while they were away: resident contributions abroad

While They Were Away:Resident Contributions Abroad

University of Minnesota Center for Global Pediatrics

Where are the residents traveling?


Objectives for International Rotations• Observe and participate in the care of patients

• Learn about and evaluate: Common childhood diseases Factors that contribute to the high mortality rate

of children Barriers to disease prevention and recognition

• Analyze the influence of culture and values on research studies

• Complete a site-specific academic project during the elective


Today

• Ashley Balsam (MP3)Phototherapy/Lightbox Project, Nicaragua

• Katie Durrwachter Erno (PL3)Antibiogram Project, Cambodia

• Ross Perko (PL3)Medicine Cabinets Project, Uganda

• Amanda Webb (PL3)Neonatal Resuscitation Project, Ethiopia

Neonatal Jaundice and Phototherapy Boxesin NicaraguaAshley Balsam, M.D.: 3rd-year Med-Peds ResidentJanielle Nordell, M.D.: 3rd-year Peds ResidentFaculty Mentors: Teri Reid, M.D. and Tina Slusher, M.D.


If you build it, they will come.


Nicaragua

• Largest country in Central America• Bordered by:

North: Honduras, South: Costa Rica East: Caribbean Sea, West: Pacific Ocean

• Second-poorest C. American country• 27% of population suffers from undernutrition, largest % in C.

America• 20% of children less than age 5 are CHRONICALLY

malnourished• Child mortality 11/100• 48% live below poverty line, 80% live on less than $2.00/day• Widespread underemployment rate, second lowest per

capita income in the western hemisphere


Background: Jalapa and Los Pipitos• “Los Pipitos”: Association of children

and families of children with disabilities in Nicaragua

Disabilities range from strabismus to mental retardation to cerebral palsy

Many pipitos reportedly “born without complications” and “normal at birth”

Clinical question arises:

Is there a preventable cause for some of the disability?


Neonatal Jaundice Background and Stats• Neonatal morbidity and mortality remain very high in developing countries

• Neonatal hyperbilirubinemia remains a leading cause of preventable brain damage, physical and mental handicap, and early death in many communities (BMC public health, 2006)

Disabilities Associated With Neonatal Jaundice (NNJ)

Country Sequelae Frequency Due to NNJ

Brazil17 Hearing loss 6% of HL from NNJ

Kenya18 Eye movement disorder, Dyskinetic movement disorder

12/23 with NNJ seen in FU11/23 with NNJ seen in FU

India19 CP, DD or abnormal ABR 12/15 FU post EBT with ABE

India20 CP 16.7% of <19yo with CP had ABE

Malaysia21 Hearing loss 28/128 with NNJ

Nigeria22 Communication disorder 4.3% of communication disorders

Nigeria23 Hearing loss 13.5% of DHI children

Nigeria24 Hearing loss 19.7% of infants with HL

Turkey25 CP Post NNJ common

Zimbabwe26 CP; DD 5/43 FU; 11/43 FU

Abbreviations:ABE = acute bilirubin encephalopathy; ABR = auditory brainstem response; EBT = ex-change blood transfusion CP = cerebral palsy; DD = developmental delay; FU = follow up; NNJ = neonatal jaundice; DHI = deaf and hearing impaired; HL = hearing loss


Neonatal Jaundice Background and Stats

• Almost all infants develop some degree of jaundice (bilirubin >1), risk determined by level based on nomogram and/or clinical appearance

• AAP recommends pediatricians evaluate neonates within 48-72h of discharge to assess jaundice

• In Jalapa and many developing countries, many births are not in the hospital, and hospital stay is 8h post-partum or less

• Estimated in 2005 that 33% of poor women in Nicaragua have access to a “trained attendant” during and after birth


Neonatal Jaundice and Los Pipitos

• Could neonatal jaundice be going undetected and untreated?

• Could there be a connection between “los pipitos” and untreated hyperbilirubinemia?


The Project• Step 1: Discussion

with local pediatricians “Really don’t have

problem with neonatal jaundice in Jalapa”

Not much treatment given, closest place > 2 hours away and expensive travel for the family

• Step 2: Clinical assessment and TCB testing of all neonates born in the hospital during our 2-week stay

• Step 3: Construction of simple phototherapy box with fluorescent lights for the hospital in Jalapa

• Step 4: Educational session for nurses, medical students, residents and physicians about newborn hyperbilirubinemia and sequelae if untreated


TCB Testing

• Transcutaneous bilirubin monitor used to test 10 babies within 24 -48h of birth

2 found with treatment level hyperbilirubinemia based on TCB nomogram

Follow-up labs: ABO incompatibility

• So we showed that neonatal jaundice is a problem...

Now what?


The Light Box

• Constructed a wooden phototherapy box with 2 banks of lights for treatment Finished just in time to treat

first treatment level jaundice neonate

Resistance to use: the importance of education and discussion


Education• Neonatal jaundice presentation for

nurses, physicians, and trainees

• How to diagnose (clinical, lab exam)

• Risk factors

• Treatment options

• How to use the phototherapy box

• Consequences if untreated

• And, most importantly: why we care


Plans For the Future

• How to diagnose jaundice: Unable to leave TCB

monitor for testing Pediatricians without an intact

plan for a follow-up exam Suggestions/Ideas:

▪ Lab testing for ABO and 24h observation for infants with risk factors?

▪ Education of mothers prior to leaving hospital▪ Serum bilirubin level for jaundice appearance

($ = problem-- $3.00 for bilirubin level)


Lasting Impact?• Accomplishments before we left:

Constructed phototherapy box Left knowledge of the design Education on jaundice and plan to disseminate knowledge

• The day we left: OB physician asked for $$ to check serum bili and ABO on 2

recently born infants who she feared would be jaundiced• The week after we left:

Received email requesting funds for a second phototherapy unit• Over the past 3 months

About 10 infants treated Return trip in July 2010: Meeting planned with local birthing

clinic directors (surrounding Jalapa) for education and possible phototherapy box construction

Antibiogram ProjectAngkor Hospital for ChildrenSiem Reap, CambodiaKatie Durrwachter-Erno, M.D. and Tara Zamora, M.D., 3rd-year Peds ResidentsFaculty mentor: Stephen Swanson, M.D.


Cambodia

• Location: SE Asia

• Population: 14 million

• Ethnic Groups: Khmer (90%), Vietnamese 5%, Chinese 1%

• Recent History: Foreign occupation, civil wars, Khmer Rouge genocide


Health Challenges of Cambodia’s Children

• 33% under age of 14• Under-five mortality rate:

91 per 1,000• 36% of children < 5 yrs

moderately to severely underweight

• 600,000 children orphaned• 1 in 7 children will die before

their 5th birthdays

Source: UNICEF


Angkor Hospital for Children (AHC)

• Freestanding children’s hospital• Friends Without A Border• All care is free • Cambodia’s only pediatric training hospital


Angkor Hospital for Children in 2008

• 113,000 children treated > 300 per day

• 2,800 inpatient admissions• 1,360 surgeries performed

• Over 2,000 healthcare workers educated

• 2,800 homecare visits made• 97% staffed by Cambodians


Low Acuity Unit

• Transition from hospital to home

• 10-bed ward

• Patients transferred from inpatient department


Homecare Program• Serves children with chronic conditions• > 200 visits per year by AHC staff• Children with HIV/AIDS, malnutrition, and

underlying cardiac disease


Antibiogram: Background

• Widespread use and abuse of antibiotics

• Unknown resistance patterns

• Limited availability for susceptibility testing

• Antimicrobial selection based on literature from developed countries


Antibiogram

• Reviewed all bacterial isolates from Jan 1 2006 – Nov 22, 2008

• Culture sources: blood, CSF, urine, pleural fluid, wound (tissue, pus)

• AHC Microbiology Lab supported by Wellcome Trust-Mahidol University Oxford Program in Bangkok


Antibiogram: Data Analysis and Cleaning

Eliminated from analysis:

• Duplicate culture results from same patients

• Rare bacteria

• Gram negative Bacilli and Streptococcus not fully identified by species


Antibiogram: Results

Remaining bacteria:

• 556 gram positive organisms

• 574 gram negative organisms


Antibiogram : Angkor Hospital for Children


Gram Positive Organisms


Gram Negative Organisms


Antibiogram: Limitations

• Results may be biased towards more resistant bacteria

Many patients have negative cultures due to prior antibiotics

Hospitalized patients

• Cultures not always obtained

• Important antibiotics not always tested


Improving Health Care

• Limitations of in vitro susceptibility testing

• Previous use of gentamicin for treating Staph aureus

• Role of the antibiogram changing clinical practice


Sustainability

• Only antibiogram with pediatric data in Cambodia• Used on wards• Continues to be updated


Ar kun (Thank you!)

Medicine Cabinet Use in Ugandan OrphanagesRoss Perko M.D., 3rd-year Peds ResidentFaculty Mentor: Troy Lund, M.D., Ph.D.with Rachel Perko, R.N. and Margaret Perko, M.S.I.


Faculty Sponsor:Troy Lund M.D., Ph.D.U of MN Peds BMT

Ugandan Colleague:Angella Kabatooro, M.D.

2002 census data:18 yrs or less = 56% of pop15 yrs or less = 49% of pop

13.7 million children1.8 million orphans13% orphaned1% increase from 1991

Causes of death in this orphan population:• Diarrhea• Dehydration• Lung infections• Malaria


Pilot Study

• Supply basic, in-home, medical supplies

• Orphanages with NO established formal medical care

• 3 separate orphanages

• Standard “medicine cabinet” contents

• Initial quiz to “orphanage mothers”

• Teaching of the contents and review of the quiz, follow

• Assess effectiveness of the cabinet and the education over time

• Quiz ?’s focus on, fever/infection, diarrhea, dehydration, ORT, wound care, signs of illness


Medicine Cabinet Contents

• Thermometer

• Acetaminophen

• Oral rehydration pkts

• Hydrocortisone

• Medical tape

• Gauze pads

• Measuring cup

• Hydrogen peroxide• Ibuprofen• Diphenhydramine• Clotrimazole• Bandages• Antibiotic cream


• Tremendous need!• Education is required and will improve

quality of initial care

• Future Follow up Re-testing Medication supply

• Enroll more orphanages

Conclusions

University of Minnesota Center for Global Pediatricswww.medicineforsickkids.org

Neonatal Resuscitation In EthiopiaAmanda Webb, M.D. and Brittany Johnston, M.D., 3rd-year Peds ResidentsFaculty Mentors: Tina Slusher, M.D. and Beatrice Murray, M.D.


Ethiopia

• Population: 80 million• 85% of the population is rural• Population of Addis Ababa: 4 million• Children’s Home Society and Family Services

»Sipara Mother & Child Health Center» Infant Care Center»Children’s Home Academy


UN Millennium Development Goals

• Goal 4: Reduce Mortality in Children Less Than 5 Mortality is 13 times more likely in developing countries Half the deaths of children under 5 in the developing world occur in

Sub-Saharan Africa Between 1990 and 2006

▪ Childhood mortality is declining (93 to 72 deaths per 1,000 live births)

▪ Although 27 countries made no progress in reducing childhood deaths

37% of under-five deaths occur in the first month of life There has been increased funding for maternal, newborn and child

health, but goals are still not being met.


Ethiopia In Detail

• 9th highest birthrate in the world

• 94% of births occur outside the hospital

• Only 6% of deliveries have a skilled birth attendant

• Maternal mortality: 850 per 100,000• Under 5 mortality: 198 per 1,000

live births Neonatal 58 per 1,000 live births Infant 55 per 1,000 live births Childhood 85 per 1,000 live births


Neonatal Causes of Death

CAUSES Ethiopia Region

Severe Infection 33% 27%

Birth Asphyxia 22% 24%

Preterm Birth 15% 23%

Neonatal Tetanus 15% 9%

Congenital Anomalies 4% 6%

Diarrhea 4% 3%

Other 6% 7%


Sipara In Detail

• 30 obstetric beds• 20 pediatric beds• 1980 deliveries per year• 920 cesarean deliveries• 5% of deliveries are attended by the

pediatrician• 620 pediatric admissions per year

Dr. Abera


Newborn Resuscitation

Location NMR pre-NRP (per 1,000 live

births)

NMR post-NRP (per 1,000 live

births)

Reduction in NMR (%)

Zubai Hospital 9.9 3.4 66

Samria Hospital 16.4 8.9 46

Moscow Hospitals 34 16 53

Tashkent Hospitals 13.11 9.89 25

India Hospitals 37 35 5

Zambia Communities 11.2 6.2 45

Chinese Hospitals 0.33 0.22 33


Newborn Resuscitation

• The basics: “Warm, dry, position,

suction, stimulate”• Positive pressure

ventilation and chest compressions

• Advanced techniques Endotracheal intubation Umbilical artery

catheterization Intra-osseous line placement

• Improving efficiency Assigning one person for

the baby Equipment Calling for the pediatrician


Nursery Update

• ‘Level 2’ Nursery• Isolette made in-country with simple materials

In an Ethiopian hospital, 67% of LBW and high-risk infants admitted to NICU from outside were cold.


• Bubble CPAP

• Uses Mild to moderate

respiratory distress Apnea of prematurity

Depth of tubein water determines

CPAP delivered

Nursery Update


Phototherapy

• Treatment for jaundice at Sipara required referral for phototherapy or exchange transfusion

• Dr. Slusher arranged for the bili-light to be donated by the manufacturer

• Developed a protocol for recognizing, diagnosing and treating jaundice early

while they were away: resident contributions abroad

Documents

university of minnesota

global pediatrics background

global pediatrics objectives

ethiopia slide

elective slide

western hemisphere slide

stats neonatal morbidity

nnj kenya