Monthly Archives: June 2012
New Global Causes of Child Mortality Data Released in Lancet, May 2012. (Reference: Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. (2012) The Lancet, Early Online Publication, 11 May 2012 doi:10.1016/S0140-6736(12)60560-1)
- The burden of mortality in children younger than 5 years varied widely across WHO regions in 2010, with the largest number of deaths seen in Africa (3·6 million) and southeast Asia (2·1 million). Breastfeeding has and is playing a crucial role in the survival of the infants.
- In 2010, neonatal mortality was highest in southeast Asia (1·096 million deaths, 52·3% of regional deaths in children younger than 5 years), with 19·2% of deaths (0·402 million, UR 0·262—0·558 million) attributable to preterm birth complications, and 21·8% of deaths (0·457 million, UR 0·359—0·551 million) attributable to pneumonia in the neonatal and postneonatal periods.Of the WHO
NEONATAL MORTALITY – HIGHEST CONTRIBUTOR TO CHILD MORTALITY
The majority of mortality is being contributed by the newly born population. Perinatal mortality has been defined as mortality of either of the mother-infant dyad during the perinatal period, which is defined as the period from 20th week of gestation to seven days after birth. Infants dying in their first week of life then highly speaks of the quality of prenatal care their mothers received. On the other hand, infant deaths occurring between seventh to the 30th day reflects the quality of infant care and may not necessarily a sequela of prenatal care.
A good question to ask is, when do these neonates die? In a data review of the deaths of neonates by day locally, it showed that most infants do not survive more than 48 hours, with a declining incidence towards the end of neonatal period. This first 48 hours of life still coincides with the perinatal period, which then clearly underscores the fact that majority of our mothers are not receiving optimum and adequate prenatal care thus leading to their demise.
Deaths of Neonates by Days, Philippines 1998-2003. (MA Silvestre, 2009).
There has been increasing preterm birth in the last few years, and preterm birth complications have contributed significantly to mortality burden among children before their fifth birthday. Locally, pregnancies are terminated prematurely because of urogenital infection (triggering preterm labor), uncontrolled maternal hypertensive disorders, abnormal bleeding (placenta previa, abruptio placenta). Having adequate access to mother-child care providers will significantly improve this saddening statistics. The PhilHealth recently reported that out of the 1400 plus cities and municipalities, only 607 cities and municipalities have mother-child care facilities; LESS than 50%.
PNEUMONIA, SECOND HIGHEST CONTRIBUTOR TO CHILD’S MORTALITY.
The peak incidence of mortality from pneumonia is the first six months of life. Pneumonia is a vaccine-preventable disease. There are currently two conjugated and one polysaccharide pneumococcal vaccines available in the market. Of these, it’s the conjugated vaccines that can protect the infant from pneumococcal death during the first six months of life, as the polysaccharide vaccine can only be administered when the child is at least 2 years of age. Unfortunately, the conjugated pneumococcal vaccine is not available in health centers due to its high cost. Majority of the population that flock to the government vaccination centers, who cannot avail of the said vaccine, are therefore vulnerable to succumb to this disease.
The newly born infant’s immune system is inexperienced, thus any infection immediately at birth may lead to infant’s death. During pregnancy, whatever antibodies the mother has through vaccination or active infection are shared to the fetus through the placenta. (Problem lies when the mother never had infection nor vaccination, there would be nil to share). These antibodies may be the only armamentarium the infant has, however do not confer absolute protection after birth, and wanes by around six months of life. However, mother also continues to provide additional antibodies to the baby after birth during breastfeeding; a process cow milk formula can and will never duplicate.
A person has two manners of acquiring antibodies – active: by producing during vaccination or active infection; and passive: through infusion of already formed antibodies during pregnancy, breastfeeding and infusion of immunoglobulin concentrate. Vaccination is a process whereby a weakened antigen (whether the organism itself of its by-product) is introduced to the individual in an attempt to trigger his immune system to produce antibodies against the offending organism, but the antigen is not strong enough to cause infection or disease by itself. Pneumococcal vaccination should then be accomplished during the infant’s first six months of life to preclude this peak incidence of death from pneumonia during this period.
What has been noticeable though, according to the article, was the mention of how breastfeeding is playing a crucial role in the survival of these infants.
WHEN TO INITIATE BREASTFEEDING?
Delaying the initiation of breastfeeding is HARMFUL!!! In an observational cohort done at Ghana, observing 10,492 infants who survived beyond their 48th hour from birth, the following were the findings:
- there is an increased risk of death from infection with increasing delay of initiating breastfeeding;
- if the breastfeeding was initiated only after 24 hours of life, there is a 2.6-fold risk of death;
- moreover, if initiation was delayed, the infant was partially breastfed (meaning baby was also given cow milk formula), the risk increases to 5.7-fold. (Reference: Edmond KM, et al. Effect of early infant feeding practices on infection-specific neonatal mortality: In rural Ghana. Am J Clin Nutr. 2007; 86:1126-31.)
In Southern Nepal, frequent home visits were done among 22,838 breastfed newborns, who survived beyond 48 hours. It was noted that
- in the first hour of life from birth, only 3.4% were breastfed;
- within 24 hours of life, 56.6% of infants were breastfed;
- babies who were partially breastfed (72.6%) were at higher mortality risk than exclusively (purely) breastfed infants- the longer the delay of initiating breastfeeding, the higher mortality rate;
- mortality was higher among late (>24 hours) than early (<24 hours) initiators
- neonatal death may be avoided if breastfeeding is initiated within first day or 24 hours of life (7.7%), but more when initiated within the first hour of life (19.1%). (Reference: Mullany LC, et al. Breast-Feeding patterns, time to initiation, and mortality risk among newborns in Southern Nepal. J Nutr, 2008; 138(3):599-603).
WHAT PHILIPPINES HAS DONE AND IS STILL DOING….
- provision of warmth and drying of the infant, simultaneously stimulating him to breath;
- uninterrupted skin-to-skin contact — this procedure allows baby to acquire maternal bacterial flora that will colonize his intestines that will serve to prime his immune system, delays onset of allergic disorder, and positive effect on the duration of breastfeeding (likelihood of prolonged breastfeeding);
- delayed cord clamping – helps prevent iron-deficiency anemia; and
- initiation of breastfeeding within the first 90 minutes of life.
(Unang Yakap video may be viewed in this link: http://www.youtube.com/watch?v=5hCP7rYHrwA)
The DOH with Bureau of Food and Drugs has also strictly implemented the Milk Code. Among the provisions of milk code are:
- exclusive breastfeeding for 0-6 months;
- no substitute nor replacement for breastmilk;
- appropriate and safe complementary feeding should start from six months onwards in addition to breastfeeding;
- breastfeeding is still appropriate for young children up to two years of age and beyond;
- infant or milk formula may be hazardous to a child’s health and damage child’s formative development;
- advertising, promotions or sponsorships of infant formula, breastmilk substitutes and other related products are prohibited;
- other related product such as, but not exclusive of, teats, feeding bottles and other feeding paraphernalia are prohibited in health facilities;
- government and all concerned stakeholders must continuously accomplish an information, dissemination campaign/strategy, and do further research on the advantages of breastmilk and the hazards of breastmilk substitutes or replacements; and
- milk companies, and their representatives, should not form part of any policy-making body or entity in relation to the advancement of breastfeeding.
For the past few days, I have been plagued by extremely premature babies for the first time, all 25 weeks gestational age, with different stories embracing each…
Parents are well-to-do. They have a business, requiring husband to be out of town. Allegedly, the current pregnancy is not of the husband’s… Mother came in to the labor room, in active phase of labor, meaning, baby is already about to come out. Based on limited data gathered by my resident, mother is about 25 weeks pregnant, had been having diarrhea few hours prior to abdominal pain.
Baby was born, I immediately provided his needs – intubation, mechanical ventilator support, umbilical vascular catheterization. Despite full support, baby’s oxygenation status was never better. Chest x-ray showed collapsed lungs due to sequelae of prematurity. Husband is out of town, the mother’s companions are her employees, who cannot help me with legalities and decision-making.
Then the obstetrician revealed, (as she has the rapport with the mother), that the mother attempted to abort the baby by ingesting some abortifacient. About six hours from birth, the father arrived, but even if he wanted to be aggressive, the baby couldn’t respond anymore to treatment. They then signed a DO NOT RESUSCITATION order. Baby expired after about 12 hours from birth.
Both parents are young and unemployed. Mother is 18 years old, father is 22. She came in too to the hospital because of abdominal pain. When at the emergency room, baby’s head was already presenting so she was rushed to the delivery room. I was called in after the baby was delivered so I rushed like an ambulance driver to the hospital. Baby’s urgent needs were provided and then I talked to the father about baby’s condition, what he needs. Unfortunately, even after he has called all possible resources, he wasn’t able to provide the medication baby badly needed.
Baby was only relying on the mechanical ventilatory support. However on the 30th hour of life, he started showing signs of deterioration. His mechanical ventilatory settings were unusually high that eventually led to rupture of both lungs (just as when I left the hospital). I had to rush back to possibly rescue baby. His x-ray revealed rupture of both lungs, with air escaping out but still within chest cavity, thus compressing both the lungs, and the heart. If this were not addressed, baby will die in a few minutes..
I called in a pediatric surgeon to insert tube to drain the air, while I only deed a rescue needle thoracentesis. Alas, after our attempts to rescue baby, he didn’t make it. He expired at about 38 hours from birth.
I was informed that there is a pregnant mother, on her 28th week gestational age, for control of labor, but if she will deliver, I will attend to the baby. At least, the baby was older this time (and so I thought)… I instructed then the NICU staff to prepare equipment that baby will need upon delivery. Only two hours after the referral, the phone rang again, calling me now to the delivery room as the baby’s head was already almost out. At least this time, I was already able to have dinner.
I rushed to the hospital and in less than 10 minutes, baby came out. But baby wasn’t looking normal, he was deformed. His head and face were deformed, the abdomen was as large as the head (normally, for a preterm, the head is larger, abdomen and chest are almost the same in diameter), the feet are compressed, looking like club foot. When I was asked what the gender of baby was, I couldn’t commit whether baby is a boy or girl. It seemed like there are scrotal sacs, but empty (which is expected at this gestational age), there was a protrusion that is hard to discern if its penis or clitoris. (In cases where genitalia is ambiguous, we are not obliged to assign a gender until we were able to document it by chromosome (DNA) analysis, so as to avoid mistake in gender assignment). Baby’s skin were also showing red spots highly suggestive that baby has congenital infection, probably german measles or cytomegalovirus. The large abdomen suggests that liver or kidney is enlarged. Whether it is a tumor or a reaction to maternal infection during the course of pregnancy, I could not be certain. Physical assessment also revealed that baby is only 25 weeks, and not 28 weeks as thought of by the mother.
Upon birth also, heart beat was already less than normal, and he was already gasping (an ominous sign of arrest). I already knew that resuscitative efforts in this kind of situation will be otiose. So, I immediately called in the grandmother (as the husband is abroad) and explained how futile resuscitating baby is. We provided comfort care, had baby baptized, and waited for baby to expire.
In retrospect, I learned that at 5 months gestational age, baby’s ultrasound revealed that there was polyhydramnios (excessive amount of amniotic fluid). The placenta was large too, heavier than the baby, also substantiating my suspicion that mother had a lethal form of asymptomatic infection that grossly affected the baby.
After 58 minutes from birth, baby expired.
It was a Sunday, it was supposed to be lazy day, rest day for me, but for some crazy reason, the world does not want me to fully enjoy my rest days, this day included. I was called in for emergency cesarean delivery at a hospital for the birth of yet again 25 weeks old baby. Baby had to be delivered as the hand is already coming out of the vagina.
Upon arrival at the hospital, the obstetrician and her assistant was already operating on the mother so I barely had time to prepare. Baby came out in few minutes and needed resuscitation as he was not spontaneously crying and breathing. We had to provide bag-mask ventilation but the equipment was dysfunctional. Also, many equipment that baby needs is not available in that hospital so I had to immediately transfer baby to a higher center. The baby is the 2nd child, the 1st child being 13 years old already and parents want the baby to live. What am I to do but to stress myself thus? (evil-grin)
The ambulance and I rushed to the other hospital in convoy. Again, his needs were provided. This time, I or perhaps the baby was lucky because the father was able to provide that much needed surfactant. Also, the baby’s lungs are not that collapsed compared to the other ones I previously mentioned.
It seemed that the mother has uterine infection as the bag of waters broke one day before she had labor pains. Usually infections at this week of gestation is lethal/deadly to the premature baby.
The baby is currently stable at present, although still requiring mechanical ventilatory support.
Apparently there are still some Filipinos who find humor in one’s ethnicity, branding them, brandishing them to elicit laughter. A classical example is this tweet that was tagged to my timeline by a concerned follower, @baklushdiana.
@pinoy_humor: English ka ng english, mukha ka namang Igorot. (You keep on speaking in English when your face looks like an Igorot).
Initially I took it lightly and thus I replied:
@drclinton: all I know is Igorots are one of the best English speakers of the country noong wala pang Powers na yan. (All I know is Igorots are one of the best English speakers of the country even without the presents of John Robert Powers in the country).
In all fairness to @pinoy_humor, he/she/it apologized saying “sorry po doc.. hindi na mauulet.:-(” [sorry doctor, it wont happen again 😦 ]. However, I was already mincing what that joke was all about and thus warned him/her/it. I replied, “that was a bad ethnic joke. Wag ka papakilala, mapupugutan ka ng ulo dito.” (“that was a bad ethnic joke. Dont reveal your identity or you will be beheaded here.” — Igorots had been previously known to be headhunters)
@pinoy_humor replied: @drclinton nakapatay ba ako ng tao, kung maka tweet naman kayo sir.. #ReadTheTwitterNameSir, apologizing is enough sir #Dot (Did I kill someone, how could you tweet such)
And then I asked him/her/it:
@drclinton: @Pinoy_Humor “what did you intend to mean with mukha ka namang Igorot for your tweet to be funny at all?” (What did you intend to mean with you look like an Igorot for your tweet to be funny at all?)
Eventually he/she/it replied:
@Pinoy_Humor: @drclinton At first I found it funny but I decided to delete it when I thought my followers like you will get mad.
Instead of me trying to accept her initial apology, I was getting enraged and asked him/her/it:
@drclinton: @Pinoy_Humor “why did you consider it funny at first? Na kaming mga Igorot at di nababagay mag-English? or kami’y mukhang nakakatawa?” (Why did you consider it funny at first? That we Igorot arent supposed to be speaking English? or that we Igorots look funny?)
@Pinoy_Humor : @drclinton Again I’m sorry. This will be my last tweet.
Shocked and angry, I screen captured that particular tweet and asked my followers if they find the tweet funny or humorous at all. In unison, everyone thought it was not humorous nor funny, it was offensive and discriminating against a fellow Filipino.