Trop Petits ?...
The assumption of responsibility of the infants < 6 months with the CNT
Pascale Delchevalerie – Michela Sonego
With all our thanks with the team of Karuzi, for their collaboration without which we could not have carried out this work.
TOO MUCH SMALL ? …
1 Introduction ...... 4
1.1 Justification
1.2 Objectif
1.3 Means
2 Analyze problem ...... 7
2.1 Extent of the problem
2.1.1 Questions that we were posed
3 Possible interventions ...... 11
3.1 In theory
3.1.1 Food
3.1.2 Nursing
3.1.3 Medical assumption of responsibility
3.2 In practice
3.2.1 Food
3.2.2 Nursing
3.2.3 Medical assumption of responsibility
Example of Burundi
4 Questions still to solve or discuss ...... 16
5 Bibliography ...... 17
6 Appendices ...... 18
6.1 Protocol of assumption of responsibility, CNT Karuzi
6.2 Hot room CNT Karuzi
1. Introduction
Each year more than 10 million children < 5 years die in the world. 3,9 million of them, (that is to say surroundings 40%) is the born one (<28 days of life).
It is estimated that 6 million these deaths could to be avoided with measurements simple to take in the DEVELOPING COUNTRIES[1]. For example, two only of these measurements, the breast-feeding and the oral rehydration, could prevent 25% of these deaths.
Fig 1 Causes of mortality
Shows the causes of mortality < 5 years and néonatale.[1]
Néonataux problems, diarrhoeas and pneumonias are the cause most frequent of death.
It is estimated that an insufficient weight is one of the most important factors subjacent mortality: in general the insufficient weight is the indirect cause of 53% of deaths < 5 years.
In this fig, we will deal more precisely of the mortality of new-born and the infants in 6 month old lower part .
Fig 2 : Proportion of dead néonatales among mortality < 5 years.
When mortality < 5 years decreases, the proportion of dead néonatales increases.2 (. 2)
Thus in the next years, if (as it is hoped) mortality < 5 years will decrease in the countries where we work, we will have to occupy us more and more of theborn ones. All the more that the problem of the AIDS, poses new sets of themes around the all small ones (beyond the cases of néonataux AIDS), to which MSF is confronted (breast-feeding in the AIDS and orphans, for example).
It is estimated that the causes of mortality among theborn ones, are:
severe 24% infections
29% asphyxiation néonatale
24% complications of prematurity
7% tetanus
98% of dead the néonatales occur in the DEVELOPING COUNTRIES, more the share at the house[1]. It is estimated that 55% of these deaths néonatales (either 18% of all deaths < 5 years) could be avoided.
One of the factors of the most important risk for mortality néonatale, it is the small weight with birth (PPN) (<2500g). The percentage of the children who are born with a small weight is very variable
Fig. 3
according to the countries. One can establish approximately an average of 16,4% of the births in the world[1]. But in certain areas of Asia and Africa one arrives at peaks much higher. (See. 3)[2]
Mortality is higher for the premature PPN, compared to the children who have a small weight by intra-uterine delay of growth.
The most frequent causes of PPN, in the DEVELOPING COUNTRIES, being the malaria, anaemia and pre-eclampsia during the pregnancy, the reduction of perinatal mortality passes inevitably through a good follow-up of maternal health.
1.1 Justification
For a few years, MSF moreover in has been confronted more with the problems of new-born and infants. The old dogma “an infant cannot badly-be nourished since it is nursed and thus we are interested only in the children > in 6 months” exhausted itself vis-a-vis the reality met on the ground and one started to seek how to deal with them; a chapter on this category of children was inserted in the Nutrition guide.
One of the countries where one observed the largest surge the small ones of less than 6 months is Burundi, amongst other things at the time of the nutritional urgency of 2000 - 2001. At that time, the mothers were also affected by malnutrition but especially by an epidemic of malaria very important and not controlled by effective treatments. The crisis passing, the CNT continued to accomodate a rather significant number infants.
Fig. 4
In an absolute number treated children, that represents 877 recipients in 38 months.[1]
If one compares with Angola, for example, in Kuito, from September 2002 to April 2003 (7 months), the CNT admitted 6% infants < 6 months (44/729) and that of Camacupa in accomodated 8.5% (54/636) from June 2002 to February 2003 (9 months), with a peak with 23.7% in October and 31.2% in November 02, month when lenombre total of admissions was falling.
This category of recipients poses many problems, since their mortality is higher than in the other children. It was also noted that a great part of these infants was in fact of the small weights of birth (PPN) not having succeeded in recovering. What led us to dig a little more the subject, by a review of the literature on the PPN (January 2003). It was then necessary to pass to the practice: how to take these children in load?
1.2 Objective
The objective of this work was to provide the foundations for the improvement of the assumption of responsibility of new-born and the infants < 6 months.
While starting with the study of the specific problems of small < 6 months in a CNT of Burundi, our wish is that one widens successively this study with other contexts and other countries.
1.3 Means
- Review of Literature.
- Design of a questionnaire to evaluate which is these infants.
- Visit ground in Burundi (March 2003) to analyze the principal problems of < 6 months.
- Analyze data of the ground.
- Proposal for a first protocol of test for the assumption of responsibility.
- Answers of the ground to announce to us the problems of application of the protocol.
- Modification of the protocol according to the answers of the ground, the consultations with neonatologists and revisions of the literature.
- List open questions either to discuss or study later on.
2. Analyze problem
2.1 Extent of the problem.
To know the entity of the problem, here initially a short synthesis of the figures of presence and mortality of the infants in the CNT of Karuzi (Burundi)
By studying the data from January to August 2003, we see that the population of the infants < 6 months represent in average 10,1% of the admissions with the CNT, but their deaths constitute 46% of all the deaths.
. 5 : Proportion of infants < 6 months, CNT Karuzi, Burundi, January at August 2003.
[1] http://www.unu.edu/unupress/food2/UID03E/uid03e05.htm
[2] http://www.childinfo.org/eddb/lbw/
[1] The Lancet, flight 362, July 5 2003 pg. 65-71
[2] The Lancet, flight 361, June 28 2003 pg. 2226-2234.
[3] Research priorities for the reduction off perinatal and neonatal morbidity and mortality in developing country
In more as from January, even if the total number of the recipients fell, the number of the infants remains more or less constant.
. 6 : Age distribution: admissions in CNT Karusi, Burundi
It east can be indications which the problems of the infants are not related to malnutrition so much, but rather with problems of neonatology.
2.1.1 Questions that we posed:
1) Who are these children?
- badly-nourished, PPN, the premature ones or simply of the sick children?
2) Are the death rates of the infants with Karuzi comparable with the data of the literature?
3) Which are the principal causes of mortality?
2.1.1.1 Who are these children?
the age bracket 0-6 month probably includes/understands all these categories of patients. It is however better to do a distinction between the new born ones (<1mois) and the others, because the assumption of responsibility and the causes of mortality are different. In addition, all these children in common have a difficulty of the breast-feeding and thus the need for correctly taking it again and for nourishing them until the moment when the breast-feeding is possible.
By studying the age of entry of the 236 infants admitted with the CNT from January to August 2003, one sees that 137 of them, is 58% enter when they have less than one month. One can thus affirm that one is in presence of a true neonatology. What, indeed, arrives at Karuzi, it is that at the hospital, especially because of problems of personnel, one does not keep theborn ones with problems (mainly small weights). Flow is exactly the opposite of that which should be in theory, with the sickest babies who are transferred from the hospital to the CNT. This fact, in him only, can already explain part of the high mortality of the infants with the CNT.
Another important consideration relates to the weight of these babies: on March 16, 2003, 17 babies present at the CNT, had entered when they had less than one month: all these babies weighed, the day of their entry, less 2500g, (what is normal, considering it is one of the criteria of entry) but what is important to notice it is that, 8 out of 17 (47%) weighed less than 1500 G.
Therefore, not only of the PPN, but of those which one names “Very Small Weights of Birth” (TPPN), children of less 1500g which are very difficult to save if there is not a minimal neonatology at disposal.
But, in fact: why do we have PPN so much?
To try to answer this question we checked the weights of birth at the Hospital of Karuzi: from January to August 2003, out of 451 births, 155 weighed less than 2500 G, is a proportion of PPN of 33,4 %, what is enormous if one compares with the average percentage of 12% of PPN, indicated in the literature like average figure in sub-Saharan Africa[1].
The percentage of TPPN on the births is 4,6%. It is true that the Hospital of Karuzi is a center of reference and thus does not completely reflect the figures of all the births in Burundi, but it is nevertheless about a so raised percentage, that it will be necessary to reflect there above.
By comparison, in Angola, in 2002, the maternity of Kuito had 5.6% (111/1864) births < 2500 G (in 7 months), and that of Camacupa in had 37.5% (27/72) in 4 months.
We did not study in a specific way this problem, but it is known that, on a side, the malaria is a big problem in Burundi and of the other, the malaria during the pregnancy is one of the most frequent causes of PPN.
The malaria can cause prematurity, but especially a delay of growth will intra uterine, not only through the symptomatic infection of the mother, but especially, through the invasion and the concentration of the parasites in the placenta, even if the infection is asymptomatic[2] A child whose mother has the placenta infected has twice more probabilities of having a small weight with the birth.[3]
If one confirms the high incidence of PPN with Karuzi, it will be necessary to act on the problem of the malaria in the mothers, as on other maternal pathologies which can cause the birth of PPN (weakens, pre-eclampsia, malnutrition) with an aim of decreasing the incidence of the PPN and thus perinatal mortality.
2.1.1.2 Are the death rates of the infants with Karuzi comparable with the data of the literature?
From January to August 2003 there were 45 deaths of infants of less than 6 months to the CNT. 34 of them, is 75% were theborn ones. 28 of these new-born, is 82% weighed less than 2500 G to the admission, therefore were PPN.
One knows very well that the PPN have a mortality more raised much than the children of adequate weight. mortality among < 6 months that we calculated in the first 8 months of the year with Karuzi is on average of 18%, but among < of 1500g it arrives at almost 30%.
[1] http://www.childinfo.org/eddb/lbw/
[2] Malaria and Newborns. Editorial. Journal of Tropical Pediatrics 2003. Vol 49, No3
Menendez C et al. The impact of placental malaria on gestational age and birth weight, J.Infect. Dis 2000 May; 181 (5): 1740-5
Steketee RW et al. The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg 2001 Jan-Feb; 64 (1-2 suppl): 28-35.
[3] Guyatt HL et al. Malaria in pregnancy as an indirect cause of infant mortality in sub-Saharian Africa. Trans R Soc Trop Med Hyg 2001, nov-dec; 95 (6): 569-76
In general it is estimated that on average, in the DEVELOPING COUNTRIES, if one take as reference the children of 2500-2999g, the relative risk of mortality during the time néonatale and post-néonatale, is 4 for the children between 2000 and 2499g; from 18 for the 1500-1999 and 50 for < 1500.[1] To quote a practical example, mortality in a service of maternity in a hospital in Bangladesh (with availability of incubators and all the normal facilities of a hospital) is 13% for all the PPN (<2500g) and arrives at 78% for the children of less 1500g.[2]
Even if these figures cannot be compared directly with those of the CNT, which receives only the “survivors”, that can explain us at least most of our mortality raised among the infants.
Mortality is higher for the premature PPN, compared to the children who have a small weight by intra-uterine delay of growth, but in our case with Karuzi, it is very difficult to make the difference between these two populations, because the majority of the children immediately do not arrive after the birth and that the mothers do not know the duration of their pregnancy.
By the literature, we know that the majority (approximately 70%) of the PPN in the DEVELOPING COUNTRIES are children with intra-uterine delay of growth rather than of the premature ones, contrary to what arrives in the Industrialized countries, where they are the premature ones which constitutes 70% of the PPN[3].