|
|
Annotations : ADVANCEMENTS IN NEONATOLOGY
Dr. Musa Mohd. Nordin FRCP (Edin) FAMM
Consultant Paediatrician & Neonatologist
Damansara Specialist Hospital
Reproductive success is influenced by the interplay of multiple factors namely genetics, environmental, social, antenatal disorders and the birth process. The newborn period represents a most vulnerable transition in life not only because neonates are most likely to die on the first day of life than at any other time but also because their health during this early neonatal period may have a bearing on their future health throughout childhood and even into adult life.
The decline in the perinatal, neonatal and infant mortality rates is a reflection of progress in various areas of activity. The raised Gross National Product has undoubtedly improved the socioeconomic well being of mothers, children and their families. Prenatal intervention through effective health education, nutritional support and family planning has helped to generate healthier mothers to face the stresses of pregnancy and labour and produce better babies. Perinatal intervention in the identification and obstetric management of high risk pregnancies and the provision of neonatal intensive care have contributed towards better care to the high risk mothers and babies.
Birthweight, a function of duration of gestation and rate of foetal growth is one of the most important factors determining survival of the neonate. Neonatal mortality increases exponentially as the birthweight falls below 2500 grams. The low birthweight ( LBW ) rate in Malaysia ( 8% ) is 2-4 times that of developed nations 1. Risk factors amenable to change through various interventional strategies include poor maternal nutrition, short birth intervals, teenage pregnancy, drug abuse, tobacco and alcohol consumption, infections and other complications of pregnancy.
Prematurity makes up approximately 5% of births but account for just over 50% of perinatal deaths. Unlike intrauterine growth restriction ( IUGR ), the aetiology of preterm birth is largely unknown. Research into the cause and prevention of preterm birth is being actively investigated. The survival of extremely premature infants ( less than 28 weeks ) in Damansara Specialist Hospital ( DSH ) is 82.3%. The gestational age specific mortality rates in DSH compares favourably with reported data from other Neonatal Intensive Care Units ( NICU and regional neonatal networks 2
Other major causes of perinatal deaths include perinatal asphyxia, infections and congenital malformations. The latter is expected to feature more prominently over the years. Increased investment in low cost technology such as resuscitation equipments, infant warming devices, infant transport incubators, appropriate hand washing facilities, assisted respiration with nasal Continous Positive Airway Pressure, rooming in facilities and the promotion of breastfeeding may generate higher payoffs in improved health outcome.
Neonatal salvage per se is sub-optimal and neonatal intensive care services must aim towards appropriate and quality neonatal care to minimise handicap, ensure intact survival and graduate more healthy survivors. One of our NICU graduate ( 7.1% ) had delayed developmental milestones consequent to post-haemorrhagic hydrocephalus and she also experienced visual impairment due to retinopathy of prematurity. Pooled data on 500 Extremely Low Birth Weight ( < 1000 grams ) survivors from studies published in the 1980s showed a median prevalence of 12% for cerebral palsy, 3% for blindness, 2% for deafness and 15% for developmental delay 3. Although the vast majority of ELBW survivors may be free from major neurodevelopmental disability, they may experience more subtle forms of morbidities which may impact on their ensuing behaviour and educational achievements. Hence the importance of a continuous, comprehensive and multidisciplinary program to follow up these ELBW survivors and their families and ensure appropriate interventions and support.
The regionalisation of perinatal services has rationalised the delivery of these cost and labour intensive NICU facilities and ensure appropriate care for the very sick newborn. In DSH, the average cost per ventilated survivor ( < 28 weeks ) was RM 64,040.00. The mean cost per non-ventilated survivor was RM 27,658.00. As a comparison, the cost per ELBW survivor in the NICU, Monash Medical Centre, expressed in the 1992 US Dollar value was USD 66,800.00 in 1991-92 4. Analysed from an economic perspective, neonatal intensive care is much more favourable than many other health care programs. The cost effective ratios are higher for bone marrow transplant ( 2x ), kidney transplant
( 3x ), heart transplant ( 5x ), liver transplant ( 8x ), renal dialysis ( 9x ), coronary bypass surgery ( 26x ) and coronary care ( 40x ).
The prohibitive cost and painful ethical issues frequently arise in the practice of caring for the sick newborn and are of major importance to the babies themselves, parents and professional staff. Hence the question is whether we can better afford the economic cost of providing appropriate standards of care for ill newborns or the moral cost of failing to do so. It is easy to forget that successful reproduction is the sine qua non for the biological survival of a community or culture.
REFERENCES
- Musa MN. A review of perinatal mortality and morbidity in Peninsular Malaysia from 1980 to 1989. M’sian J of Child Health 1993; 5:9-19
- Donoghue DA. Australian and New Zealand Neonatal Network 1994. Sydney, AIHW National Perinatal Statistics Unit, 1996.
- Musa MN. Outcome of extremely premature infants in Damansara Specialist Hospitall (1998 – 2000 ). KPJ Medical Digest 2002: April:9-12
- Victorian Infant Collaborative Study Group. Economic outcome for intensive care of infants of birthweight 500-999 g born in Victoria in the post-surfactant era. J Paediatric Child Health 1997; 33:202-8
|
 |
|
|
|
|
|
| Published
articles from 60's-70's |
|
|
