Thesis

KNOWLEDGE,ATTITUDES AND PRACTICES OF BURUNDI GENERALIST DOCTORS IN THE MANAGEMENT OFPREMATURE AFTER DISCHARGE: A CROSS-SECTIONAL STUDY CARRIED ON 100 GENERALISTDOCTORS

From September 19^th to November 18^th 2018

Prince Emmy NGOMA

A THESIS

Submitted to the Faculty of Health Sciences

Department of Medicine

In Partial Fulfillment of the Requirements

For the Degree

DOCTOR IN GENERAL MEDICINE

UNIVERSITE ESPOIR D’AFRIQUE

Bujumbura-Burundi

February, 2019

STUDENT’S DECLARATION

I declare that this is my original research work and to the best of my knowledge, it has not been presented for the award of degree or certificate in any university or institution.

Prince Emmy NGOMA

Signature……………………………………………………. Date………/……. /2019

This Academic thesis was realized under the supervision and guidance of:

Bond G. Randall (MD, FAAP, FAACT, FEAPCCT)

Signature……………………………………………………. Date………/……. /2019

ABSTRACT

Introduction: Progress in neonatal care has led to an increasing number of survivors among PTIs. Thus, growth and development monitoring has to be done for these survivors to diagnose and deal with the large variety of long-term complications. In Burundi context, the generalist Doctor is the cornerstone of PTIs care. Meanwhile, less was known about knowledge, attitudes and practices of the generalist vis-à-vis the after-discharge follow up of PTIs.

Objective: To determine the level of knowledge and the willingness of general practitioners in the follow-up of premature infants.

Materials and methods: A cross-sectional survey was carried out and included general doctors practicing in different hospitals and health care centers in Burundi from September 19^th to November 18^th. The data was collected using pre-established questionnaires. Data analysis was done using Microsoft Excel 2013.

Results: Of the 100 respondents 67 were male. The mean age of the participants was 34.8 ±3.3 years. The largest group were in the age group of 31-35 years (49%). 86% were practicing in public institutions and the location of practice was rural in 69%. 86% of the surveyed have been practicing for 1-5 years. The main source of information about prematurity management is internet for 74% of the generalist doctors. 62% of the respondents declared to have responsibility to care for PTIs. The developmental delay was the more recognized long-term complication, followed by mental disabilities in 43%, poor growth 34% other complications were lowly mentioned. All the respondents thought there should be an after-discharge monitoring for PTIs though items to be monitored were unequally known among physicians. Knowledge of the surveyed related to immunization schedule and doses was also heterogeneous. For the majority, there was no additional vaccine for PTIs. According to 68% of the participants, doses of vaccines to be administrated in preterm babies and babies born at term are different. Only 7% of the generalist doctors in our survey systematically looked for long term complications in PTIs. Finally, all the respondents affirmed they had not enough knowledge about PTIS monitoring after discharge and wished to get CME opportunities on this.

Conclusion: The majority of generalist doctors are involved in PTIs care in Burundi. Their knowledge about PTIs after discharge management is low. Hospitals do not have different protocols for PTIs care. All our respondents estimated that their level of knowledge about different aspects of after-discharge care is not enough.

List of Abbreviations

AAP : American Academy of Pediatrics

AGA : Appropriate for Gestational Age

Anti-HBs : antibody to hepatitis B surface antigen

CA : Corrected Age

CH : Chronological age or “actual age”

CLD : chronic lung disease

DTaP : diphtheria and tetanus toxoids and acellular pertussis

DTwP : diphtheria and tetanus toxoids and wholecell pertussis

ELBW : extremely low birth weight

FT : full-term

GA : Gestational age

HBIG : Hepatitis B Immune Globulin

HBsAg : hepatitis B surface antigen

HBV : hepatitis B virus

Hib : Haemophilus influenzae type b

IPV : inactivated poliovirus

IUGR : Intrauterine Growth Restriction

KMC : Kangaroo Mother Care

LBW : Low birth Weight

LGA : Large for Gestational Age

LMP : last menstrual period

MCV : meningococcal C conjugate vaccine

NICU : Neonatal Intensive Care Unit

OPV : oral poliovirus

PCV7 : heptavalent pneumococcal conjugate vaccine

PMA : Postmenstrual Age

PT : Preterm

PTB : Preterm Birth

PTI : Preterm Infant

RDS : Respiratory Distress Syndrome

ROP : Retinopathy of prematurity

RSV : Respiratory Syncytial Virus

SD : Standard Deviation

SGA : Small for Gestational Age

US : United States

VLBW : very low birth weight

WHO : World Health Organization

Chapter 0

Introduction

Preterm birth, defined as childbirth occurring at less than 37 completed weeks or 259 days of gestation, is a major determinant of neonatal mortality and morbidity and has long-term adverse consequences for health (Beck S et al, 2010).

Around the world, about 15 million babies are born prematurely every year (WHO, 2012). There is an average of 12% of premature births in poor countries compared with 9% in higher income countries (Blencowe H et al, 2012). In 2005 more than 500,000 infants in the United States—one in every eight—were born prematurely (before 37 weeks’ gestation). That’s 12.7% of all U.S. births that year (Barbara LM, 2009). In Africa, Beck et Al. found an estimated rate of preterm births of 11.9% in 2010. (Beck S et al, 2010). Sub-Saharan Africa and south Asia account for over 60 percent of preterm births worldwide. Of the fifteen million babies born too early each year, more than one million die due to complications related to preterm birth (US Agency of International Development, 2015). In Kenya according to a study conducted at the Kenyatta National Hospital (KNH), the prevalence of preterm birth among live births is 18.3% (Wagura P et al, 2018). In Senegal, at Grand Yoff General Hospital (GYGH) in 2013, out of 501 newborns 141(28.1%) were premature babies (Sow et al, 2018). In Burundi, according to a research conducted during 2011 and 2012, out of 4260 babies born in Kabezi Hospital, 437 (9.7 %) were born prematurely (Ndelema et al, 2016)

Apart from its immediate complications, long-term consequences are numerous. They include life-long health complications, cognitive and behavioural deficits, and economical and educational consequences. Premature infants are likely to be affected by many medical conditions that are harmful to the brain, such as respiratory distress syndrome (RDS) and intraventricular haemorrhage. A study conducted in 2011 demonstrated that children born prematurely may have brain abnormalities such as thinning of the corpus callosum, hippocampus volume reduction, and prefrontal cortex lesions (Foord et al, 2011). Children who are born prematurely have higher rates of cerebral palsy, sensory deficits, learning disabilities and respiratory illnesses compared with children born at term. The morbidity associated with preterm birth often extends to later life, resulting in enormous physical, psychological and economic costs (Beck S et al, 2010). Research done in 2008 found that sixty percent of babies born at 26 weeks of gestation have long-term disabilities that include chronic lung disease, deafness, and blindness and neurodevelopment problems. Infants born at 31 weeks were found to be 30 percent less susceptible to these conditions. Premature children who survive into adolescence continue to demonstrate consequences of their early entry into life. Males born between 22 and 27 weeks were 76 percent less likely to reproduce, whereas women born during the same gestational period were 67 percent less likely to have children. Another research revealed that women who are born prematurely are at much higher risk of giving birth to preterm offspring as well, however, the study revealed men showing no signs of premature successors (Swamy et al, 2008).

To account for prematurity, growth and development monitoring should be done according to adjusted age (age in months from term due date). Premature infants should gain 20 to 30 g (0.71 to 1.06 oz) per day after discharge from the hospital. Growth parameters may be improved in the short term with the use of enriched preterm formula or breast milk fortifier. Each well-child examination should include developmental surveillance so that early intervention can be initiated if a developmental delay is diagnosed. Routine vaccination should proceed according to chronologic age with minor exceptions, and respiratory syncytial virus immune globulin is indicated in preterm infants who meet the criteria (Amy LH and Cathy AB, 2007)

In Burundi, due to the small number of Pediatricians, monitoring of the premature is widely supposed to be a task of the generalist doctor. Meanwhile, less is known about the level of knowledge, attitudes and practices of the generalists about the after-discharge follow up of premature infants. We sought to investigate these factors in a population of Burundi generalist physicians

STUDY OBJECTIVES

1. Broad objective

The main objective of our study is to determine the level of knowledge and the willingness of general practitioners in the follow-up of premature infants.

2. Specific objectives

· Evaluate the level of skills of general physician about pre-matures

· Highlight the willingness of the general practitioner and his skills in the care of the premature child after discharge.

Chapter 1

Literature Review

I. Definitions

- Preterm birth

The World health Organization defines preterm birth as any birth before 37 completed weeks of gestation or fewer than 259 days since woman’s first day of the last menstrual period (LMP). Further subdivision is commonly done on the basis of gestational age (GA): extremely preterm (<28 accepted="" and="" b="" birth="" completed="" definition="" extensively="" gestation="" is="" late="" moderate="" most="" of="" or="" preterm="" the="" this="" used="" very="" weeks="">(Howson CP et al, 2012).

A limitation of this definition is that there is no boundary between spontaneous abortion and viable birth (Quinn JA et al, 2016). The low cut-off (e.g. 24 or 20 weeks’ gestation) that distinguishes between preterm birth and spontaneous abortion varies by location. The limit of viability is currently around 22 weeks’ gestation, but survival at this gestational age is still rare (Costeloe et al, 2000; Saigal and Doyle, 2008). Most Western countries consider an infant at 25 weeks’ gestation potentially viable and recommend treatment (Cuttini et al, 2000).

About 5% of preterm births occur at less than 28 weeks (extreme prematurity; EP), about 15% at 28–31 weeks (severe or very preterm; VP), about 20% at 32–33 weeks (moderate prematurity, MP) and 60–70% at 34–36 weeks (near term birth; NTB) (Goldenberg et al, 2008).

Preterm infants are also classified by BW:

●Low birth weight (LBW) – BW less than 2500 g

●Very low birth weight (VLBW) – BW less than 1500 g

●Extremely low birth weight (ELBW) – BW less than 1000 g

- Appropriate for Gestational Age (AGA):

AGA is usually defined as infants born with growth parameters plotting between the 10th and 90th percentile.

- Large for Gestational Age (LGA):

Infants born with growth parameters greater than two SD from the mean, usually defined as above the 90th percentile.

- Small for Gestational Age (SGA):

Infants born with growth parameters less than two SD from the mean, usually defined as below the 10th percentile. These infants can be born at term or pre-matures (Oregon Pediatric Nutrition Practice Group, 2013).

- Intrauterine Growth Restriction (IUGR):

Failure to sustain intrauterine growth at expected rates; can be caused by placental insufficiency, infection, malnutrition, etc. May or may not be born prematurely (Oregon Pediatric Nutrition Practice Group, 2013). Small for gestational age (SGA) fetuses or newborns are those smaller in size than normal for their gestational age, most commonly deﬁned as a weight below the 10th percentile for the gestational age. This classiﬁcation was originally developed by a 1995 World Health Organization (WHO) expert committee, and the definition is based on a birth weight-for-gestational-age measure compared to a gender-speciﬁc reference population (De Onis M and Habicht JP, 1996; WHO Expert Committee, 1995).

Despite the presence of many pathophysiological events that may lead to intrauterine growth restriction, SGA is not universally associated with growth restriction. Small for gestational age (SGA), is commonly used as a proxy for intrauterine growth restriction (IUGR), particularly in settings where serial ultrasonography is not readily available (De Onis M and Habicht JP, 1996; Lee AC et al, 2010). However, fetuses that are SGA are not necessarily growth restricted; they in fact maybe constitutionally small. If SGA babies have been the subject of intrauterine growth retardation (IUGR), the term ‘‘SGA associated with IUGR” is used. IUGR refers to a fetus that is unable to achieve its genetically determined potential size. This functional deﬁnition aims to identify a population of fetuses at risk for poor pregnancy outcomes, and excludes fetuses that are SGA but are not pathologically small. Neonates born with severe SGA (or with severe short stature) are deﬁned as having a length less than 2.5 standard deviation below the mean (Clyton PE et al, 2007).

- Asymmetric SGA:

Infants who have reduced body weight, but growth for head and length have been spared; often indicates short-term intrauterine growth restriction.

- Symmetric SGA:

Infants born with small body (weight and length) and head growth; often indicates that the intrauterine growth restriction was prolonged.

- Gestational Age:

Indicates time elapsed between first day of the last menstrual period and the day of delivery in weeks and days.

- Chronological age (CH) or “actual age”:

Indicates the time elapsed from the actual day of birth in days, weeks, months, and years. Chronological age is also known as “postnatal age”.

- Corrected Age (CA):

CA is equal to chronological age minus the number of weeks born before 40 weeks in weeks, and months. Also known as “adjusted age” and is the more appropriate term used post discharge to describe children up to 3 years of age who are born preterm.

- Postmenstrual Age (PMA):

Indicates the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (chronological age) in weeks and days. This is the preferred term used to describe the age of the preterm infant during the perinatal period neonatal hospital stay. After the perinatal period, “corrected age” is the preferred term (Oregon Pediatric Nutrition Practice Group, 2013).

II. Epidemiology

Preterm birth (PTB) is a major determinant of neonatal mortality and morbidity and has long-term adverse consequences for health (Goldenberg RL et al, 2008; Wang ML et al, 2004).

Approximately 1 million children die each year due to complications of preterm birth (Liu et al, 2016). Preterm births are a significant global health issue worldwide and a leading cause of perinatal morbidity and mortality. The incidence of PTB has not changed during the last 50 years. Every year about 15 million babies are born preterm. (Lawn JE et al, 2006). The rate of preterm birth ranges from 5% to 18% of babies born.

In many countries rates of premature births have increased between the 1990s and 2010s. More than 60% of preterm births occur in Africa and South Asia, but preterm birth is truly a global problem. In the lower-income countries, on average, 12% of babies are born too early compared with 9% in higher-income countries. Within countries, poorer families are at higher risk (WHO, 2018).

In the USA, the preterm delivery rate is 12–13%; in Europe and other developed countries, reported rates are generally 5–9% (Zeitlin et al, 2008). The preterm birth rate has risen in most industrialized countries, with the USA rate increasing from 9.5% in 1981 to 12.7% in 2005 (Goldenberg et al, 2008) despite the advancing knowledge of risk factors and mechanisms related to preterm labour, and the introduction of many public health and medical interventions designed to reduce preterm birth.

According to a research done in 2012, the top 10 countries with the greatest number of preterm births are India (3 519 100), China (1 172 300), Nigeria (773 600), Pakistan (748 100), Indonesia (675 700), United States of America (517 400), Bangladesh (424 100), Philippines (348 900), Democratic Republic of the Congo (341 400) and Brazil with 279 300 (Blencowe H et al, 2012).

III. Mortality

Prematurity is the second leading cause of infant mortality after congenital abnormalities (Amy LH and Cathy AB, 2007). Mortality rates for preterm infants increase with decreasing gestational age and are higher both during the first 28 days, and during the first year of life, compared with term infants. (Lindström K, 2011). The chance of survival is about zero at less than 23 weeks, 15% at 23 weeks, 55% at 24 weeks % and 80% at 25 weeks (Wilkins P, 2008). Around the world, one million out of six million child deaths are due to complications of prematurity (Liu L et al, 2014). Prematurity is associated with approximately one-third of all infant deaths in the United States (George TM, 2018).

Nevertheless, by improving good practices many lives can be saved. It is estimated that at least 75% of preterm infants would survive with appropriate treatment (WHO, 2015).

IV. Pre-Discharge Care in NICU

Adequate pre-discharge care is important to save lives and prevent complications. Phillips RM et al, proposed a protocol for the in-hospital assessment and care of preterm new born. The guidelines consist of four main items to be focused on: stability, screening, safety and support (Phillips RM et al, 2013):

1. Stability

To ensure the PTI stability, the health care team, beside family education, has to make an initial assessment, work to reduce the risks of respiratory distress, maintain neutral thermal environment, reduce risks of sepsis, hypoglycemia and risks of feeding difficulties, ensure the first breastfeeding is successful and continued otherwise perform breast pumping and supplement when needed. In the NICU, the healthcare team should also focus on reducing the risks of hyperbilirubinemia and optimizing the neurologic development.

2. Screening

The screening should consist of newborn screening to be done 24 h after feeding is initiated. At this stage, there should be reported abnormal results or plans for repeat testing to primary care provider. An early hearing screening should be done with referral to audiology service if indicated. The healthcare team should evaluate infant for congenital anomalies and consider pulse oximetry screening for congenital heart defects per hospital protocol. A maternal screening is also necessary and should comprise of biological screening, reviewing mother’s smoking history or ingestion of illicit drugs, screen for psychiatric illness or perinatal mood disorders (including postpartum depression and post-traumatic stress disorder) and evaluate mother’s understanding of any referrals made.

3. Safety

To ensure PTIs safety, the physicians should emphasize on proper hand hygiene when handling baby or feeding equipment, proper equipment, positioning, and monitoring of the newborn for bathing, diapering, and routine care and set a model safe sleeping practices when placing baby in bed.

4. Support

Staff support:

There is an imperative to assess adequacy of staff support for physicians, midwives, nurses, lactation and feeding specialists, social workers, occupational therapists, physical therapists, case managers, transition/discharge planners, and home health services, including availability of staff to support level of services offered, stafﬁng ratios, competencies and skills and availability of referral services.

Family Support:

Assessing adequacy of family support includes partner’s presence, involvement, and coping and Grandparents and/or friends cooperation.

V. Transition of care

Transition of care involves a set of actions designed to ensure continuity of care from inpatient to outpatient healthcare providers. Planning for transition of care should begin at the time of admission. Optimal transition of care relies on accountable healthcare providers who ensure that accurate and complete information is successfully communicated and documented (National Transitions of Care Coalition Measures Work Group, 2008). The transition from the NICU to home can be stressful. The American Academy of Pediatrics (AAP) recommends that planning for discharge from the NICU should include the following six critical components: (1) parental education; (2) implementation of primary care; (3) evaluation of unresolved medical problems; (4) development of the home care plan; (5) identification and mobilization of surveillance and support services; and (6) determination and designation of follow-up care (American Academy of Pediatrics Committee on Fetus and Newborn, 1998).

VI. Discharge

The practice has been to discharge the babies who reached the 35 th week of gestation when they attain the minimum post-birth weight of 2000 g. Advances in neonatal care and the participation and competence of parents in the care of PTIs have led to changes in the discharge criteria for these patients in the past few years. Indicators such as the estimated delivery date or body weight are no longer the main criteria and have become secondary to the adequate stabilization of the patient. At present, PT infants are frequently discharged with weights of less than 2kg, as there is evidence that early discharge is safe if it is based on physiological criteria (Brooten D et al, 1986; Davise DP et al, 1979; Oscar G et al, 1993).

There is a growing body of evidence demonstrating the feasibility and safety of discharging babies early (Picone S et al, 2011; Mokhachane M et al, 2006; Merritt TA et al, 2003; Cruz H et al, 1997). Earlier discharges decrease the length of time the infant is separated from his or her parents, improves bonding and reduces the potential negative effects on parenting. Fewer days in the NICU reduces the risk of the infant contracting infections while hospitalized, which would significantly increase the number of days in the hospital. Another major reason that a premature infant may be discharged earlier is to keep medical costs reduced allowing the NICU to target their resources toward the higher risk infants requiring more intensive care (Oregon Pediatric Nutrition Practice Group, 2013).

Nevertheless, discharge from the NICU of a preterm infant requires close attention to the specific health problems the infant may face, as well as planning the multidisciplinary follow-up that may be required. Thoughtful and thorough discharge planning may reduce the risk of morbidity, mortality and readmission, which are frequent in this group of patients (Barkemeyer BM, 2015). Doing so, a checklist for the discharge of the PT infant may be very useful for this purpose (Table 2).

Table 2. Discharge checklist for the preterm infant (Fernández IB et al, 2017).

Thermoregulation	The patient is able to maintain a normal body temperature (36–37°C) when fully clothed in an open bed	□
Nutrition at discharge	The patient can meet his or her full energy requirements and achieve adequate weight gain through full enteral feeding. We must promote the establishment of adequate breastfeeding	□
Respiratory stability	The patient is able to maintain respiratory stability in the supine position	□
Apnoea of prematurity	An apnoea-free interval of at least one week (up to 2 weeks in PT infants of lesser GA) has been observed after caffeine discontinuation	□
Bronchopulmonary dysplasia	If the patient needs home oxygen therapy, an individualised social and family assessment will be performed to ensure that the family has the necessary resources (home oxygen, pulse oximetry, etc.). Parents will be trained to identify and intervene in high-risk situations	□
Retinopathy of prematurity	The patient has undergone a ROP screen and, when applicable, post-discharge follow-up ophthalmological care has been arranged	□
Neurologic risk	Referral to early intervention services and follow-up neurologic care based on the degree of neurologic risk or impairment. The neurologic follow-up must be coordinated with primary care and early intervention services.	□
Anaemia of prematurity	Adequate energy and iron intake and absence of clinical manifestations of anaemia	□
Vaccination	The patient has received the first dose of the HepB vaccine and, depending on the length of stay, other necessary doses of this and other vaccines based on the official immunisation schedule	□
RSV prophylaxis	If the patient qualifies for palivizumab, schedule the necessary post-discharge appointments	□
Hearing screen	Must be performed prior to discharge, and a referral given if hearing loss is detected	□
Family and environment	Absence of social or family risk factors, or arrangement of follow-up and support services	□

VII. Complications in preterm infants

Complications of the preterm infant are divided into short-term complications and long-term sequelae in patients who survive and are discharged from the neonatal intensive care unit (NICU) (Eichenwald EC and Stark AR, 2008).

1. Acute complications

Short-term complications result from anatomic or functional immaturity during the neonatal period. The risk of developing complications increases with decreasing gestational age (GA) and birth weight (BW) (Fanaroff AA et al, 2007). They are the common cause of the frequent re-admission of the PTI to NICU and increase the risk of long-term sequelae (Oregon Pediatric Nutrition Practice Group, 2013; Eichenwald EC and Stark AR, 2008).

In a report from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network, the following complications and their frequencies were seen in 8515 very low birth weight (VLBW) infants: Respiratory distress (93%), retinopathy of prematurity (ROP) in 59 %, Patent ductus arteriosus 46 %, bronchopulmonary dysplasia 42 %, late-onset sepsis 36 %, Necrotizing enterocolitis (NEC) 11 %, grade III intraventricular hemorrhage (IVH) and Grade IV IVH 7 and 9 % and periventricular leukomalacia 3 % (Stoll BJ et al, 2010).

Immature feeding patterns, such as uncoordinated suck/swallow/breathe, ineffective milk transfer, and increased sleepiness because of immature brain/central nervous system (CNS) development increase on postpartum days 2–5. (Engle WA et al, 2007; Spitzer AR et al, 2010; McCormick MC et al, 2006 ; Escobar GJ et al, 2006). Feeding failure, in both breastfed and formula-fed newborns, can be caused by other morbidities more common in preterm infants, such as respiratory distress, cold stress, sepsis, hyperbilirubinemia, low muscle tone, and decreased stamina. Congenital heart disease and patent ductus arteriosis, also more common (RM Phillips et al, 2013).

2. After-discharge and long-term complications

PTIs are at risk of a great number of health problems. Poor growth, pulmonary problems, developmental delays, hearing and vision deficits, risk of child abuse or neglect, behavior disturbances, and learning disabilities, as well as problems relating to initial heightened risk (eg, congenital anomalies) are frequent in PTIs. Other problems that may develop include those of family dynamics (eg, divorce) secondary to the stressful situation (Committee on Practice and Ambulatory Medicine and Committee on Fetus and Newborn, 1996).

Studies show that bronchopulmonary dysplasia or chronic lung disease, apnea and bradycardia, cryptorchidism, gastroesophageal reflux, sudden infant death syndrome (SIDS), ventriculomegaly, and hernias are more common among premature infants than full-term infants (Amy LH and Cathy AB, 2007).

Preterm infants are often anemic because of low iron stores, decreased erythropoietin production, decreased red blood cell survival, infections, and frequent venipuncture (Robert LG et al, 2014).

12% to 50% of very premature infants have disabilities such as cerebral palsy, intellectual disability, and visual or hearing impairment. These infants also later perform worse in mathematics, reading, and spelling compared with term infants (Robert LG et al, 2014).In long term studies, the over-all incidence of handicaps was 66 per cent; 50 per cent had moderate to severe handicaps. The highest incidence of moderate to severe handicaps (85 per cent), occurred in the smallest infants of shortest gestational age, and the lowest incidence (20 per cent), in infants of 1,450 Gm. and 33 weeks' gestation (Lubchenco LO et al, 1972).

In a study of 241 children born between 22 and 25 weeks who were currently at school age, 46% had severe or moderate disabilities such as cerebral palsy, vision, hearing or learning problems. 34% were mildly disabled and 20 percent had no disabilities, while 12 percent had disabling cerebral palsy (Marlow N et Al, 2005; Bell EF et al, 2014). Saeidi S et al found the mean age of developmental indexes for all premature LBW infants were significantly different with term and AGA and concluded that children with history of prematurity and low birth weight have more disability and developmental delay (Saeidi S et al, 2016).

Another study demonstrated that the risks of medical and social disabilities extend into adulthood and are higher with decreasing gestational age at birth and include cerebral palsy, intellectual disability, and disorders of psychological development, behavior, and emotion, disabilities of vision and hearing, and epilepsy (Moster D et al, 2008). Thus, preterm born children need long term follow up and developmental screening tests (Saeidi S et al, 2016).

VIII. After discharge care

1. Short-term follow-up care

Preterm infants should be seen by their community primary care provider within 1–2 days after transition/ discharge from the hospital; the provider should assess the infant’s continued stability, review screening results, ensure ongoing safety, and evaluate the adequacy of support systems. It is especially important that breastfeeding PTIs be seen within a day after transition/discharge because of the feeding challenges so prevalent in this population. The community follow-up care provider should have received a copy of the transition/discharge summary from the in-hospital care provider prior to the initial follow-up visit (Engle WA et al, 2007).

Short-term follow-up care should include weekly assessments until the infant reaches 40 weeks of corrected gestational age (GA) (the infant’s due date) or is clearly thriving (The Academy of Breastfeeding Medicine, 2011). More frequent visits may be necessary if weight or bilirubin checks are indicated (RM Phillips et al, 2013). According to Robert LG et Al, the screening should be undergone till 9 to 12 months’ chronologic age (Table 3).

Table 3. Post discharge Follow-up Recommendations for PTIs (Robert LG et al)

Timing	Growth and nutrition	Other recommendations
24 to 48 hours after discharge	Measure weight (compare birth, discharge, and current), length, and head circumference; perform physical examination Review feeding history (type, amount of feeding)	Assess void/stool pattern, maternal adaptation; counsel parents to reduce the risk of sudden infant death syndrome (each visit for first 12 months) Review and verify any future specialty appointments with the parents; Review hospital course, medications, medical equipment, and immunizations (hepatitis B1); if weight is less than discharge weight, a follow-up visit in 72 to 96 hours is recommended
2 to 4 weeks after discharge	Measure weight, length, and head circumference; perform physical examination Review feeding history (type, amount of feeding)	Add iron for breastfed infants, lower dose for formula-fed infants Review any past and future specialty appointments with the parents Use premature growth chart for 24 months (catch-up growth occurs in head circumference first, then in weight and length); assess medications and ongoing clinical complications
2 months’ chronologic age	Measure weight, length, and head circumference; perform physical examination Review feeding history (type, amount of feeding)	Review any past and future specialty appointments with the parents; Perform developmental screening Administer immunizations per schedule: rotavirus (> 6 weeks and < 15 weeks of age), palivizumab (Synagis) Assess medications and ongoing clinical complications Repeat hearing screening in at-risk infants (3 months of age)
4 months’ chronologic age	Measure weight, length, and head circumference; perform physical examination Review feeding history (type, amount of feeding); consider initiating complementary foods	Review any past and future specialty appointments with the parents; Administer immunizations per schedule: palivizumab Assess medications and ongoing clinical complications Screen for iron deficiency (4 to 8 months of age) and developmental status
6 months’ chronologic age	Measure weight, length, and head circumference; perform physical examination Review feeding history (type, amount of feeding), initiate complementary foods	Review any past and future specialty appointments with the parents† Immunizations (per schedule): Palivizumab Influenza at 6 months’ chronologic age (2 doses, 4 weeks apart) Screen for ophthalmologic problems (6 to 9 months) and developmental status
9 to 12 months’ chronologic age	Measure weight, length, and head circumference; perform physical examination Review feeding history (type, amount of feeding), continue advancing diet, transition to whole milk at 12 months	Administer immunizations per schedule Screen for iron deficiency, lead level (12 to 24 months), and developmental delay; repeat hearing screening

2. Long-term follow up of preterm born children

There is no recognized endpoint to long-term follow-up care of preterm infants. Because research has documented increased morbidities during infancy, childhood, adolescence, and through adulthood, follow-up care must begin at birth and continue, with varying degrees of surveillance and reﬂecting individual needs, throughout the lifespan (RM Phillips et al, 2013). Usual health surveillance for the majority of children comprises regular visits to a Maternal and Child Health Nurse (or equivalent), or to a primary care doctor for checks on the child’s health, growth and development, and to organize immunizations. Follow-up rates for these services are high during infancy and steadily fall during the preschool years. Those who are at higher risk are worthy of a more structured and specialized program of follow-up (Wang CJ et al, 2006).

Thus, a group of experts proposed four broad domain for long term follow up of clearly identifiable groups of survivors, such as those born preterm or with ill-health who are known to have adverse long-term outcomes, with higher than expected rates of health or developmental problems, compared with children born at term and in good health: physical health, mental health, learning and cognition, and quality of life (Doyle et al, 2014).

Table 4. Long term screening for high risk infants (Adapted from Doyle et al, 2014)

Broad domain of screening	Areas of screening
Physical health	General health, Growth, Feeding problems, Special senses, Neurological, Motor skills, Cardiovascular health, Respiratory health, Metabolic/endocrine and Reproduction
Mental health	neurobehavioral evaluation, social abilities and psychological traits (shyness, poor attention, lower cognitive abilities)
Quality of Life	as adaptive skills (feeding, dressing, toileting, communication, mobility, socialization and emotional regulation), Self-esteem and well-being and the ability to form and maintain relationships.
Learning and cognition	cognitive development, Language, Emotional well-being and self-regulation, social competence, approaches to learning, communication skills, Cognitive ability, and Academic progress
Family concerns	Parents mental health, Carer-child interaction and Social support

Phillips RM et al propose a multidisciplinary approach in which the continued stability, screening, safety, and support of PTIs and their families should be assessed at each follow-up visit. Ongoing follow-up care should continue to be culturally, developmentally, and age-appropriate, taking into account families’ preferences and ensuring that parents are active participants in making informed decisions about follow-up testing and therapeutic interventions. Communication should occur and education should be provided in ways that are appropriate for families see (Table 5) (Phillips RM et al, 2013).

Table 5. Long-Term Follow-Up Care of Preterm Infants (Phillips RM et al, 2013)

	HEALTHCARE TEAM	FAMILY EDUCATION
STABILITY
SCREENING
Sensory Screening	Evaluate for sensory impairments, including hearing, sight, and sensory integration. Follow-up brainstem auditory evoked response (BAER) results if referral had been made. Monitor for syndrome of auditory neuropathy/ auditory dyssynchrony (normal otoacoustic emission (OAE) with abnormal auditory brain response (ABR)).	Provide education about increased risk for sensory impairments: - hearing impairment or deafness, - visual impairment or blindness, - disorders of sensory integration. - Auditory and visual processing delay. Stress importance of hearing or vision follow-up: Review date, time, and location of follow-up appointments. Stress importance of alerting primary care provider of any concerns about hearing, vision, or speech.
Developmental Screening	Perform regular developmental screening using valid and reliable assessment tools, such as: - Modiﬁed Checklist for Autism in Toddlers (MCHAT) - American Academy of Pediatrics’ (AAP) Bright Futures, including Pediatric Symptom Checklist (ages 4 years and up). - Brief Infant Toddler Social Emotional Assessment (BITSEA), for age 12–36 months	Teach about LPI’s increased risk for developmental delays: Psychomotor delay, Cerebral palsy, Cognitive delay, Delay in school readiness, Increased need for special educational services, Increased disability (74% of total disability associated with preterm birth). Stress importance of developmental follow-up: Review date, time, and location of follow-up appointments.
Behavioral Screening	Ask parents about any signs of behavioral or emotional disturbances in toddler or child. Assess family’s support system and coping abilities. Make referrals as indicated.	Educate about LPI’s increased risk for behavioral and emotional disturbances: - Attention disorders - Hyperactivity - Internalizing behaviors - Autism - Schizophrenia. Stress importance of alerting primary care provider regarding abnormal behaviors.
Maternal Screening	Review ingestion of illicit and prescription drugs or other substances during pregnancy and refer mother to drug or alcohol rehabilitation program, if indicated. Review use of prescription or herbal medications or supplements of concern, if identiﬁed. Review smoking history (present or past use): - Refer family members who smoke to smoking cessation program - Encourage mothers who quit smoking during or just prior to pregnancy to avoid relapse - Screen for psychiatric illness or perinatal mood disorders - Make referrals for treatment if indicated. - Evaluate mother’s understanding of any referrals made.	Provide referrals to smoking cessation, drug or alcohol treatment, psychiatric, or support services, if indicated. Explain risks of secondhand smoke exposure. * Stress importance of providing a smoke-free environment for all infants and children, especially those born prematurely. * Secondhand smoke exposure is associated with apnea, Sudden Infant Death Syndrome (SIDS) , behavior disorders, hyperactivity, oppositional deﬁant disorder, sleep abnormalities, and upper respiratory infections. Explain risks and beneﬁts of prescription and herbal medications and supplements, if indicated. * Where medications are indicated, encourage use of medications compatible with breastfeeding, if possible. Provide information about postpartum depression and post-traumatic stress disorder and encourage parents to seek help if needed. Provide contact information for local professional and community resources as appropriate to provide assistance for parenting support, substance abuse, domestic violence, and mental health issues
SAFETY
Family Risk Factors	Assess family risk factors and make referrals if needed: * Drug or alcohol use in home. * Smokers in home. * Domestic violence. * Mental health issues. * Social services involvement. Evaluate parents’ understanding of any referrals made.	Provide verbal and written information about where to get professional and community support.
Developmental Risk Factors	Assess for ﬁne and gross motor development and behaviors that may lead to potential safety risks.	Review LPI’s increased risk for ﬁne and gross motor development and behaviors that may lead to potential safety risks: * Hyperactivity. * Seizure disorder.
SUPPORT
Infant Support	Assess adequacy of family’s support system. Identify family’s support needs: * Parent support groups for speciﬁc disabilities. * State parent-to parent groups or other parenting support groups. * State parent training and information Ask parents if they have any questions or concerns that have not already been addressed. Provide a call-back number for general questions that come up when family is home.	Reinforce LPI’s increased risk for need of specialized support and resources. Provide verbal and written information about how to ﬁnd state and community resources
Family Support	Assess adequacy of family’s support system. Identify family’s support needs: * Parent support groups for speciﬁc disabilities. * State parent-to parent groups or other parenting support groups. * State parent training and information Ask parents if they have any questions or concerns that have not already been addressed. Provide a call-back number for general questions that come up when family is home.	Reinforce increased risk of need for specialized family support due to special needs of infants born prematurely. Provide verbal and written information about how to ﬁnd state and community resources for families of infants born prematurely.

3. Post discharge Feeding and Growth monitoring

Neurodevelopmental delay has been associated with inadequate nutrition in the early postnatal period (Velaphi S, 2011). The goal of nutritional support in preterm infants is to achieve a postnatal growth rate similar to that of infants at a similar post conceptual age (Morgan JA et al, 2012). After discharge, a weight gain of 15 to 20 g per kg per day is typically desired for catch-up growth, whereas a gain of 20 to 30 g per kg day is sufficient for those tracking well on the growth curve (Martin CR, 2009). To achieve these growth rates, the recommended minimal caloric requirement for healthy preterm infants is 110 to 130 kcal per kg per day; however, infants with extra uterine growth restriction may require up to 150 kcal per kg per day.29-31 (Griffin IJ and Cooke RJ, 2009; Bhatia J, 2005; Hulzebos CV and Sauer PJ, 2007)

Growth recovery to the original birth weight percentile should be achieved by one to two months’ corrected age (Cooke R, 2011). The goal for infants with extra uterine growth restriction is to approach the 50th percentile of weight for age by two years’ chronologic age (Robert LG et al, 2014).

Physicians should be familiar with the use growth charts. The Fenton growth chart is useful for assessing growth parameters for preterm infants up to 50 weeks’ corrected age; thereafter, the World Health Organization growth chart can be used (Fenton TR, Kim JH, 2013). Growth of all preterm infants should be plotted on the growth curve at their corrected age and not their chronologic age until three years of age. The order for catch-up growth is typically head circumference, weight, then length (Robert LG et al, 2014).

Indeed, to promote appropriate growth or catch-up growth after hospital discharge, PTIs should be weighed biweekly to weekly for the first four to six weeks after hospital discharge, and then every two months thereafter. Nutrient-fortified breast milk or enriched formula should be considered when the infant’s weight falls below the 10th percentile for corrected age. Infants who maintain growth or consistently exceed the 10th percentile for corrected age can receive standard formula or unfortified breast milk (Robert LG et al, 2014).

Family education should assess parents’ knowledge and reinforce importance of good nutrition. Reinforce the health beneﬁts of exclusive breastfeeding with appropriate fortiﬁcation or supplementation if indicated, until 6 months of age. Physicians should provide verbal and printed information about appropriate introduction of healthy solid foods after 6 months of age, assess parents’ ability to choose and obtain healthy baby food and encourage continued breastfeeding until at least 1 year of age or longer in addition to solid foods. They should also reinforce the importance of continuing to monitor growth (RM Phillips et al, 2013).

Table 6. General Post discharge Feeding Recommendations for PTIs (Robert LG et al)

Infant weight	Recommendations
10th percentile or greater - Infants with birth weight at discharge appropriate for corrected age - Infants born small for gestational age who have adequate discharge weight for corrected age and have shown postnatal catch-up growth	Allow the infant to eat on demand approximately every 2 to 4 hours with a goal of about 120 to 150 mL per kg per day and continued growth surveillance · Breastfeeding: preferred · Formula feeding: standard formula is sufficient · Complementary foods can be introduced between 4 and 6 months’ corrected age
Less than the 10th percentile or inadequate catch-up growth Infants born at appropriate weight for gestational age but with discharge weight below the reference growth chart (extrauterine growth restriction) Infants born small for gestational age with discharge weight still below the reference chart	Consider consultation with a dietitian or neonatologist Allow the infant to eat on demand approximately every 2 to 4 hours with a goal of about 120 to 150 mL per kg per day and continued growth slowly approaching the 50th percentile Breastfeeding: Nutrient fortification until 6 months of age or until weight is > 25th percentile§ Formula feeding: Enriched formula (22 to 24 kcal per oz) until weight is > 25th percentile Complementary foods can be introduced between 4 and 6 months’ corrected age

In Burundi context, there are no enough pediatricians and no sufficient material means to apply such protocols. The generalist doctor is the pillar of primary health care. Therefore, he has a key role in diagnosing, caring and referring PTIs. The general physician needs to know what to look for at every visit. He should know the schedule of follow-up, and when to refer PTIs for specialized screening. For instance, poor weight gain or growth delay should be diagnosed by the generalist himself during visits. The generalist may refer systematically PTIs to ophthalmologist for ROP screening and to audiologist for hearing deficits diagnosis and prevention. Development should be screened regularly. The generalist may be able to evaluate the necessity of referring PTIs to pediatrician whenever needed.

4. Immunizing PTIs

a. Timing

Medically stable PT infants should receive all routinely recommended childhood vaccines at the same chronologic age as recommended for FT infants. Under most circumstances, gestational age at birth and birth weight should not be limiting factors when deciding whether a PT infant is to be immunized on schedule. Infants with birth weight less than 2000 g, however, may require modification of the timing of hepatitis B immunoprophylaxis depending on maternal HBsAg status (Thomas NS, 2003).

b. Dosing

Vaccine dosages normally given to FT infants should not be reduced or divided when given to PT and LBW infants. Although studies have shown decreased immune responses to some vaccines given to very early gestational age (<29 administration="" any="" are="" b="" delay="" disease="" diseases="" doses="" full="" given.="" immunity="" in="" infants="" initiating="" most="" neonates="" of="" precludes="" prevent="" produce="" pt="" severity="" sufficient="" the="" these="" to="" vaccine-induced="" vaccine-preventable="" vaccines="" weeks="" when="">(Thomas NS, 2003)

c. Vaccine Administration

The anterolateral thigh is the site of choice when administering intramuscular vaccines to PT infants. The choice of needle length used for intramuscular vaccine administration is made on the basis of the available muscle mass of the PT infant and may be less than the standard 7⁄8-inch to 1-inch length used for FT infants (CDC, 2002).

d. Vaccines’ indications

ü Hepatitis B

Infants Born to HBsAg-Negative Mothers

Medically stable PT infants and infants weighing greater than 2000 g at birth should be treated like FT infants and preferentially receive the first dose of monovalent hepatitis B vaccine shortly after birth and no later than hospital discharge. Practitioners who are certain of the mother’s negative HBsAg status and wish to use a hepatitis B-containing combination vaccine for PT infants with birth weight greater than 2000 g must delay the first dose of the combination vaccine until the infant is at least 6weeksofage.There is no contraindication to giving a birth dose of hepatitis B vaccine as the first of 4 doses when a combination vaccine containing hepatitis B vaccine subsequently is used. The final dose of hepatitis B vaccine should not be given earlier than 6 months chronologic age. Medically stable PT and LBW infants with birth weight less than 2000 g should receive the first dose of hepatitis B vaccine as early as 30 days of chronologic age regardless of gestational age or birth weight. Alternatively, PT and LBW infants weighing less than 2000g showing consistent weight gain leading to discharge home from the hospital before attaining 30 days of age should receive the first dose of hepatitis B vaccine at the time of hospital discharge(Thomas NS, 2003)

Infants Born to HBsAg-Positive Mothers

PT infants born to mothers who are HBsAg positive must receive hepatitis B vaccine and Hepatitis B Immune Globulin (HBIG) within 12 hours after birth, regardless of gestational age or birth weight. Infants weighing less than 2000 g and born to HBsAg-positive mothers should not have the birth dose of hepatitis B vaccine counted as part of the HBV immunization series, and 3 additional doses of hepatitis B vaccine should be given starting at 1 month of age. Combination vaccines containing a hepatitis B component have not been assessed for efficacy when given to infants born to HBsAg-positive mothers. All infants of HBsAg-positive mothers should be tested for the presence of anti-HBs and HBsAg at 9 to 15 months of age, after completion of the HBV immunization series. Some experts prefer to perform serologic testing 1 to 3 months after completion of the primary series (Thomas NS, 2003).

Infants Born to Mothers Whose HBsAg Status Is Unknown

All PT and LBW infants born to mothers whose HBsAg status is unknown at the time of delivery should receive monovalent hepatitis B vaccine within 12 hours of birth. Because infants weighing less than 2000 g have less predictable responses to hepatitis B vaccine given at birth, they should be given HBIG by 12 hours of life if the mother’s HBsAg status cannot be determined within that time period. HBIG may be delayed up to 7 days for PT and LBW infants weighing more than 2000 g at birth while awaiting the mother’s HBsAg test results. (Thomas NS, 2003).

ü DTaP, Hib, and IPV Vaccines

All medically stable PT infants should begin routine childhood immunization with full doses of any DTaP, Hib, and IPV vaccines at 2 months of chronologic age regardless of gestational age or birth weight (Thomas NS, 2003).

ü Pneumococcal Conjugate Vaccine

All PT and LBW infants are considered at increased risk of invasive pneumococcal disease, and medically stable PT patients should receive full doses of PCV7 beginning at 2 months of chronologic age (Thomas NS, 2003)

ü Influenza

All PTIs are considered at high risk of complications of influenza virus infection and should be offered influenza vaccine beginning at 6 months of age and as soon as possible before the beginning and during influenza season. PT and LBW infants receiving influenza vaccine for the first time will require 2 doses of vaccine administered 1 month apart (Thomas NS, 2003).

ü Respiratory Syncytial Virus (RSV)

RSV Vaccine Indications (AAP Committee on Infectious Diseases and Committee on Fetus and newborn, 2003):

o Infants born before 28 weeks’ gestation; vaccine should be given during their firs

o RSV season

o Infants born at 29 to 32 weeks’ gestation who are younger than six months at beginning of RSV season

o Children younger than two years with chronic lung disease requiring medical therapy within six months of the beginning of RSV season

o Children younger than two years with hemodynamically significant cyanotic and acyanotic congenital heart disease

o Consider infants born at 32 to 35 weeks’ gestation with at least two of following risk factors:

Ø Child care attendance School-age siblings

Ø Exposure to environmental air pollutants

Ø Congenital abnormalities of the airways

Ø Severe neuromuscular disease

o Consider infants with severe immunodeficiency

Chapter 2

Materials and methods

Materials

1. Study design

A cross-sectional survey that was carried out.

2. Study area

The study was done in different hospitals and health care centers where there is a general practitioner in Burundi.

3. Study period and limitation

The data was collected in the period of the study.

4. Period of the study

September 19^th to November 18^th in Burundi.

5. Inclusion criteria

- A Generalist doctor and in practice of the medical profession.

6. Exclusion criteria

- No longer practice general medicine primarily because of secondary orientation.

- To be practicing the medical profession for less than 1 year.

Methods

7. Data collection

The collection of data was made using pre-established questionnaires developed for the study which were filled by me during interviews. The questionnaire was developed in such a way as to facilitate the collection of different data and the statistical exploitation.

8. Data analysis

Data analysis was done using Microsoft Excel 2013. The tables and charts were done using Microsoft Word 2013 and Excel 2013.

Chapter 3

Results

Socio-demographic characteristics of the respondents

1. Gender of the participants

Chart: Distribution of Doctors According to Gender

Source: Data collected on field

Of the 100 respondents 67 were male.

2. Age

The mean age of our respondents was 34.8 ±3.3 years with the minimum of 28 and the maximum of 43.

Table: Distribution of Doctors According to Groups of Age

Class of age	Number	Percentage
≤30 years	8	8
31-35 years	49	49
36-39 years	31	31
≥40	10	10
Total	100	100

Source: Data collected on field

The table show that our respondents were in the age group of:

- 31-35 years (49%)

- 36-39 years for 31%

- 30 years old or less for 8 %

- 40 years or greater for 10 %.

3. Type of Service

Chart: Distribution of Doctors According to the type of practice

Source: Data collected on field

The majority (86%) of the respondents was practicing in public institutions whereas 24 % were in private service.

4. Location of practice

Chart: Distribution of Doctors According to the location of practice

Source: Data collected on field

The location of practice was rural in 69% of the cases and urban in 31%.

5. How long have you been practicing as a physician?

The mean of duration of practice was 3.3 ±2.2 years.

Table: Distribution of Doctors According to Groups of Duration of Practice

Years of practice	Number	Percentage
1-5	86	86
6-10	13	13
11 or more	1	1
Total	100	100

Source: Data collected on field

The results in the table above show that 86% of the participants in our study have been practicing for 1-5 years, 13% for 6-10 years and only 1% for 11 years or more.

6. What is your main source of information about prematurity management?

Chart: Distribution of Doctors According to Main Source of Information about prematurity management

Source: Data collected on field

According to the chart above, the main source of information about prematurity management is:

- internet for 74% of our generalist doctor

- pediatricians for 8%

- books and journals for 5%

- CME programs for 13% of our respondents.

7. What is prematurity?

All the respondents (100%) were able to give the right definition of premature birth.

8. Do you often have responsibility to care for PTIs?

Chart: Distribution of Doctors According to the responsibility to care PTIs

Source: Data collected on field

The majority i.e. 62% of the generalist doctors who participated in our survey reported to have responsibility to care for preterm infants.

9. What ages are cared for at your hospital or health center?

Table: Distribution of Doctors According to the ages cared for in their hospital or health center

Age cared for	Number	Percentage
All ages of prematurity	10	10
≥28 weeks	12	12
≥30 weeks	51	51
None	27	27

Source: Data collected on field

- 27 % said their hospital did not care for any premature infant

- 51% said their hospital cared for only the 30 weeks and beyond only

- 12% said their hospital care for 28 weeks and older

- 10% said their hospital cared for all ages of premature infants

10. Does your hospital have a protocol for fluid requirements for PTIs based on age? Chart: Distribution of Doctors According to existence in their hospital of protocols for fluid requirements for PTIs based on age (n=73).

Source: Data collected on field

Of the 73 doctors whose hospitals cared for PTIs, 59 (81%) said their hospital had protocol for fluid requirements for premature infants based on age.

11. Does your hospital have a protocol for what age/weight to begin feeding pre-matures and how to advance volume of formulas?

Table: Distribution of Doctors According to the existence of protocol for what age/weight to begin feeding pre-matures and how to advance volume of formulas (n=73)

Answer	Number	Percentage
Yes	22	30
No	46	63
Don’t know	5	7
Total	73	100

Source: Data collected on field

Over the 73 participants whose health care facilities were caring for PTIs, 46 (63%) said their health care facilities did not have protocol feeding PTIs, 22 (30%) said yes and 5 (7%) did not know.

12. Does your hospital have a protocol for Necrotizing Enterocolitis NEC?

Chart: Distribution of Doctors According to the existence of a protocol for Necrotizing Enterocolitis in their hospital (n=73)

Source: Data collected on field

Over the 73 doctors who recognized that their health care center often cares for PTIs, only 20 (27%) declared the existence of protocol for NEC in their health care facility, 44 (60%) said there was not and 9 (12%) did not know.

13. Does your hospital use Kangaroo care often?

Table: Distribution of Doctors According to the use of kangaroo care in their hospital (n=73)

Answer	Number	Percentage
Yes	56	77%
No	19	26%
I don’t know	8	11%
Total	73	100%

Source: Data collected on field

Over the 73 generalist doctor whose hospital used to care for PTIs, 56 (77%) said their hospital used Kangaroo care often, 19 (26%) said their hospital did not use Kangaroo care often and 8 (11%) did not know

14. Does your hospital have a protocol for what weight to permit discharge?

Table: Distribution of Doctors According to the existence of protocol for what weight to permit discharge in their hospital (n=73)

Answer	Number	Percentage
Yes	34	47
No	32	44
I don’t know	7	10
Total	73	100

Source: Data collected on field

15. According to you, what are the risks for preterm infants after discharge?

Table: Distribution of Doctors According to the recognized risks in PTIS after discharge

Answer	Number	Percentage
Developmental delay	56	56
Mental disabilities	43	43
Poor growth	34	34
Learning disabilities	15	15
Hearing and vision deficits	12	12
Susceptibilities to infectious diseases	9	9
Parental and social concerns	0	0

One could cite one or more risks

Source: Data collected on field

The developmental delay was the more recognized long-term complication, followed by mental disabilities in 43%, poor growth 34%, learning disabilities 15%, hearing and vision deficits were invoked by 15 physician and susceptibility to infection by 9% of the respondents.

16. Do you think there is a particular after-discharge monitoring for premature infants?

All the respondents thought there should be an after-discharge monitoring for premature infants.

17. Among the following, what are the items to be focused on in preterm infants monitoring?

Table: Distribution of Doctors According to the cited items to be focused on in preterm infants monitoring

Answer	Number	Percentage
Growth	48	48
Development	34	34
Vaccinations	8	8
Vision	7	7
Hearing	5	5
Respiratory	1	1
Parental and social concerns	0	0

One could cite one or more items; Source: Data collected on field

Of the 100 doctors who care for PTIs after discharge, the number who spontaneously mentioned screening for the following:

- 48 generalists spontaneously mentioned growth as an item in PTIs monitoring

- 34 mentioned developmental follow up

- The awareness about vaccinations, vision screening, hearing, and respiratory were respectively 8, 7, 5 and 1%.

18. Do you think there are any differences between the preterm immunization schedule and the immunization schedule for babies born at term?

Table: Distribution of the respondents According to whether there was difference between the preterm immunization schedule and the immunization schedule for babies born at term

Answer	Number	Percentage
Yes	83	83
No	9	9
Can’t tell	8	8
Total	100	100

Source: Data collected on field

The majority (83%) said there were differences between the preterm immunization schedule and the immunization schedule for babies born at term, 9 said there was no difference and 8% could not tell.

19. When are vaccines supposed to start for pre-matures?

Table: Distribution of Doctors According to when they think vaccines should start for PTIs

Answer	Number	Percentage
After birth immediately	9	9
After the PTI has reach 37 weeks	14	14
It depends on the PTI wellbeing	28	28
After discharge	36	36
Can’t tell	13	13
Total	100	100

Source: Data collected on field

36% of the respondents thought PTIs should receive vaccines after discharge, according to 28% the surveyed, the schedule should depend on PTIs wellbeing, and 14% thought vaccines should begin after PTIs have reach 37 weeks while 9% suggested they should start after birth immediately. 13% could not tell.

20. Do you think there are additional vaccines recommended for babies born before term?

Table: Distribution of the respondents According to whether there were additional vaccines recommended for babies born before term

Answer	Number	Percentage
Yes	9	29
No	91	71
Total	100	100

Source: Data collected on field

For the majority, there was no additional vaccine for PTIs and for 29% there should be additional vaccines for PTIs.

21. Do you think there are differences in dose of vaccines to be administrated between the preterm babies and babies born at term?

Table: Distribution of the doctors According to whether there are differences in dose of vaccines to be administrated between the preterm babies and babies born at term

Answer	Number	Percentage
Yes	68	68
No	32	32
Total	100	100

Source: Data collected on field

According to 68% of the participants, doses of vaccines to be administrated in preterm babies and babies born at term are different.

22. In your medical practice, do you systematically search for long term complications in children born before term?

Table: Distribution of the doctors According to systematic search for long term complications in PTIs

Answer	Number	Percentage
Yes	7	7
No	93	93
Total	100	100

Source: Data collected on field

Only 7% of the generalist doctors in our survey systematically looked for long term complications in children born before term 93% did not.

23. Do you think you have enough knowledge about pre-matures’ monitoring after discharge?

All the respondents affirmed they had not enough knowledge about pre-matures’ monitoring after discharge and expressed their need to get continuous education.

Chapter 4

Discussion and literature review

I. Socio-demographic characteristics

Gender

Of the 100 respondents 67 were male.

Our result is similar to the one reported by Aurélie Carron whose study conducted on the place of generalist doctors in prematurity follow up in France, noticed male predominance with 68.3% (Aurélie CARRON, 2012). This should be the reality on the ground where the male doctors seem to be majority in Burundi. In a recent study conducted in medical schools on social media use by medical interns in Burundi, the predominance of male sex (69%) was noticed (Dusabe IH, 2018).

Age

In our study, the mean age of our respondents was 34.8 ±3.3 years, with the minimum of 28 and the maximum of 43.

The participants of our study are younger than the one of Aurélie Carron in her study where the average age was 51 years (±10.3) with minimum of 30 and maximum of 69 years (Carron A, 2012). This difference could be explained by the fact that general medicine is a specialty in France.

The majority of our respondents was in the age group of 31-35 years (49%), followed by the class of 36-39 years with 31% of all the respondents, 30 years old or less was 8 %; and 40 years or greater were 10 %.

Our results are similar to those of Rwamo NC whose findings showed that 94% of the generalists were aged less than 40.These results reveal that the majority of generalist doctors on the ground are young in Burundi. This can be explained by a movement of generalist doctors from clinical practice to other sectors seeking for professional advantages or to pursue specialization studies.

Type of practice

In our series, the majority (86%) of the respondents was practicing in public institutions whereas 24 % were in private service.

This is because the majority of health care centers and hospital in Burundi are public.

Location of practice

The location of practice was rural in 69% of the cases and urban in 31%.

Aurelie in her study reported similar results with the majority of generalist doctor 66.7% in semi-rural practice, 31.7% in rural practice and only one 1.7% in urban location.

In our study doctors in rural practice seemed more likely to respond to our questionnaire in our study. The lack of time was the justification of urban doctors who did not respond to our questionnaire.

Duration of practice

The mean of duration of practice was 3.3 ±2.2 years. The results show that 86% of the participants in our study have been practicing for 1-5 years, 13% for 6-10 years and only 1% for 11 years or more.

These results are similar to those of Rwamo CN in her study on generalist perceptions about chronic kidney disease in which 90% of the generalist doctors were in practice for less than 10 years, 8% for 10-20 years and only 2% for 20-30 years. According to Aurelie’s study, the mean duration of practice was 19 years. Our results and the one of Rwamo suggest that the large part of generalist are young in medical practice.

II. Knowledge, attitudes and practices

Source of information about prematurity management

According to our findings, the main source of information about prematurity management is internet for 81% of our generalist doctor, pediatricians for 8%, books and journals in 5% while CME programs are source of information for 13% of our respondents.

Many hypothesis can be tempted to explain these results. In fact, there are no enough libraries were medical information is available. Moreover, the spread of internet use among medical professionals is slowly replacing the traditional source of medical knowledge. Anyway, CME is the common and more effective way to increase and update knowledge for doctors. In a study carried out in Algeria on knowledge, “attitudes and practices of health professionals regarding to immunization of low birth weight newborns”, Laajab reported that 23.3% of the surveyed had participated in a CME program on this topic (Laajab F, 2014). It is a great challenge that pediatricians and CME were reported as the main sources of information about prematurity by respectively only 8 and 13%. Though, all the respondents (100%) were able to give the right definition of premature birth.

Responsibility to care for preterm

The majority i.e. 62% of the generalist doctors who participated in our survey reported to have responsibility to care for preterm infants. Aurelie in France reported results a little different with only 52.5% who followed PTIs up and 47.5% who did not. This difference should be explained by the availability of pediatricians in France contrary to Burundi where they are rare and even the few existing prefer to stay in Bujumbura.

51% of the surveyed affirmed their hospital used to care for PTIs of 30 weeks of age and beyond, 10 said their hospital cared for PTIs of all ages, 12% for 28 weeks and beyond. For 27 % of doctors their health facility did not care for any age of prematurity. This is because hospitals caring for all ages of PTIs are rare in Burundi.

Care for PTIs in NICU

In 2018, a study that included neonatal nurses indicated that 48.2% of the participants reported practicing kangaroo care (Deng Q et al, 2018). The great prevalence of Kangaroo care use in our study, is it due to the awareness or conviction of the generalist doctors about the efficacy and advantages of this technique or the lack or unsufficience of incubitors in Burundi hospitals ? We did not find any convicing explanation for this. It is heartening that this technique is widely adopted by generalist as it is cheaper in terms of salaries and other running costs and feasible as an at-home form of care (Kadam et al, 2005). Kangaroo mother care results in better weight gain, decreases the risk of serious infections and hypothermia, stabilizes physiological parameters, decreases the hospital stay, promotes breast feeding and has no adverse effect on growth and mortality in LBW babies (Ali SM et al, 2009).

Over the 73 generalist doctor whose hospital used to care for PTIs, 34 (47%) said their hospital had a protocol for what weight to permit discharge, 32 (44%) said their hospital did not have a protocol while 7 (10%) did not know. Over these 73 physicians, 59 (81%) said their hospital had protocol for fluid requirements for premature infants based on age, 46 (63%) said their health care facilities did not have protocol feeding PTIs, only 20 (27%) declared the existence of protocol for NEC in their health care facility, 34 (47%) said their hospital had a protocol for what weight to permit discharge.

The lack of guidelines is perhaps related to an absence of standardized protocols on national level. Even if these protocols existed they may be unknown to the majority of generalist doctors. Surprisingly, some of the surveyed were unaware about what was done in Neonatology Unit of their hospital. This should be the result of the subdivision of hospital services where doctors attached to a service are not informed enough about the remaining services of their hospitals.

Knowledge about risks for preterm infants after discharge

According to the risks for preterm infants after discharge, the developmental delay was the more recognized long-term complication, followed by mental disabilities in 43%, poor growth 34%, learning disabilities 15%, hearing and vision deficits were invoked by 15 physician and susceptibility to infection for only 9% of the respondents. This shows that generalist doctors are not enough aware about long-term complications in PTIs.

In our survey, all the respondents thought there should be an after-discharge monitoring for premature infants. Nevertheless, the items to be focused on in preterm infants after-discharge monitoring were not well known by the respondents. Indeed, the results show that only 48 generalists mentioned growth as an item in PTIs monitoring, 34 mentioned developmental follow up, the awareness about vaccinations, vision screening, hearing and respiratory were very low. None of the respondent mentioned parental and social concerns.

After-discharge monitoring for premature infants

According to the pertinence of an after-discharge follow up, all the respondents thought there should be an after-discharge monitoring for premature infants. Nevertheless, doctors do not converge on the items to be focused on. Ou results show that 48 generalists mentioned growth as an item in PTIs monitoring, 34 mentioned developmental follow up, the awareness about vaccinations, vision screening, hearing, and respiratory were respectively 8, 7, 5 and 1%. None of the respondent mentioned parental and social concerns.

According to immunization, the majority (83%) said there were differences between the preterm immunization schedule and the immunization schedule for babies born at term, 9 said there was no difference and 8% could not tell. 36% of the respondents thought PTIs should receive vaccines after discharge, according to 28% the surveyed, the schedule should depend on PTIs wellbeing, and 14% thought vaccines should begin after PTIs have reach 37 weeks while 9% suggested they should start after birth immediately. 13% could not tell. For the majority, there was no additional vaccine for PTIs and for 29% there should be additional vaccines for PTIs. According to vaccines schedule, 36% of the respondents thought PTIs should receive vaccines after discharge, 28% depending the PTIs wellbeing and after the PTI has reach 37 weeks for 14%. 9% suggested after birth immediately while 11 could not tell. The majority (83%) said there were differences between the preterm immunization schedule and the immunization schedule for babies born at term, 9 said there was no difference and 8% could not tell. For the majority, there was no additional vaccine for PTIs and for 29% there should be additional vaccines for PTIs. According to 68% of the participants, doses of vaccines to be administrated in preterm babies and babies born at term are different. According to 68% of the participants, doses of vaccines to be administrated in preterm babies and babies born at term are different.

Several studies recommend that all PT infants receive, with the qualified exception of hepatitis B vaccine given at birth, full doses of all routinely recommended childhood vaccines at a chronologic age consistent with the schedule used for full-term (FT) infants (Saari TN, 2003). According to the timing, authors recommend that medically stable PT and LBW infants should receive all routinely recommended childhood vaccines at the same chronologic age as recommended for FT infants. Under most circumstances, gestational age at birth and birth weight should not be limiting factors when deciding whether a PT or LBW infant is to be immunized on schedule. Infants with birth weight less than 2000 g, however, may require modification of the timing of hepatitis B immunoprophylaxis depending on maternal HBsAg status (Saari TN, 2003). Nowadays in France, Germany Belgium and many other countries, the first immunization is recommended to be administrated at 2^nd, 3^rd and fourth months for every newborn should they be preterm or on full-term infants with low birth weight (Office federal de la santé publique, 2003); (Office federal de la santé publique, 2004). Vaccine dosages normally given to FT infants should not be reduced or divided when given to PT and LBW infants. Although studies have shown decreased immune responses to some vaccines given to VLBW, ELBW, and very early gestational age (<29 administration="" and="" any="" are="" b="" delay="" disease="" diseases="" doses="" full="" given.="" immunity="" in="" infants="" initiating="" lbw="" most="" neonates="" of="" precludes="" prevent="" produce="" pt="" severity="" style="mso-bidi-font-weight: normal;" sufficient="" the="" these="" to="" vaccine-induced="" vaccine-preventable="" vaccines="" weeks="" when="">(Saari TN, 2003).

Therefore, the recommendation en vogue is to not to delay the immunization for PTIs and LBW and to give vaccine at the same chronologic age as full-term infants with the same doses (Saari TN, 2003).

The results of our study show a great lacunae in terms of knowledge regarding to the immunization of the PTIs among Burundi generalist doctors. Further studies should assess specifically the practices of immunizations in PTIs in Burundi hospitals and health centers to highlight the impact of this low knowledge.

Doctors practices regarding long-term complications diagnosis

Only 7% of the generalist doctors in our survey systematically looked for long term complications in children born before term.

According to authors, neonatal follow-up program (NFP) is becoming the corner stone of standard, high quality care provided to newborns at risk of future neuorodevelopmental delay. Most of the recognized neonatal intensive care units in the developed countries are adopting NFP as part of their mandatory care for the best long term outcome of high risk infants, especially very low birth weight (VLBW) infants. Unfortunately, in the developing and in underdeveloped countries, such early detection and intervention programs are rarely existing, mainly because of the lack of awareness of and exposure to such programs in spite of the increasing numbers of surviving sick newborns due to advancement in neonatal care in these countries (Sobaih BH, 2012). This result demonstrate that PTIs long-term follow up remain at every low level in Burundi. All the respondents affirmed they had not enough knowledge about pre-matures’ monitoring after discharge and suggested to get more skills to be more efficient.

Chapter 5

Conclusion and recommendations

Conclusion

Our study on “Knowledge, attitudes and practices” showed that the majority of generalist doctors are involved in PTIs care in Burundi. Their knowledge about prematurity after discharge management is low. Hospitals are not well organizing PTIs care suitably as a great number of them do not have related protocols. All our respondents estimate that their level of knowledge about different aspects of after-discharge care is not enough and expressed their need to get continuous education.

Recommendations

To the Ministry of Public Health and Fighting against Aids:

- To increase the number of pediatricians

- To supply hospital’s neonatal care units in modern and sufficient medical equipment

- To establish protocols on PTIs after discharge management

- To organize regularly CME on PTIs care for general doctors

To the generalist doctors of Burundi:

- To update their knowledge on PTIs after discharge care on a regular schedule

- To look for long term complications in PTIs during every medical visit

References

Aeadoe Mow, Nueye M, Aoiro D, Pdongo BA, Coundoul AM, Keita Y, Sow NF, Seck MA, Fatah M, Sylla A, Faye PM, Ndiaye O. Prematurity: Epidemiology and Etiological Factors in a Maternity Ward in Dakar. Clinics Mother Child Health 2018, 15:1 DOI: 10.4172/2090-7214.1000288

Ali, S. M., Sharma, J., Sharma, R., & Alam, S. (2009). Kangaroo mother care as compared to conventional care for low birth weight babies. Dicle Medical Journal/Dicle Tip Dergisi, 36(3)

Altman M, Vanpée M, Cnattingius S, Norman M. Neonatal morbidity in moderately preterm infants: a Swedish national population-based study. J Pediatr 2011; 158:239.

American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate—proposed guidelines. Pediatrics 1998;102(2 pt 1):411-7.

American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and newborn. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics 2003;112(6 pt 1):1442-6.

Amy LH and Cathy AB. Outpatient Care of the Premature Infant. Am Fam Physician. 2007 Oct 15;76(8):1159-1164.

Barbara L.M. 2009. Solving the Puzzle of Prematurity. Am J Nurs. 2009 January ; 109(1): 60–63. doi:10.1097/01.NAJ.0000344041.49768.ec.

Barkemeyer BM. Discharge planning. Pediatr Clin North Am, 62 (2015): 545-556.http://dx.doi.org/10.1016/j.pcl.2014.11.013 Medline

Beck S, Wojdyla D, Say L, Pilar Betran A, Merialdi M, Harris Requejo J, Rubens C, Menon R, Van Look P: The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. Bull World Health Organ. 2010, 88 (1): 1-80. 10.2471/BLT.08.062554.View Article Google Scholar

Bell EF, Acarregui MJ. Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2014;12:CD000503. doi: 10.1002/14651858.CD000503.pub3. Epub 2014 Dec 4.

Benavente Fernández I, Sánchez Redondo MD, Leante Castellanos JL, Pérez Muñuzuri A, Rite Gracia S, Ruiz Campillo CW, et al. Criterios de alta hospitalaria para el recién nacido de muy bajo peso al nacimiento. An Pediatr (Barc). 2017;87:54.e1–54.e8

Bhatia J. Post-discharge nutrition of preterm infants. J Perinatol. 2005; 25(suppl 2):S15-S16.

Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, Adler A, Garcia CV, Rohde S, Say L, Lawn JE. National, regional and worldwide estimates of preterm birth. The Lancet, June 2012. 9;379(9832):2162-72. Estimates from 2010.

BMC Pregnancy Childbirth. 2018 Apr 19;18(1):107. doi: 10.1186/s12884-018-1740-2.

Brooten D, Kumar S, Brown PL, Butts P, Finkler AS, Bakewell-Sachs S, Gibbons A, Delivoria-Papadopoulos M.A randomized clinical trial of early hospital discharge and home follow-up of very-low-birth-weight infants. N Engl J Med, 315 (1986), pp. 934-939 http://dx.doi.org/10.1056/NEJM198610093151505 Medline

Carron, A. (2012). La place du médecin généraliste dans le suivi des enfants prématurés: suivi comparatif en Ariège (Doctoral dissertation, UNIVERSITÉ TOULOUSE III).

Centers for Disease Control and Prevention. General recommendations on immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR Recomm Rep. 2002;51(RR-2):1–36

Clyton PE,Cianfarani S, Czemichow P, Johannsson G, Rapaport R, Rogol A. management of the child born small for gestational age through to adult age: a consensus statement of the International Societies of Pediatric Endocrinology and the growth Hormone Research Society. J Clin Endocrinol Metab 2007;92:804-10.

Committee on Practice and Ambulatory Medicine and Committee on Fetus and Newborn.

Cooke R. Nutrition of preterm infants after discharge. Ann Nutr Metab. 2011;58(suppl 1):32-36.

Costeloe K, Hennesy E, Gibson AT, Marlow N, Wilkinson AR.The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability.Pediatrics.2000 Oct;106(4):659-71.

Costeloe KL, Hennessy EM, Haider S, et al. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ 2012; 345:e7976.

Cruz H, Guzman N, Rosales M, et al. Early hospital discharge of preterm very low birth weight infants. J Perinatol 1997; 17: 29–32.

Cuttini et al. End-of-life decisions in neonatal intensive care: physicians' self-reported practices in seven European countries. EURONIC Study Group. Lancet. 2000 Jun 17;355(9221):2112-8.

Davies DP, Haxby V, Herbert S, McNeish AS. When should pre-term babies be sent home from neonatal units? Lancet. 1979 Apr 28;1(8122):914–915. [PubMed]

De Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee. Am J Clin Nutr 1996;64:650–8.

Deng, Q., Zhang, Y., Li, Q., Wang, H., & Xu, X. (2018). Factors that have an impact on knowledge, attitude and practice related to kangaroo care: National survey study among neonatal nurses. Journal of clinical nursing, 27(21-22), 4100-4111.

Doyle et al. Long term follow up of high risk children: who, why and how? BMC Pediatrics 2014, 14:279 http://www.biomedcentral.com/1471-2431/14/279

Dusabe IH (2018). Evaluation de l’utilisation des médias sociaux par les étudiants de médecine en satage d’internat au Burundi (Doctoral dissertation).

Eichenwald EC, Stark AR. Management and outcomes of very low birth weight. N Engl J Med 2008; 358:1700.

Engle WA, Tomashek KM, Wallman C. Committee on Fetus and Newborn, American Academy of Pediatrics. ‘Late-preterm’ infants: a population at risk. Pediatrics 2007; 120: 1390–1401.

Escobar GJ, Clark RH, Greene JD. Short-term outcomes of infants born at 35 and 36 weeks gestation: we need to ask more questions. Semin Perinatol 2006; 30: 28–33.

Fanaroff AA, Stoll BJ, Wright LL, et al. Trends in neonatal morbidity and mortality for very low birthweight infants. Am J Obstet Gynecol 2007; 196:147.e1.

Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.

Ford, R. M., Neulinger, K., O’Callaghan, M., Mohay, H., Gray, P., & Shum, D. (2011). Executive Function in 7–9-Year-Old Children Born Extremely Preterm or with Extremely Low Birth Weight: Effects of Biomedical History, Age at Assessment, and Socioeconomic Status. Archives of Clinical Neuropsychology, 26(7), 632– 644.

George TM. The incidence and mortality of preterm infant. 2018.

Goldenberg RL., et al. “Epidemiology and causes of preterm birth”. Lancet 371.9606 (2008): 75-84.

Griffin IJ, Cooke RJ. Nutrition of preterm infants after hospital discharge [published correction appears in J Pediatr Gastroenterol Nutr. 2009;48(1): 121-122]. J Pediatr Gastroenterol Nutr. 2007;45(suppl 3):S195-S203.

Holman RC, Shay DK, Curns AT, et al. Risk factors for bronchiolitisassociated deaths among infants in the United States. Pediatr Infect Dis J. 2003;22(6):483-490.

Howson CP, Kinney MV, Lawn J. Born Too Soon. The global action on preterm birth. March of Dimes, PMNCH, save the children, WHO; 2012.

https://www.semanticscholar.org/paper/Premature-Birth-Current-Etiopathogenic-%2C-of-Conduct-Paula/549405398eb35a85bdd5a8527f7d089d458cb426 accessed on 2018-08-08

Hulzebos CV, Sauer PJ. Energy requirements. Semin Fetal Neonatal Med. 2007;12(1):2-10.

Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes; Behrman RE, Butler AS, editors. Preterm Birth: Causes, Consequences, and Prevention. Washington (DC): National Academies Press (US); 2007.

Joffe S, et al. Rehospitalization for respiratory syncytial virus among premature infants. Pediatrics. 1999;104(4 pt 1):894-899.

Kadam, S., Binoy, S., Kanbur, W., Mondkar, J. A., & Fernandez, A. (2005). Feasibility of kangaroo mother care in Mumbai. The Indian Journal of Pediatrics, 72(1), 35-38.

Karolina Lindström. Long-term Consequences of Preterm Birth: Swedish National Cohort Studies. Stockholm 2011

LAAJAB, F. (2014). La vaccination des enfants de faible poids de naissance: connaissances, attitudes et pratiques des professionnels de santé étude prospective à propos de 70 cas (Doctoral dissertation)

Lawn JE., et al. “One year after The Lancet Neonatal Survival Series- was the call for action heard?” Lancet 367.9521 (2006): 15411547.

Lee AC, Katz J, Blencowe H, Counsens S, Kozuki N, Vogel JP, et al. National and regional estimates of term and preterm babies born small for gestational age in 138 low-income and middle-income countries in 2010. Lancet Glob Health 2013;1:e26-36.

Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet. 2016;388(10063):3027-35.

Liu L, Oza S, Hogan D, Perin J, Rudan I, Lawn JE, et al. Global, regional, and national causes of child mortality in 2000±13, with projections to inform post-2015 priorities: an updated systematic analysis. Lancet. 2014; 385: 430±40. doi: 10.1016/S0140-6736(14)61698-6 PMID: 25280870.

Lubchenco L.O. et al. Long-term follow-up studies of prematurely born infants. II. Influence of birth weight and gestational age on sequelae. The Journal of Pediatrics , Volume 80 , Issue 3 , 509 - 512

Marlow N, Wolke D, Bracewell MA, Samara M. Neurologic and Developmental Disability at Six Years of Age after Extremely Preterm Birth. N Engl J Med. 2005 Jan 6;352(1):9-19.

Martin CR, Brown YF, O’Shea TM, et al. Nutritional practices and growth velocity in the first month of life in extremely premature infants. Pediatrics. 2009;124(2):649-657.

McCormick MC, Escobar GJ, Zheng Z, Richardson DK. Place of birth and variations in management of late preterm (‘‘near-term’’) infants. Semin Perinatol 2006; 30: 44–47.

Merritt TA, Pillers D and Prows SL. Early NICU discharge of very low birth weight infants: A critical review and analysis. Semin Neonatol 2003; 8: 95–115.

Mokhachane M, Saloojee H and Cooper PA. Earlier discharge of very low birthweight infants from an under-resourced African hospital: A randomised trial. Ann Trop Paediatr 2006; 26: 43–51.

Morgan JA, Young L, McCormick FM, et al. Promoting growth for preterm infants following hospital discharge. Arch Dis Child Fetal Neonatal Ed. 2012;97(4):F295-F298. 26. Clark RH, Thomas P, Peabody J. Extrauterine growth restriction remains a serious problem in prematurely born neonates. Pediatrics. 2003;111 (5 pt 1):986-990.

Moster D, Lie RT, Markestad T. Long-Term Medical and Social Consequences of Preterm Birth. N Engl J Med. 2008 Jul 17;359(3):26273. doi: 10.1056/NEJMoa0706475.

Ndelema et al. 2016. Low-tech, high impact: care for premature neonates in a district hospital in Burundi. A way forward to decrease neonatal mortality https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-015-1666-y

Office federal de la sante publique. Commission suisse pour les vaccinations. Prevention de la rougeole, des oreillons et de la rubeole. Berne, Office fédéral de la santé publique, 2003, Directives et recommandations.

Office federal de la sante publique. Commission suisse pour les vaccinations. Immunisation passive post-expositionnelle. Directives et recommandations. , Berne, Office fédéral de la sante publique 2004.

Online version article available at http://pediatrics.aappublications.org/content/98/4/786

Oregon Pediatric Nutrition Practice Group. Nutrition Practice Care, Guidelines for Preterm Infants Guidelines for Preterm Infants in the Community 2013 http://public.health.oregon.gov/HealthyPeopleFamilies/wic/Pages/providers.aspx

Oscar G. Casiro, Mary Elizabeth McKenzie, Leyah McFadyen, Carla Shapiro, Mary M.K. Seshia, Nigel MacDonald, Michael Moffatt, Mary S. Cheang.Earlier discharge with community-based intervention for low birth weight infants: a randomized trial.Pediatrics, 92 (1993): 128-134 Medline

Paula CB. Premature Birth. Current Etiopathogenic Considerations, Of Conduct At Birth And Postpartum For Premature Foetuses. 2015

Phillips RM, Goldstein M, Hougland K, Nandyal R, Pizzica A, Santa-Donato A, Staebler S, Stark AR, Treiger TM and Yost E. Multidisciplinary guidelines for the care of late preterm infants. Journal of Perinatology (2013) 33, S5–S22; doi:10.1038/jp.2013.53

Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 1995;854:1–452.

Picone S, Paolillo P, Franco F, et al. The appropriateness of early discharge of very low birth weight newborns. J Matern Fetal Neonatal Med 2011; 24(Suppl. 1): 138–143.

Quinn JA et Al. Case definition and Guideline for data collection, analysis, and presentation of immunisation safety data. Vaccine 34 (2016) 6047-6057

Robert LG, Jeffrey B, Eric H. Common Questions About Outpatient Care of Premature Infants. American Family Physician August 2014, 90(4): 244-251

Saari, T. N. (2003). Immunization of preterm and low birth weight infants. Pediatrics, 112(1), 193-198.

Saeidi, Reza and Rahmani, Shaghayegh and mohammadzadeh, Ashraf and shah farhat, Ahmad and Saeidi, Maryam and ataei, Alireza (2016) Developmental Outcomes of Premature and Low Birth Weight Infants. Iranian Journal of Neonatology IJN, 7 (1). pp. 62-66.

Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008 Jan 19;371(9608):261-9.

Schalij-Delfos, N. E., de Graaf, M. E., Treffers, W. F., Engel, J., & Cats, B. P. (2000). Long term follow up of premature infants: detection of strabismus, amblyopia, and refractive errors. British journal of ophthalmology, 84(9), 963-967.

Sobaih BH. Neonatal follow-up program: Where do we stand? Sudan J Paediatr 2012;12(1):21-26)

Sow et al. Clinics Mother Child Health 2018, 15:1 DOI: 10.4172/2090-7214.1000288

Spitzer AR, Ellsbury DL, Handler D, Clark RH. The Pediatrix Baby Stepss Data Warehouse and the Pediatrix Quality Steps improvement project system— tools for ‘meaningful use’incontinuous quality improvement. Clin Perinatol 2010; 37: 49–70.

Stoll BJ, Hansen NI, Bell EF, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126:443.

Swammy G.K, Ostbye T, Skjaerven R. 2008. Association of Preterm Birth with Longterm Survival, Reproduction, and Next-generation Preterm Birth. Journal of the American Medical Association, 299 (12): 1429-1436

The Academy of Breastfeeding Medicine. ABM Clinical Protocol No. 10: Breastfeeding the late preterm infant (34 0/7 to 36 6/7 weeks gestation). Breastfeed Med 2011; 6: 151–156.

The Role of the Primary Care Pediatrician in the Management ofHigh-risk Newborn Infants. Pediatrics 1996;98(4);786-91.

Thomas NS. Immunization of Preterm and Low Birth Weight Infants. Pediatrics 2003;112;193

US Agency for International Development, Project Concern International https://reliefweb.int/report/rwanda/rwanda-profile-preterm-and-low-birth-weight-prevention-and-care

Velaphi S. Nutritional requirements and parenteral nutrition in preterm infants. S Afr J Clin Nutr. 2011;24(3):S27-S31.

Wagura P, Wasunna A, Wamalwa D, Ng’ang’a P. Laving A, Prevalence and factors associated with preterm birth at kenyatta national hospital. BMC Pregnancy Childbirth. 2018 Apr 19;18(1):107. doi: 10.1186/s12884-018-1740-2.

Wang ML, et al. “Clinical outcomes of near- term infants”. Pediatrics 114.2 (2004): 372-376.

WHO.int. [homepage on the website]. Preterm birth Fact sheet N°363. [Retrieved 28 July 2018]. http://www.who.int/news-room/fact-sheets/detail/preterm-birth

Wilkins. P. Care of the Extremely Low Birth Weight Infant. Manual of neonatal care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & 146. ISBN 9781608317776.

World Health Organisation (WHO). (2012). Born too soon: The global action report on preterm birth. Geneva, Switzerland.www.eatrightoregon.org/opnpg

www.uptodate.com/contents/incidence-and-mortality-of-the-preterm-infant accessed 2018-8-8

Zeitlin J et Al., Differences in Rates and Short-term Outcome of Live Births Before 32 Weeks of Gestation in Europe in 2003: Results From the MOSAIC Cohort. Pediatrics Apr 2008, 121 (4) e936-e944; DOI: 10.1542/peds.2007-1620.

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Costeloe K, Hennesy E, Gibson AT, Marlow N, Wilkinson AR.The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability.Pediatrics.2000 Oct;106(4):659-71.

Doyle et al. Long term follow up of high risk children: who, why and how? BMC Pediatrics 2014, 14:279 http://www.biomedcentral.com/1471-2431/14/279

Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet 2008 Jan 19;371(9608):261-9.

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