A. F. Malan

The value of a scoring system for hypoxic ischaemic encephalopathy in predicting neurodevelopmental outcome

Abstract A numeric scoring system for the assessment of hypoxic ischaemic encephalopathy during the neonatal period was tested. The value of the score in predicting neurodevelopmental outcome at 1 y of age was assessed. Forty‐five infants who developed hypoxic ischaemic encephalopathy after birth were studied prospectively. In addition to the hypoxic ischaemic encephalopathy score all but two infants had at least one cranial ultrasound examination. Thirty‐five infants were evaluated at 12 months of age by full neurological examination and the Griffiths Scales of Mental Development. Five infants were assessed at an earlier stage, four who died before 6 months of age and one infant who was hospitalized at the time of the 12 month assessment. Twenty‐three (58%) of the infants were normal and 17 (42%) were abnormal, 16 with cerebral palsy and one with developmental delay. The hypoxic ischaemic encephalopathy score was highly predictive for outcome. The best correlation with outcome was the peak score; a peak score of 15 or higher had a positive predictive value of 92% and a negative predictive value of 82% for abnormal outcome, with a sensitivity and specificity of 71% and 96%, respectively. For the clinician working in areas where sophisticated technology is unavailable this scoring system will be useful for assessment of infants with hypoxic ischaemic encephalopathy and for prognosis of neurodevelopmental outcome.

The management of polycythaemia in the newborn infant

Abstract The management of polycythaemia with hyperviscosity in newborn babies who are clinically well, or who only have minor signs, is not clear. Forty-nine such babies were randomly divided so that 24 were given a partial plasma exchange transfustion and the others were left hyperviscous. The babies were compared with normal controls. Clinical signs were more frequent in exchanged babies, and one developed necrotizing entercolitis. Of the hyperviscous babies 41% had plethoric lungs, 12% abnormal electrocardiograms, 9% were hypocalcaemic and 30% hypomagnesaemic. Behavioural testing after birth revealed differences in both groups when compared with controls. There were more poor scores in the exchange transfusion group. Neurological examination did not reveal marked differences among the groups. Developmental and neurological achievement at 8 mth of age was normal in all the babies. In the present study it is suggested that newborn babies with hyperviscosity who are clinically well or who only have minor signs do not necessarily benefit from partial plasma exchange transfusion.The management of polycythaemia with hyperviscosity in newborn babies who are clinically well, or who only have minor signs, is not clear. Forty-nine such babies were randomly divided so that 24 were given a partial plasma exchange transfusion and the others were left hyperviscous. The babies were compared with normal controls. Clinical signs were more frequent in exchanged babies, and one developed necrotizing entercolitis. Of the hyperviscous babies 41% had plethoric lungs, 12% abnormal electrocardiograms, 9% were hypocalcaemic and 30% hypomagnesaemic. Behavioural testing after birth revealed differences in both groups when compared with controls. There were more poor scores in the exchange transfusion group. Neurological examination did not reveal marked differences among the groups. Developmental and neurological achievement at 8 mth of age was normal in all babies. In the present study it is suggested that newborn babies with hyperviscosity who are clinically well or who only have minor signs do not necessarily benefit from partial plasma exchange transfusion.

Patterns of retarded fetal growth.

The measurement of weight, length and head circumference at birth was used to document the size and shape of infants born at term in a population where mothers are relatively short and underweight. Different patterns of intrauterine growth are proposed to explain the variation in the infants appearance at birth. Most of the small-for-gestational-age infants were proportionately stunted. This pattern of fetal growth is probably characteristic of infants born to undernourished mothers in economically developing communities, and reflects prolonged intrauterine growth retardation.

Implementation of kangaroo mother care : A randomized trial of two outreach strategies

AIM To test whether a well-designed educational package on the implementation of kangaroo mother care (KMC) used on its own can be as effective in implementing KMC in a healthcare facility as the combination of a visiting facilitator used in conjunction with the package. SETTING Thirty-four hospitals in KwaZulu-Natal Province, South Africa. METHOD The hospitals were paired with respect to their geographical location and annual number of births at the facility. One hospital in each pair was randomly allocated to receive either the implementation package alone (group A) or the implementation package and visits from a facilitator (group B). Hospitals in group B received three facilitation visits. All hospitals were evaluated by a site visit 8 mo after launching the process and were scored by means of a progress-monitoring tool. OUTCOMES Successful implementation was regarded as demonstrating evidence of practice (score>10) during the site visit. RESULTS Group B scored significantly better than group A (p<0.05). All 17 hospitals in group B demonstrated evidence of practice, with the median score of the group being 15.44 (range 10.29-22.94). Twelve of the hospitals in group A demonstrated evidence of practice and the median score was 11.33 (range 1.08-21.13). CONCLUSION Successful implementation was achieved in most of the hospitals irrespective of the strategy used. However, facilitation with an implementation package was clearly superior to using a package alone. Some sites do not need facilitation for successful implementation.

Relative placental weight in congenital syphilis

Summary A placental weight-birth weight graph based on 13601 births was constructed. A group of 74 infants with congenital syphilis was then plotted on the centiles. The placentae in congenital syphilis were significantly heavier than expected for infant weight. The routine use of placental weight-birth weight graphs is advocated, especially in infants who are underweight for gestational age and in areas where syphilis is prevalent.

Spontaneous Pneumothorax in the Newborn

The obstetrical, clinical, radiological and biochemical findings in 7 cases of spontaneous pneumothorax of the newborn are presented. All the infants survived. Attention i s drawn to the presence of a chest bulge as a prominent physical sign in the diagnosis of pneumothorax. The significance of irritability in association with a rapid respiratory rate is discussed.

Placental size of small-for-gestational-age infants at term

Placental size was compared between appropriate-for-gestational age (AGA) and small-for gestational age (SGA) infants born at term. Placental weight, chorionic plate area and villous surface area were significantly reduced in the SGA infants. Although the ratio of placental weight to birth was similar in the AGA and SGA infants, the latter had significantly underweight placentas for their head circumference and crown-heel length. The ratios of placental weight to assessed brain weight and villous surface area to assessed brain weight were also significantly reduced in the SGA infants. It is concluded that the study SGA infants had both absolutely and relatively small placentas.

The Electrocardiogram in Respiratory Distress Syndrome: The Praecordial P Wave as an Aid to Assessment

Although the respiratory distress syndrome (RDS) has been the subject of extensive study and review, the clinical and prognostic evaluation, and the therapy, still present considerable difficulties. This report concerns a progressive change in the electrocardiogram, which was found to be of value in assessing severity and prognosis. Attention was drawn to these variations in pattern in a recent brief communication to the Lancet (Sutin and Heese, 1964).

Implementation of kangaroo mother care: A randomized trial of two outreach strategies: Kangaroo mother care implementation trial

Aim: To test whether a well‐designed educational package on the implementation of kangaroo mother care (KMC) used on its own can be as effective in implementing KMC in a healthcare facility as the combination of a visiting facilitator used in conjunction with the package. Setting: Thirty‐four hospitals in KwaZulu‐Natal Province, South Africa. Method: The hospitals were paired with respect to their geographical location and annual number of births at the facility. One hospital in each pair was randomly allocated to receive either the implementation package alone (group A) or the implementation package and visits from a facilitator (group B). Hospitals in group B received three facilitation visits. All hospitals were evaluated by a site visit 8 mo after launching the process and were scored by means of a progress‐monitoring tool. Outcomes: Successful implementation was regarded as demonstrating evidence of practice (score>10) during the site visit. Results: Group B scored significantly better than group A (p<0.05). All 17 hospitals in group B demonstrated evidence of practice, with the median score of the group being 15.44 (range 10.29–22.94). Twelve of the hospitals in group A demonstrated evidence of practice and the median score was 11.33 (range 1.08–21.13).

Measuring implementation progress in kangaroo mother care: Progress in kangaroo mother care

Aim: To describe the development and testing of a monitoring model with quantitative indicators or progress markers that could measure the progress of individual hospitals in the implementation of kangaroo mother care (KMC). Methods: Three qualitative data sets in the larger research programme on the implementation of KMC of the MRC Research Unit for Maternal and Infant Health Care Strategies in South Africa were used to develop a progress‐monitoring model and an accompanying instrument. Results: The model was conceptualized around three phases (pre‐implementation, implementation and institutionalization) and six constructs depicting progress (awareness, adopting the concept, mobilization of resources, evidence of practice, evidence of routine and integration, sustainable practice). For each construct, indicators were developed for which data could be collected by means of the monitoring instrument used in a walk‐through visit to a hospital. The instrument has been tested in 65 hospitals.