Use of Suctioning during Newborn Resuscitation and Its Effects on Heart Rate in a Low-Resource Setting, Tanzania.

Suctioning of newborns immediately after birth, as part of delivery room resuscitation, is only recommended if the airway is obstructed. The aim of this study was to describe the use of suctioning during newborn resuscitation among survivors versus those who died within 3 days and potential suction-related heart rate responses and associations to newborn characteristics. This was a retrospective observational study from July 2013 to July 2016 in a referral hospital in rural Tanzania. Research assistants observed and documented all deliveries, newborn resuscitations were video-recorded, and newborn heart rates were captured with a dry-electrode electrocardiogram. Liveborn infants ≥34 weeks gestation who received ventilation and with complete datasets were eligible. All 30 newborns who died were included, and a total of 46 survivors were selected as controls. Videos were annotated and heart rate patterns were observed before and after the suction events. Suctioning was performed more frequently than recommended. No differences were found in suctioning characteristics between newborns who died versus those who survived. In 13% of suction events, a significant heart rate change (i.e., arrhythmia or brief/sustained >15% fall in heart rate) was observed in relation to suctioning. This represents a potential additional harm to already depressed newborns undergoing resuscitation.

Early-Life Enteric Pathogen Exposure, Socioeconomic Status, and School-Age Cognitive Outcomes.

Early-life experiences of enteric infections and diarrheal illness are common in low-resource settings and are hypothesized to affect child development. However, longer-term associations of enteric infections with school-age cognitive outcomes are difficult to estimate due to lack of long-term studies. The objective of this study was to examine the relationship between enteropathogen exposure in the first 2 years of life with school-age cognitive skills in a cohort of children followed from birth until 6 to 8 years in low-resource settings in Brazil, Tanzania, and South Africa. The study included participants from three sites from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health Study who were enrolled just after birth and followed for enteric infections, diarrheal illness, and cognitive development until 2 years of age. When the children were school-age, further data were collected on reasoning skills and semantic/phonemic fluency. We estimated associations between the burden of specific enteric pathogens and etiology-specific diarrhea from 0 to 2 years with cognitive test scores at 6 to 8 years using linear regression and adjusting for confounding variables. In this study, children who carried more enteric pathogens in the first 2 years of life showed overall decreases in school-age cognitive abilities, particularly children who carried protozoa, although this was not statistically significant in this sample. Socioeconomic factors such as maternal education and income were more closely associated with school-age cognitive abilities. Early-life enteric pathogens may have a small, lasting influence on school-age cognitive outcomes, although other socioeconomic factors likely contribute more significantly.

Fetal to Neonatal Heart Rate Transition during Normal Vaginal Deliveries: A Prospective Observational Study.

Documentation of fetal to neonatal heart rate (HR) transition is limited. The aim of the current study was to describe HR changes from one hour before to one hour after normal vaginal deliveries. We conducted a prospective observational cohort study in Tanzania from 1 October 2020 to 30 August 2021, including normal vaginal deliveries with normal neonatal outcomes. HR was continuously recorded from one hour before to one hour after delivery, using the Moyo fetal HR meter, NeoBeat newborn HR meter, and the Liveborn Application for data storage. The median, 25th, and 75th HR percentiles were constructed. Overall, 305 deliveries were included. Median (interquartile range; IQR) gestational age was 39 (38-40) weeks and birthweight was 3200 (3000-3500) grams. HR decreased slightly during the last 60 min before delivery from 136 (123,145) to 132 (112,143) beats/minute. After delivery, HR increased within one minute to 168 (143,183) beats/min, before decreasing to around 136 (127,149) beats/min at 60 min after delivery. The drop in HR in the last hour of delivery reflects strong contractions and pushing. The rapid increase in initial neonatal HR reflects an effort to establish spontaneous breathing.

Impact of Shigella infections and inflammation early in life on child growth and school-aged cognitive outcomes: Findings from three birth cohorts over eight years.

BACKGROUND: Shigella infections cause inflammation, which has been hypothesized to mediate the associations between Shigella and child development outcomes among children in low-resource settings. We aimed to assess whether early life inflammation and Shigella infections affect school-aged growth and cognitive outcomes from 6-8 years of age. METHODOLOGY/PRINCIPAL FINDINGS: We conducted follow-up assessments of anthropometry, reasoning skills, and verbal fluency in 451 children at 6-8 years of age in the Brazil, Tanzania, and South Africa sites of MAL-ED, a longitudinal birth cohort study. We estimated the associations between Shigella burden and inflammation with linear growth at 2, 5, and 6-8 years of age, and with the cognitive test scores using linear regression and adjusting for potential confounding variables. We also assessed whether inflammation mediated the associations between Shigella and school-aged outcomes using a regression-based approach to mediation analysis. A high prevalence of Shigella was associated with a 0.32 (95% CI: 0.08, 0.56) z-score lower height-for-age z-score (HAZ) at 6-8 years compared to a low prevalence of Shigella. Intestinal inflammation had a smaller association with HAZ at 6-8 years. Shigella burden had small and consistently negative associations with cognitive outcomes in Brazil and Tanzania, but not South Africa, and the estimates were not statistically significant. Systemic inflammation was strongly associated with lower verbal fluency scores in Brazil (semantic fluency z-score difference: -0.57, 95% CI: -1.05, -0.10; phonemic fluency z-score difference: -0.48, 95% CI: -0.93, -0.03). There was no evidence that intestinal inflammation mediated the association between Shigella and HAZ or cognitive outcomes. CONCLUSIONS/SIGNIFICANCE: While Shigella infections were consistently associated with long-term deficits in linear growth, the estimates of the negative associations between Shigella and cognitive outcomes were imprecise and only observed in the Brazil and Tanzania sites. Systemic inflammation was strongly associated with lower semantic and phonemic fluency scores in Brazil only, highlighting the site-specificity of effects.

Delivery Room ST Segment Analysis to Predict Short Term Outcomes in Near-Term and Term Newborns.

BACKGROUND: ST-segment changes to the fetal electrocardiogram (ECG) may indicate fetal acidosis. No large-scale characterization of ECG morphology immediately after birth has been performed, but ECG is used for heart rate (HR) assessment. We aimed to investigate ECG morphology immediately after birth in asphyxiated infants, using one-lead dry-electrode ECG developed for HR measurement. METHODS: Observational study in Tanzania, between 2013-2018. Near-term and term infants that received bag-mask ventilation (BMV), and healthy controls, were monitored with one-lead dry-electrode ECG with a non-diagnostic bandwidth. ECGs were classified as normal, with ST-elevations or other ST-segment abnormalities including a biphasic ST-segment. We analyzed ECG morphology in relation to perinatal variables or short-term outcomes. RESULTS: A total of 494 resuscitated and 25 healthy infants were included. ST-elevations were commonly seen both in healthy infants (7/25; 28%) and resuscitated (320/494; 65%) infants. The apparent ST-elevations were not associated with perinatal variables or short-term outcomes. Among the 32 (6.4%) resuscitated infants with "other ST-segment abnormalities", duration of BMV was longer, 1-min Apgar score lower and normal outcomes less frequent than in the resuscitated infants with normal ECG or ST-elevations. CONCLUSIONS: ST-segment elevation was commonly seen and not associated with negative outcomes when using one-lead dry-electrode ECG. Other ST-segment abnormalities were associated with prolonged BMV and worse outcome. ECG with appropriate bandwidth and automated analysis may potentially in the future aid in the identification of severely asphyxiated infants.

Cognitive Outcomes at 18 Months: Findings from the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) Trial.

Micronutrient deficiencies and enteric infections negatively impact child growth and development. We enrolled children shortly after birth in a randomized, placebo-controlled, 2 × 2 factorial interventional trial in Haydom, Tanzania, to assess nicotinamide and/or antimicrobials (azithromycin and nitazoxanide) effect on length at 18 months of age. Cognitive score at 18 months using the Malawi Developmental Assessment Tool (MDAT), which includes gross motor, fine motor, language, and social assessments, was a secondary outcome. Here, we present the MDAT results of 1,032 children. There was no effect of nicotinamide (change in development-for-age Z score [DAZ] -0.08; 95% CI: -0.16, 0) or antimicrobials (change in DAZ 0.04; 95% CI: -0.06, 0.13) on overall MDAT score. The interventions had no effect on cognitive outcomes in subgroups defined by gender, socioeconomic status, birthweight, and birth season or on MDAT subscores. Further analyses are needed to identify targetable risk factors for impaired cognitive development in these settings.

Early Life Experiences and Trajectories of Cognitive Development.

BACKGROUND: Multiple factors constrain the trajectories of child cognitive development, but the drivers that differentiate the trajectories are unknown. We examine how multiple early life experiences differentiate patterns of cognitive development over the first 5 years of life in low-and middle-income settings. METHODS: Cognitive development of 835 children from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite observational cohort study was assessed at 6, 15, 24 (Bayley Scales of Infant and Toddler Development), and 60 months (Wechsler Preschool and Primary Scale of Intelligence). Markers of socioeconomic status, infection, illness, dietary intake and status, anthropometry, and maternal factors were also assessed. Trajectories of development were determined by latent class-mixed models, and factors associated with class membership were examined by discriminant analysis. RESULTS: Five trajectory groups of cognitive development are described. The variables that best discriminated between trajectories included presence of stimulating and learning resources in the home, emotional or verbal responsivity of caregiver and the safety of the home environment (especially at 24 and 60 months), proportion of days (0-24 months) for which the child had diarrhea, acute lower respiratory infection, fever or vomiting, maternal reasoning ability, mean nutrient densities of zinc and phytate, and total energy from complementary foods (9-24 months). CONCLUSIONS: A supporting and nurturing environment was the variable most strongly differentiating the most and least preferable trajectories of cognitive development. In addition, a higher quality diet promoted cognitive development while prolonged illness was indicative of less favorable patterns of development.

Distribution of heart rate and responses to resuscitation among 1237 apnoeic newborns at birth.

AIM OF THE STUDY: Describe the distribution of the first recorded heart rate (HR) in apnoeic term/near-term newborns, HR responses to basic resuscitation (no intubation, chest compressions and/or medication), and relationship to 24-h outcomes. We also document patient characteristics and care provider behaviour stratified by first HR. METHODS: Descriptive study from July 2013 through June 2018 at Haydom Hospital in Tanzania. All deliveries were observed by assistants recording data. Bag-mask ventilation and ECG data were recorded by resuscitation monitors. Newborns with ≥5 ventilations and ECG signal-data were included. RESULTS: 1237 term/near-term newborns with median (25th, 75th percentiles) gestation 38 (37, 40) weeks and birth weight 3140 (2750, 3500) grams fulfilled inclusion criteria. The first HR, measured median 102 (73, 144) s after birth following drying/stimulation, was distributed into two peaks with centres around 60 and 165 bpm, 51% were ≥100 bpm. After ventilation, the HR distribution shifted to a single-peak, with median 161 bpm. At least one low-high HR transition crossing 100 bpm was noted in 44% of newborns. The HR increase occurred over median 9.2 (6.2, 13) s, was 60 (43, 77) bpm, and 86% followed a ventilation sequence of 23 (16, 34) s duration. 72% of the newborns with first HR < 60 bpm survived following ventilations only. Both first and final HR were significantly related to 24-h outcomes. CONCLUSIONS: The first recorded HR was distributed into two peaks on each side of 100 bpm. Ventilation increased HR in most newborns. Lower first and final HR were related to gradually more adverse 24-h outcomes.

Midwives' and Women's Perception on Moyo Fetal Heart Rate Monitor for Intrapartum Fetal Heart Rate Monitoring; A Cross-Sectional Study.

BACKGROUND: The annual global neonatal mortality stands at 2.5 million deaths, 1 million of them dying within the first day of life. An additional 2.6 million are stillborn globally, the majority of them due to intrapartum events. Optimal fetal heart rate (FHR) monitoring has the potential to timely detect fetuses at risk and, if coupled with timely obstetric responses may save more newborns. Moyo is a new Doppler with nine crystals capable of monitoring FHR both intermittently and continuously. AIM: To assess women's and midwives' opinions on the use of Moyo for intrapartum FHR monitoring. METHODS: We conducted a cross-sectional study using a structured questionnaire to assess women's and midwives' perception. Women who gave birth at the hospital who used Moyo were interviewed using a questionnaire immediately before discharge from the hospital. Twenty-eight midwives who have been using Moyo for more than 6 months were also interviewed using a structured questionnaire. Data were analyzed using excel and result presented in figures. RESULTS: In total 113 postpartum women who were monitored using Moyo were interviewed before discharge. Out of these, 46 (40.7%) were first-time mothers and the rest were multipara. In total, 95 women (84.1%) used Moyo and other devices for FHR monitoring, 81 (72%) said Moyo was better than Fetoscopes and handheld Doppler, two-third 75 (66.4%) felt that Moyo was comfortable and 93 (82.3%) would like Moyo to be used on them in the future. Out of 28 midwives, 11 (39.3%) used Moyo continuous only, 3 (10.7%) used Moyo intermittently only and 14 (50.0%) used both intermittent and continuous. Thirteen (46.4%) midwives prefer to use Moyo both intermittent and continuous. Sixteen (55.6%) said Moyo was effective, 21 (75%) felt comfortable to use Moyo, and 13 (46.4%) said Moyo was easy to use. CONCLUSION: The majority of midwives and women who used Moyo felt that Moyo was comfortable for intrapartum FHR monitoring. Moyo can be used both intermittently and continuously depending on the user's preferences.

Early Life Child Micronutrient Status, Maternal Reasoning, and a Nurturing Household Environment have Persistent Influences on Child Cognitive Development at Age 5 years: Results from MAL-ED.

BACKGROUND: Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. OBJECTIVE: The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. METHODS: Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. RESULTS: Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin receptor concentration (ß: -1.81, 95% CI: -2.75, -0.86), number of years of maternal education (ß: 0.27, 95% CI: 0.08, 0.45), maternal cognitive reasoning score (ß: 0.09, 95% CI: 0.03, 0.15), household assets score (ß: 0.64, 95% CI: 0.24, 1.04), and HOME child cleanliness factor (ß: 0.60, 95% CI: 0.05, 1.15). In multivariable models, the mean rate of enteropathogen detections, burden of illness, and complementary food intakes between birth and 2 y were not significantly related to 5-y cognition. CONCLUSIONS: A nurturing home context in terms of a healthy/clean environment and household wealth, provision of adequate micronutrients, maternal education, and cognitive reasoning have a strong and persistent influence on child cognitive development. Efforts addressing aspects of poverty around micronutrient status, nurturing caregiving, and enabling home environments are likely to have lasting positive impacts on child cognitive development.