by Dato’ Dr Lim Nyok LingHospital SelayangKuala Lumpur

State Of Sabah

Singapore

East Coast

State Of Sarawak

East Malaysia

KualaLumpur

Brunei

Population : 23.8 Population : 23.8 MillionMillion

PeninsularMalaysia

Malaysia the Country

Size : 330,600 Sq KmSize : 330,600 Sq Km

MOH budget : 6.32%

Gross national income: RM 12,956 per capita

Definition of Perinatology

• The Art and Science of diagnosis and treatment of disorders of the perinate

• Perinatologists are obstetricians who specialise in high-risk pregnancies

• Neonatologists specialise in the care of critically ill or low-birthweight infants

Some milestones in perinatal medicine

Category Year(s) Description

Antenatal aspects 1752 Queen Charlotte’sHospital : World’s1st maternityhospital

Fetal assessment 1819/ 1821 Rene/ laennacintroducesstesthopscope,Kergaradec on f etus

Labour and delivery 1610 1st internationalcaesarean section

1700s Forceps

1953 Vacuum extractor

Fetal physiology 1900-50 Barcrof t and others: principles ofplacental gasexchange and f etalcirculation

A Proposal for a New Method of Evaluation of the Newborn Infant

Virginia Apgar, M.D., New York, N. Y.

Department of Anesthesiology, Columbia University,College of Physicians and Surgeons and the Anesthesia Service,

The Presbyterian Hospital.

From Current Researches in Anesthesia and Analgesia, July-August, 1953, page 260.

The evolution of incubatorsYear(s) Developer/product Comments

1835, 1850 George von Ruehl 1st known incubator in StPetersburgh

1880-3 Stephanie Tarnier Tarnier incubator installed in1880 at Port-Royal Maternite

1893 Pierre Budin Budin popularises Tarnierincubator and establishes theworld’s fi rst ‘special care unit f orpremature infants’ at Materniteand Clinique Tarnier in Paris

1930-50s Large-scalecommercialincubators

Worldwide distribution of AirShields and commercialventilators

1970-80 Modern incubators Transport incubators with built-in ventilators and monitoringequipment developed

Jean Louis Paul Denucé

Berceau incubateur pour les enfants nés avant terme

Journal de Médicine de Bordeaux 1857; 2: 433-440

1st published account of introducing an incubator

1828 - 1897

1884: Small flexible rubber tube for gavage feeding

Other early incubators

Berlin Exposition 1896

Earl’s Court 1897

Omaha Trans-Mississipi Exposition 1898 Paris Exposition 1900

Buffalo Exposition 1901

Coney Island 1903-1943

Portland, Oregan 1906

Mexico City 1908

Rio de Janiero 1910

Lakeside Amusement Park, Denver 1913

Panama Pacific International Exhibition, San Francisco 1915

Baby incubatorshows

Powerful symbolof technology

and creation ofpublic ?awarenessor ?sensationalism

Interior of incubator-baby show

Ventilatory Care and Respiratory Disorders

Neonatal-perinatal Medicine. Fanaroff & Martin 7th edition

Resuscitation &oxygen

Antiquity to early70s

Mouth-to-mouthbreathing

1878 Tarnier uses O2 indebilitatedpremature babies

Assisted ventilation 1930s-80s Alexander Grahamdevelops negativepressure- jacket

1971 CPAP f or newborns

1973; 1970-80s I MV; HFV,monitoring ofpulmonary function

Surf actant 1903 Hayline membranesnoted in RDS

1980, 1989-91,1995

1st eff ective clinicaltrial, commercialsurf actantsavailable,widespread useantenatal steroid

Neonatal-perinatal medicine

• A niche of its own

• Bridges obstetrics with paediatrics and intensive care with primary care

Stories of the Past

• The first neonatologist was a midwife• Midwife-in-Chief of Port Royal

Maternity Paris (1881-1895)• Mission to experiment and develop

the care of prematures in incubators• 6 incubators were set in use

attended by 5 wet nurses, this increased to 14 incubators by 1893

Census of first PBU (18 months from 1893-

1895)• 721 infants treated (90% breastfed)• 357 (49.5%) died, 24 not viable• Smallest infant was 780gm at 5.5 months gestation.

Survived 113 days• 74 (10%) artificial feeding ie diluted sterilised cow’s

milk (41% died of enteritis)• Mrs Henry indicated that artificial feeding was

particularly dangerous during the first two months• She worked closely with hospital pharmacists and

gave an accurate composition of artificial formulas

Pediatric Research 1998,43(4): 231

Professor Pierre Budin (1846-1907) and modern perinatal care (Arch Dis Child 1995; 73(3) 193F-5F

•Succeeded Tarnier in 1898 as Professor of Obstetrics at University of Paris

•An outstanding doctor, scientist and teacher

•Many contributions to perinatal medicine

•Recognised need to educate mother and colleagues in infant care from birth to weaning

Thought only of science, of doing good, and of friendshipAlways courteous and loyal

Made an Officer of the Legion d’honneur

• Created first baby clinic in Paris in 1892 to provide ongoing supervision of health care

• Attention given to warmth, cleanliness and provision of safe milk

• Achieved a remarkable fall in mortality and similar clinics set up elsewhere including England

Essentials of Neonatal care. The Nursling

• Responsibilities of the accoucheur…. takes every precaution that the child will be born sound and viable, and throughout the first two years of life, directs its feeding with utmost care

• Gestational age and weight at birth…. Everything ought to be done to ensure that an infant be born at a term, well-developed and in a healthy condition. But…. Infants are born prematurely…in addition there are tiny, puny infants with great vitality

The use of incubators

• 1880 : Tarnier installed the first incubator at the Maternite. Apparatus similar to that of artificial hatching of eggs (child hatchery)

• Ought weaklings in incubators be clothed or not? … preferable ..at least to clothe them lightly, so as to conserve their warmth and yet leave them absolute freedom

• …better to put by mother’s bedside…monitors temperature of incubator and suckles baby

Hypothermia and cyanotic attacks

• Mortality among prematures appalling if temperature is depressed

• Temperature must be maintained at all times and may be done by use of incubators, hot baths and other means

• We must provide it fuel by giving it food

• Higher risk of cyanotic attacks in those underfed

• Recommended feeding from spoon or gavage if not strong enough to suck

Wet nurses and hygiene

Recognised the predisposition ofprematures to infection and • prohibited infants of wet-nurses from being taken

into dressing-room for weaklings and

• obliged every wet-nurse to wash her face and hands and change her uniform each time she feeds the weaklings

• Separate dressing room from lavatory for wet-nurses

PIETRO LIBERI Padua 1614 — 1687 Venice. A Foundling Hospital with Wet Nurses Caring

for Sixteen Children, while Benefactors Look on

Sterilisation of milk• Bacteria develop in milk with extreme

facility…Diarrhoeas are caused by microbes… Cold does not destroy organisms

• Heat is bactericidal… applied by pasteurisation and sterilisation

• Any milk remaining in a bottle after a feed ought not to be offered again….organisms of mouth.. Enters bottle… rapidly multiply… produce alterations in milk

Mother-child bonding and breastfeeding

• First save the infant• Second save it in such a way that when it

leaves the hospital it does so with a mother able to suckle it

• So when a weakling has to be fed by a wet-nurse I place a vigorous infant at the mother’s breast. Her lacteal secretion is thus established. Soon she can nurse her own one and will continue to suckle it on leaving the Clinique

Prognosis of premature infants

• It has been alleged that they remain puny and weakly all their lives,many have Little’s disaese, and they have feeble intellectual development… but this is not so

• Encountered only one case of Little’s disease out of 1100 admissions and a girl of BW 950 gm who at 7 years of age spoke French and German

• Allegations of permanent bodily and mental debility of weaklings…. Are entirely without foundation

Prematurity as a public health problem

Am J Public Health 1996;86(6): 870-8

In United States• Before WW1 besides medicine, other

interests including philantropy, labour and women’s organisations were mobilised against infant mortality

• In 1920s : Premature infant campaign was led and dominated by physicians

Prematurity as a public health problem

Am J Public Health 1996;86(6): 870-8

• Temperature and Chilling

• Warm air incubators first used in US in 1890

• Feeding : advocated breastmilk

• Disease : infected isolated from well babies and protected in incubators

Prematurity as a public health problem

Am J Public Health 1996;86(6): 870-8

Specialisation

• Until at least 1920s : Physicians attending the birth took care of the newborn

• Paediatricians did not treat NB during the 1930s and 1940s in many hospitals

No-man’s land• Newborn care wrote a critic in 1930s ‘occupies

a no-man’s land’ in the field of medicine and ignored to a large extent by both the obstetrician and paediatrician

• The emergence of the premature nursery, directed by a paediatrician and staffed by paediatric residents and interns represented an important milestone in the separation of obstetrics from neonatal care

Increasing line of responsibility for

paediatricians• Late 40s-50s : Treatment of neonates

outside the delivery room

• 50s : Entry of paediatricians into delivery rooms for high-risk deliveries

• 60s : Paediatricians increasingly called to resuscitate newborn babies

Herman N Bundesen

Instituted a number of public health responses andcampaigns to save lives of prematures

Gave frequent radio talks, paid for burial…if necropsy permittederected a flash light system on death of premature

Commisioner of Health in Chicago (1922-27, 1930-60)

Am J Public H. 1996; 86(6): 870-8

New York and Chicago citywide plan

• Established quality standards of hospital care for prematures

• Designated centres which qualify to provide service

• Hospitals which could not meet the standards for a adequate and continued care should with the help of the Health Department transfer infants to approved hospitals

History of Health Care

• 1874: development of hospitals in Federated Malay States driven by tin industry

• 1893-1910 : Several hospitals built for curative services

• 1900 : IMR established

• 1928 : Preventive services developed

Early paediatricians

• Came to Malaya in 1936.• Famous for identifying kwashiokor• Champion for breastfeeding• Recognised need for preventive

medicine• Had a passion for babies

Dame Cicely Delphine Williams

Early paediatriciansC Elaine Field• 1949-1955: Child Health specialist

Federation of Malaya.• Involved greatly in education of staff, parents

and prevention of diseases and malnutrition• Supervised care of newborn and prematures

in Penang Maternity Hospital• Set up Isolation Unit and first Premature

baby Unit

Early paediatricians

Others• DP Bowler• M Kumaradeva• Harbans Virik• Gwen Smith • Alan E Dugdale• K Somasundram

Datuk Paduka Abdul Wahab Mohamed Ariff

• 1971-1974; deputy Director of Health• Responsible for setting up PBUs in other states• Planned for better rural health services • Introduced ‘Gerakan Perbidanan’ in 1971 in

‘Battle Against Maternal Deaths’• Encouraged and promote training in Paediatrics

for doctors and nurses• Organised clinical departments in UKM and post-

graduate training in paediatrics and obstetrics

Early obstetricians• Dame Janep Campbell• Dr Lyon • Dr JD Llewellyn Jones• Dr Joseph Aeria• Dr Awang Hussein • Dr Poh Peng Toh• Dr Ariffin Marzuki• Dr Thomas Ng• Dr Maheswaran

George Orwell (O’Brien in 1984)

1st 20 years post-independence

Emphasis on• Promotive and preventive measures• Provision of maternal and child health

(immunisation and well-baby clinics)• Health education/health promotion• Improvement of environment• Provision of basic first aid and OP curative

services• Equitable distribution of health facilities

1st 40 years of independence

• Steady improvement of Health indices and vital statistics

• Health service focuses on equity, accessibility, affordability, changing disease pattern, environmental health, technologies, globalisation and liberalisation

Specific developments for perinatal health

• 1923 : Midwifery Legislation responsible for midwives training and antenatal welfare clinics.

• 1954 : Midwives Ordinance with setting up of Board to regulate training and conduct of midwives

• 1966 : Midwifery Act Aim to regulate training and practice and conduct of midwives including TBAS

Specific developments for perinatal health

• 1953 : Family Planning Association (S’gor)

• 1956 : Rural Health Program -State responsibility

• 1957: Maternal and Child Health - Federal responsibility

• 1969: Basic training for TBAs

Development of Health Services

1976 1987 2001Main HealthCentres

39 149 855

Health SubCentres

122 236 In above

MCH Clinics 56 101

Midwivesclinics

643 829

CommunityClinics

1940

Source : MOH

Institutional and Domicillary Deliveries

Types ofdeliveries

1980 1990 2000

I nstitutional Peninsular Sabah Sarawak

47.1% 75.6%61.6%90.3%

97.5%73.8%97.7%

Domicillary Peninsular Sabah Sarawak

51.8% 10.3%31.8%9.7%

2.5%16.1%2.3%

Trained Personnel Peninsular Sabah Sarawak

82.0% 96.4%74.2%90.9%

99.2%78.9%97.8%

Health Facilities 2000

Government Hospitals 127

No of Beds 37519

Private Hospitals/Maternity Homes

224

No of Beds 9547

GovernmentHealth Clinics

2871

Neonatal Intensive Care

• Neonatal ventilation started in the late 70s in some hospitals as part of general ICU care

• NICUs set up in big hospitals in stages from early 1980s

• Expertise, equipment and facilities gradually improved

• NICUs in practically all hospitals with paediatricians

• Level III intensive (ventilated) beds number 4-8 in each government hospital

• A few hospitals have facilities for >10 ventilated beds

Neonatal Intensive Care

• Demand for NICU beds exceeds supply

• Nurse : patient ratio for intensive care usually in region 1:3-4

• Limited number of neonatologists & neonatal nurses

• Priority is usually for bigger babies

Some Issues in the

Provision of Neonatal Intensive Care

• Subspecialty training in neonatology being formalised

• Accreditation of facilities for level of neonatal care also being looked into

• Intensive neonatal care is available in

some private hospitals but cost is high, and parents are mostly self-financing

Some Issues in the

Provision of Neonatal Intensive Care

• All hospitals with obstetrician perform LSCS. A few have maternal-foetal specialists

• All hospitals with paediatricians ventilate newborns

• Neonatal transport largely an individualised escort system

• A regionalised retrieval system in 2 states currently

Perinatal Centres

• Antenatal diagnosis : Chorionic villous

biopsy; Amniocentesis, percutaneous

umbilical blood sampling

Limited Cytogenetic services

Specimens often sent overseas (ie

Australia and USA)

• Assisted reproduction : Mainly in private hospitals

• Foetal monitoring ie USS, CTG

High technology

• Mechanical ventilation

ie IPPV in all, HFOV in a few and Nitric

oxide therapy in 1 centre

• Surfactant therapy since 1994

• Bedside ultrasound scanning in the bigger units

• Cardiorespiratory monitoring

• Percutaneous central line insertion

• Umbilical vessel catherisation

• Parenteral nutrition

High Technology in NICUs

Training and Expertise

Nurses• 1952: 1st school for nurse

midwives in Penang• 1971: 1st postbasic paediatric

nursing course in Kuala Lumpur• 1985: 1st postbasic neonatal

nursing course in Johor Baru

For doctors• Currently 11 medical schools

• Post-graduate training in Obstetrics & Gynaecology and paediatrics available in 3 medical schools and bigger MOH hospitals

• Both Masters (local) and membership /fellowship (overseas) qualifications recognised

• Subspecialty training usually done part locally and part overseas

Manpower Training

For Nurses

• Basic & postbasic (in neonatal and midwifery) courses are all done locally

Other allied health professionals

• Local training for Pharmacists, Physiotherapists, Occupational therapists, Laboratory technicians etc

• No respiratory therapists/ biomedical engineers

Manpower Training

Key Programs/ Activities

• Dato’ Dr Johan Thambu formulated the Colour Coding System for risk approach in obstetrics and Dr Mahinder Singh in neonatology in mid ‘80s

• BFHI was launched in 1993

• Perinatal Society of Malaysia registered in December 1993 and held 1st Scientific Meeting and AGM in January 1994

Key Programs/ Activities

• A formal Neonatal Resuscitation Program under the chairmanship of Professor Boo was started in 1996

• A rapid reporting system for SBs and NDs was developed and implemented in 1998

• CPGs initiated by PSM were drawn up and published in 1995

The Neonatal Resuscitation Program (NRP),

originally known as Neonatal Advanced Life Support (NALS),

was developed at the Charles R. Drew Postgraduate School of Medicine

in Los Angeles, California by Ronald S. Bloom, MD, and

Catherine Cropley, RN, MN, and was finalized in 1985

NRP in Malaysia

• A Perinatal Society activity in collaboration with UKM and MOH

• First launched on 2nd September 1996 (old version)

• 8,272 providers and 1,552 instructors trained

• Revised version launched in Oct 2001• 2,279 providers and 701 instructors

trained

0

10

20

30

40

50

1955 1975 1980 1990 1992 1996 2000

PMR

NMR

IMR

Per 1000 Births

* *

Ref: Vital Statistics Department

* Early NMR

Perinatal, Neonatal and Infant Mortality Rates in Peninsular Malaysia

Livebirths, perinatal and neonatal mortality (1999) and LBW rate (1995-

2000)Source:WHO, Geneva May 2001

Europe 7.4 10 6 6

Malaysia 0.53 11.2 5.2 9.7

LBs (mil) PMR per1000 TBs

NMR per1000 LBs

LBW rate%

World 129.6 52 31 16

Africa 28.7 76 42 14

Asia 76.0 53 34 19

LatinAmerica

11.6 28 17 10

NorthAmerica

4.1 7 4 7

Oceania 0.2 58 34 14

Trend in Infant MortalityTokyo, Japan

0

10

20

30

40

50

60

70

80

90

1940 1950 1960 1970 1980 1990 1997 2000

Infant Mortality (/1,000)

Neonatal Mortality (/1,000)

3.4/1.8

Figure 1.5: Classification of Causes of Deaths, 1999

Lethal congenital malformation

17.5%

Normally formed MSB23.4%

Asphyxia14.7%

Immaturity13.0%

Infection5.3%

Others13.4%

Unknown12.7%

Stillbirths and Neonatal Deaths 1999 (PNM 1/97)

• Breastfeeding• Mother and baby-friendly facilities,

parent visiting and involvement• Approach to the extremely

preterm / LBW infant • Congenital anomalies• Diagnosing and managing

encephalopathy and asphyxia

Special areas for attention

• Neonatal infections

History of breastfeeding and the medical profession

(Lancet 1999; 354: 77-78)

Factors influencing BF pattern

• Occupational and financial

• Religious, cosmetic, superstitious

• Medical influence not predominant one

• BF has had 2 rivals : substitution of mother and substitution of milk

Substitution of mother

• Authorities such as Soranus, Galen and Oribasius in the 2nd-4th century AD taught on how to select the prudent wet nurse, the appropriate breast and milk and how to feed

• Physicians at that time had accepted wet nursing but it is questionable to what extent they had promoted it

Substitution of milk• Industrial Revolution hit BF even harder

by combining the mass employment of women and the production of increasingly sophisticated substitutes of human milk

• Physicians energetically involved in this new fashion and manipulated the composition of formulas, explored mammals milk etc.. But they seem rather to have followed than created this deviation

• Launched in 1993 and 1st BFHI hospital in 1995

• All hospitals in the Ministry of Health have been declared Baby Friendly (ie achieved BFHI status) in 1997

• Presently 113/115 accredited (2 new hospitals)

• Reassessment programme launched in 1998• 60/73 reassessed passed

Baby Friendly Hospital Initiative (BFHI)

• Only 2 hospital has achieved the BFHI status

• Generally provide support to mothers who wish to breastfeed but usually not very aggressive in promoting, encouraging and persuading mothers to breastfeed

Feeding Practices in Private Hospitals

Role of paediatricians in promoting and protecting

BFAAP policy.

Pediatrics 1997;100(6):1035-39• Promote and support enthusiastically• Be knowledgeable and skilled• Promote good hospital policies• Work collaboratively with obstetric

community and other health care providers

• Familiarise and establish effective communication with support groups

Mother-Friendly Childbirth Initiative

(Coalition for Improving Maternity Services)

• Promoting a wellness model of maternity care that will improve birth outcomes and substantially reduce costs

• This mother, baby and family-friendly model focuses on prevention and wellness as alternatives to high-cost screening, diagnosis and treatment programs

Ten steps of Mother-friendly Childbirth

Initiative A mother-friendly hospital, birthcentre or home service1 provides birthing mothers support

access to support personnel2 provides accurate descriptive and

statistical information about its practices and procedures

3 provides culturally competent care

Ten steps of Mother-friendly Childbirth

InitiativeA mother-friendly hospital, birthcentre or home service5 Has clearly defined policies for

collaborating, communicating and linking for post-discharge care

10 Strives to achieve the WHO-UNICEF ‘ Ten Steps of ‘Baby-Friendly Hospital Initiative’

NICU visiting policies and parental involvement

• Good communication between parents and staff of paramount importance

• Parents need a great deal of support• Differing practices: Northern Europe

more inclined to involve parents in decision making and allow free visiting time; S Europe more inclined to restrict visiting hours and often make decisions for parents

Arch Dis Child 1999;81(2) F90-91

In Malaysia...• Prior to 1958 : Children separated from

mothers in hospitals.

• ‘The first thing that I did…. was to allow mothers to accompany their sick babies in the wards…. The principal matron once marched in and said that I had reduced nursing to nothing and she would be withdrawing her nurses…. She never visited the wards again.

Harbans Virik

• Rooming-in for mothers but poor family-centredness

‘reduced nursing to nothing’ ???

How low can you go?

Neurologic and developmental disability after extremely preterm

birth (Wood NS et al. NEJM 2000; 343:378-84)

• Total of 4004 infants 20-25 weeks from 276 maternity units studied up till 30 months.

• 1185 had signs of life• 30% died in delivery room• 811 admitted to NICUs (497 ie 61.3% died)• Only 27% LBs survived. 49% survivors had

disability in one or more domains and 1/4 was severe

EPICure: Health Status of survivors of extreme prematurity at one year Marlow N. Pediatric Research 1998; 43(4):220

• At 1 year babies born before 26 weeks have high rates of morbidity particularly in respiratory function and feeding

• Of 1 year old children 32 of 300 (10.7%) free of any impairment or disability

• 87 (29%) had a major disability (abnormal neurology or development or need for home O2

Outcomes of infants 25 weeks and below

• Victorian collaborative study reported severe disability (CP, DS <3SD and bilateral blindness) rate of 9% (4-18%)

• In UK Northern Ireland network severe disability rate reported as 24 %

Neonatal Research Network 1993-94.

Vohr et al. Pediatrics 2000;105:1216-26

• Multicentre study of 1151 ELBW survivors at 18-22 months

• 63% survivors at discharge but comparable morbidity of 48%

0

50

100

1993 62.6 23.1

1996 69.3 30.8

2000- 2001 71 40.2

VLBW ELBW

% survival

Survival on discharge

Refs: MPA VLBW study 1993 & 1996

MOH Modified budgeting system study 2001

VLBW ELBW

N = 868 134

N = 962 211

N = 1060 261

Survival on dischargeVLBW infants Hospital

Selayang

0

50

100

2001 82.4 60.7 90

2002 81.8 60 92

VLBW ELBW 1000-

% survival

VLBW ELBW

N = 102 28

N = 137 45

NZ: 1998-99 90 80 97

Refs:HS NICU CensusANZNN. Arch Dis Child 2003;88:F23-8

Gestational Age (mo.) Admitted Died

6 9 0

6 1/2 18 4

7 37 6

7 1/2 9 0

8 20 0

8 1/2 1 0

Unknown 2 0

Total 96 10

Medical News: New York City. JAMA 115:1648, 1940

Mortality Experienced at Exhibit during

New York World's Fair 1939-1940

Perinatal management at lower margin of viability

(Arch Dis Child 1996;74:F214-8)

Generally accepted : Intact survival >50% beyond 27weeks and only minimally at 22 weeks

Suggested guideline• immediate management of threatened delivery at

23-26 weeks : transfer, antenatal steroids, tocolysis and intrapartum Abs

• prenatal counselling for parents with up-to-date information (tables and charts)

• management at delivery -senior paediatrician available and plan of action outlined to parents

• ? Full CPR

• Reasonable not to offer to resuscitate 23-24 weekers (to execute plan if parents agree and infant is born in poor condition)

• Discourage to seek active treatment for 22 weeks

• Encourage at 25-26 weeks• Be prepared to withdraw if severe disability

becomes >90%• CPR may be inappropriate for VLBW infants

Meadow et al addresses

Who should have the decisive say in the Mx of critically ill

neonatesWhen a dispute arises between parents andcare-givers?

• recognise predictive accuracy of ‘physician intuition’ about neurologic morbidity …

• Although ‘life and death’ decisions will always be difficult, practice of maximising parental decision-making and providing data and clinical intuition of care providers at multiple points throughout on which to base those decisions...

Current Opinion in Pediatrics 2002, 14(2) 149-50

6.2

10.8

20.7

0

5

10

15

20

25

1970 1980 1990

Souce: Statistics Department

Proportions of Infant Deaths due to Congenital Abnormalities

26

21

1613

3

10 9

1

0

5

10

15

20

25

30

Congenital Anomalies

Asphyxia

ImmaturityHMD

ICHInfection

Miscell Unknown

Total Deaths : 99

Annual Report MHKL

CAUSES of NICU DEATHS (KKM Unit 1997)

Prevention Strategies at Primary Health Care LevelPrimary prevention

• Mass Rubella vaccination

• Healthy lifestyle education

• Care of diabetic women

• Genetic counseling

• Thalassaemia screening

• Folic acid supplementation

Prevention Strategies at Primary Health Care Level

Secondary prevention

• Identification of at risk mothers for

referral to centres for further

investigation

• Maternal ultrasound screening

Prevention Strategies at Primary Health Care Level

Tertiary prevention

Cord blood Screening for

Glucose- 6- phosphate-

dehydrogenase deficiency

Hypothyroidism

Neonatal physical examination

Referral for early surgery /treatment

Prevention strategies at hospital level

• Education• Antenatal diagnosis• Diagnosis and early treatment of

abnormalities and rehabilitation

• Genetic counselling• Collaboration with primary care doctors

Metabolic and genetic services

• Clinical services available in Paediatric Institute, UM and USM support from IMR, LPPKN and other laboratories

• Diagnoses presently possible for many disorders including

• Townsend Brooke Syndrome• Extended William syndrome• Frasier’s syndrome• Alpha glutaric acidaemia

Definition of asphyxia• Asphyxia defined experimentally as impaired gas

exchange accompanied by the development of metabolic acidosis

• Fetal asphyxia is progressive hypoxaemia and hypercapnia with a significant metabolic acidaemia

• Timing of the onset and progression of these changes can be difficult or impossible to ascertain

Neonatal encephalopathy• Neonatal encephalopathy is a clinically defined

syndrome of disturbed neurological function in the infant at or near term during the first week after birth manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, altered consciousness,and often seizures

• Hypoxia and ischaemia have often not been proved

• Over 75% of cases have no intrapartum hypoxia

Are these conditions preventable?

• Were there risk factors for an antenatal cause?

• Was there a sentinel hypoxic event?

• Was there an intervention that could reduce the occurrence of the event?

• Could the signs of fetal compromise reasonably have been detected?

• Was there an avoidable major delay in expediting delivery?

• Was there suboptimal care at any phase of pregnancy and delivery and neonatal care

Medico-legal cases that have been settled according to

disciplines (MOH 1995-2001)

Obstetrics & gynaecologySurgery

2822

OrthopaedicsPaediatrics

131

AnaesthesiaMedicine

54

PsychiatryOpthalomology

32

ENTUrology

31

Total 82

Source: Dr Mohd Norzi. MOH

Neonatal Infections

• Infections are a major cause of

morbidity and mortality in the

Neonatal Intensive care Unit (NICU)

• Widespread use of antibiotics have

been associated with increasing

problems of resistant microorganisms

Blood stream infections in NICU

H Selayang 2002 MHKL 1991

Total admissions 1329 1926

BOR 92.3%

Early- onsetinfections

20 35

Late- onsetinfections

62 106

BacteraemicInfection rate

6.17% 7.1%

Deaths associatedwith infections(mortality rate)

7/76(9.2%)

40/132(30.3%)

Refs: HS Infection surveillance data 2002 Med J Mal 1995;50:59-63

0 5 10 15 20 25

MRSEMRSAGBS

Staph aureus

Klebsiella sp

Pseudomonas

Candida

Stenotroph

E coliFlavobac

Moraxella

Grp A strep

Enterococcus

AcinetobacterBulkhoderia

CorynebacteriumBacillus

Blood steam infections in NICU Hospital Selayang 2002

Prevention of nosocomial sepsis

Strategies to reduce incidence:

• handwashing• use of universal precautions• avoiding overcrowding• promoting enteral nutrition• removal of venous lines

Approximately 20% of VLBW infants have an infectious episode before hospital discharge

Discharge Planning AAP proposed guidelines

Pediatrics 1998;102:411-17

6 critical components• parental education

• implementation of primary care

• evaluation of unresolved medical problems

• development of a home care plan

• identification and mobilisation of surveillance and support services

• determination and designation of follow-up

• Home nursing and community support

• Long- term FU and rehabilitation for for diagnosis and management of neurodevelopmental disability

• Collaboration between family health and hospital very important

Discharge and follow-up care

• Of all the advances of the 20th century none has made more impact than the publication and dissemination of scientific information through journals and books…..

Audit and research• Own hospital and unit census

ongoing

• National Neonatal Registry being piloted

• Generally very little basic science or even clinical research being done

• Prevention and Mx of prematurity (PPROM, hormone deficient states, developmental care)

• Prevention and management of chronic lung disease

• Prevention and treatment of ROP

• Understanding and prevention of NEC

• Understanding and management of neonatal encephalopthy and asphyxia

Awaiting new developments

Vagaries in practiceLessons from the past

• Oxygen therapy blinded 10000 worldwide before the 1950s

• Prophylactic penicillin + sulfisozole associated with kernicterus

• Withholding all food or fluid from premature infants up to 4 days, a practice that persisted from the early 50s till 60s increased the possibility of spastic diplegia and lowered neonatal survival

8th Malaysia Plan (2001-2005)

Perinatal & Maternal Health given priority

Objectives:• To achieve a national PMR of 8 per 1000 TBs

• To provide a patient focused service and facilities to ensure a fulfilling pregnancy, birth and post-partum experience

8th Malaysia PlanStrategies• To develop a system of integrated service• To establish a comprehensive perinatal database• To upgrade perinatal services ie facilities,

subspecialists training, etc• To establish baby and family friendly services• To establish preventive service in antenatal

mothers including periconceptual foilc acid• To establish clinical genetic and metabolic services

National Center for Child Health and Development (Tokyo, Japan)

　 　Adult

Child Fetus

Fetal medicine

Neonatal (NICU)

Carried over diseases

Psychosocial medicine

Transplant

Critical Care (PICU)

Perinatal Medicine

Pediatric Medicine

Reproductive Medicine

Pregnancy Genetic medicine

High-risk pregnancyCongenital anomalies

Infertility

Neonate

Extended Children’s Hospital

Perinatal Medicine

Maternal

Interd

isciplin

ary Me

dicine

Adolescent

Full Ceiling Pendant System

Ceiling System and Nothing on the floorinfection control and workability

Newport Ventilator

Head cooling unit

Humidifier

Medical gases & electricity

NO controller

Computer System

Hospital Information System with individual terminal

Critical Care System at bedside

Conclusion• Perinatology has come a long way• Need to continually improve. Learn from

experience of others and ourselves, always asking

• Be always compassionate

• Effective collaboration between various sectors must be developed

Acknowledgement• Dato’ Dr Sam Abraham• Dato’ Dr Johan Thambu• Dato’ Dr Alex Mathews• Dr Rachel Koshy• Dr Lailanor bin Ibrahim• Dr Rusnah Sutan• Dr Choy Yew Sing• Dr Japaraj

• Dr Noor Aziah Zainal Abidin

• Encik Jaafar bin Mohamed Idris

• Ms Rita Ho• Dr Katsuyuki Miyasaka• Dr Chew Thean Meng• Dr Ismail Haron• S/N Ruslina Abu Hassan• Lembaga Jururawat