Monday, November 15, 2010

INDIA & HEALTH

 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.