Browsing by Subject "Neonatology"

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    Correlation between transcutaneous bilirubin and total serum bilirubin levels among preterm neonates at Groote Schuur Hospital
    (2012) Yaser, Abdallah; Rhoda, Natasha; Tooke, Lloyd
    Includes abstract. Includes bibliographical references.
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    The development of a neonatal vital signs database
    (1992) Berelowitz, Jonathan; Poluta, Mladen; Woods, David R; Van der Elst, Clive; Mann, Michael D
    Modern intelligent monitoring systems use digital computer technology to analyze and evaluate physiological vital signs. This analytical and evaluative process is performed by algorithms developed for this purpose. The degree of 'intelligence' of the monitoring system is dependent on the 'sensitivity' and 'specificity' of these algorithms. In order to develop robust and clinically valid algorithms, a database of representative waveforms is required. The aim of this thesis was to create a neonatal vital signs database to be used for this purpose, by means of a computer-based central station. The computer was interfaced to a number of neonatal monitors (Neonatal ICU, Groote Schuur Hospital). The monitors were interrogated to obtain patient condition, ECG waveforms and respiration waveforms using the impedance technique. When possible, percentage oxygen saturation was also captured. The database contains 509 documented clinical records obtained from 35 patients and 20 records containing examples of technical alarm conditions and high frequency noise. Additional patient record data is included. Clinical events recorded include apnoea, bradycardia, periodic breathing tachycardia, tachypnoea and normal traces. These events were recorded against a variety of signal quality conditions that have been characterized in Appendix C. A prototype rate detection algorithm was checked using samples from the database.
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    Factors associated with provision of mothers' own breast milk for Very Low Birth Weight (VLBW) infants on a South African tertiary care neonatal unit
    (2017) Mutesu-Kapembwa, Kunda; Raban, Moegammad Shukri; Joolay, Yaseen
    Background: The maternal struggle to provide adequate breast milk for the infants' nutritional needs disadvantage preterm infants as the outcomes of those exclusively breast milk fed are superior to those fed infant formula. Objectives: To determine the proportion of Mothers' Own breast Milk (MOM) consumed by very low birth weight (VLBW) infants at Groote Schuur Hospital and explore potential maternal difficulties to provide MOM. Methods: In a prospective cross sectional study of 104 VLBW infant-mother dyads admitted between January and May 2015, an interviewer administered a structured questionnaire to the participating mothers before day 3 and on day 14. Infant folders were reviewed for gestational age, weight, and mode of delivery and the proportion of MOM received on days 1, 7 and 14 of life. Results: Ninety-one (88%) infants received <25% of enteral feeds as MOM on day 1. MOM made up >75% of enteral feeds in 60 infants (62%) on day 14 of life and 56(57.7%) received 100% as MOM. Infants with 2 or less siblings (22.2% vs 33.7% p=0.010) received a greater proportion MOM on day 14 as compared to those with larger families. 85.7% of the interviewed mothers would have preferred to stay in the hospital with their infants post discharge. Infant's weight, mode of delivery, maternal age, HIV status, hypertension, breastfeeding counselling, income, transport mode or distance from the hospital had no impact on MOM provision. Conclusion: Domestic responsibilities may affect mothers' breast milk provision to the newborn preterm. Breast-feeding counselling did not improve breast milk provision in this study. The effectiveness of current counselling methods may need to be examined and improved. Facilitating accommodation and rooming in of mother infant pairs from delivery to discharge may be useful in improving MOM provision to VLBW infants.
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    Growth velocity of extremely low birth weight preterms at Groote Schuur Hospital nursery
    (2011) Lango, M O
    To describe the growth velocity of extremely low birth weight babies seen at Groote Schuur Hospital nursery and to compare this to growth velocities of similar babies in published literature.
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    The influence of birth site on short-term outcomes of encephalopathic newborn infants treated with therapeutic hypothermia at Groote Schuur Hospital, Cape Town, South Africa
    (2015) Nakibuuka, Victoria; Horn, Alan R; Rhoda, Natasha R
    Background: International consensus guidelines recommend that term or near-term newborns with moderate or severe hypoxic ischaemic encephalopathy (HIE) should be treated with induced hypothermia within 6 hours of birth, but many of the affected babies are born outside treatment centers. There are conflicting data describing the influence of birth site on outcome after HIE - and no published data from South Africa. Objective: To compare the frequency of abnormal outcome (mortality or abnormal aEEG) before discharge between inborn and outborn infants treated with hypothermia Methods: This was a retrospective analysis of data extracted from a prospectively collated registry of babies with moderate or severe HIE, treated with hypothermia in a tertiary hospital in South Africa, between 1 January 2011 and 31 December 2012. Results: A total of 57 babies were treated with hypothermia of which 23 (40%) were inborn and 34 (60%) outborn. Cooling was initiated earlier among the inborn babies (age 2.3 hours vs. 4.3 hours, p=0.002). Pregnancy complications and abnormal intrapartum fetal heart rates occurred more frequently in inborn infants (65.2 % vs. 24.2 %, p=0.0001 and 47.8% vs. 20.6%, p =0.03 respectively). More outborn babies died or had an abnormal aEEG at 48 hours (32 % vs. 22 %, p=0.556) and fewer outborn babies achieved normal feeding at discharge (22% vs. 38%, p = 0.189), but these differences were not statistically significant. Conclusion: The majority of infants treated with induced hypothermia in an urban/peri-urban setting in South Africa were not born in a cooling centre. There were significant delays in initiating cooling among the outborn babies. Short-term morbidity and mortality were not significantly different in outborn babies but interpretation is limited by the small sample size.
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    Morbidity and Mortality in small for gestational age very low birth weight infants in a middle-income country
    (2021) Mangiza, Marcia; Tooke, Lloyd; Rhoda, Natasha Raygaan
    Objective: To evaluate the impact of small for gestational age on outcomes of very low birth weight infants at Groote Schuur Hospital, Cape Town, South Africa. Study design: Data was obtained from Vermont Oxford Network Groote Schuur Hospital database from 2012 to 2018. Fenton growth charts were used to define small for gestational age as birth weight < 10th centile for gestational age. Results: Mortality (28.9% vs 18.5%, adjusted risk ratio (aRR) 2.1, 95% confidence interval (CI) 1.6-2.7), bronchopulmonary dysplasia (14% vs 4.5%, aRR 3.7, 95% CI 2.3-6.1) and late onset sepsis (16.7% vs 9.6%, aRR 2.3, 95% CI 1.6-3.3) were higher in the small for gestational age than in the non-small for gestational age group. Conclusion: Small for gestational age infants have a higher risk of mortality and morbidity among very low birth weight infants at Groote Schuur Hospital. This may be useful for counseling and perinatal management.
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    Quality of neonatal cranial ultrasound Interpretation among doctors in the Western Cape Metro: a clinical survey
    (2023) Belay, Fitsum; Pillay, Shakti; Horn Alan
    Background: Cranial ultrasound (cUS) is a recommended skill for paediatric and neonatal trainees in South Africa. Surveys in other countries showed inadequate knowledge and subsequently a global trend towards standards and training recommendations. There are no guidelines for training of clinicians performing cUS in South Africa. Objectives: To survey the following aspects of cUS among paediatric and neonatal trainees in the University of Cape Town (UCT): duration of paediatric training, experience and supervision; knowledge of reporting content, procedural and technical aspects; interpretation of common neonatal cUS pathologies and confidence in scan interpretation and counselling. Methods: An online survey was sent to all trainees, who had worked at least one month at a neonatal unit on the UCT training platform. The survey included seven questions on cUS interpretation. Procedural and image knowledge was compared between groups with ≥ 24 months' experience versus shorter duration. Results: Thirty-one paediatric registrars and five neonatal subspecialty senior registrars were sent the survey. Twenty-six surveys were returned (72%). None of the trainees had attended a formal cUS course, 18 (69%) had attended a formal lecture from a neonatologist, and 8 (30%) had attended a formal tutorial from a consultant. Ten (38%) trainees received initial training from other registrars, medical officers, or self-study. The components of a cUS report were stated as description of anatomy and haemorrhage by 24 (92%) and 21 (81%) respectively; only 17 (65%) mentioned ventricular size and other aspects of reporting were less frequently mentioned. Only 7 (27%) trainees knew the correct number of images to be taken in the coronal and sagittal planes. Correct identification of the major features of images ranged from 12% to 92% but was below 40% in five questions. Duration of training only affected answers in two questions; trainees with ≥ 24 months experience were more likely to correctly identify a normal scan (58% vs. 14%; p=0.038) and less likely to assign abnormal prognosis in a term infant with increased white matter echogenicity (0% vs. 43%; p=0.017). Conclusions: Our survey shows inadequate and variable cUS training and competency in paediatric and neonatal trainees in our institution. The findings indicate the need for a structured training program and standardised diagnostic and training criteria to accredit clinicians who perform and report on neonatal cUS.
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    Rapid versus slow rate advancement of feeds for enterally fed extremely low birth weight infants < 1000g: randomised controlled trial
    (2014) Raban, Moegammad Shukri; Harrison, Michael C; Horn, Alan R; Modi, Neena
    Background The timeous achievement of full enteral nutrition in a preterm infant is a critical prerequisite for optimal growth, neurodevelopment and long-term wellbeing. However, the optimal enteral feeding regimen for preterm infants has not been established, and wide variations occur in practice. The debate on the most appropriate feeding strategy is nuanced by studies suggesting that early introduction of enteral feeds and the rapid advancement of enteral feeds may increase the risk of feeding intolerance and may be involved in the pathogenesis of necrotising enterocolitis (NEC). Objective 1. To review randomised controlled trials (RCT); examining the effect that the rate of advancement of enteral feeds has on the incidence of; NEC, mortality, growth, health care utilisation and other morbidities in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants. 2. To establish the safety and efficacy of commencing enteral breast milk feeds at 24 ml/kg/day on the day of birth and advancing enteral breast milk feeds at 36 ml/kg/day, in infants weighing ≤ 1000 g.
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    Retinopathy of Prematurity in a cohort of neonates at Groote Schuur Hospital
    (2016) Keraan, Qaunitah; Joolay, Yaseen; Horn, Alan
    Background: Screening for Retinopathy of Prematurity (ROP) is recommended to prevent possible blindness. Prior to 2016, resource limitations precluded routine ROP screening at Groote Schuur Hospital (GSH). Previous pilot studies at GSH did not detect ROP requiring treatment. However, improved survival of very low birth weight infants may affect the prevalence of ROP. Objectives: The study objectives were to: i) Determine the prevalence and severity of ROP in a prospective cohort of premature infants; ii) Describe the association with pre-specified potential risk factors; iii) Assess the feasibility of screening for ROP in our resource-limited setting. Methods Infants with a birth weight of < 1251 g or gestational age < 31 weeks admitted to the GSH neonatal unit from November 2012 to May 2013 were screened. A paediatric ophthalmologist examined the infants at 4 weeks chronological age or 32 weeks corrected gestational age, with follow-up examinations as indicated. Results: Screening was performed in 135 of 191 eligible infants. A total of 313 ROP examinations were performed; 38.5% of infants required a single examination and 16.3% required more than four. The mean gestational age and weight at birth were 30.1 ± 1.9 weeks and 1056 ± 172 g respectively. Seventy-four infants were female (54.8%). Only black (57.0%) and coloured (42.9%) infants were represented. ROP was diagnosed in 40 (29.6%) infants: Eight (5.9%) infants had clinically significant ROP. No infants had stage 4 or 5 ROP. No infants weighing more than 1250 g required treatment. Two infants received laser treatment. Infants with ROP had a lower mean gestational age and lower mean birth weight than those without ROP: 29.2 ± 1.6 vs. 30.5 ± 1.9 weeks (P < 0.002) and 988 ± 181 g vs. 1085 ± 160 g (P = 0.001) respectively. Infants with ROP were more likely to have received a blood transfusion (P < 0.002); to have late onset sepsis (P = 0.024); and to have receive d exclusive breast milk feeds (P = 0.005). There were no significant differences in the level of respiratory support, the need for oxygen therapy, the occurrence of apnoea, early sepsis or severe intraventricular haemorrhage in infants with ROP compared to no ROP. On multivariate analysis, only gestational age was independently associated with ROP was gestational age (RR 0.85; 95% CI 95% 0.740 - 0.988; p=0.03). When gestational age was excluded in post-hoc analysis, birth weight (RR 0.99; 95% CI 0.997 - 0.999; P=0.03) and blood transfusions (RR 1.71; 95% CI 1.0 27 - 2.859; P=0.03) were independently associated with ROP. Infants <1000 g had a 2.5 times higher risk of having ROP than their larger counterparts (95% CI 1.05 - 5.90, P=0.03). ROP screening was completed in 91.1% (123/135) of infants. Conclusion Clinically significant ROP was found in this study. In contrast to previous studies conducted in this setting, two patients received laser treatment. Extensive resources were required for successful screening. The strong association with birth weight and gestational age suggests that infants with lower birth weights and gestational ages should be prioritized for screening in our resource-limited setting.
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    The short-term outcomes of HIV-exposed versus HIV-unexposed very low birth weight infants
    (2017) Riemer, Linda Jane; Tooke, Lloyd
    Introduction: HIV exposed but uninfected infants have been shown to have a higher morbidity and mortality than unexposed infants. There is almost no literature comparing the short-term outcomes of HIV exposed versus unexposed VLBW neonates who are born prematurely. Methods: A retrospective review of all VLBW neonates who were admitted at Groote Schuur Hospital nursery from 2012-2014. Data were obtained from the Vermont Oxford Database and the Prevention of Mother to Child register. Results: A total of 1593 VLBW neonates were admitted during the 3 years of which it was possible to obtain maternal HIV status in 1579 babies. Of these 1579 babies, 316 (20%)were HIV exposed. Eleven of the 230 (4.8%)infant HIV tests were positive. There was no difference in mortality, birth weight, gestational age, length of stay, sepsis and delivery room outcomes for the HIV-exposed (HIVE), maternal ARV-exposed (mARVE) and HIV-positive neonates. Differences between HIV exposed and HIV unexposed neonates were noted in an increased risk of NEC [OR 1.83 (1.2-2.8)] and an increased need for ventilation [OR 1.35 (1.01-1.8)]. Maternal antiretroviral exposed neonates developed less NEC compared with maternal antiretroviral under-exposed neonates with a birth weight under 1000grams appearing to contribute in the development and outcome of NEC. Differences in HIV-positive neonates included more chronic lung disease [OR 5.49 (1.31-23)] and more necrotising enterocolitis [OR 4.12 (1.02-17.18)]. Conclusion: This study is the first to compare the short-term outcomes of HIV exposed and HIV unexposed very low birth weight infants and consider maternal ARV exposure. It demonstrated no difference in birth weight, gestational age, mortality or sepsis. Necrotising enterocolitis is increased in the HIV exposed neonates especially if they are under-exposed to maternal antiretrovirals. Adequate maternal antiretrovirals may have a protective effect on incidence of necrotising enterocolitis and respiratory outcomes.
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    Short-term outcomes of inborn vs out-born very low birth weight neonates (< 1500 g) in the Groote Schuur neonatal nursery
    (2018) Gibbs, Lyndal; Harrison, Michael
    Background and aim: The Groote Schuur Hospital (GSH) Neonatal Nursery provides Level 3 care for the Metro West Health District in the Western Cape. Worldwide, VLBW neonates have improved outcomes when delivered in Level 3 neonatal units, compared with those who are transported from other facilities. This study aims to identify the characteristics and clinical outcomes of our VLBW patients, with emphasis on differences between inborns and outborns. Methodology: A retrospective cohort study. VLBW neonates admitted to the GSH Neonatal Nursery between 1 January 2012 and 31 December 2013 were enrolled on the Vermont Oxford Network database and reviewed. Maternal and infant characteristics, and outcomes at the time of discharge from hospital were analysed. Results: A total of 1032 VLBW neonates were enrolled. 906 (87.8%) were delivered at GSH, and 126 (12.2%) were outborn. Access to antenatal care, antenatal steroids and inborn status were statistically significant predictors for mortality and survival without morbidity. The mothers of inborn patients were more likely to have received antenatal care (89.1% vs 57.9%, p <0.0001) and antenatal steroids (64.2% vs 15.2%, p <0.0001). Inborns required less ventilatory support (16.2% vs 57.9%, p <0.0001) and surfactant administration (25.3% vs 65.1%, p <0.0001). Inborns had a lower incidence of late infection (8.8% vs 23.4%, p <0.0001), severe intraventricular haemorrhage (3.7% vs 13.9%, p <0.0001) and chronic lung disease (5.3% vs 13.4%, p =0.003). The incidence of necrotising enterocolitis was similar between the two groups (5.9% vs 8.7%, p =0.227). 18.4% of inborns and 33.3% of outborns demised (p <0.0001), mostly on the first 2 days of admission. Mortality declined as birth weight increased. Of the survivors, 83.5% of inborns and 70.2% of outborns did not develop serious morbidity (p =0.003). Significant morbidity and mortality was noted in the outborn group weighing 800g and less, with only one outborn patient in the cohort surviving to discharge without major morbidity. Conclusion: VLBW neonates delivered at Groote Schuur Hospital had better outcomes than their outborn counterparts. Perinatal regionalisation is beneficial to our patients, with antenatal care, timeous in-utero transfer and antenatal steroids contributing to excellent outcomes.
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    Strengthening Antibiotics Stewardship At Mowbray Maternity – Neonatal Unit
    (2023) Mkony, Martha; Rhoda, Natasha Raygaan
    Objective To assess antimicrobial usage, prescription practices, sensitivity patterns, hand hygiene (HH) practices and adherence to antibiotic stewardship principles in the neonatal unit at Mowbray Maternity Hospital (MMH). Study design: Mixed method observational study was done at MMH. A point of prevalence survey to assess antibiotic stewardship and HH audits were conducted using the WHO tools in two phases, a baseline in December 2020 and post-intervention from March to May 2021. Results: 246 Neonatal unit patient folders were reviewed between December 2020 and May 2021. At baseline, compliance with treatment guidelines was 90% which improved to 100% post-intervention. We found 37(15.0%) babies were on antibiotics, with 64.9 % of those on first-line antibiotics (Access group). Using multivariate logistic regression, extremely preterm infants were more likely to be on antibiotics with an odds ratio of 11, which was statistically significant. We found eight organisms (18.9%), which included one Carbapenem-resistant enterococci -Klebsiella pneumoniae. For HH, a total of 444 opportunities were observed. Moment 5 had the lowest overall mean compliance of (57.4%), which was statistically significant with a p-value =0.0172. The overall HH compliance was 83.7% at baseline and 80.9% post-intervention; however, this was not statistically significant (p-value = 0.909). Conclusion: Strict adherence to treatment guidelines and good HH are essential factors for the good antibiotic stewardship seen at the MMH neonatal unit. This was reflected by low antibiotic usage, good HH compliance and low HAI rate. Further improvement requires ongoing HH audits and training, especially focusing on HH moment 5, after touching the patient's surroundings.
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    Symptomatic congenital syphilis in a tertiary neonatal unit: a retrospective descriptive study
    (2016) Pillay, Shakti; Tooke, Lloyd
    Background: Syphilis is a disease that was first described in the 1300s and now 700 years later, despite preventive measures and effective treatment, continues to impact on a global scale, with the burden falling largely on the developing world. We could find no recent published literature looking at predictors of outcomes in neonates born with symptomatic congenital syphilis, especially in the context of a tertiary neonatal setting. Methodology: The study design was a retrospective descriptive folder review of neonates born with symptomatic congenital syphilis at Groote Schuur Hospital (GSH) from January 2011 to December 2013. One of the primary objectives was to address outcome as well as look at modifiable preventable factors. All neonates treated at GSH (inborn and outborn) who tested serologically positive for syphilis together with clinical signs of syphilis were included. Data was obtained from the National Health Laboratory System (NHLS) database, as well as the notification and death registers at GSH nursery. All data was collected in a Microsoft excel spread sheet and analysed using Microsoft StatPlus. Results: Fifty of eighty neonates (62.5%) with positive syphilis serology as well as clinical signs of congenital syphilis were included together with their fifty mothers. The majority (98%) of mothers were inadequately untreated. Nineteen neonates demised. There were no statistically significant differences between the deaths and survivors in terms of gestational age (p = 0.15), birth weight (p = 0.08) or maternal age (p = 0.51). Two significant predictors of mortality were one minute and five minute Apgar scores of less than five ([RR], 3.5; 95% CI 1.6-7.7 and [RR], 2.9; 95% CI 1.5-5.3 respectively). Hydropic neonates, tended to be sicker at birth, requiring intubation and inotropes, which was associated with a poorer outcome (increased risk of mortality). Conclusion: Despite the introduction of a National Syphilis Screening programme more than twenty years ago together with a large proportion of pregnant women having access to antenatal care, congenital syphilis is still prevalent in South Africa. Failure to access antenatal care, poor partner tracing and a number of modifiable health worker related failures contribute to poor maternal diagnosis and treatment. Many neonates with congenital syphilis require aggressive interventions and there is a high mortality rate. This dissertation adds to the existing body of research particularly with regard to predictors of outcome in tertiary neonatal settings. Certain categories of neonates have a lower survival rate and guidelines about limitation of care may need to be considered in order to optimise resource allocation particularly in resource-constrained settings. Further research is required to elaborate how best to develop protocols in these neonates.
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    The use of inhaled nitric oxide to treat persistent pulmonary hypertension of the newborn in a tertiary public hospital in South Africa from 2010-2014: morbidity, mortality and cost
    (2018) McAlpine, Alastair; Horn, Alan R; Tooke, Lloyd
    Background and rationale: Inhaled nitric oxide (iNO) is recommended for the treatment of severe persistent pulmonary hypertension of the newborn (PPHN) because it reduces the need for extracorporeal membrane oxygenation (ECMO). There is insufficient evidence that iNO reduces mortality in the absence of ECMO. Although neonates in some South African public hospitals have access to iNO, ECMO is not available. Oral sildenafil can be effective in settings where iNO is not available, but its effect on outcome and cost of treatment in this setting have not been described. The literature review in the first part of this thesis describes five studies reporting short-term outcomes of PPHN in the absence of ECMO. No studies from South Africa were identified. Only two studies described outcomes after iNO – the coadministration of Sildenafil with iNO was only reported in one small study. There were insufficient published data to guide management in settings where ECMO is not available. Aim: To describe a cohort of term and near term neonates with PPHN who were treated with iNO, with or without sildenafil, in a tertiary neonatal unit in South Africa Objectives: (i) to describe the characteristics at birth, the clinical course, and shortterm outcomes; (ii) to determine if any variables were associated with mortality; (iii) to describe the relationship between the use of sildenafil and cost of care, represented by the duration of intubation and iNO use; and (iv) to describe the frequency of sildenafil prescription. Methods. A retrospective review was carried out on folders of neonates with PPHN who were treated with iNO in Groote Schuur Hospital, Cape Town, South Africa, between January 2010 and December 2014. Results. Forty neonates were included – most were full term (85%). Meconium aspiration syndrome (MAS) was the commonest cause of PPHN (50%), followed by intrapartum hypoxia (20%), sepsis (17.5%), pulmonary hypoplasia (7.5%) and idiopathic (5%). Fourteen neonates (35%) died. Pulmonary hypoplasia and pneumothorax were associated with mortality (p=0.037 and p=0.004 respectively). An FiO2 of 1.0 and an iNO dose of ≥ 20 ppm at 24 and 48 hours respectively, both predicted death (specificity 89% vs. 100%, sensitivity 67% vs. 43% and p=0.003 vs. p=0.007 respectively). Sildenafil was prescribed more often after 2011 (83% vs. 65%) and was associated with increased survival (p=0.018) – early administration was associated with a shorter time to extubation (p=0.012) and a shorter course of iNO (p=0.044). Conclusion. The treatment of PPHN with iNO in the absence of ECMO was associated with high mortality, particularly in neonates with congenital lung abnormalities. The FiO2 and iNO requirements at 24 and 48 hours respectively could be used to identify neonates who are unlikely to benefit from continued treatment. Sildenafil was prescribed with increasing frequency during the study. The combination of iNO with sildenafil was associated with more cost-effective care and improved short term outcomes. These findings provide a potential basis for costsaving measures and resource allocation.