Extremely Low
Birth Weight (ELBW)Newborn Survival in India and other developing country.
Dr. Rajatsubhra Mukhopadhyay
MD[CHILD],DCH,MBBS
Director of Child Health Care Arambagh,
Arambagh
ABSTRACT
:
In this article the importance of finding out the risk
factors of morbidity and mortality of ELBW , in terms of Indian context for the
reduction of NMR (infant mortality rate) has been tried . The review paper
shows the Sepsis is a very important cause of ELBW. And in home based
management also shows Sepsis is the main cause of newborn mortality. As main
bulk of population in India resides in rural areas and many of them prefer home
delivery. So to reduce NMR, proper management protocol is needed for home
delivery of all types of LBW newborns.
Moreover the lack of sufficient
tertiary centers leads to high patient load in tertiary centres. Improper timing of newborn birth management in ELBW
due high patient’s load in these centres also implies the additional system’s
of newborn management to develop. This can cut down the cost of newborn
delivery[including the ELBW newborn] also.Though morbidity and mortality of
ELBW are with risk factors are nicely described in the paper of Dr.
Mukhopadhyay et. al. but ELBW’S nutrition and its risk, the temperature
regulation of ELBW with the risk of hypothermia
are not covered in the
article. However this is a pioneering work to depict ELBW’S management problem which should be kept
in mind during ELBW’S management at home based management of newborn delivery
also.
KEYWORDS
: ELBW, Neonatal Mortality Rate (NMR), Rural
India , Sepsis, Home based management, Nutrition in LBW.
The newborn who is
below 1kg is defined as. Extremely low birth weight (ELBW) newborn. According to UNICEF the total
incidence of Low Birth Weight (LBW) is 30% in India (1)
.This is divided as : LBW, who is < 2.5 kg- 1.5 kg Very Low Birth Weight
(VLBW) 1.5 kg – 1 kg and ELBW < 1 kg.
Only 32.8% of this
baby get birth in tertiary centre out of
which 14% is < 2kg (2) . According international data neonatal mortality
rate is 5 in developed country and 53 in least developed country (3,4) . NMR is 61% of infant mortality and half
of child mortality is developing country (3)
. So to minimize IMR[Infant Mortality Rate]. NMR must to be reduced. Both are
linked together. And IMR is one of the three parameter of Human Development
Index[HDI] of a country. So to become developed IMR must be reduced. 83 % in
rural India are born at home (4,5) .
Standard advice is to admit in hospital for the high risk pregnancy and ill
newborn (4,6) . But at rural area
this is not always possible. And also poor motivation literacy and are the factors for home delivery (7,8,9) .
Hence to improve the neonatal survival ,home
based management must be developed in India.
In this
article the paper from PGI Chandigrah on “ PREDICTORS OF MORTALITY AND
MORBIDITIES IN EXTREEMLY LOW BIRTH WEIGHT NEONATES” by Dr. Kanya Mukhopadhyay,
Deepak Louis, Rama Mahajan and Praveen Kumar, INDIAN PEDIATRICS, VOL- 50, Dec
15, 2013; p: 1119-1125
has been reviewed to find out the factors for reduction of
NMR in India.
CAUSES OF MORTALITY AND MORBIDITY OF ELBW IN INDIA:
Major causes of
mortality as described in this paper are sepsis, birth asphyxia,pulmonary
heamorrhage,birth weight<800grm.,ventilation.hypotensive shock and causes of morbidity are lack of antenatal
steroid,ventilation and duration of oxygen therapy.
But apart from that hypothermia with temperature regulation
and ELBW’S nutritional part are also to
be discussed (10) .
This was a prospective Cohort study. And the aim was define the morbidity
and mortalities of the ELBWS as there is
no well established data in this field .And
it is well described here as have been discussed latter.
TERTIARY VS. HOME BASED CARE FOR LBW [INCLUDING ELBW.]
- From top to bottom level care the basic findings are the same.
According to afore- said
Indian scenario the importance is to be given also in home based management of
the low birth weight which also includes ELBW. One study by Abhay T. Bang et.
al. by SEARCH ( Society for Education Action and Research in Community Health)
Gadchiorli, Maharastra, 442605, India , published in lancet 1999, 354, 1955-61,shows
with HOME BASED MANAGEMENT STRATEGY in 1995-96 :at the time of starting their
work, the death < 1.5 kg was9out of 13[that means too high] . And in
1997-98,that was reduced to 4out of 16 with their adopted method.
This article of Abhay
T. Bang et. al. have mainly focused on Sepsis is a major cause.They have shown
that this type of management can be done in low cost.
And here the reviewing paper of Dr. Kanya Mukhopadhyay et. al also describes
the Sepsis as an important cause of ELBW mortality. Along with that she has
also mentioned that the Antenatal Steroid reduces the mortality of ELBW. So at home delivery the prevention of Sepsis
and proper antenatal care can reduce the
NMR.
- How this two different study catches two same important things, the Sepsis and Antanatal steroid?
CAUSES OF LOW BIRTH WEIGHT [LBW] IN INDIA:
In India
the cause of LBW in multi factorial. Out of which IUGR new born are more common
than PRETERM newborn( 10) . Which is again depends on maternal nutrition, early
marriage, multiple pregnancy, poor
spacing and gentic factors (10,11) . So
to reduce the ELBW and LBW birth, the proper guidance is to be taken with a
girl child since her childhood to through out marital life and antenatal period (10)
.Here comes the role of antenatal steroid.
A VAST COUNRTY AND LIMITED TOP LEVEL CENTRES.
This
study by Dr. Mukhopadhyay et. al. also confessed that in PGI –Chandigarh for
the large member of patient load all
ELBW delivery could not be properly
shifted. So if this happens in tertiary centre. That means more centres are
needed for the tertiary care to provide
LBW.
THE CONTRIBUTIONS OF THIS STUDY:
As it is well- known that ELBW’S are prone to higher morbidity and mortality (12) . And in developing country it has no enough
data base. So the study was conceptualized. Only two previous study by Tagare
et. al. (13) and Narayan et. al. (14) have been published on ELBW mortality in
India. But the morbidity and risk factor
were not discussed. So this study will play a great role in this field as a pioneer
work in India like developing country. Small
for gestational age (SGA) babies
are divided as LBW (Low Birth Weight) (<2.5 kg- 2kg), very Low Birth Weight
( 2 kg- 1.5kg), extremely low birth weight (ELBW) (1.5 kg). All most all of these
babies are managed in institution . This
study has been published with a cohort study showing the predictors of the risk
factors of ELBW survival. The article
clear and they have used all the sensitive parameters like, Zubrow’s chart has been used for blood pressure (15) . Volpe’s IVH classification is utilized for the
Intra Ventricular Hemorrhage[IVH] (16)
. For NEC[Necrotising Entero Colitis] , Bell’s staging (17) has been given
.And all the Survived newborns
were discharged as per Kaplan and Meier’s method.
It is not clear why the authors have mentioned of not using
VIT A here.
Figures and charts are appropriate to put the research
method mathematically fruitful.
No doubt this work
will help in pediatrics and neonatology field in India and other developing
country. Here many relation have been point out as cause of mortality and
morbidity in ELBW. Among these hypotensive shock and the Sepsis is the major
cause of mortality. [ Narayan et. al. found out the risk factors are LBW,
Gestational age .] Here septic shock, ventilation, ventilation associated pneumonia
( VAP), IVH, Cerebral palsy, Periventricular leukomalcia, Duration of oxygen therapy as a
cause of BronchoPulmonaryDysplasia, Low lung volume and ROP ( Retinopathy of Prematurity)
all have been found as the mordity factors.With lower oxygen
the reduction of ROP have been newly point out in this
article.
But the hypothermia with temperature regulation has not been
discussed here.
NUTRITION IS ALSO A CHALLENGE FOR ELBW:
But a
few areas like the nutrition of the ELBW and its out come on morbidity and
mortality ,type of feeding, and its way and risk and complication (18) is surprisingly not discussed here. In the
ELBW : nutrition with Total Parenteral
Nutrition (19) with glucose, amino-acid and fat emulsion (20) which might consist of PUFA (21) and recently MUFA, are also (22) have
not been discussed. However the authors
have properly conceptualized the whole matter. And have established so many
risk factors.
In
limitation they have mentioned that this is the level III care study. But still all ELBW could not be
properly attended always at due time for the huge patient load.
IS THIS CARE SUFFICIENT TO REDUCE NMR IN INDIA IN NEAR FUTURE?
The
vast population in India and in developing country till date many deliveries occur
in home (4,5) . This way of study and its management is not
giving to help in this field . This
needs different approach. Of course referral to the higher centre is very
important. But proper motivation is still not achieved . and
also there is lack of proper
communication ,tertiary care centre and
poverty of the people (7,8,9) .
The writing is clear, concise and appropriate.
Dr. Mukhopadhyay et. al. has been mentioned
that this study cannot be generalized to
those who did not get admitted in to NICU. They have given the Sepsis in the major
cause (46%) of ELBW death. And the home based management with SEARCH study for
LBW also give prior importance on Sepsis, which was reduced from 27.5 %
mortality rate in 1995-96 to 6.6% in 97-98 (table 6). So the development for organized
home based newborn care is also important
besides the tertiary care.This can cut down the cost burden for the
management of the of ELBW .And this will be helpful for the poor people in
rural India. However this is a pioneering work to depict ELBW’S management problem which should be
kept in mind as the risk factors during
ELBW’S management at home based management of newborn delivery also.
ACKNOWLEDGEMENT
: I’m grateful to Mr. Plaban
Das (M.A.) my assistant for the computer use and arrangement of the data. And
also to the data base of Indian pediatrics where from the research paper I have
collected.
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INDOLOGY-A SUBJECT FOR HEAVENLY EARTH IN COMING DAYS.
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