Now, even the tiniest baby has a fighting chance to live
View(s):Kumudini Hettiarachchi reports on a pilot project launched under the neonatal retrieval concept that will help premature and critically ill newborns
An ambulance pulls up to the entrance of the premier children’s hospital in Colombo and a group of health workers in baby pink loads an incubator, with calculated moves, gently but at the same time urgently. As passers-by mainly, mothers and fathers with ill little ones coming into the Lady Ridgeway Hospital (LRH) for Children stop and stare, the Sunday Times is allowed to take a peek at the incubator – it is a ‘baby’ for sure, but one made of rubber.
Dr. Ramya de Silva
We are witnesses to ‘neonatal retrieval training’ organised by the Perinatal Society of Sri Lanka in collaboration with the Family Health Bureau under the guidance of three experts from the United Kingdom.
Under the neonatal retrieval concept, premature and critically ill newborns at peripheral hospitals who need specialised care at a tertiary hospital such as the LRH, would be transported in special ambulances equipped with incubators fitted with mechanical ventilators, infusion pumps and monitors that can be used in a mobile scenario. This type of transport system would attempt to provide a neonatal intensive care unit environment with uninterrupted care, it is learnt.
“This is a new concept for Sri Lanka,” points out LRH’s Consultant Paediatrician-in-Charge of the Neonatal Intensive Care Unit (NICU), Dr. Ramya de Silva, explaining that though the country’s health indices with regard to children are good, the way newborns, especially premature babies who need support are transported from the periphery to the centre could be improved tremendously.
The neonatal (first four weeks of life) mortality rate is 6.1 per 1,000 live births and the infant (first year of life) mortality rate is 8.4 per 1,000 live births. Eighty percent of infant deaths occur during the neonatal period.
Checking out how to bring down the numbers further, Dr. de Silva, who is President of the Perinatal Society, looked into the baby deaths. A significant number died due to congenital defects and that unfortunately could not be changed. But she found that 28% or more of the babies who died in the first week of birth were pre-term babies. “Therefore, we needed to develop a strategy to improve the numbers,” she pointed out.
Even though the country has an excellent network of hospitals and qualified doctors, pre-term newborns fall into a special category. They are vulnerable to low temperature as although they are tiny they have a large relatively bigger surface area for heat loss. The heat loss is also rapid because they have no thick skin fat. When it is cold, we shiver to retain heat but they can’t. Large babies have brown fat and burn it to generate heat but smaller babies don’t, points out Dr. de Silva.
Low temperature or hypothermia, which even on its own is a killer, could set off a cascade of adverse conditions. They could become hypoglycaemic (low blood sugar) and hypoxic (find it difficult to breathe). The worst-case scenario is brain haemorrhage, according to this Paediatrician.
These are the issues that a medical team would face when transferring a baby from one hospital to another. However, to overcome these issues, no high-tech but simple measures such as keeping a hot water bottle and the baby covered would be needed.
The lungs of these pre-term babies are not mature and they cannot breathe on their own. They need artificial ventilation. Annually, the LRH gets between 450-500 such babies from all over the country and the turnover is not rapid because they have to be kept in the LRH NICU for many weeks, it is learnt. As the centre will not have facilities to accept each and every baby who needs special care, an option is to get such babies from the periphery, stabilize them and return them to the periphery.
For that, the transport had to be looked at and a routine ambulance was just not good enough, she says. A “dedicated” ambulance equipped with an incubator and a neonatal transport ventilator with a continuous supply of oxygen is a must, as much as a specialized team. The incubator also needs to be anchored so that the baby does not go backwards and forwards, depending on the movement of the ambulance.
The babies are so tiny that even a slight jerk could cause a brain bleed (haemorrhage) ending in permanent disability or even death. This is why even the ambulance driver needs to be conscious about the tiny life just behind him, and not rev up, brake and stop suddenly, the Sunday Times understands, while the baby also needs to be well secured in the incubator.
Giving thought to all these issues Dr. de Silva invited the three-member team from the United Kingdom comprising Consultant Neonatologist and Transport Lead Dr. Charlotte Bennett and Consultant Neonatologist Dr. Amit Gupta from John Radcliffe Hospital, Oxford and Advanced Neonatal Nurse Practitioner Kate Convery from the London Transport Service. While conducting training workshops for more than 100 funded by UNICEF, they along with the local team looked at the facilities available at the LRH, spoke to ambulance drivers and saw first-hand how a newborn was brought from a peripheral hospital to LRH.
This was a term baby who was finding it difficult to breathe as the muscle that separates the chest and the abdomen was missing and needed treatment at the Paediatric Surgical Unit. The baby was on a tray in an open trolley with a nurse holding the endo-tracheal tube and a doctor squeezing the bag, the Sunday Time understands.
Having also visited the hospitals of Wathupitiwela and Khethumathi, Panadura, and assessing the facilities, the Family Health Bureau liaising with the team has decided to launch a pilot project in the Western Province, linking LRH with the five hospitals of Khethumathi, Wathupitiwela, Horana, Homagama and Negombo.
The pilot project funded by the WHO, is to assess and find ways and means of using the resources available to a maximum, to give even very ill newborns a fighting chance to live.
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