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      Efficacy of a Low-Cost Bubble CPAP System in Treatment of Respiratory Distress in a Neonatal Ward in Malawi

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          Abstract

          Background

          Respiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care.

          Methods

          We conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups.

          Findings

          87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived.

          Interpretation

          Use of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.

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          Most cited references21

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          3.6 million neonatal deaths--what is progressing and what is not?

          Each year 3.6 million infants are estimated to die in the first 4 weeks of life (neonatal period)--but the majority continue to die at home, uncounted. This article reviews progress for newborn health globally, with a focus on the countries in which most deaths occur--what data do we have to guide accelerated efforts? All regions are advancing, but the level of decrease in neonatal mortality differs by region, country, and within countries. Progress also differs by the main causes of neonatal death. Three major causes of neonatal deaths (infections, complications of preterm birth, and intrapartum-related neonatal deaths or "birth asphyxia") account for more than 80% of all neonatal deaths globally. The most rapid reductions have been made in reducing neonatal tetanus, and there has been apparent progress towards reducing neonatal infections. Limited, if any, reduction has been made in reducing global deaths from preterm birth and for intrapartum-related neonatal deaths. High-impact, feasible interventions to address these 3 causes are summarized in this article, along with estimates of potential for lives saved. A major gap is reaching mothers and babies at birth and in the early postnatal period. There are promising community-based service delivery models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale and also being tested through a network of African implementation research trials. To meet Millennium Development Goal 4, more can and must be done to address neonatal deaths. A critical step is improving the quantity, quality and use of data to select and implement the most effective interventions and strengthen existing programs, especially at district level. Copyright © 2010 Elsevier Inc. All rights reserved.
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            Newborn survival in low resource settings--are we delivering?

            The annual toll of losses resulting from poor pregnancy outcomes include half a million maternal deaths, more than three million stillbirths, of whom at least one million die during labour and 3.8 million neonatal deaths--up to half on the first day of life. Neonatal deaths account for an increasing proportion of child deaths (now 41%) and must be reduced to achieve Millennium Development Goal (MDG) 4 for child survival. Newborn survival is also related to MDG 5 for maternal health as the interventions are closely linked. This article reviews current progress for newborn health globally, with a focus on the countries where most deaths occur. Three major causes of neonatal deaths (infections, complications of preterm birth, intrapartum-related neonatal deaths) account for almost 90% of all neonatal deaths. The highest impact interventions to address these causes of neonatal death are summarised with estimates of potential for lives saved. Two priority opportunities to address newborn deaths through existing maternal health programmes are highlighted. First, antenatal steroids are high impact, feasible and yet under-used in low resource settings. Second, with increasing investment to scale up skilled attendance and emergency obstetric care, it is important to include skills and equipment for simple immediate newborn care and neonatal resuscitation. A major gap is care during the early postnatal period for mothers and babies. There are promising models that have been tested mainly in research studies in Asia that are now being adapted and evaluated at scale including through a network of African implementation research trials.
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              Neonatal mortality from respiratory distress syndrome: lessons for low-resource countries.

              Respiratory distress syndrome (RDS) is a major contributor to neonatal mortality worldwide. However, little information is available regarding rates of RDS-specific mortality in low-income countries, and technologies for RDS treatment are used inconsistently in different health care settings. Our objective was to better understand the interventions that have decreased the rates of RDS-specific mortality in high-income countries over the past 60 years. We then estimated the effects on RDS-specific mortality in low-resource settings. Of the sequential introduction of technologies and therapies for RDS, widespread use of oxygen and continuous positive airway pressure were associated with the time periods that demonstrated the greatest decline in RDS-specific mortality. We argue that these 2 interventions applied widely in low-resource settings, with appropriate supportive infrastructure and general newborn care, will have the greatest impact on decreasing neonatal mortality. This historical perspective can inform policy-makers for the prioritization of scarce resources to improve survival rates for newborns worldwide.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                29 January 2014
                : 9
                : 1
                : e86327
                Affiliations
                [1 ]Department of Pediatrics, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
                [2 ]Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
                [3 ]Department of Bioengineering, Rice University, Houston, Texas, United States of America
                [4 ]Department of Respiratory Care, Texas Children's Hospital, Houston, Texas, United States of America
                Hôpital Robert Debré, France
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: RRR-K MO HEM EM. Performed the experiments: RRR-K MO HEM EM EOS KK JB ZM. Analyzed the data: RRR-K MO EOS. Contributed reagents/materials/analysis tools: SI HM JB AG. Wrote the paper: RRR-K MO HEM EM KK EOS ZM SI JB AG. Designed training materials for bCPAP: SI HEM JB AG. Led the staff training: SI.

                Article
                PONE-D-13-29073
                10.1371/journal.pone.0086327
                3906032
                24489715
                dc9f4141-5596-41d0-bd8b-ac02935b7ff4
                Copyright @ 2014

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 15 July 2013
                : 7 December 2013
                Page count
                Pages: 8
                Funding
                This work was made possible through the generous support of the Saving Lives at Birth partners: the United States Agency for International Development (USAID), the Government of Norway, the Bill & Melinda Gates Foundation, Grand Challenges Canada, and the World Bank. It was prepared by William Marsh Rice University and does not necessarily reflect the views of the Saving Lives at Birth Partners. Funding was also provided by the African Network for Drugs and Diagnostics Innovation (ANDI). 1. USAID Cooperative Agreement Award No. AID-OAA-A-13-00014, www.usaid.gov 2. African Network for Drugs and Diagnostics Innovation (ANDI), www.andi-africa.org. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology
                Biotechnology
                Bioengineering
                Biomedical Engineering
                Medical Devices
                Engineering
                Bioengineering
                Biomedical Engineering
                Medical Devices
                Medicine
                Global Health
                Pediatrics
                Neonatology
                Pediatric Pulmonology
                Pulmonology
                Social and Behavioral Sciences
                Economics
                Health Economics
                Cost-Minimization Analysis

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