A NÁLISIS FODA - E STRATÉGICO

Respiratory distress syndrome (RDS) is a common cause of neonatal mortality in many parts of the world. Developed countries spend a vast expenditure on equipment, training and research for babies with RDS. Such expenditure would be inconceivable in developing countries.

Reports of RDS in developing countries are seldom an overall incidence from any one country but rather from various hospital studies. For reasons to be discussed this incidence may increase with improvements in perinatal care. Largely, the major determinant of the incidence of RDS is the proportion of deliveries which are preterm. Common pulmonary conditions that need to be differentiated from RDS are transient tachypnoea of newborn, pneumonia, pneumothorax and PPHN. The factors associated with RDS are shown in Table 3.13.

The diagnosis of RDS is made from the combination of clinical and radiological findings. It is rarely occurs over 38 weeks gestation. There is a tachypnoea, grunting, retraction of chest wall in moderate to severe cases. Multiple randomised, controlled clinical trials indicate the benefits of surfactant replacement therapy, including reduction in the severity of RDS.

The overall mortality of the RDS has now been reduced to between 5% and 10%. Up to 50% of babies weighing less than 1.5 kg and who survive RDS will require readmission to a general paediatric ward within first year of life.

Hypothermia and Hypoglycaemia

Hypothermia and hypoglycaemia may be prevented through simple and inexpensive interventions. Risk factors for hypoglycaemia include birth asphyxia, prematurity and hypothermia. Hypothermia is common in developing countries, affecting more than half of all newborns in many communities, and is associated with an increased risk of mortality. Hypothermia also is associated with increased rates of morbidity, including increased risk of neonatal infections, coagulation defects, acidosis, delayed foetal-to- newborn circulatory adjustment, hyaline membrane disease and IVH.

Hypothermia can be prevented by simple measures such as ensuring a warm environment during delivery, Table 3.11: Major birth defects and inherited disorders

in the developing world • Down syndrome

• Thalasaemia • Sickle cell disease • G6PD deficiency • Oculocutaneous albinism • Cystic fibrosis

• Phenylketonuria

• Neural tube defects and hydrocephalus • Congenital heart disease

• Cleft lip and plate

• Developmental dysplasia of hip

Table 3.13: Factors associated with RDS • Higher male incidence

• Caesarean section without labour • Second twin

• Maternal diabetes

Table 3.12: Complications associated with prematurity • Respiratory distress syndrome

• Hypothermia • Hypoglycaemia

• Haemorrhagic and periventricular white matter brain injury • Bronchopulmonary dysplasia

• Necrotising enterocolitis • Apnoea/Anaemia of prematurity

early breastfeeding and skin-to-skin contact with the mother, proper bathing, drying and swaddling, and prompt identification and rewarming of hypothermic neonates. Basic knowledge and practice of thermal control, however, generally are inadequate among healthcare providers and families in developing countries. The effects of hypothermia on babies are shown in Table 3.14.

Haemorrhagic and Periventricular White Matter Brain Injury [Periventricular Leukomalacia (PVL)] The germinal matrix is a weakly supported and highly vascularised area that is prone to rupture upon fluctuations in cerebral blood flow. This condition remains the most common cause of death in very LBW neonate ventilated for RDS. Most IVH occurs in the first 72 hours after birth.

The incidence and severity of IVH is inversely proportional to gestational age and rare after 32 weeks post- conceptional age. The development of large IVH is usually associated with subtle clinical deterioration in a ventilated child with increase in ventilatory support, anaemia, fall in blood pressure, acidosis and neurological signs. Cranial ultrasonography is the most frequent imaging modality used to diagnose IVH. The classification of IVH is shown in Table 3.15.

To date, no single intervention has been found to prevent IVH although many approaches have been tried. Best approach would be to minimise the hemodynamic instability during the perinatal period. Uncomplicated IVH has a good prognosis. About 30% of infants with IVH went on to develop post-haemorrhagic ventricular dilatation and have the highest risk of adverse neurodevelopmental outcome. Prognosis for

the white matter brain injury is even more difficult to ascertain as not all brain injuries are haemorrhagic but there is no doubt that PVL is the most powerful predictor of cerebral palsy. BIBLIOGRAPHY

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Table 3.14: Effects of hypothermia on babies • Lethargy

• Poor feeding/weak cry • Peripheral oedema

• Marked facial oedema (may give false impression of healthy infant)

Table 3.15: Classification of IVH (Volpe) Grade I Haemorrhage of germinal matrix

Grade II Intraventricular haemorrhage without ventricular dilatation

Grade III Intraventricular haemorrhage with ventricular dilatation

Grade IV Intraventricular haemorrhage with parenchymal involvement

Paediatric Genetics

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