Discussion
illness, malaria, PT/LBW, motor disability, acute illness, cerebral palsy, malnutrition, disability
MALARIA, RECRUITMENT, FEBRILE ILLNESS, NEONATAL ENCEPHALOPATHY, CEREBRAL PALSY, MALNUTRITION
This study describes growth and neurodevelopmental outcomes for a rural community sample of PT/LBW survivors. Infants were similar in gestational age to other community-based samples from countries with NMR>5 and constituted a relatively low-risk sample of PT/LBW infants compared with high-resource contexts or LMIC settings with available NICU care. Only 27% were born at the county’s tertiary referral hospital, with the remaining born at other rural facilities. Surviving infants would thus be expected to have better outcomes than their counterparts requiring neonatal intensive care in urban settings of Africa.Rates of stunting and underweight were higher than locally reported data, suggesting a higher risk of malnutrition in the current PT/LBW sample than in the general population of young children in the local community. Direct comparison to growth data from available community-based African samples is complicated by differences in country under-5 malnutrition rates when these studies took place.This study demonstrates that standardised assessments can be locally implemented to enhance neurodevelopmental evaluation at the community level. Directly administered, standardised neurodevelopmental assessment tools identified delay or disability in 8.6% of PT/LBW infants. This proportion is lower than global estimates from settings with high NMR but NICU care available, where one might anticipate higher-risk infants surviving. It is more comparable to, but still lower than that of other cited community-based studies.The HINE was successfully used as an assessment for cerebral palsy or motor disability risk. Approximately 2% of children showed concern for being non-ambulatory by 2 years, and one additional child met clinical criteria for cerebral palsy but was not included in the sample due to acute illness at the time of visit. While these numbers are low, the percentage is not markedly different than the 3.4% of children with neonatal encephalopathy who had ‘sub-optimal’ HINE scores in a recent Ugandan study.In addition to malnutrition and neurodevelopmental risks, a high proportion of the sample were reported to have experienced acute childhood illness in their lifetime, including malaria, diarrhoeal disease and serious febrile illness. Children in the current study had higher rates of acute respiratory infection in the last 2 weeks than local averages for children under 5 years (26% vs 13%).Our data may underestimate true developmental delay/disability rates for PT/LBW infants for two reasons. First, participants were part of a larger cRCT evaluating the effect of an intrapartum and immediate postnatal intervention package on PT/LBW neonatal survival in which the control arm also received two of the four interventions. Post-hoc univariate analyses revealed no significant differences in growth or neurodevelopment between babies born at control versus intervention sites (This study has several limitations. First, the study design did not allow for direct comparison to term, normal birth weight controls and it was not possible to investigate factors contributing to poor growth or neurodevelopmental outcomes through multivariate analyses. Additionally, there were too few babies in the highest-risk PT/LBW categories to separately investigate their neurodevelopmental outcomes. There were several constraints related to recruitment for this study. The parent study was not originally designed as a longitudinal follow-up past 28 days, and this meant that we did not have recurrent contact with caregivers between the infant turning 28 days and the follow-up study recruitment call, which occurred up to 17 months later. Additionally, a national health worker strike significantly reduced recruitment into the parent study during the birth months of 18-month-olds, markedly reducing the number of potentially eligible children at this age. Although only 6.9% of those contacted declined to participate, 25.9% were unreachable and 20.4% of those scheduled for an informational recruitment visit did not attend that visit, so it was not possible to describe the study to them in detail. The analysed sample consisted of just under 50% of the identified eligible sample (