Neonatal Care: Past, Present and Future Professor Dr Mohammod Shahidullah Department of Neonatology, BSMMU President, Bangladesh Paediatric association (BPA) President, Federation of Asia Ocenia Perinatal Society (FAOPS) Chairman, National Technical Working Committee , (NTWC) , Bangladesh
Presentation Outline • Introduction • Basics of Neonatal care & its organization • Evolution of neonatal care in Bangladesh • Neonatal care in the past • Neonatal care at present • Visionary for future neonatal care
Introduction Standard facility care for sick newborn had been a priority area at all times
What Evidence says……. • Scale-up of full supportive care of sick k newborn at facility for r pre re-term rm newborn rn, , sepsis, jaundice etc. have the potential effect of re reducing neonatal mortality in high burd rden countries. Lancet ‘Every Newborn Series 3’: Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Page 12-13
Basics of newborn care at facility Fluid & Thermal nutrition Care Infection control Respiratory support
Organization of neonatal care Allocated Space Infrastructure Supplies Neonatal Care Equipments Human Investigations resources Laboratory & In house
What was the reality • Till eighties preventive and public health programmes got due importance • Budget allocation for developing & maintaining neonatal care unit was insufficient • Establishing standard neonatal care unit was in fact economic burden for the national health care system
How neonatal care started its journey? • E nthusiasm among paediatricians initiated care for newborn in this country • Neonatal care at facility thereafter evolved a lot through a long journey over last 4 decades • Last 4 decades can be divided into two era: - past and present • Current concern is - the era to come in future.
Neonatal Care:The Past
Evolution of the Care • Medicine • Pediatrics • Neonatology
The Past….. • The past began in early eighties • Ended in the last century • The span was a period of twenty years • Only one or two tertiary care hospitals started this type of newborn care
Neonatal Unit: Brief History Year Place Key Person 1978 Dhaka Shishu Hospital Prof Khaleda Banu 1981 IPGM&R Prof M R Khan 1982 Dhaka Medical College Prof Maleka Khatoon 1986 Sir Salimullah Medical Prof M A Rob College
IPGM&R Dhaka Medical College Dhaka Shishu Hospital
The Past : Quality of care • Quality of care was very primitive and not organized • Few beds allocated for sick newborns inside the paediatric ward • No trained nursing staff • Thermal care was not optimal nor meticulous to keep in neutral thermal zone (NTZ) • Few closed incubator in some tertiary care hospital
Neonatal Care along with general Paediatric Care
Incubator
Quality of care…. • Enteral nutrition was offered by NG tube • Venous access was difficult • IV infusion given with butterfly needle in eighties • Use of I/V canula and microburette started in nineties • Lack of availability of micro infusion pump was a challenge to provide infusion for preterm babies • Parenteral nutritient was only glucose
Microburette & Butterfly Needle
Quality of care …….. • Intravenous access for medication was only possible in few tertiary care hospital • For district hospitals and below intramuscular medications were used • Capillary blood glucose ( CBG) estimation was established in nineties • Blood sample collection was a difficult task & investigations were seldom done
Quality of care……. • Respiratory care was only with supplemental oxygen from cylinders • No central supply of respiratory gases • No monitoring device for status of oxygenation & no scope for doing arterial blood gas (ABG)
Oxygen Cylinder as a source of Oxygen therapy
Neonatal Care: at Present
Neonatal care at present…… • The present era began from the beginning of the new millennium • There has been significant progress as due emphasis has been given on neonatal health • Neonatal care has been organized at all level of health care facilities • Infrastructure has already been developed • Equipment/supplies have been provided
Neonatal care at present…… • Trained human resources are being developed • Professional bodies (BNF, BPA, PSB ) have come forward for developing neonatal health care • Developing partners are coming forward with all support • Generation of competent neonatologists are on the way
Neonatal care at present…… • Private sector has also taken the lead in establishing neonatal units based on Western standards of equipments and personnel
Neonatal care set up : current Bangladesh Perspective • BSMMU • BIRDEM • Dhaka Shishu Hospital • Medical Colleges • Corporate Hospitals • District & Upazila hospitals
NICU,BSMMU Yellow Block
NICU, BSMMU Main Entrance
Upgrading District Hospitals with SCANU
Geographical Coverage for SCANU Existing SCANU (41) Planned SCANU (9) Existing SCANU UNICEF-30 SDF-10 JICA-1 Planned SCANU UNICEF- 6 Mamoni-3
Strengthen Service Delivery Capacity Development of Human Resource • 550 medical officers and around 1200 nurses were trained in the Emergency Triage and Treatment for sick newborns (ETAT) at BSMMU and other training centers during 2011-15 • More than 100 SSNs have been provided long term (30 days) training on SCANU SOP at BSMMU • A visual learning tool on SOP was developed by UNICEF with technical support from BSMMU and professionals 31
Quality of care • Incubators and radiant warmers are being used in all level of care meticulously by trained staffs • Intravenous access is no longer difficult • Accurate administration of IV fluids with the use of syringe/infusion pump is a turning point for caring extremely preterm infants • Minimal enteral nutrition (MEN) with expressed breast milk and addition of amino acid as parenteral nutrient are being employed for nutritional care
Portable Warmer Radiant Warmer
Infusion Pump & Syringe Pump
Paradigm shift • Convulsion Per Rectal Diazepam PHB • Perinatal Asphyxia -Oradexon ,NHCo3, 10%Calcium gluconate, 25%glucose 10% glucose , Adrenalin,Phenobarbitone,NS
Quality of Care …… • A significant improvement in respiratory care has been observed in the last decade • Use of surfactant in many tertiary and corporate hospitals has brought a dramatic change in respiratory morbidities in preterm babies • Respiratory support with CPAP, IMV/SIMV are available in many centres
Mechanical Ventilator
Cardiac monitor Cardiac Monitor CPAP
Surfactant Therapy
Quality of Care …… Monitoring of respiratory status using pulse oxymeters and arterial blood gas (ABG) are wide practised Electronic monitoring of cardiorespiratory status Newer phototherapy strategies include LED phototherapy, bili-blankets jin addition to conventional phototherapy
Phototherapy Unit
Quality of Care …… There are ample scope for doing different laboratory tests In-house facilities for bed side X rays, Echo, USG are increasingly available Neonatal surgery are increasingly being done more with better outcome now a days
Bed Side In House ABG analyser Echocardiogram
Quality of Care ….. Neonatal screening programmes like ROP, Hearing Screening, Thyroid screening, Developmental screening are the promising activities practised in some tertiary care centres to prevent future disabilities
ROP screening
Neonatal Care: at Future
Neonatology Future in Bangladesh
Therapeutic Hypothermia (TH) • Neonatal encephalopathy(NE) from Perinatal asphyxia, occurs in 2.0–6.0 / 1000 live births • Intellectual delay and cerebral palsy are often severe. • TH is the gold standard in NE • Two types of TH Selective head cooling Total body cooling
Therapeutic hypothermia…… Limitations: High cost of equipment Meticulous care Trained care giver (doctor, nurses )
Total Perenteral Nutrition • Nutrition for preterm in NICU • Any infant unable to tolerate adequate enteral feeding for more than 2-3 days PN support. • PN and/or enteral nutrition should begin within 24 hours after birth .
TPN • Who are the candidates? All preterm less than 32 weeks Late preterm and term babies unlikely to reach full oral feeds within 5 days Any surgical condition involving GIT • Advantages: Better weight gain Better metabolic homeostasis Less risk of Osteopenia of prematurity
TPN • Advantages: Easy to manage acid base disorder Easy to optimize nutrition despite severely ill condition which enhances growth and development in extremely premature babies • Limitation: Requires trained manpower (preferably dietician/nutritionist) High cost
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