Premature and Low Birth Weight(NICU)at Pediatric Department

(Kampong-Cham Provincial Hospital)

LORN TRY Patrick,MD,DES,AFSA,DCH,DHMAssist.Professor of Pediatric,IU,SHUChief of Pediatric Department,Deputy directorKampong.Cham Provincial Hospital

Layout of the presentation

• Epidemiology

– Under-5 mortality in Cambodia

– Date on prematures/LBW in neonate unit, Kampong Provincial Referral Hospital (PRH)

• Criteria for admission of neoanates

• Referral form for neonates

• Management of premature/LBW

– Score de FARR

Layout of the presentation

• Management of premature/LBW

– Classification of newborns by intrauterine growth & gestational age

– Score de Silverman (respiratory distress)

– Management of premature/LBW

– Use of steroids and its outcomes

• Challenges, lessons learnt and ways forward

Under-5 mortality in Cambodia

• Cambodia continues to suffer from very high neonatal mortalities:

– 28/1000 live births (CDHS2005);

– 27/1000 live births (CDHS2010),

– 18.4/1000 lives birth (Report 2013, New York, UNICEF,2013) WHO Western Pacific Region

.

Problem and problem analysis, Kampong Cham PRH, 2009-2014

39%42%

48%53% 52%

56%

28%24% 23%

19% 21% 19%

33% 34%29% 28% 26% 25%

0%

10%

20%

30%

40%

50%

60%

2009 2010 2011 2012 2013 2014

Pe

rce

nta

ge

Years

Premature birth asphyxia infection

Causes of neonate deaths, Kampong Cham PRH, 2013 (N=111),2014

80

20

92

102

19 16

1

Premature Birth asphyxia Infection Neo tetnus

0

20

40

60

80

100

120

Causes of deaths

Nu

mb

er

of

de

ath

s

2013 2014

Number of Neonates admitted to the Neonate Unit and Its CFR (%) (N=1009), 2011-2012 (17 months)

9

103

556

333

8

89%

42%

10% 7%0% 0%

20%

40%

60%

80%

100%

0

100

200

300

400

500

600

< 1 1-1.5 1.6-2.5 2.6-3.9 >4

CFR

(%

)

Nu

mb

er

of

Ne

on

ate

s

Weights of Neonates (Kg)

Number of Neonates CFR

Number of Neonates admitted to the Neonate Unit and Its CFR (%) (N=1038), 2014 (12 Months)

11

150

515

350

13

100%

39%

8% 8%0% 0%

20%

40%

60%

80%

100%

120%

0

100

200

300

400

500

600

< 1 1-1.5 1.6-2.5 2.6-3.9 >4

CFR

(%

)

Nu

mb

er

of

Ne

on

ate

s

Weights of Neonates (Kg)

Number of Neonates CFR

ADMISSION CRITERIA

• Low birth weigh < 2000 g

• Birth asphyxia ( Apgar score 3 at 0 mn or < 7 at 5 mn)

• Fever of mother T0 ≥ 380 c (before or at delivery)

• Premature rupture of membrane > 18 hours

• Premature rupture of membrane > 12 hours + bad coloration (green) or bad smelling of amniotic fluid.

Prepare by Dr.LORN TRY Patrich,Pediatrician,Deputy director of

hospital10/23/2011 9

ADMISSION CRITERIA (con’t)

• Other signs of baby :

– Respiratory Distress syndrome

– Central or peripheral cyanosis

– Jaundice in 24 hours of life

– Convulsion

– Vomiting

– Fever > 38o c

– Bleeding

– No succion , No cry

Prepare by Dr.LORN TRY Patrich,Pediatrician,Deputy director of

hospital10/23/2011 10

11

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Management

Management of Premature/LBW in Kampong Cham PRH

• Put in incubator

• Blood glucose

• Fluid IV (D 10%) 3 days after that change

• AB by National Guideline Neonatal sepsis

• Nutrition Enteral (by nasogastric tube) if weight <1500g (Breast milk)

Management of Premature/LBW in Kampong Cham PRH (con’t)

• Vit K

• CPAP or intubation if RDS

• Discharge with KMC at home

• Follow up in 2 Months (Exam Ophtalmology, Psycomotor developpement , Iron supplementary)

Correlation between use of steroids and CFR, Kampong Cham PRH, 2012, 2014

18

14

0

2

4

6

8

10

12

14

16

18

20

0 10 20 30 40 50 60 70

CFR

(%

)

Use of steroid (%)

Challenges

• Intensive work with close monitoring

• Shortage of staff

• Lack of materials and maintenance not in place

• No transport system of babies to NICU

• Space is not permitted to implement KMC

• No feedback information for the babies who are referred to other health facilities

• Limited space of the NICU and increased number of admission

Prepare by Dr.LORN TRY Patrich,Pediatrician,Deputy director of

hospital10/23/2011 20

Lessons learnt• Annually increased number of sick newborns

admitted to NICU

• Improved care, especially mothers with complications and other underlying diseases (HBP, eclampsia, and urinary tract infections , diabetes, chorioamniolitis, …. )

• Improved practices of sick children

– Emergency care of sick newborn

– KMC

– Breastfeeding

– Transfer of babies which requires further assistance from maternity ward

Lessons learnt (con’t)

• Improved post natal care (PNC)

– Early detection and referral of sick newborns

– Exclusive breastfeeding

– Hygienic cord/skin care

– Recognition of danger signs and knowing when to seek care

– Where referral is not possible, neonatal sepsis should be considered

• Stronger commitment of supports from management levels (MoH, PHDO, Hospital) and development partners

Ways forwardAdvocate for supporting the following:

• Increase number of staff and train them in neonatal care (MOH/PHDO/Hospital?)

• Expand the INCU and space for KMC (MoH/PHDO/Hospital/Partners?)

• Identify budget for purchasing and maintaining the equipments and for ensuring supplies (MoH/PHDO/Partners?)

• Identify appropriate referral system in the hospital from maternity ward to INCU

References

1. Action plan for healthy newborn infants in the Western Pacific region (2014-2020),WHO Regional office for the Western Pacific, ISBN 978 92 90616634,2014.

2. Safe Motherhood Clinical management Protocols referral hospital,National reproductive Health Program, Ministry of Health, June 2013 .

3. CPG Neonatal sepsis,Working group,MOH 2012

THANK YOU VERY MUCH