The past decade has seen an intensifying focus on child survival so that countries can meet the fourth Millennium Development Goal of reducing under-5 child mortality by two thirds. Recently there has been increasing recognition of the importance of newborn deaths (deaths in the first month of life) which now account for over 40% of all children dying under the age of five. Progress in reducing these newborn deaths has been slow globally with over 3 million deaths still occurring each year.
However, many millions more babies are affected by illnesses and complications yet survive, and very little is known about of the risks of long term impairment worldwide. A study published Online First by The Lancet shows that more than one third (37%) of babies with complications such as preterm birth, obstetric complications, jaundice or infections then suffer long-term developmental consequences. The Article is by Dr Michael K Mwaniki, Centre for Geographic Medicine Research, Kenya Medical Research Institute, Kilifi, Kenya, and Dr Joy Lawn of Saving Newborn Lives/Save the Children, Cape Town, South Africa, and colleagues.
The report's authors raise a serious concern that, while it is good news that neonatal care is improving, some nations-especially those with intensive care but poor monitoring and little follow up data-could already be experiencing an epidemic of disability similar to that seen in high-income countries in the middle of the last century, such as retinopathy of prematurity causing blindness in thousands of surviving babies in the 1960s in Europe and North America.
Many babies who survive these serious illnesses do go on to develop normally thanks to the elasticity of the human brain and its ability to adapt. But in some newborn babies, these injuries or 'insults' can cause varying degrees of long-term neurodevelopmental impairment. Intrauterine and neonatal insults substantially affect the global burden of disease, measured in disability-adjusted life-years, because they contribute to a large number of deaths and also to long-term disability. These impairments cause a major economic burden with lost earning potential. This new review suggests the situation may be even more common than realised in the very countries where many families are already in poverty. In addition the social burden on families is heavier as social and state support is usually not available for disabled children in developing countries.
In this systematic review, the authors found 153 studies suitable for inclusion, spanning the period 1966 to 2011 and reporting neurodevelopmental consequences after neonatal complications. The pooled risk estimate (weighted mean) of at least one impairment associated with one or more of the insults studied (excluding HIV) was 37%. This risk was not significantly affected by region, period of data collection, duration of the follow-up or study design. However, since most of the high quality studies included were from Europe and North America, the authors believe this may have given an incomplete assessment of the global picture, although it is a more accurate picture of the situation in high-income countries. Data is most lacking from the regions with the most births and is especially lacking for some specific outcomes such as behavioral conditions.
They found a risk of at least one severe impairment of 18%, of at least one moderate impairment of 5%, and of at least one mild impairment of 10%. The most common impairments were learning difficulties, cognition, or developmental delay (59% of impaired children), cerebral palsy (21%); hearing impairment (20%); and visual impairment (18%). Only 40 (26%) studies included data for multidomain impairments. These studies included 2815 individuals, of whom 1048 (37%) had impairments, with 334 (32%) having multiple impairments.
Regarding the effect of HIV exposure or infection on long term impairment, the authors note that "With the expansion of antiretroviral treatment for children in many countries, including those in resource-poor regions, many HIV-infected neonates survive into adulthood." The shift of paediatric AIDS to being a long term chronic care condition increases the emphasis on healthy survival. While currently available data suggests HIV infection in the neonatal period has worse effects on neurodevelopment than later HIV infections, larger studies are needed to clarify the picture.
The role of neonatal sepsis and infections are also highlighted. Since the median impairment after preterm birth alone was 28%, and that of septic premature neonates was 49%, they say that "sepsis probably increases the likelihood of neurological impairment in preterm neonates. Moreover, the degree of impairment was more likely to be severe for septic preterm neonates than in nonseptic neonates."
The authors say the policy implications of their study include a much greater focus on the quality of neonatal care, as well as more resources for short and long-term follow-up and rehabilitation services. Things that are known to work must be broadly applied, such as cost-effective interventions to prevent tetanus and intrapartum brain insults as well as to identify and treat sepsis, jaundice, and preterm birth complications including timely and safe use of oxygen and antenatal steroids.
The authors conclude: "Rehabilitation and supportive care might improve quality of life. However, changes to policy and programmes are unlikely without a more cohesive, interagency, proactive approach to improving data...As neonatal care is improving in middle-income and low-income countries, are we recreating the epidemics of impairment because of prematurity, such as retinopathy, seen in the mid-20th century in Europe and North America? We need better data to clarify this issue."
In a linked Comment, Dr Lucy Thompson, Mental Health and Wellbeing, University of Glasgow, UK and Professor Christopher Gillberg, Gillberg Neuropsychiatry Centre, Gothenburg, Sweden, point out the importance of behavioural problems, concluding: "Behavioural problems are often the first sign for parents and caregivers that a child is not developing along the desired trajectory. There is a need to understand and identify these signs better so as to achieve a fuller appreciation of the complex interactions of neurodevelopmental sequelae of perinatal and neonatal insults."
Dr Joy Lawn, Saving Newborn Lives/Save the Children, Cape Town, South Africa. T) +27 21 532 3494 / +27 798 839 706. E) firstname.lastname@example.org
Dr Lucy Thompson, Mental Health and Wellbeing, University of Glasgow, UK. T) +44 (0) 141 201 9239 E) email@example.com