Overcoming the challenges to survive - the story of baby Chit Htun

In Myanmar, prematurity is a leading cause of death in the first year and the Ayeyarwady region records the highest levels of neonatal mortality nationally.

Maternal malnutrition, poverty, lack of health education and a lack of access to antenatal care make the early stages of life very difficult, particularly in rural areas. In many cases hypothermia, a leading cause of infant death often goes unrecognised and untreated, likewise, low blood sugar (hypoglycaemia) and a low level of oxygen (hypoxia).

©2018/Myaung Mya Paediatric Team

For those who are admitted to neonatal units malnutrition is a problem. There are often delays feeding and supportive feeding approaches such as nasogastric (NG) feeding are not routine. Units experience nursing and medical shortages and staff change department frequently which means staff often find it difficult to practice in the most effective way.

The limited number of working incubators, monitoring equipment, infusion pumps, and laboratory facilities, combined with power cuts, overcrowding of hospital wards mean babies face daily challenges. Infection control management is difficult across all areas of hospital care for babies and children.

With this background, the odds were stacked against one baby boy, Chit Htun, weighing 1000gms and ten weeks early, born at Myaungmya General Hospital in the Ayeyarwady region.

On arrival to the neonatal unit, he was hypothermic, 35oC, increasing the risk of death. Careful nursing assessment and observation found intermittent respiratory arrest (where the baby stops breathing) and bradycardia (a low heart rate, often leading to death) requiring stimulation. Incubator care, oxygen therapy, IV fluids, antibiotics and respiratory stimulant medication with aminophylline were his main management. Hypoglycaemia and jaundice also required management.

During these first few crucial days, Chit Htun’s condition was closely monitored, despite his nurse caring for another six babies during her shifts. Intensive nursing was essential for his survival. Hypothermia compromises weight gain, decreasing his chances of survival. Chit Htun’s premature birth mean that his suck reflex (ability to suck) was not developed to breast or safely spoon or cup feed. Nasogastric feeding with breast milk was started on day two.

Kangaroo mother care (KMC), a practice of providing continuous skin-to-skin contact between baby and carer particularly for preterm and low birth weight babies promotes bonding, breast feeding and reduces mortality. Furthermore, neurodevelopment is promoted by close attention to these special neonatal physiological needs.

However, it is frequently not practiced with such small babies, especially while receiving oxygen or intravenous therapy. In a case of Chit Htun, mother, father and grandfather all enjoyed KMC with their boy from day two, oxygen and IV fluids attached as they did so. The smallest and youngest baby ever to get KMC in Myaungmya.

Breast milk was expressed and given either freshly via NG tube or kept refrigerated. Safely storing breast milk was another ‘first’ for the unit. Ten weeks later, he is now term, 1.7kg (3lbs 11oz), confidently sucking over 220ml/kg a day. His proud nurses are planning discharge! Chit Htun is going home.

KMC, NG feeding, earlier expression, storage, and initiation of breast milk feeding are now established as neonatal care routines in this hospital. Hypoglycaemia and temperature management has improved. Neonatal development is better understood. Parental education has expanded. The lessons learnt are an investment in the future survival of these tiny patients. Chit Htun is one of the smallest babies to have survived in this region.

The team at Myaungmya have proven that providing high quality, neonatal care to babies with extremely low birth weight babies is possible at a small district hospital in Ayeyarwady region.

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The Myanmar Paediatric and Neonatal Care Programme is a partnership between the Myanmar Paediatric Society, Royal College of Paediatrics and Child Health and United Nations Children’s Fund (UNICEF).

The programme aims to improve the quality of facility-based emergency paediatric care at 21 District Hospitals across four regions – Ayeyarwady, Magway, Kayin and Sagaing, in Myanmar.

The programme is a quality improvement programme which uses mentoring, formal training sessions with both, doctors and nurses in management of critical newborn and childhood illnesses. Sustained mentoring over 6 months as newly-acquired knowledge and skills are put into daily practice. Also, it includes facility improvement planning to identify and address latent errors and enable an environment supportive of better clinical practice. Hosptials share their knowledge and progress and support each other through regular meetings.

Blog prepared by Royal College of Paediatric & Child Health (RCPCH) and United Nations Children’s Fund (UNICEF)