Neonatal CPAP for Respiratory Distress Across Malawi and Mortality Jennifer Carns, PhD, a,b Kondwani Kawaza, FCP, c Sara Liaghati-Mobarhan, BS, a Aba Asibon, MPH, a Mary K. Quinn, MPH, a Alfred Chalira, MCHD, d Norman Lufesi, MPhil, d Elizabeth Molyneux, FRCPCH, c Maria Oden, PhD, a,b Rebecca Richards-Kortum, PhD a,b abstract OBJECTIVES: Our aim in this observational study was to monitor continuous positive airway pressure (CPAP) usage and outcomes in newborn wards at 26 government hospitals in Malawi after the introduction of CPAP as part of a quality-improvement initiative. CPAP was implemented in 3 phases from 2013 through 2015. METHODS: Survival to discharge was analyzed for neonates treated with nasal oxygen and/or CPAP with admission weights of 1 to 2.49 kg at 24 government hospitals with transfer rates ,15%. This analysis includes neonates admitted with respiratory illness for 5.5 months before (621 neonates) and 15 months immediately after CPAP implementation (1836 neonates). A follow-up data analysis was completed for neonates treated with CPAP at all hospitals during an additional 11 months (194 neonates). RESULTS: On implementation of CPAP, survival to discharge improved for all neonates admitted with respiratory distress (48.6% vs 54.5%; P = .012) and for those diagnosed with respiratory distress syndrome (39.8% vs 48.3%; P = .042). There were no significant differences in outcomes for neonates treated with CPAP during the implementation and follow-up periods. Hypothermia on admission was pervasive and associated with poor outcomes. Neonates with normal mean temperatures during CPAP treatment experienced the highest survival rates (65.7% for all neonates treated with CPAP and 60.0% for those diagnosed with respiratory distress syndrome). CONCLUSIONS: A nurse-led CPAP service can improve outcomes for neonates in respiratory distress in low-resource settings. However, the results show that real-world improvements in survival may be limited without access to comprehensive newborn care, especially for small and sick infants. WHAT’S KNOWN ON THIS SUBJECT: Preterm birth is the leading cause of global child mortality, and respiratory distress syndrome is the most common cause of death in preterm infants. In Malawi, improvements in the management of neonatal respiratory failure are needed to reduce neonatal mortality. WHAT THIS STUDY ADDS: This study shows that a nurse- led continuous positive airway pressure service can be implemented and sustained in district-level hospitals on national scale in Malawi. The introduction of continuous positive airway pressure reduced neonatal mortality, but improvements were limited by pervasive hypothermia. To cite: Carns J, Kawaza K, Liaghati-Mobarhan S, et al. Neonatal CPAP for Respiratory Distress Across Malawi and Mortality. Pediatrics. 2019;144(4):e20190668 a Rice 360 Institute for Global Health Technology, Houston, Texas; b Department of Bioengineering, Rice University, Houston, Texas; c Department of Pediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi; and d Department of Clinical Services, Ministry of Health, Lilongwe, Malawi Drs Richards-Kortum, Molyneux, Oden, and Kawaza conceptualized and designed the study and drafted the initial manuscript; Dr Carns conducted the initial data analysis and drafted the initial manuscript; Ms Quinn coordinated and supervised data collection and the management of the study and drafted the initial manuscript; Mr Lufesi, Mr Chalira, Ms Liaghati-Mobarhan, and Ms Asibon coordinated and supervised data collection and the management of the study; and all authors contributed to the critical interpretation of the results, reviewed and revised the manuscript, and approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2019-0668 Accepted for publication Jul 22, 2019 PEDIATRICS Volume 144, number 4, October 2019:e20190668 ARTICLE Downloaded from http://publications.aap.org/pediatrics/article-pdf/144/4/e20190668/1078163/peds_20190668.pdf by guest on 15 February 2022