Improving the Treatment of Neonatal Sepsis in Resource-Limited Settings: Gaps and Recommendations.

Neonatal sepsis causes significant global morbidity and mortality, with the highest burden in resource-limited settings where 99% of neonatal deaths occur. There are multiple challenges to achieving successful treatment of neonates in this setting. Firstly, reliable and low-cost strategies for risk identification are urgently needed to facilitate treatment as early as possible. Improved laboratory capacity to allow identification of causative organisms would support antimicrobial stewardship. Antibiotic treatment is still hampered by availability, but also increasingly by antimicrobial resistance - making surveillance of organisms and judicious antibiotic use a priority. Finally, supportive care is key in the management of the neonate with sepsis and has been underrecognized as a priority in resource-limited settings. This includes fluid balance and nutritional support in the acute phase, and follow-up care in order to mitigate complications and optimise long-term outcomes. There is much more work to be done in identifying the holistic needs of neonates and their families to provide effective family-integrated interventions and complete the package of neonatal sepsis management in resource-limited settings.

The COVID19 Pandemic has Changed Women's Experiences of Pregnancy in the UK.

INTRODUCTION: During the SARS-CoV-2 pandemic, maternity care has been substantially altered to reduce transmission of the SARS-CoV-2 virus. Many antenatal services are now restricted or delivered online, and visiting has been restricted during labour and in the postnatal period. METHODS: We conducted an online survey from 1st August to 31st December 2020 to investigate the experiences of women who were pregnant or breastfeeding in the UK during the SARS-CoV-2 pandemic. The survey included 55 open and closed questions and required 5 min to complete. We publicised the survey using social media. RESULTS: We received 96 responses, including 66 currently pregnant women and 22 women who were pregnant during the pandemic. The response rate was 70.1% of survey views. We found mixed experiences of the impact of the pandemic on antenatal and perinatal care, notably with some women feeling visiting restrictions were insufficient and others feeling they were too strict. Twenty-nine women received no information about COVID-19, and 6 women found it very difficult to find information. Thirty-nine women would have liked to have more information about breastfeeding after a pregnancy affected by COVID-19, and 37 women wanted more information about antibody persistence and transfer. DISCUSSION: Additional support is required for pregnant and lactating women during the current pandemic. Provision of information and support, including via social media, may improve women's experiences of pregnancy in the current environment.

Neonatal outcomes and indirect consequences following maternal SARS-CoV-2 infection in pregnancy: a systematic review.

OBJECTIVES: To identify the association between maternal SARS-CoV-2 infection in pregnancy and individual neonatal morbidities and outcomes, particularly longer-term outcomes such as neurodevelopment. DESIGN: Systematic review of outcomes of neonates born to pregnant women diagnosed with a SARS-CoV-2 infection at any stage during pregnancy, including asymptomatic women. DATA SOURCES: MEDLINE, Embase, Global Health, WHOLIS and LILACS databases, last searched on 28 July 2021. ELIGIBILITY CRITERIA: Case-control and cohort studies published after 1 January 2020, including preprint articles were included. Study outcomes included neonatal mortality and morbidity, preterm birth, caesarean delivery, small for gestational age, admission to neonatal intensive care unit, level of respiratory support required, diagnosis of culture-positive sepsis, evidence of brain injury, necrotising enterocolitis, visual or hearing impairment, neurodevelopmental outcomes and feeding method. These were selected according to a core outcome set. DATA EXTRACTION AND SYNTHESIS: Data were extracted into Microsoft Excel by two researchers, with statistical analysis completed using IBM SPSS (Version 27). Risk of bias was assessed using a modified Newcastle-Ottawa Scale. RESULTS: The search returned 3234 papers, from which 204 were included with a total of 45 646 infants born to mothers with SARS-CoV-2 infection during pregnancy across 36 countries. We found limited evidence of an increased risk of some neonatal morbidities, including respiratory disease. There was minimal evidence from low-income settings (1 study) and for neonatal outcomes following first trimester infection (17 studies). Neonatal mortality was very rare. Preterm birth, neonatal unit admission and small for gestational age status were more common in infants born following maternal SARS-CoV-2 infection in pregnancy in most larger studies. CONCLUSIONS: There are limited data on neonatal morbidity and mortality following maternal SARS-CoV-2 infection, particularly from low-income countries and following early pregnancy infections. Large, representative studies addressing these outcomes are needed to understand the consequences for babies born to women with SARS-CoV-2. PROSPERO REGISTRATION NUMBER: CRD42021249818.

Antenatal care and perinatal outcomes of asylum seeking women and their infants.

OBJECTIVES: Asylum seekers have been highlighted as a particularly vulnerable group of expectant mothers due to complex medical and psychosocial needs, as well as the difficulties they may face in accessing care. Our aim was to examine if there were differences in the antenatal care and perinatal outcomes for asylum seeking women when compared to age- and ethnicity-matched controls delivering at the same hospital. METHODS: Two age- and ethnicity-matched non-asylum seeking controls were identified for each asylum-seeking woman. Electronic patient records were analysed to determine the amount of antenatal care received and neonatal outcomes. RESULTS: Thirty-four asylum-seeking women were identified who had term born infants. The median number of antenatal care episodes at the delivering hospital was significantly fewer amongst asylum-seeking women compared to controls (three vs. nine, p<0.0001). The median number of antenatal ultrasound examinations at the delivering hospital amongst asylum-seeking women was one (IQR 1-2), compared to three (IQR 3-4) in the controls (p<0.0001). The postnatal length of stay was significantly longer for infants of asylum-seeking women (median three vs. two days, p=0.002). Thirty-seven percent of asylum seeking women but none of the controls required assistance from social services. There was a significant correlation between antenatal and postnatal costs for asylum seeking women (r=0.373, p=0.042), but not for controls (r=0.171, p=0.181). CONCLUSIONS: The increased postnatal length of stay in the infants of asylum seeking mothers may reflect their mother's reduced antenatal care and hence insufficient discharge planning for mothers and infants with increased social needs.

A randomised crossover trial of closed loop automated oxygen control in preterm, ventilated infants.

AIM: To determine whether closed loop automated oxygen control resulted in a reduction in the duration and severity of desaturation episodes and the number of blood gases and chest radiographs in preterm, ventilated infants. METHODS: Infants were studied on two consecutive days for 12 hours on each day. They were randomised to receive standard care (standard period) or standard care with a closed loop automated oxygen control system (automated oxygen control period) first. RESULTS: Twenty-four infants with a median gestational age of 25.7 (range 23.1-32.6) weeks were studied at a median postconceptional age of 27.4 (range 24.3-34.9) weeks. During the automated oxygen control period, there were fewer desaturations that lasted >30 seconds (P = .032) or >60 seconds (P = .002), infants spent a higher proportion of the time within their target SpO2 range during the automated oxygen control period (P < .001), and fewer manual adjustments were made to the inspired oxygen concentration (mean 0.58 vs mean 11.29) (P < .001). There were no significant differences in the number of blood gases (P = .872) or chest radiographs (P = .366) between the two periods. CONCLUSION: Closed loop automated oxygen delivery resulted in fewer prolonged desaturations with more time spent in the targeted oxygen range.

Antenatal and perinatal outcomes of refugees in high income countries.

OBJECTIVES: The World Health Organisation (WHO) has highlighted a marked trend for worse pregnancy-related indicators in migrants, such as maternal and neonatal morbidity and mortality, poor mental health and suboptimal care. The aim of this study was to determine whether such adverse outcomes occurred in refugees who moved to high income countries by comparing their antenatal and perinatal outcomes to those of non-immigrant women. METHODS: A literature search was undertaken. Embase and Medline databases were searched using Ovid. Search terms included "refugee", "pregnan*" or "neonat*", and "outcome". RESULTS: The search yielded 194 papers, 23 were included in the final analysis. All the papers included were either retrospective cohort or cross-sectional studies. The refugees studied originated from a wide variety of source countries, including Eritrea, Somalia, Afghanistan, Iraq, and Syria. Refugee women were more likely to be socially disadvantaged, but less likely to smoke or take illegal drugs during pregnancy. Refugee women were more likely to have poor, late, or no attendance at antenatal care. Miscarriages and stillbirth were more common amongst refugee women than non-refugees. Perinatal mortality was higher among refugees. CONCLUSIONS: Despite better health care services in high income countries, refugee mothers still had worse outcomes. This may be explained by their late or lack of attendance to antenatal care.

Maternal smoking and cannabis use during pregnancy and infant outcomes.

Background Our aim was to determine the prevalence of tobacco smoking and e-cigarettes and cannabis use during pregnancy, whether these were influenced by ethnicity, and their relationship to perinatal outcomes. Methods A study was carried out in 4465 infants whose mothers delivered during 2017 and 2018. Self-reported maternal smoking, e-cigarette and cannabis use at booking were recorded. Outcome measures were birthweight and head circumference z-scores and admission to the neonatal intensive care unit (NICU). Results Two hundred and five women reported smoking cigarettes (4.7%), five were using e-cigarettes (0.11%) and 106 were using cannabis (2.43%). Women were most likely to smoke if young (15-19 years old) or from a mixed-race or White background. Cigarette smoking was associated with a lower mean z-score for birthweight (-0.587 vs. -0.064) and head circumference (-0.782 vs. -0.157) (both outcomes P < 0.0001). Young, mixed-race women were most likely to be both smoking and using cannabis during pregnancy and their infants had a lower birthweight mean z score (-0.989 vs. -0.587, P = 0.028) and head circumference z score (-1.33 vs. 0.782, P = 0.025) than cigarette use alone. Conclusion Young, mixed-race women were most likely to be both smoking and using cannabis during pregnancy and should be targeted for cessation programmes.

Closed loop automated oxygen control in neonates-A review.

AIM: Neonates frequently require supplementary oxygen but may develop complications if the oxygen saturation is outside the target range. This review aimed to determine whether the algorithms used in closed loop automated oxygen control systems influenced their efficacy and whether use of the systems reduced relevant, long-term neonatal complications. METHODS: A literature search was conducted using PubMed and Google Scholar. The search terms were 'closed loop' or 'automat*', 'oxygen' and 'neonat*'. RESULTS: Eighteen studies were identified: sixteen comparison clinical studies, an observational study and an animal study. Overall, closed loop automated oxygen control was associated with an increased percentage of time spent within the target oxygen saturation range and there were fewer manual adjustments to the inspired oxygen concentration when compared with manual oxygen control. The systems were effective in infants on non-invasive respiratory support or mechanically ventilated, but no study included term-born infants. No long-term data were available to determine if complications of oxygen toxicity were reduced. CONCLUSION: Closed loop automated oxygen control has been shown in short term trials including preterm and low birth weight infants to improve target saturation achievement. Whether long-term outcomes will be improved with their use requires investigation.

Child labour in low- and middle-income countries and its consequences for mental health: a systematic literature review of epidemiologic studies.

In low- and middle-income countries, large numbers of children are involved in work. Whilst studies have shown that child labour may be harmful to children's physical health, little is known about child labour's effects on mental health. It is important to understand the relationship between work and mental health problems during childhood, and identify possible risk factors for poorer mental health. A systematic literature review was conducted. Published papers in any language that compared the mental health of children (<18 years) who had been exposed to work with those who had not been exposed to work were included. Twelve published observational studies on the association between child labour and general psychopathology, internalising and externalising problems were identified. Child labour was found to be strongly associated with poor mental health outcomes in seven studies. More significant associations were found between child labour and internalising problems than externalising problems. The burden of poor mental health as a result of child labour is significant given the numbers of children in work. Risk factors for poorer mental health were involvement in domestic labour, younger age, and greater intensity of work, which could be due to the potential of child labour to cause isolation, low self-esteem, and perception of an external locus of control. The risk factors suggested by this review will have implications for policy makers. Additional research is needed in low-income countries, risk factors and also into the potential psychological benefits of low levels of work.