Neonates

I promised ages ago to write about the neonatal ward and never did, so here goes. The ward is next to the main paeds ward and has two sections- the main room with cots, a resuscitaire (used in the UK to resuscitate babies but here as another incubator) and a few incubators, of which only one works. There's also a bed so one Mum can be there with her baby. The other room has 7 beds and is used for the stable babies on antibiotics to be with their Mums and also the preterm babies receiving Kangaroo care. The number of babies varies from about 3 to about 25, but there are usually 10-15. The unit looks after babies from birth to 1 month of age. Most come in straight from maternity or from the community on day 1 or 2 of life. Some have fevers or other signs of sepsis and are treated on a cocktail of antibiotics for 5-10 days. These babies usually do well. Another set of babies are suffering from birth asphyxia (basically lack of oxygen either because of a problem during the pregnancy, during labour or straight after labour). This is a lot more common here than back home, mostly I think because most births are in the community and problems aren't recognised until very late. Giving birth in hospital is expensive. The caesarian rate here is really high because only the most complicated cases come. These babies are often quite unwell and can have lots of seizures. Sometimes they respond well and recover quickly but others don't and you can tell from quite early on that they are likely to develop cerebral palsy or other long-term problems. It's really sad because if they survive they are much more likely to end up malnourished when they are older and are less likely to survive to adulthood.

There are also lots of premature babies. We don't usually know exactly how premature they are because most women aren't sure when they are due but some are very small. When they are first born they are put in the incubators if available and given oxygen and intravenous fluids. We use aminophylline to help prevent apnoeas (stopping breathing suddenly due to the immaturity of the brain). In the UK we use caffeine which is apparently a metabolite of aminophylline. They also all have antibiotics. Once their breathing settles they are started on feeds of expressed breast milk given via a naso-gastric tube. At this point they can usually start Kangaroo care. This is a great system that was started in Colombia and involves postioning the naked baby next to its Mum's bare chest and then wrapping them both in lots of layers. It's basically using the Mum as an incubator and is used a lot now in low-resource settings. The babies are discharged home once they have reached 1.5kg and continue Kangaroo at home. At this stage they are still too small and immature to breast-feed so the Mums continue nasogastric feeding or give them expressed milk using a spoon.

There are also a few babies with other problems, such as congenital problems or babies who came in from the community. One baby I saw had been burnt really badly because her older siblings had been playing with a candle near her. In the UK, a story like that would trigger at least a discussion with social services but here there's no child protection set-up. Another baby that stands out was a tiny little thing who was brought in at 2 weeks because she hadn't been feeding or crying. It was immediately obvious that she was very premature which was probably why she couldn't feed. She'd been born in a rural village and been taken to a traditional healer. She was extremely malnourished and really unwell. It broke my heart because she'd probably have done ok if she'd been brought in a birth but as it was we never managed to get her any stronger and she died after a couple of weeks. There are so many factors involved and it's stories like that that make you realised the importance of education, community health programmes and working with traditional healers to teach them how to recognise their limitations and when to refer to a hospital.

In my second week here I was by myself (except for a very helpful and very good medical student) and I was petrified at the idea of having to do the neonatal ward round. The ward was really busy and lots of the babies were very sick. I was right to be worried, and I almost left at the end of the week! There was a pair of twins, one of whom was very poorly but there was nothing else to do for her. She was on antibiotics and fluids and although she was jaundiced the only treatment for that here is sunbathing (!) and she wasn't stable enough for that. I worried about her all night and the next day saw her first on the ward round. I was just about to examine her when I realised she wasn't breathing. Luckily Emma was there and Jess, the student and together we started to resuscitate her. I'd never been at a full-blown neonatal resuscitation before and was very grateful I'd done the course as otherwise I'd have been totally overwhelmed. Even then though it was pretty stressful. We tried everything but never got a heart rate so after 25 minutes I decided we should stop. I spoke to the Dad (one of very few people in Kagando who spoke good English) and explained what had happened. It was awful, but it got worse because I suddenly realised the nurse had restarted resuscitating her, saying she thought she had a heartbeat. The Dad looked hopeful for a bit but we went over and listened and there wasn't one so I put my foot down and said we had to stop. I think the nurse was quite inexperienced but so am I and the whole situation was so awful. Thankfully the other twin did really well and the parents were so sweet and so in love with her! I really didn't want to go back the next day but I had to, because there was nobody else. A couple of days later we had another resuscitation of a very premature baby who'd come in after being born at home. Her twin had already died. Unfortunately the outcome was the same, but the nurses were much more helpful and supportive and it helped so much. I don't really feel ready to be making decisions about stopping resuscitation but here even the nurses sometimes have to, as there are so few doctors. Luckily it will be years before I'm in a similar position at home.

There are lots of neonatal deaths here, and I imagine we are only seeing the tip of the iceberg as many probably don't make it to hospital. It's really sad but it's also sad to see the ones who survive but you know will have developmental and health problems long term. On the other hand most get better and it's lovely when you see the premature babies coming back for review and they've put on loads of weight and are doing well. The 'kangaroo' room is also always really sociable and happy as all the women chat and help each other. If a mother's too ill to care for her baby or if she dies in labour everyone else works together to help and the babies are usually looked after by relatives or neighbours. Ugandans are such warm friendly people, almost always smiling!

Soon I'll be working in a big tertiary Neonatal Intensive Care Unit in the UK. It will be interesting to compare it to Kagando's NICU!