Prematurity Survival and Prognosis Challenges in management immediate & long term care needs

1. PrematuritySurvival and PrognosisChallenges in management immediate & long term care needs Dr.J.Kumutha Expert Advisor (Ch) NHM ,Tamilnadu

2. Global, regional estimates of preterm birth in 2014 • 1241 data points • 107 countries • Estimated 14·84 million • Estimated global preterm birth rate - 10·6% (9.8% in 2010) • 12· 0 million (81·1%) Asia and sub-Saharan Africa

3. TOP Ten countries

4. State wise preterm admission in SNCU Year 2018

5. Preterm admission (<37 Weeks) / Birth Weight Kerala Tamilnadu

6. NMR in India 2000-2015Gains in newborn health • During 2000-2015: • Neonatal infection fell by66% • Birth asphyxia or trauma fell by76% • Prematurity/low birth weight rosemodestly Source: Million Death Study Lancet. September 2017.

7. NMR in India 2000-2015Gains in newborn health –Rural vs urban

8. Treatment Outcome of Preterm in India

9. Cause of Death – Less than 2000 gm

10. Preterm (<37 Weeks) Outcome 2016-2018 Kerala Tamilnadu N=11523

11. Preterm (<37 Weeks) Cause of Death Kerala Tamilnadu

13. 101 VLBW babies available for follow up at CA 1 year 3% - Cerebral Palsy (CP) 3% suspect abnormality (mild hypotonia) 11% gross motor and 8% language abnormal Score of<70 in 17% (MeDQ) & 25.7% (MoDQ) VLBW babies. ELBW – 71 babies At 1 year, 24% were neurologically abnormal At 18 months composite adverse outcome in 35.4 % of babies.

16. ND Outcomes –Japanese VLBW cohort 2003-14 • Death or CP and Death or DQ <70 • Cystic PVL • IVH grade 3 or 4 • Sepsis • Gastrointestinal perforation • CLD • Severe ROP Birth Weight <1500 and gestation >22 weeks 3104 infants born in 2003 and 2004 2847 infants survived (91.7%) 1826 followed up at 3 years of age (64%) Death before evaluation 8.3% Cerebral palsy 8.7% DQ < 70 15.4% Aggressive early Nutrition

17. Predictors of NDI at 5 years CAP Trial Birth Weight 500 to 1250 grams 1640 of 2006 had completer assessment at 5 yrs (82%) Death or Disability -23%, Death - 7%

18. Predictors - combined Outcome BPD PVL, IVH ROP Sepsis

19. Prenatal Package

20. Antenatal Corticosteroids

21. Antenatal steroids - data Kerala Tamilnadu

22. Maternal Antibiotics for PPROM Paul DA. Maternal antibiotics and decreased periventricular leukomalacia in very low-birth-weight infants. Arch PediatrAdolesc Med. 2003 Feb;157(2):145-9.

23. MgSO4 for women at risk of preterm birth for neuroprotection of fetus • 5 RCTs • Reduced risk of CP • NNT to avoid CP is 63 • Neuroprotective role for antenatal magnesium sulphate therapy given to women at risk of preterm birth for the preterm fetus is now established Doyle LW et al. Magnesium sulphate for women at risk of preterm birth for neuroprotection of the fetus. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004661

24. LSCS • Elective LSCS only after 39 completed weeks • Late preterm morbidity • Unnecessary admission • Policy to be in Place

25. Delivery Room care

26. In-utero Transport • Higher incidence of grades III/IV IVH in transported infants between 1001 - 2000 gms compared with maternal transports • In utero transport of selected high-risk pregnancies is preferred despite the ability to provide safe, effective transport of ill neonates over extremely long distances Leviton A, Fenton T, Kuban KC, Pagano M : Labour and delivery charecteristics and the risk of germinal matrix hemorrhage in low birth weight infants, J Child Neurol 6. 35 – 40, 1991.

27. Early Skin-to-skin contact • Skin-to-skin (SSC) keeps baby warmer, regulates breathing & keeps blood sugar levels higher • Breastfeeding • Baby cries less , better sleep • Better gut health & immunity • Enhances bonding • Reduced postpartum depression Early skin-to-skin contact for mothers and their healthy newborn infants: RHL commentary ( November 2007).

28. Early vs delayed umbilical cord clamping in Preterm infants 60 to 120 seconds • Fewer transfusions for anaemia (three trials, 111 infants; relative risk (RR) 2.01, 95% CI 1.24 to 3.27) • Less intraventricular haemorrhage (Five trials, 225 infants; RR 1.74, 95% CI 1.08 to 2.81)

29. Additional Resources Needed

30. Infant and Young Child Feeding India

31. Missed opportunity – Institutional delivery and early initiation of breastfeeding Percent Source: NFHS -4, 2015-16

32. SNCU/NICU

33. Respiratory support

34. Saturation Targets: 85 -89% vs. 90-94% NeOProM meta-analysis (Five Trials, 4965 infants)

35. CPAP Vs with assisted ventilation with / without surfactant Reduction of

36. Early use of Caffeine (0-2 days) • Decreased incidence of death (OR, 0.90; 95% CI, 0.82 to 0.98) • BPD (OR, 0.507; 95% CI, 0.396 to 0.648) • IVH (OR, 0.540; 95% CI, 0.364 to 0.801) • PVL (OR, 0.560; 95% CI, 0.494 to 0.635) • ROP requiring laser (OR, 0.447; 95% CI, 0.223 to 0.897) J Korean Med Sci. 2015 Dec;30(12):1828-35.

37. Nutrition Bundle • Early and Aggressive Enteral Nutrition • Colostrum on Day 1 • Rapid progression of feeds (trophic feeds to nutritive feeds: 30 ml/kg/day) • Human Milk Fortifier once on full feeds • Kangaroo mother care • Early and Aggressive TPN/ELBW • 3 to 4 gram Protein and Lipid • Continue till 100ml/kg/day of Enteral Feeds Mothers Own Milk PDHM Time to reach full feeds/ Time to regain birth weight

38. Breast feeding Wheel

39. 29 Operational

40. CLABSI Bundle Line Insertion • Hand hygiene • Maximum barrier precautions • Chlorhexidine skin prep Line Maintenance • Multimodal education and training • Check entry site for inflammation • Dedicated lumen for TPN • Daily review for line necessity

41. VAP prevention Bundle • Hand hygiene • Endotracheal tube care • Head elevation 30/ higher, lateral position • Off sedation • Oral hygiene • Daily assessment of readiness to wean

42. Kangaroo care • Improved - growth - breast feeding rate • Reduced nosocomial infections • Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, et al. A RCT kangaroo mother care: results of follow-up at 1 year of corrected age. Pediatrics 2001;108:1072–9.

43. Kangaroo Care -Coverage

44. Developmental Supportive Care

45. Family Centered Care • Encourage parents to observe their infants behaviour /cues • Teach parents to identify infant’s readiness for touch and handling • Encourage parents to assist with - cares - gentle touch, - containment

46. Impact of intervention packages SNCU

47. Greatest challenge

49. New Initiatives • Neonatal Package –Ayushman Bharat • Pneumococcal vaccine • Hearing screening –OAE/BERA • Quality improvement projects

50. To summarize …. • Cost effective interventions play a major rule • Quality survival is the goal • The growth trajectory to be closely monitored • Follow up into child hood mandatory