a good nutritional status. Higher risk of mortality in PICU was associated fluid overload percentage of > 10% (HR 9.6, 95% CI: 7.4-12.6), the need of mechanical ventilation support (HR 2.7, 95% CI: 1.6-4.6), vasoactive drugs (HR 1.5, 95% CI: 1.2-2.0) and the presence of congenital anomaly (HR 1.4, 95% CI: 1.0-1.9). On the contrary, cerebral palsy (HR 0.3, 95% CI: 0.1-0.5) and post-operative patients (HR 0.4, 95% CI: 0.3-0.6) had lower mortality. CONCLUSION: PICU mortality in pediatric patients with sepsis is associated with fluid overload percentage of > 10%, the need for mechanical ventilation support, the need of vasoactive drugs, and the presence of congenital anomaly. In septic patients in PICU, those with cerebral palsy and admitted for post-operative care had better survival.

Equity in maternal health outcomes in a middle-income urban setting: a cohort study.

BACKGROUND: Low socioeconomic status (SES) is associated with more adverse perinatal health outcomes, risk factors and lower access to and use of maternal health care services. However, evidence for the association between SES and maternal health outcomes is limited, particularly for middle-income countries like sub-Saharan Ghana. We assessed the association between parental SES and adverse maternal and perinatal outcomes of Ghanaian women during pregnancy, delivery and the postpartum period. METHODS: A prospective cohort study of 1010 women of two public hospitals in Accra, Ghana (2012-2014). SES was proxied by maternal and paternal education, wealth and employment status. The association of SES with maternal and perinatal outcomes was analyzed with multivariable logistic and linear regression. RESULTS: The analysis included 790 women with information on pregnancy outcomes. Average age was 28.2 years (standard deviation, SD 5.0). Over a third (n = 292, 37.0%) had low SES, 176 (22.3%) were classified to have high SES using the assets index. Nearly half (n = 374, 47.3%) of women had lower secondary school or vocational training as highest education level. Compared to women with middle assets SES, women with low assets SES were at higher risk for miscarriage (odds ratio, OR 1.61, 95% CI 1.06 to 2.45) and instrumental delivery (OR 1.74, 95% CI 1.03 to 2.94), but this association was not observed for the other SES proxies. For any of the maternal or perinatal outcomes and SES proxies, no other statistically significant differences were found. CONCLUSION: Women attending public maternal health care services in urban Ghana had overall equitable maternal and perinatal health outcomes, with the exception of a higher risk of miscarriage and instrumental delivery associated with low assets SES. This suggests known associations between SES, risk factors and outcomes could be mitigated with universal and accessible maternal health services.

Does body mass index early in pregnancy influence the risk of maternal anaemia? An observational study in Indonesian and Ghanaian women.

BACKGROUND: Anaemia is common among pregnant women, especially in low- and middle-income countries (LMICs). While body mass index (BMI) relates to many risk factors for anaemia in pregnancy, little is known about the direct relation with anaemia itself. This is particularly relevant in Southeast Asia and Sub-Saharan Africa where the prevalence of anaemia in pregnancy and the associated adverse outcomes is among the highest worldwide. This study aimed to assess the association between early pregnancy BMI and anaemia at first antenatal care visit in Indonesian and Ghanaian women. In addition, the associations between early pregnancy anaemia and adverse birth outcomes was assessed. METHODS: Prospective cohort studies of women in early pregnancy were conducted in Jakarta, Indonesia (n = 433) and in Accra, Ghana (n = 946), between 2012 and 2014. Linear regression analysis was used to assess relations between early pregnancy BMI and pregnancy haemoglobin levels at booking. Logistic regression analyses were used to assess associations between early pregnancy anaemia as defined by the World Health Organization (WHO) criteria and a composite of adverse birth outcomes including stillbirth, low birth weight and preterm birth. RESULTS: Indonesian women had lower BMI than Ghanaian women (23.0 vs 25.4 kg/m2, p < 0.001) and higher mean haemoglobin levels (12.4 vs 11.1 g/dL, p < 0.001), corresponding to anaemia prevalence of 10 and 44%, respectively. Higher early pregnancy BMI was associated with higher haemoglobin levels in Indonesian (0.054 g/dL/kg/m2, 95% CI 0.03 to 0.08, p < 0.001) and Ghanaian women (0.044 g/dL/kg/m2, 0.02 to 0.07, p < 0.001). Accordingly, risk for anaemia decreased with higher early pregnancy BMI for Indonesians (adjusted OR 0.88, 0.81 to 0.97, p = 0.01) and Ghanaians (adjusted OR 0.95, 0.92 to 0.98, p < 0.001). No association between anaemia and the composite of adverse birth outcomes was observed. CONCLUSION: Higher BMI in early pregnancy is associated with higher haemoglobin levels at antenatal booking and with a reduced risk of anaemia in Indonesian and Ghanaian women.

Hyperemesis gravidarum and placental dysfunction disorders.

BACKGROUND: Evidence about the consequence of hyperemesis gravidarum (HG) on pregnancy outcomes is still inconclusive. In this study, we evaluated if occurrence of hyperemesis gravidarum is associated with placental dysfunction disorders and neonatal outcomes. METHODS: A prospective cohort study was conducted in a maternal and child health primary care referral center, Budi Kemuliaan Hospital and its branch, in Jakarta, Indonesia. 2252 pregnant women visiting the hospital for regular antenatal care visits from July 2012 until October 2014 were included at their first clinic visit. For women without, with mild and with severe hyperemesis, placental dysfunction disorders (gestational hypertension, preeclampsia (PE), stillbirth, miscarriage), neonatal outcomes (birth weight, small for gestational age (SGA), low birth weight (LBW), Apgar score at 5 min, gestational age at delivery) and placental outcomes (placental weight and placental-weight-to-birth-weight ratio (PW/BW ratio)) were studied. RESULTS: Compared to newborns of women without hyperemesis, newborns of women with severe hyperemesis had a 172 g lower birth weight in adjusted analysis (95%CI -333.26; -10.18; p = 0.04). There were no statistically significant effects on placental dysfunction disorders or other neonatal outcome measures. CONCLUSIONS: The results of our study suggest that hyperemesis gravidarum does not seem to induce placental dysfunction disorders, but does, if severe lead to lower birth weight.

Ramadan fasting and newborn's birth weight in pregnant Muslim women in The Netherlands.

Many Muslim women worldwide are pregnant during Ramadan and adhere to Ramadan fasting during pregnancy. In the present study, we determined whether maternal adherence to Ramadan fasting during pregnancy has an impact on the birth weight of the newborn, and whether the effects differed according to trimester in which Ramadan fasting took place. A prospective cohort study was conducted in 130 pregnant Muslim women who attended antenatal care in Amsterdam and Zaanstad, The Netherlands. Data on adherence to Ramadan fasting during pregnancy and demographics were self-reported by pregnant women, and the outcome of the newborn was retrieved from medical records after delivery. The results showed that half of all the women adhered to Ramadan fasting. With strict adherence to Ramadan fasting in pregnancy, the birth weight of newborns tended to be lower than that of newborns of non-fasting mothers, although this was not statistically significant ( - 198 g, 95 % CI - 447, 51, P= 0·12). Children of mothers who fasted in the first trimester of pregnancy were lighter at birth than those whose mothers had not fasted ( - 272 g, 95 % CI - 547, 3, P= 0·05). There were no differences in birth weight between children whose mothers had or had not fasted if Ramadan fasting had taken place later in pregnancy. Ramadan fasting during early pregnancy may lead to lower birth weight of newborns. These findings call for further confirmation in larger studies that should also investigate potential implications for perinatal and long-term morbidity and mortality.

Development and validation of a prognostic model to predict birth weight: individual participant data meta-analysis.

Objective: To predict birth weight at various potential gestational ages of delivery based on data routinely available at the first antenatal visit. Design: Individual participant data meta-analysis. Data sources: Individual participant data of four cohorts (237 228 pregnancies) from the International Prediction of Pregnancy Complications (IPPIC) network dataset. Eligibility criteria for selecting studies: Studies in the IPPIC network were identified by searching major databases for studies reporting risk factors for adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction, and stillbirth, from database inception to August 2019. Data of four IPPIC cohorts (237 228 pregnancies) from the US (National Institute of Child Health and Human Development, 2018; 233 483 pregnancies), UK (Allen et al, 2017; 1045 pregnancies), Norway (STORK Groruddalen research programme, 2010; 823 pregnancies), and Australia (Rumbold et al, 2006; 1877 pregnancies) were included in the development of the model. Results: The IPPIC birth weight model was developed with random intercept regression models with backward elimination for variable selection. Internal-external cross validation was performed to assess the study specific and pooled performance of the model, reported as calibration slope, calibration-in-the-large, and observed versus expected average birth weight ratio. Meta-analysis showed that the apparent performance of the model had good calibration (calibration slope 0.99, 95% confidence interval (CI) 0.88 to 1.10; calibration-in-the-large 44.5 g, -18.4 to 107.3) with an observed versus expected average birth weight ratio of 1.02 (95% CI 0.97 to 1.07). The proportion of variation in birth weight explained by the model (R2) was 46.9% (range 32.7-56.1% in each cohort). On internal-external cross validation, the model showed good calibration and predictive performance when validated in three cohorts with a calibration slope of 0.90 (Allen cohort), 1.04 (STORK Groruddalen cohort), and 1.07 (Rumbold cohort), calibration-in-the-large of -22.3 g (Allen cohort), -33.42 (Rumbold cohort), and 86.4 g (STORK Groruddalen cohort), and observed versus expected ratio of 0.99 (Rumbold cohort), 1.00 (Allen cohort), and 1.03 (STORK Groruddalen cohort); respective pooled estimates were 1.00 (95% CI 0.78 to 1.23; calibration slope), 9.7 g (-154.3 to 173.8; calibration-in-the-large), and 1.00 (0.94 to 1.07; observed v expected ratio). The model predictions were more accurate (smaller mean square error) in the lower end of predicted birth weight, which is important in informing clinical decision making. Conclusions: The IPPIC birth weight model allowed birth weight predictions for a range of possible gestational ages. The model explained about 50% of individual variation in birth weights, was well calibrated (especially in babies at high risk of fetal growth restriction and its complications), and showed promising performance in four different populations included in the individual participant data meta-analysis. Further research to examine the generalisability of performance in other countries, settings, and subgroups is required. Trial registration: PROSPERO CRD42019135045.

Survival of Left-to-Right Shunt Repair in Children with Pulmonary Arterial Hypertension at a Tertiary Hospital in a Low-to-Middle-Income Country.

Background: In low-to-middle-income countries, repair of the left-to-right shunts congenital heart disease (CHD) are often done with existing pulmonary arterial hypertension (PAH). Long-term outcomes data of this condition in either low-to-middle or high-income countries are limited. We conducted a study to evaluate the outcomes of children with PAH related to left-to-right shunt CHD who underwent surgical or transcatheter repair. Methods: All cases of PAH related to left-to-right shunt CHD repairs from 2015-2018 were retrospectively reviewed with additional new patients who underwent repair within our study period (2019-2020). Cases with complex congenital heart disease and incomplete hemodynamic echocardiography or catheterization measurements were excluded. Kaplan-Meier curves, log-rank test, Cox regression with Firth's correction and restricted mean survival time were used for survival analysis. Results: Of the 118 patients, 103 patients were enrolled and 15 patients were excluded due to complex congenital heart disease and missing hemodynamic measurements prior to repair. Overall, median age at intervention was 44 months, mPAP mean was 43.17 ± 16.05 mmHg and Pulmonary Vascular Resistance index (PVRi) mean was 2.84 ± 2.09 (WU.m2). Nine patients died after repair. The survival rate for patients with PAH-CHD at 1 day, 30 days and 1400 days (4 years) was 96.1%, 92.1%, and 91.0% respectively. Patients with persisting PAH after correction had -476.1 days (95% confidence interval [CI]: -714.4, -237,8) shorter survival over 4 years of follow up compared to patients with reversed PAH. PVRi was found to be the influencing covariate of the difference of restricted mean survival time between these groups. Conclusion: In low-to-middle income settings, with accurate PAH reversibility assessment prior to intervention, repair of left-to-right shunt CHD with existing PAH in children has a favourable outcome. Inferior survival is found in patients with persistence of PAH. PVRi at baseline predicts between-group survival difference.

Anxiety and Its Associated Factors During the Initial Phase of the COVID-19 Pandemic in Indonesia.

Introduction: Coronavirus disease 2019 (COVID-19) is caused by a novel coronavirus which has not been identified previously in humans. The disease leads to respiratory problems, systemic disorders, and death. To stop the virus transmission, physical distancing was strongly implemented, including working and school from home (WFH & SFH). The limitation altered daily routines and needs advanced to adapt. Many have felt uncomfortable and this could have triggered anxiety symptoms. This study aimed to evaluate the proportion of significant anxiety symptoms and its association with COVID-19-related situations in an Indonesian context during the initial months of the pandemic. Methods: An online community survey was distributed through social media and communication platforms, mainly WhatsApp, targeting people >18 years old in Indonesia. Anxiety symptoms were assessed using Generalized Anxiety Disorder-7 (Indonesian Version). Demographical data and information on social situation related to the COVID-19 pandemic were collected. The proportion of clinically significant anxiety symptoms was calculated and the association with demographic and social factors was assessed using chi square test (χ2) and logistic regression for multivariate analysis. Results: Out of 1215 subjects that completed the survey, 20.2% (n = 245) exhibited significant anxiety symptoms. Several factors, such as age (AOR = 0.933 CI 95% = 0.907-0.96), sex (AOR = 1.612 CI 95% = 1.097-2.369), medical workers (AOR = 0.209 CI 95% = 0.061-0.721), suspected case of COVID-19 (AOR = 1.786 CI 95% = 1.001-3.186), satisfaction level of family support (AOR = 3.052 CI 95% = 1.883-4.946), and satisfaction level of co-workers (AOR = 2.523 CI 95% = 1.395-4.562), were associated with anxiety. Conclusion: One out of five Indonesian people could have suffered from anxiety during the COVID-19 pandemic. The riskiest group being young females, people who had suspected cases of COVID-19, and those with less satisfying social support. Nevertheless, health workers were found to have a lesser risk of developing anxiety. Accessible information and healthcare, social connection, supportive environment, and mental health surveillance are important to prevent bigger psychiatric problems post-pandemic.

Ramadan exposure and birth outcomes: a population-based study from the Netherlands.

BACKGROUND: Ramadan, the Islamic month of daytime fasting, is observed by many pregnant Muslims. Although pregnant women are exempt, many prefer to fast. Previous research has shown long-term adverse effects on various health outcomes among the offspring, but evidence on effects on perinatal outcomes is mixed. This study investigates effects of Ramadan during pregnancy among Muslims in the Netherlands. METHODS: Data from the Perinatal Registry of the Netherlands (Perined) on all births between 2000 and 2010 to mothers recorded as Mediterranean (i.e. of Turkish/Moroccan descent, a proxy for Muslim) (n = 139,322) or as ethnically Dutch (n = 1,481,435) were used. Ramadan exposure was defined using an intention-to-treat approach as the occurrence of a Ramadan during gestation. Muslims with versus without a Ramadan occurring during gestation were compared using difference-in-differences analyses. In these multiple linear/logistic regressions, non-Muslims were additionally included in order to take out potentially remaining confounding through seasonal effects. RESULTS: The occurrence of a Ramadan during pregnancy among Muslims was not associated with altered birth weight, gestational length, newborn's sex, perinatal mortality, low Apgar, or mild congenital anomalies. Odds for severe congenital anomalies were higher among the exposed (odds ratio: 1.17; 95% confidence interval: 1.00, 1.37), but this association became non-significant when adjusting for multiple testing. CONCLUSIONS: Despite earlier research showing long-term adverse health effects of prenatal exposure to Ramadan, there seems to be little or no relation between exposure to Ramadan during pregnancy and birth outcomes.

Ramadan during pregnancy and birth weight of newborns.

Previous studies suggest that Ramadan exposure during pregnancy might affect the health of women and their babies, particularly through the effect of fasting. This study aimed to evaluate the association between Ramadan exposure and fasting during pregnancy on the birth weight of newborns. This study concerned 1351 pregnant women from a prospective cohort in Jakarta, Indonesia. Ramadan exposure was based on the actual overlap between Ramadan and pregnancy. Women's fasting behaviour was recorded among 139 women who came for antenatal care between 10 July 2013 and 7 August 2013, and those who had fasted for at least 1 d (n 110) were classified as exposed to Ramadan fasting. Furthermore, a 24 h dietary recall was performed and repeated 1 month later. Birth weight of newborns who were exposed to Ramadan during pregnancy did not significantly differ from those who were not, both in the total and trimester-specific analysis. Maternal fasting did not seem to affect the birth weight of newborns (-72 (95 % CI -258, 114) g; P = 0·44), although there was a non-significant trend towards lower birth weight with fasting in the second and third trimester. Women who fasted had significantly lower total energy, macronutrient and water intake as compared with women who did not. Women's intake was also lower during Ramadan (regardless of their fasting behaviour) as compared with 1 month later. Lifestyle changes that occur with Ramadan and fasting during pregnancy are associated with lower reported energy intake. We cannot conclude on the effect of fasting on birth weight due to low statistical power.

Predictors of Ramadan fasting during pregnancy.

Although the health effects of Ramadan fasting during pregnancy are still unclear, it is important to identify the predictors and motivational factors involved in women's decision to observe the fast. We investigated these factors in a cross sectional study of 187 pregnant Muslim women who attended antenatal care visits in the Budi Kemuliaan Hospital, Jakarta, Indonesia. The odds of adherence to fasting were reduced by 4% for every week increase in gestational age during Ramadan [odds ratio (OR) 0.96; 95% confidence interval (CI) 0.92, 1.00; p=0.06] and increased by 10% for every one unit increase of women's prepregnancy body mass index (BMI) (OR 1.10; 95% CI 0.99, 1.23; p=0.08). Nonparticipation was associated with opposition from husbands (OR 0.34; 95% CI 0.14, 0.82; p=0.02) and with women's fear of possible adverse effects of fasting on their own or the baby's health (OR 0.47; 95% CI 0.22, 1.01; p=0.05 and OR 0.43; 95% CI 0.21, 0.89; p=0.02, respectively), although they were attenuated in multivariable analysis. Neither age, income, education, employment, parity, experience of morning sickness, nor fasting during pregnancy outside of Ramadan determined fasting during pregnancy. Linear regression analysis within women who fasted showed that the number of days fasted were inversely associated with women's gestational age, fear of possible adverse effects of fasting on their own or the fetal health, and with opposition from husbands. In conclusion, earlier gestational age during Ramadan, husband's opinion and possibly higher prepregnancy BMI, influence women's adherence to Ramadan fasting during pregnancy. Fear of adverse health effects of Ramadan fasting is common in both fasting and non-fasting pregnant women.

BReastfeeding Attitude and Volume Optimization (BRAVO) trial: study protocol for a randomized controlled trial.

BACKGROUND: A growing body of evidence shows the short-term benefits of breastfeeding, which include protection against infections, allergies, and lung diseases. However, evidence on the long-term benefits of breastfeeding is scarce and often conflicting. The BReastfeeding Attitude and Volume Optimization (BRAVO) trial is designed to study the effect of breastfeeding on early signs of later chronic diseases, particularly cardiovascular, respiratory, and metabolic risks later in life. In addition, the effectiveness of breastfeeding empowerment in promoting breastfeeding will also be evaluated. METHODS/DESIGN: This study is an ongoing randomized trial in Jakarta, Indonesia, that began in July 2012. Pregnant women are being screened for their breastfeeding plan in the third trimester, and those with low intention to breastfeed are randomly allocated to either receiving an add-on breastfeeding-optimization program or usual care. Primary outcomes include breastfeeding rate, lung function, and blood pressure during the first year of life and vascular/cardiac characteristics, which will be measured at the age of 4 to 5 years. Child growth and infection/illness episodes are measured, whereas cognitive testing is planned for the children at 5 years of age. DISCUSSION: To date, 784 women (80 %) have been randomized of the 1,000 planned, with satisfactory completeness of the 1-year follow up (90.1 %). Included mothers are of lower socioeconomic status and more often have blue-collar jobs, similar to what was observed in the pilot study. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01566812 . Registered on 27 March 2012.

Does pre-pregnancy BMI determine blood pressure during pregnancy? A prospective cohort study.

OBJECTIVES: To evaluate if pre-pregnancy body mass index (BMI) determines blood pressure throughout pregnancy and to explore the role of gestational weight gain in this association. In addition, the effects of pre-pregnancy BMI and gestational weight gain on the occurrence of gestational hypertension and pre-eclampsia were investigated. DESIGN: Prospective cohort study. SETTING: Maternal and child health primary care referral centre, Jakarta, Indonesia. POPULATION AND MEASUREMENTS: 2252 pregnant women visiting Budi Kemuliaan Hospital and its branch for regular antenatal care visits from July 2012 to April 2015. Pre-pregnancy BMI (kg/m(2)) was based on self-reported pre-pregnancy weight and measured height at first visit. Gestational weight gain was calculated as weight at the day of delivery minus the pre-pregnancy weight. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured during pregnancy at every visit. Linear mixed models were used to analyse this relation with repeated blood pressure measures as the outcome and pre-pregnancy BMI as the predictor. When looking at gestational hypertension and pre-eclampsia as outcomes, (multiple) logistic regression was used in the analysis. RESULTS: Independent of pre-pregnancy BMI, SBP and DBP increased by 0.99 mm Hg/month and 0.46 mm Hg/month, respectively. Higher pre-pregnancy BMI was associated with higher pregnancy SBP (0.25 mm Hg/kg/m(2); 95% CI 0.17 to 0.34; p<0.01) and DBP (0.18 mm Hg/kg/m(2); 0.13 to 0.24; p<0.01) in adjusted analysis. Every 1 kg/m(2) higher pre-pregnancy BMI was associated with 6% and 9% higher odds for gestational hypertension (adjusted OR (aOR) 1.06; 95% CI 1.03 to 1.09; p<0.01) and pre-eclampsia (aOR 1.09; 1.04 to 1.14; p<0.01). Accounting for gestational weight gain did not attenuate these associations. CONCLUSIONS: Pre-pregnancy BMI determines the level, but not the change, of blood pressure in pregnancy and is linked to higher odds for gestational hypertension and pre-eclampsia, independent of gestational weight gain.