Jalemba Aluvaala: The treatment and outcomes of care for sick newborns
Care for even the sickest newborns in many countries is limited by the resources available but there are some key interventions that can save lives. Delivering these interventions requires doctors and nurses to work together and often it is the continuous care provided by the nursing team together with families that is critical. Despite this a number of babies die and understanding risks is important to help provide information to families, to help plan care and should help us design better systems of care.
My name is Jalemba Aluvaala, I’m a paediatrician and epidemiologist working in newborn research, particularly focusing on hospital care of newborns in Kenya, potentially in other low and middle-income countries. My interests are looking at how best to improve care and by extension the survival of newborns in that part of the world.
My call in being a clinician is taking care of children, and my interests are derived from my experiences as a clinician: how best to improve the care for newborns, the first 28 days of life, because in our part of the world many preventable deaths occur in the first days of life. This led me into research and trying to answer questions, which we meet on a day-to-day basis in our clinical practice. Within the HSDN (HSDN work is my background), the most common illnesses for the newborns reflect what occurs in the population. We have infections, we have pre-term births – babies that are born too soon – and the complications of being born too soon. We have babies that are born with low birth weights and the complications of low birth weights. We also have babies that do not breathe well or do not breathe at all at the time of their birth, and we are particularly interested in the effect of that on their brain cells. Also, quite commonly for the newborns whom we see in the hospitals, lots of them have jaundice, a yellowing of the skin.
For the small and sick babies admitted to the facilities, the package of care most of them need is ‘essential newborn care’ which refers to infection prevention and control, feeding the babies, keeping the babies warm, kangaroo-mother care for the low birth weight babies. Whereas the interventions are for particular vulnerabilities these babies have, these need to be provided continuously and they need to be provided within a system. What we realise is that families are a really important part of the system that provides care within the hospitals, particularly the mothers and the support system for the mothers – they need to have the extended family to be able to provide care.
We also know that whilst we start registering the deaths we also have many babies that are surviving, and the care that we provide is to ensure that just beyond surviving they should survive and thrive. We know that if we do not provide a quality of care they may survive but survive with lots of disabilities. For instance they may have convulsive disorders, they may have cerebral palsy, they may have problems with their eyes, so whereas we are looking at improving survival we are also looking beyond. It is quite possible with existing interventions to reduce the mortality that we are observing in hospitals, at population levels by up by 80% and up to 70% of this mortality can actually be reduced by providing good quality interventions at hospital level.
When we receive small and sick babies in hospital, we need to have better ways of identifying those at highest risk of death and those at high risk of potential adverse outcomes. Currently we have been using the gestation at the time of delivery but you have problems with the availability of that data. We have also tried using their weights and categorising their weights but that still leaves differences within their existing weight category. We are looking at using approaches where you combine several characteristics of these babies to come up with an estimate of their risk of particular outcomes. For instance death: we can use information for individual patient levels of what we call ‘prognosis scores’ to decide, if this baby pass a certain threshold or risk of death, should we care for them in certain facilities or should we transfer them to a higher-level facility. That is at an individual patient level but looking at organisation of care, we are coming to a point where we are trying to categorize the levels of neonatal care across our Health System, and one of the things we are looking at is how we link the risk of certain outcomes to the appropriate level of care.
Looking at newborn health specifically in Nairobi, we know from existing data that the highest risk of death for newborns in Kenya is actually in Nairobi where we have 39 deaths per 1000 live births so it is a critical area for the country. We looked recently at services that are available at inpatient level for the small and sick newborns, and we found that most of the available care is provided in public facilities. Whereas there is lots of care in these facilities, there are lots of opportunity to actually improve the kind of care that we have when providing in these facilities. We understand that based on our work and information that we have, the standard level of care is going to make the biggest difference in Nairobi because that it is the level that is most lacking currently. There is a lot of research that can be done but right now, once we start improving survival we need to look at other important outcomes.
The primary business of babies is to grow and develop, so how well are babies growing, can you measure their weights for instance, can you measure their head circumferences? If you are able to measure their weights, how rapidly are they growing, are they growing appropriately, are they attaining their weights as expected? This is particularly linked to how well they are feeding. Just looking beyond the hospital, we are also particularly interested in measuring their growth and weight gain once they leave for home, for these special groups of babies, are they able to sustain their growth at home? Is their weight gain at home appropriate? Beyond just the weight gain, the brains of these babies are particularly vulnerable to insults during the time when they are small and sick in the newborn units. Are we able to look at neurodevelopmental outcomes, are they attaining their learning appropriately, are they having behaviour issues or any other neurodevelopmental problems like cerebral palsy and convulsive disorders and so on which you can pick up, follow up and manage them as outpatients and look at long term survival of these babies.
This interview was recorded in December 2018.