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To assess the impact of the introduction of kangaroo mother care (KMC) in hospitals using the Perinatal Problem Identification Programme (PPIP) in South Africa, a survey was conducted of the PPIP sentinel sites in South Africa requesting information on the practice of KMC in the hospital and if practised, when it had been initiated. Data on live births and the neonatal deaths of infants weighing between 1000 and 1999 g for each institution were obtained from the national PPIP database and, where applicable, divided into two periods, before and after the introduction of KMC. The practice of KMC and PPIP data could be combined for 40 of the hospitals that had responded to the survey. Of these, eight hospitals had not initiated KMC by January 2005, 21 had PPIP data for a period after KMC had commenced and 11 had PPIP data for periods before and after the introduction of KMC. The neonatal death rate (NNDR) for all hospitals with no KMC or before the introduction of KMC was 88.14/1000 live births, whereas the NNDR for hospitals with KMC or after the introduction of KMC was 71.43/1000 live births [relative risk (RR) 0.81; 95% confidence interval (CI) 0.72-0.91]. For the 11 hospitals that had reliable PPIP data for periods before and after the initiation of KMC, the NNDR was 87.72/1000 live births before KMC and 60.76/1000 live births after KMC had been introduced (RR 0.62; 95% CI 0.53-0.73). The large and significant reduction in the NNDR of neonates weighing between 1000 and 1999 g was associated with the introduction of KMC.

Aim: To describe the development and testing of a monitoring model with quantitative indicators or progress markers that could measure the progress of individual hospitals in the implementation of kangaroo mother care (KMC)., Methods: Three qualitative data sets in the larger research programme on the implementation of KMC of the MRC Research Unit for Maternal and Infant Health Care Strategies in South Africa were used to develop a progress-monitoring model and an accompanying instrument., Results: The model was conceptualized around three phases (pre-implementation, implementation and institutionalization) and six constructs depicting progress (awareness, adopting the concept, mobilization of resources, evidence of practice, evidence of routine and integration, sustainable practice). For each construct, indicators were developed for which data could be collected by means of the monitoring instrument used in a walk-through visit to a hospital. The instrument has been tested in 65 hospitals., Conclusion: The progress-monitoring model enables the quantification of individual hospitals' progress in the process of implementing KMC and an objective measurement of the effectiveness of different outreach strategies. The model also has potential to be adapted for measuring progress in other innovative healthcare interventions on a large scale.

Aim: To test whether a well-designed educational package on the implementation of kangaroo mother care (KMC) used on its own can be as effective in implementing KMC in a healthcare facility as the combination of a visiting facilitator used in conjunction with the package., Setting: Thirty-four hospitals in KwaZulu-Natal Province, South Africa., Method: The hospitals were paired with respect to their geographical location and annual number of births at the facility. One hospital in each pair was randomly allocated to receive either the implementation package alone (group A) or the implementation package and visits from a facilitator (group B). Hospitals in group B received three facilitation visits. All hospitals were evaluated by a site visit 8 mo after launching the process and were scored by means of a progress-monitoring tool., Outcomes: Successful implementation was regarded as demonstrating evidence of practice (score>10) during the site visit., Results: Group B scored significantly better than group A (p<0.05). All 17 hospitals in group B demonstrated evidence of practice, with the median score of the group being 15.44 (range 10.29-22.94). Twelve of the hospitals in group A demonstrated evidence of practice and the median score was 11.33 (range 1.08-21.13)., Conclusion: Successful implementation was achieved in most of the hospitals irrespective of the strategy used. However, facilitation with an implementation package was clearly superior to using a package alone. Some sites do not need facilitation for successful implementation.

Objective: To assess the efficacy of recombinant human erythropoietin (rHuEpo) in the treatment of the anemia of prematurity., Methodology: A double-blind, placebo-controlled study was conducted on 80 preterm infants (< or = 32 weeks; postnatal age, 2 to 8 weeks; central hematocrit < or = 35%). Patients were randomly assigned to receive subcutaneous rHuEpo (Eprex, 600 U/kg per week) or an equivalent volume of placebo, for up to 6 weeks. All patients received supplements of vitamin E (25 IU) and iron (3 mg/kg per day). The iron supplement was increased if declining serum ferritin measurements were noted., Results: Treatment and placebo groups did not differ significantly with respect to mean gestational age, birth weight, hematocrit, or reticulocyte count at study entry. Fewer transfusions were administered to those receiving erythropoietin (7 compared with 21; P = .002). Compared with the placebo group, the infants receiving rHuEpo had a higher mean hematocrit (32.3 +/- 4% vs 29.3 +/- 6.2%; P = .014) and absolute reticulocyte count (223 +/- 73 vs 124.9 +/- 73 x 10(9)/L; P < .001) at the end of the study. The mean neutrophil count was not significantly reduced at study exit (P = .8), nor at any other period during the trial in the rHuEpo group. Intercurrent events (mostly infections) were not increased in the treatment group, although there was one case of sudden infant death syndrome at age 4 months., Conclusions: Using a dose of rHuEpo of 600 U/kg per week, this study has shown a clear reduction in the requirement for blood transfusion in preterm infants.

A prospective 2-year follow-up study of infants with birth weights of less than 1250 g was undertaken at Groote Schuur Hospital Neonatal Intensive Care Unit. For a 12-month period beginning July 1988, all live infants born at Groote Schuur Hospital or referred to the Neonatal Intensive Care Unit were included in the study cohort. The aim of the study was to document the morbidity, mortality, and neurodevelopmental outcome of these infants to 2 years of age. Of 235 liveborn infants, 143 (61%) survived to discharge. One hundred twenty-six infants were born weighing less than 1000 g; 42% survived to discharge. One hundred nine infants weighed 1000 g or more at birth, and 83% survived to discharge. Better survival was documented for infants whose mothers attended antenatal care, who weighed more than 900 g, and who were of greater than 30 weeks' gestation. Eleven infants died in the first 6 months after discharge. One hundred six infants (83% of survivors) underwent Griffiths developmental testing and clinical assessment at 1 year of age. Ninety-six (91%) of these survivors were seen and tested at 2 years of age. Of the 106 infants assessed at 1 year of age, 6 infants had cerebral palsy, 6 were globally developmentally delayed without signs of cerebral palsy, and 1 infant showed significant motor delay with a normal developmental quotient. At 2 years of age 1 additional infant had cerebral palsy and 9 more infants are likely to be mentally retarded. At 2 years of age the major handicap rate was, therefore, 22%. Sixty-nine percent of surviving infants, and all but 1 of the infants with cerebral palsy, were underweight for gestational age at birth. There was a tendency for these underweight-for-gestational-age infants to score less well at 2 years of age. Infants who received ventilation and infants with a birth weight of less than 1000 g were not found to score less well than other infants in the cohort.

A medical and financial assessment of the Neonatal Unit at Groote Schuur Hospital showed that the emphasis was on high care provided at a cost of R265 per patient per day. Intensive care cost R530 and low care R88 per day. The average was R172 per day. Infants of very low birth weight (< 1,500 g) accounted for 58% of expenditure. Half of this amount was spent on infants of below 1,000 g; the cost was R14 621 per survivor and R344 per quality-adjusted life-year. The cost declined progressively for infants of greater birth weight. There are a paucity of comparable local data, but the cost of the care was very reasonable.

A prospective study of newborns whose mothers had untreated or inadequately treated syphilis was undertaken. The infants were followed up for 3-4 months to ascertain whether they had congenital syphilis. A number of variables were analysed as possible predictive factors for the development of congenital syphilis. A maternal Venereal Disease Research Laboratory (VDRL) titre of 1:32 or above indicated which infants would develop congenital syphilis with a sensitivity of 93% and a specificity of 78%. The risk of a congenitally infected infant was significantly higher amongst the group of untreated mothers (p = 0.036). Low birthweight per se did not appear to be a predictor of the subsequent diagnosis of congenital syphilis. Using these simple predictive factors it may be possible to determine which at-risk infants would most benefit from careful supervision or a full 10-day course of therapy.

Seventeen neonates with congenital syphilis were studied to determine the immune response of the fetus following intra-uterine infection with Treponema pallidum. The results were compared with those from healthy controls matched for gestational age, birth weight and sex. B cells, IgM, and circulating immune complexes were significantly elevated in the infected newborns. There were no differences in lymphocyte transformation to phytohaemagglutinin (PHA) and in the CD3, CD4, and CD8 lymphocytes between infants with congenital syphilis and controls. Newborns with congenital syphilis have a heightened humoral response but no quantitative abnormality in cell-mediated immunity. Speculation on the role of the circulating immune complexes is presented.

Birth weights and perinatal deaths for the Peninsula Maternal and Neonatal Service were analysed for 1974-1987. There were differences in birth-weight distribution between the ethnic groups, and within the white group, over time, and these influenced the crude perinatal mortality rates. Once birth weight had been adjusted for, there was a downward trend in the data for all groups. The improvement in the perinatal mortality rates was related to better survival in each group. There was no difference in the standardisation rates between the coloured and white infants. Blacks, however, had significantly higher rates when compared with the coloured and white births.

The haematocrit values in 51 babies were studied to observe the possible variations due to the method and time of sampling and to relate these findings to blood viscosity. A good correlation (r = 0,9536) between haematocrit values of warmed heel capillary blood and of central venous samples was found. Prediction of venous value from a known sample of capillary blood can be made using regression lines and 95% confidence limits. The correlation between venous and unwarmed blood samples from the heel is not as good. A central venous haematocrit value of 65% or greater gave a 100% risk of the infant's blood being hyperviscous. Hyperviscosity occurred in 71% of infants with a capillary haematocrit value of 65 - 68% but the figure rose to 81% when the peripheral haematocrit value was 68% or more.

The accuracy of gestational age assessment (Dubowitz et al., 1970) was tested for infants weighing 1500 g or less. There was good correlation with known dates. This system is applicable to and accurate for infants delivered very prematurely.

The management of polycythaemia with hyperviscosity in newborn babies who are clinically well, or who only have minor signs, is not clear. Forty-nine such babies were randomly divided so that 24 were given a partial plasma exchange transfusion and the others were left hyperviscous. The babies were compared with normal controls. Clinical signs were more frequent in exchanged babies, and one developed necrotizing entercolitis. Of the hyperviscous babies 41% had plethoric lungs, 12% abnormal electrocardiograms, 9% were hypocalcaemic and 30% hypomagnesaemic. Behavioural testing after birth revealed differences in both groups when compared with controls. There were more poor scores in the exchange transfusion group. Neurological examination did not reveal marked differences among the groups. Developmental and neurological achievement at 8 mth of age was normal in all babies. In the present study it is suggested that newborn babies with hyperviscosity who are clinically well or who only have minor signs do not necessarily benefit from partial plasma exchange transfusion.

A simple method of examining the placenta and its attached membranes after vaginal delivery was used to assess the site of placental insertion in utero. The placental site was determined in 187 term infants. Birth weight and length were not influenced by the position of the placenta, but infants with placentas situated at the fundus had significantly larger heads. Infants with low-lying placentas were at no growth disadvantage.

The rheumatoid factor (RF) latex test was evaluated as a test for congenital syphilis. High risk newborns of mothers with untreated or inadequately treated syphilis were studied. The asymptomatic infants were followed up for between 3 and 4 months (or longer if the VDRL test was positive). The overall performance of the RF latex test was better than that of the other tests studied, even though the sensitivity was 46.7%. The specificity and positive predictive value of the test were 100% whilst the negative predictive value was 86.4%. The test was negative in all 84 controls studied. Although a negative RF latex test cannot be used to exclude congenital syphilis in an asymptomatic infant, a positive test in the presence of maternal syphilis should lead one to strongly suspect congenital syphilis.

The birth weight, length, head circumference and body proportions of infants born to women with well-controlled diabetes were compared with those of infants born to poorly controlled diabetics. The latter infants were significantly heavier, with a greater weight/length ratio and a smaller head circumference/weight ratio, while their length, and head circumference/length ratio were appropriate for age. The size and body proportions of infants born to well-controlled diabetics were normal. Hairiness of the pinna was observed in infants born to both well- and poorly controlled diabetics, and may prove to be a useful clinical sign in identifying the infant of a diabetic mother.

The use of a portable electro-encephalographic (EEG) recorder has proved to be a very useful additional investigation in the neonatal intensive care unit. The normal EEG patterns in term infants are easily recognizable. Inactive or burst/suppression (paroxysmal) recordings during the first week of life signify a poor prognosis.

The placentas of 1,081 infants born to Coloured primigravidas in Cape Town were examined. The values for gross and trimmed placental weight, chorionic surface area and thickness are given for each week of gestation from 32 to 41 weeks. These results indicate the pattern of placental growth and provide a basis for further studies to evaluate deviations of intra-uterine growth in this population.

Normal values for the nitroblue tetrazolium (NBT) test in full-term, premature and small-for-gestational-age infants are presented. The NBT reduction was elevated in all groups of babies studied. There was no statistical difference between the groups and the range was wide. Infected babies also showed elevated NBT reduction. However, 60% of the results obtained in the infected group fell within the same range as those obtained in normal neonates. This renders the test unhelpful in the diagnosis of bacterial infection in the neonatal period.

Cord plasma cortisol concentrations were measured in 52 preterm infants and related to amniotic fluid infection as evidenced by positive bacterial cultures. The cortisol levels were significantly raised in the group with an infected intra-uterine environment (519 +/- 158 nm/l) compared with the non-infected group (325 +/- 134 nm/l). This effect was independent of length of gestation, duration of rupture of membranes, or duration of labour. Infants with fetal growth retardation had raised cortisol levels (555 +/- 207 nm/l), while maternal dexamethasone therapy suppressed the levels (197 +/- 76 nm/l). Only 2 infants developed hyaline membrane disease, and in both bacterial culture was negative and cord cortisol levels low (231 and 239 nm/l). It is suggested that amniotic fluid infection may play a role in reducing the incidence of hyaline membrane disease by increasing fetal cortisol production.

This study examined aspects of newborn feeding in a maternity hospital and also investigated feeding practices during the first 6 months of life. Four hundred and fifty mothers were interviewed while in the maternity hospital. The majority (93%) had booked for their confinement and had attended antenatal clinics regularly. Most had had early contact with the baby at birth and stated that they thought breast-milk was best for the baby. Despite this only 54.6% had given breast-milk as the first feed and only 10% had done so within the first hour. Most mothers (54%) stated that they preferred a timed feeding routine to demand-feeding, while 86% planned to give water between feeds. The majority indicated they would change to formula feeds should they experience problems with breast-feeding. A follow-up visit of 78 mothers 6 months later showed that 50% breast-fed exclusively for 3 - 4 months and 23% for 6 - 7 months. When feeding problems occurred only 27% of the mothers utilised the local authority baby clinic for help. The main reasons given for stopping breast-feeds were insufficient milk, the need for employment and feeding problems. The implications of these findings are discussed.

The survival, growth and neurodevelopmental status of a group of non-White infants of very low birthweight, who were managed in the Neonatal Intensive Care Unit of Groote Schuur Hospital, is reported. The effect of certain high-risk perinatal factors on this status is assessed.

Pairs of twins born concordant for weight score equally on both neurological and external criteria. The assessed gestational age of discordant twins is significantly different; while scoring equally on neurological criteria, the lighter twin scores less on external criteria. It is suggested that this pattern of underscoring may also be present in growth retarded singletons. If external criteria are used in estimating the gestational age of growth retarded infants, the results should be interpreted with caution.

Maternal weight recorded on the day after delivery correlated significantly with maternal skinfold thickness measured at multiple sites. Skinfold thickness probably reflects total body fat stores. It is suggested that the relationship between maternal weight and fetal birth weight may be mediated by the amount of maternal fat available to meet the energy requirements of the growing fetus.