The management of sick young infants at primary health centres in a rural developing country.

AIMS: To investigate the epidemiology of illness among young infants at remote health clinics in a rural developing country, and to determine risk factors for mortality that might be used as triggers for emergency treatment or referral. METHODS: Multi-site 12 month observational study of consecutive presentations of infants less than 2 months, and an investigation of neonates who died in one district without accessing health care. RESULTS: Forty per cent of 511 young infant presentations occurred in the first week of life and most of these in the first 24 hours. Twenty five deaths were recorded: 18 in the health facilities and seven in villages. In addition there were eight stillbirths. Clinical signs predicting death were: not able to feed, fast respiratory rate, apnoea, cyanosis, "too small", "skin-cold", and severe abdominal distension. Signs indicating severe respiratory compromise were present in 25% of young infants; failure to give oxygen therapy was a modifiable factor in 27% of deaths within health facilities. A high proportion of seriously ill young infants were discharged from health facilities early without adequate follow up. A common reason for not seeking care for fatally ill neonates was the perception by parents that health staff would respond negatively to their social circumstances. CONCLUSIONS: Clinical signs with moderate positive predictive value for death may be useful triggers for emergency treatment and longer observation or urgent referral. The results of this study may be useful in planning strategies to address high neonatal mortality rates in developing countries.

The management of children with cancer in Papua New Guinea: a review of children with cancer at Port Moresby General Hospital.

In the period of three and a half years between January 1998 and June 2001, 64 children with cancer were seen at the Paediatric Unit of Port Moresby General Hospital (PMGH). 62 children presented for the first time, whilst 2 were under review, having started treatment in 1996. The male:female ratio was 1.8:1. The median age was 60 months with an interquartile range of 36-84 months. 50% of the children were from the Port Moresby area, 15% from Central Province and 35% were referred from other provinces. Lymphoma, with Burkitt's lymphoma predominating, was as common as leukaemia. 20 (31%) of the children presented either at an advanced stage of disease or with cancer associated with a poor prognosis with available treatment, and were not offered curative treatment. 2 children transferred overseas for treatment. Of 42 families offered treatment 38 accepted and continued. At review 5 years after the start of the study 19 of the 20 children not offered treatment were known to have died and the outcome for 1 was unknown. Of the 38 children who underwent treatment at PMGH 24 (63%) were known to have died, 2 (5%) were still under treatment, 7 (18%) were in remission and the outcome for 5 (13%) was unknown. Of the 24 known to have died, remission induction failed in 16, relapse followed remission in 3 and 5 died from infection. The mean (SD) survival of those who died was 3.9 (3.4) months. 24 (51%) of the 47 known deceased children died in hospital, including 7 (32%) of the 22 referred patients. Significant problems were encountered in patient treatment. Infections occurred in 74% of treated children and drug shortages were experienced in 26%. The substantial problems faced by the families included marital discord, major financial hardship and, for those referred from other provinces whose children died, major delays and difficulties in repatriation. It is suggested that in Papua New Guinea the most appropriate approach to treatment for most children with cancer is the model in which paediatricians at the child's nearest appropriately staffed hospital take responsibility. Appropriate drug regimens, readily available drugs, ongoing advice and data collection should be coordinated through a central source. Accurate data should facilitate rational decisions.

Leukaemia in children in Papua New Guinea: an unusual pattern.

We report data on 110 children aged <15 years diagnosed with leukaemia during two periods covering 13.25 years. The data sets were consistent. The reported incidence of leukaemia was low. Only 34 (31%) of the children were diagnosed with acute lymphoblastic leukaemia (ALL) compared with 54 (49%) children with acute myeloid leukaemia (AML). The overall mean (SD) age was 6.6 (3.5) years, 6.1 (3.5) for ALL and 6.9 (3.5) for AML. There was no evidence of an early childhood peak of ALL. The male : female ratio was 1.2 : 1 for all leukaemias, 1.3 for ALL and 1.25 for AML. Only eight (22%) of those diagnosed with ALL were classified as type L1. Our figures reflect a relative absence of the common (cALL) cell type in early childhood leukaemia and support the role of infection and its effect on the immune system in the aetiology of childhood leukaemia. Our data also revealed an unusually high proportion of chronic myeloid leukaemia (CML).

Perinatal asphyxia at Port Moresby General Hospital: a study of incidence, risk factors and outcome.

We investigated the incidence and outcome of perinatal asphyxia (PA) at Port Moresby General Hospital by a retrospective chart review and prospective collection of data, spanning a total of 2.5 years. 125 babies weighing more than 2000 g at birth with a gestation of 34 weeks or more and with no obvious congenital abnormalities were diagnosed to have PA. During the same time period 22,700 liveborn babies were delivered, a PA incidence of 5.5/1000 livebirths. There was a 31% mortality and considerable morbidity. Hospital records for 114 affected babies and 115 controls (the next baby born by normal delivery) were compared. Significant risk factors for PA were: previous stillbirth or neonatal death, fetal heart rate abnormalities, membranes ruptured for more than 12 hours prior to delivery, meconium staining, antepartum haemorrhage, maternal fever, prolonged first and second stages of labour, preterm or post-term delivery and operative delivery. In only 73 affected babies was the 5-minute Apgar score recorded as 6 or less. All 34 of the babies with grade 3 hypoxic ischaemic encephalopathy (HIE) either died (30) or had serious neurological impairment. The treatment of affected babies remains largely supportive and some causes of PA are currently unavoidable. It is, however, widely accepted that some cases of perinatal asphyxia may be prevented by the delivery of high-risk pregnancies in obstetric facilities with appropriate intervention and by good neonatal resuscitation. Sophisticated or expensive equipment is not a necessity.