BackgroundSimulators are an extensively utilized teaching tool in clinical settings. Simulation e... more BackgroundSimulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.MethodsSixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training ...
ObjectiveNutrition societies recommend using standardised parenteral nutrition (SPN) solutions. W... more ObjectiveNutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes.DesignThis was a quality improvement initiative. Data were collected retrospectively before and after the intervention.SettingA tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan.PatientsAll NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018.InterventionsA team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU.Main outcome measuresWe recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during ...
Purpose We aimed to assess the effectiveness of wheat soya blend plus (WSBP) provided during preg... more Purpose We aimed to assess the effectiveness of wheat soya blend plus (WSBP) provided during pregnancy and lactation on weight gain during pregnancy, reduction of low birthweight (LBW), and improvement in nutritional status in infants at 6 months of age in Thatta and Sujawal districts of Sindh, Pakistan. Methods A cluster randomized-controlled trial was conducted in Thatta and Sujawal districts in Pakistan from August 2014 to December 2016. A total of 2030 pregnant women were enrolled in the study. These women and their infants were followed during pregnancy and first 6 months of life. Pregnant women received a monthly ration of 5 kg (i.e., 165 g/day) of WSB + during pregnancy and the first 6 months of their lactation period. Results There was no difference in weight gain during pregnancy between the intervention and control groups ( n = 496, 326.7 g/week 95% CI 315.2–338.1 vs. ( n = 507, 306.9 g/week, 95% CI 279.9–333.9 P = 0.192), after adjustment with different factors. The reduction in the prevalence of LBW was not different between intervention and control groups ( n = 325, 34.0%, 95% CI 31.7–36.4, vs. ( n = 127, 34.3%, 95% CI 27.2–41.5, P = 0.932). Significant reductions in risk of stunting ( n = 1319 RR 0.85, 95% CI 0.73–0.99, P = 0.041), wasting ( n = 1330 RR 0.77, 95% CI 0.65–0.91, P = 0.003), and underweight ( n = 1295 RR 0.77, 95% CI 0.69–0.87, P < 0.001) were observed in infants at 6 months of age in the intervention as compared to the control group. However, no difference was noted on reduction in the risk of stunting among infants at 6 months of age in the intervention and control group ( n = 1318 RR 0.91, 95% CI 0.78–1.07, P = 0.253) after adjustment. A significant reduction in anemia was noted ( n = 1328 RR 0.94, 95% CI 0.91–0.98, P = 0.002) in infants at 6 months of age in the intervention as compared to the control group in adjusted analysis. Conclusions Provision of WSB + during pregnancy and the first 6 months of lactation is effective in reducing the risk of under nutrition and anemia in infants at 6 months of age. This study can potentially guide the government and donor agencies in investing in nutritional programmes, especially for pregnant and lactating women living in vulnerable settings.
Adequacy of zinc intake from breast milk alone becomesmarginal in relation to infant requirements... more Adequacy of zinc intake from breast milk alone becomesmarginal in relation to infant requirements by around 6 mo of age. Simple and cost-effective strategies are needed at the population level to ensure adequate intakes of zinc in infants and toddlers in populations at risk of zinc deficiency. We determined the amount of absorbed zinc (AZ) from a micronutrient powder (MNP) without and with 10 mg of zinc (MNP+Zn) added to local complementary foods used in Pakistan and the impact on the exchangeable zinc pool (EZP) size. As a nested study within a large, prospective, cluster randomized trial, 6-mo-old infants were randomly assigned to receive MNP or MNP+Zn. Stable isotope methodology was applied after;3 and 9 mo of use to measure AZ fromMNP-fortified test meals of rice-lentils (khitchri) and EZP. Nineteen infants per group completed the first metabolic studies and 14 and 17 infants in the MNP andMNP+Zn groups, respectively, completed the follow-up studies. AZs were (mean6 SD) 0.16 0.1...
Background Neonatal mortality due to preterm birth and low birthweight remains a significant chal... more Background Neonatal mortality due to preterm birth and low birthweight remains a significant challenge in Pakistan. Kangaroo mother care (KMC) is a unique, low-cost intervention proven to reduce neonatal mortality and morbidity and increase exclusive breastfeeding rates. However, KMC has not been attempted in community settings in Pakistan. We aim to implement and evaluate the effectiveness of a community-based KMC package to reduce neonatal morbidity and mortality among preterm and low birthweight (LBW) infants, which will provide evidence for policy development and the large-scale implementation of KMC across the country. Objective The primary objective of this trial is to reduce neonatal mortality among preterm and LBW infants. The secondary objectives are growth (measured as weight gain), reduced incidence of possible serious bacterial infection, and increased exclusive breastfeeding and continued breastfeeding practices. Methods We designed a community-based cluster randomized ...
Journal of Ayub Medical College, Abbottabad : JAMC, 2020
BACKGROUND Retinopathy of prematurity (ROP) is a preventable and treatable vasoproliferative diso... more BACKGROUND Retinopathy of prematurity (ROP) is a preventable and treatable vasoproliferative disorder of the retina which develops mostly in preterm babies. It is a leading cause of childhood blindness and more common in under developed countries. Prevalence of the severe ROP is 7.7% in Pakistan. We reviewed the characteristics of preterm babies with severe ROP to evaluate the predictors of sight threatening ROP. METHODS Our study was conducted at the NICU of Aga Khan University Hospital which is a tertiary care private sector hospital in Karachi. Ninety-seven cases of severe ROP were found out of which 83 cases were enrolled. Data on determinants for ROP were collected including gestational age, birth weight, weight gain at two and four weeks, h/o blood transfusion, supplementary oxygen, presence of PDA and its treatment. Data analysis was done by using SPSS version 20.0. RESULTS Frequency of severe ROP in our cohort was 5.95%. Mean gestational age for severe ROP was 28.27±1.79 and...
We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (L... more We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (LHWs) at a community level with the standard CMAM program provided at the health facility. A two-arm cluster randomised controlled trial was conducted in a rural district in sindh Pakistan. The primary outcome was recovery from SAM and secondary outcomes were relapse, defaulter and mortality rate. A total of 829 children were recruited in the trial (430 in intervention and 399 in control groups). No significant difference was noted in recovery rate between the intervention and control groups (79.2% vs 85.6%, p = 0.276). Similarly, no significant differences were noted in relapse (p = 0.757), weight gain (p = 0.609), deaths (p = 0.775) and defaulter rate (p = 0.324) across the groups. Compliance of RUTF was significantly higher in the control group (93%) than in the intervention group (87%), p < 0.000. Our results showed no impact of SAM treatment on performance indicators of CMAM (recovery, relapse, death and default) between the standard CMAM programme performed at the health facility by the government and NGO staff and the programme performed at health house level by the LHWs in Pakistan. We recommend further robust trials in other settings to confirm our results.
Background: Pakistan is experiencing a rapid nutrition transition with a shift from underweight t... more Background: Pakistan is experiencing a rapid nutrition transition with a shift from underweight to overweight and obesity. This paper will examine the role of household socioeconomic position (SEP), community SEP and urbanicity on the nutritional status (underweight, overweight and obesity) of Pakistani women. Methods: We analysed data on 34,391 women aged ≥20 years enrolled in 2011 National Nutritional Survey of Pakistan (NNS). The NNS is a nationally representative survey employing a multistage stratified cluster sampling design. We assessed household SEP through a wealth index constructed using items from household possessions, utilities and housing conditions. We assessed the relationship of urbanicity, household and community SEP with categories of body mass index (BMI) using multinomial logistic regression where normal BMI (18.6-22.5 kg/m 2 ) was the reference category. Results: Overall, 15% of women were underweight (BMI<18.5 kg/m 2 ), 14% were pre-overweight (BMI 23.00-24...
Background Puerperal sepsis (PS) is one of the major causes of maternal death, contributing to 26... more Background Puerperal sepsis (PS) is one of the major causes of maternal death, contributing to 26 000 deaths per year in developing countries. Early recognition and treatment are essential to managing PS but numerous social, cultural and technical barriers prevent or delay access to care and necessary medical attention. Through this qualitative study, we identified barriers to care seeking for puerperal sepsis among recently delivered women in Matiari, Pakistan. Methods We conducted 20 in-depth interviews among recently delivered women with and without sepsis and their family members. Key informant interviews were conducted with 14 healthcare providers and traditional birth attendants. The themes used for content analysis were knowledge of danger signs, factors affecting care seeking and local treatment practices for postpartum sepsis. Results Recently delivered women, their family members and traditional birth attendants were unaware of the word PS or the local translated term for ...
Objective Central line associated bloodstream infection (CLABSI) is an important cause of morbidi... more Objective Central line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions. Design This was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative. Setting A tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. Patients All patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission. Interventions CPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment. Main outcome measures CLABSI rates pre...
Objectives The objectives of impact evaluation were to assess the prevalence and impact of nutrit... more Objectives The objectives of impact evaluation were to assess the prevalence and impact of nutrition-based supplementation on stunting in children under-five year of age. Methods Baseline and endline surveys on a sub-set of population in 2014 and 2017 were conducted in two districts of Sindh, Pakistan. Children 6–23 months received a daily ration of 50 g/day of lipid based nutrient supplement-medium quality (LNS-MQ). Children aged 24–59 months received a micronutrient powder sachet containing the RDA for 15 micronutrients every alternate day for at least 6 months. Results 2195 children at baseline and 2923 at endline were included in analysis. A significant reduction of 10% (45% at baseline; 40% at endline; P = 0.003) was observed in the stunting prevalence among children 6–59 months in intervention areas, but only a 2% reduction (52% at baseline; 51% at endline; P = 0.46) was noted in control areas. There was a significant reduction of 8% in the prevalence of underweight in interve...
IntroductionIn 2016, 2.6 million children died during their first month of life. We assessed the ... more IntroductionIn 2016, 2.6 million children died during their first month of life. We assessed the effectiveness of an integrated neonatal care kit (iNCK) on neonatal survival and other health outcomes in rural Pakistan.MethodsWe conducted a community-based, cluster randomised, pragmatic, open-label, controlled intervention trial in Rahim Yar Khan, Punjab, Pakistan. Clusters, 150 villages and their lady health workers (LHWs), were randomly assigned to deliver the iNCK (intervention) or standard of care (control). In intervention clusters, LHWs delivered the iNCK and education on its use to pregnant women. The iNCK contained a clean birth kit, chlorhexidine, sunflower oil, a continuous temperature monitor (ThermoSpot), a heat reflective blanket and reusable heat pack. LHWs were also given a hand-held scale. The iNCK was implemented primarily by caregivers. The primary outcome was all-cause neonatal mortality. Outcomes are reported at the individual level, adjusted for cluster allocatio...
To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and fol... more To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and folate deficiencies in women of reproductive age (WRA) in Pakistan. A secondary analysis was conducted on data collected through the large-scale National Nutrition Survey in Pakistan in 2011. Anaemia was defined as haemoglobin levels <12 g/dL, vitamin B12 deficiency as serum vitamin B12 levels of <203 pg/mL (150 pmol/L) and folate deficiency as serum folate levels <4 ng/mL (10 nmol/L). A total of 11 751 blood samples were collected and analysed. The prevalence of anaemia, vitamin B12 deficiency and folate deficiency was 50.4%, 52.4% and 50.8%, respectively. After adjustment, the following factors were positively associated with anaemia: living in Sindh province (RR 1.07; 95% CI 1.04 to 1.09) P<0.00, food insecure with moderate hunger (RR 1.03; 95% CI 1.00 to 1.06) P=0.02, four or more pregnancies (RR 1.03; 95% CI 1.01 to 1.05) P<0.00, being underweight (RR 1.03; 95% CI 1.00 t...
Background The preferred timing of umbilical-cord clamping in preterm infants is unclear. Methods... more Background The preferred timing of umbilical-cord clamping in preterm infants is unclear. Methods We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. Results Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were av...
Hemi-truncus arteriosus is a rare congenital cardiovascular malformation. It usually presents in ... more Hemi-truncus arteriosus is a rare congenital cardiovascular malformation. It usually presents in infancy and leads to development of progressive pulmonary vascular disease, heart failure, and death. We report a case of hemi truncus arteriosus in a 12-day-old neonate who was successfully managed at our institute.
BackgroundDespite evidence for the benefits of vitamin A supplementation (VAS) among children 6 t... more BackgroundDespite evidence for the benefits of vitamin A supplementation (VAS) among children 6 to 59 months of age, the feasibility of introduction and potential benefit of VAS in the neonatal period in public health programmes is uncertain.ObjectiveThe primary objective was to evaluate the feasibility and effectiveness of early neonatal VAS (single dose of 50 000 international units within 48–72 hours after birth) delivered through the public sector Lady Health Worker (LHW) programme in rural Pakistan and to document its association with a reduction in mortality at 6 months of age.MethodsA community-based, cluster randomised, placebo-controlled trial was undertaken in two districts of rural Pakistan. LHWs dispensed vitamin A/placebo in identical capsules to newborn infants within 48–72 hours of birth. Follow-up visits were undertaken at 1 week of age and every 4 weeks thereafter until 6 months of age.ResultsOf a total of 15 433 consecutive pregnancies among eligible women of repro...
BackgroundSimulators are an extensively utilized teaching tool in clinical settings. Simulation e... more BackgroundSimulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.MethodsSixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training ...
ObjectiveNutrition societies recommend using standardised parenteral nutrition (SPN) solutions. W... more ObjectiveNutrition societies recommend using standardised parenteral nutrition (SPN) solutions. We designed evidence-based SPN formulations for neonates admitted to our neonatal intensive care unit (NICU) and evaluated their outcomes.DesignThis was a quality improvement initiative. Data were collected retrospectively before and after the intervention.SettingA tertiary-care level 3 NICU at the Aga Khan University in Karachi, Pakistan.PatientsAll NICU patients who received individualised PN (IPN) from December 2016 to August 2017 and SPN from October 2017 to June 2018.InterventionsA team of neonatologists and nutrition pharmacists collaborated to design two evidence-based SPN solutions for preterm neonates admitted to the NICU.Main outcome measuresWe recorded mean weight gain velocity from days 7 to 14 of life. The other outcomes were change in weight expressed as z-scores, metabolic abnormalities, PN-associated liver disease (PNALD), length of NICU stay and episodes of sepsis during ...
Purpose We aimed to assess the effectiveness of wheat soya blend plus (WSBP) provided during preg... more Purpose We aimed to assess the effectiveness of wheat soya blend plus (WSBP) provided during pregnancy and lactation on weight gain during pregnancy, reduction of low birthweight (LBW), and improvement in nutritional status in infants at 6 months of age in Thatta and Sujawal districts of Sindh, Pakistan. Methods A cluster randomized-controlled trial was conducted in Thatta and Sujawal districts in Pakistan from August 2014 to December 2016. A total of 2030 pregnant women were enrolled in the study. These women and their infants were followed during pregnancy and first 6 months of life. Pregnant women received a monthly ration of 5 kg (i.e., 165 g/day) of WSB + during pregnancy and the first 6 months of their lactation period. Results There was no difference in weight gain during pregnancy between the intervention and control groups ( n = 496, 326.7 g/week 95% CI 315.2–338.1 vs. ( n = 507, 306.9 g/week, 95% CI 279.9–333.9 P = 0.192), after adjustment with different factors. The reduction in the prevalence of LBW was not different between intervention and control groups ( n = 325, 34.0%, 95% CI 31.7–36.4, vs. ( n = 127, 34.3%, 95% CI 27.2–41.5, P = 0.932). Significant reductions in risk of stunting ( n = 1319 RR 0.85, 95% CI 0.73–0.99, P = 0.041), wasting ( n = 1330 RR 0.77, 95% CI 0.65–0.91, P = 0.003), and underweight ( n = 1295 RR 0.77, 95% CI 0.69–0.87, P < 0.001) were observed in infants at 6 months of age in the intervention as compared to the control group. However, no difference was noted on reduction in the risk of stunting among infants at 6 months of age in the intervention and control group ( n = 1318 RR 0.91, 95% CI 0.78–1.07, P = 0.253) after adjustment. A significant reduction in anemia was noted ( n = 1328 RR 0.94, 95% CI 0.91–0.98, P = 0.002) in infants at 6 months of age in the intervention as compared to the control group in adjusted analysis. Conclusions Provision of WSB + during pregnancy and the first 6 months of lactation is effective in reducing the risk of under nutrition and anemia in infants at 6 months of age. This study can potentially guide the government and donor agencies in investing in nutritional programmes, especially for pregnant and lactating women living in vulnerable settings.
Adequacy of zinc intake from breast milk alone becomesmarginal in relation to infant requirements... more Adequacy of zinc intake from breast milk alone becomesmarginal in relation to infant requirements by around 6 mo of age. Simple and cost-effective strategies are needed at the population level to ensure adequate intakes of zinc in infants and toddlers in populations at risk of zinc deficiency. We determined the amount of absorbed zinc (AZ) from a micronutrient powder (MNP) without and with 10 mg of zinc (MNP+Zn) added to local complementary foods used in Pakistan and the impact on the exchangeable zinc pool (EZP) size. As a nested study within a large, prospective, cluster randomized trial, 6-mo-old infants were randomly assigned to receive MNP or MNP+Zn. Stable isotope methodology was applied after;3 and 9 mo of use to measure AZ fromMNP-fortified test meals of rice-lentils (khitchri) and EZP. Nineteen infants per group completed the first metabolic studies and 14 and 17 infants in the MNP andMNP+Zn groups, respectively, completed the follow-up studies. AZs were (mean6 SD) 0.16 0.1...
Background Neonatal mortality due to preterm birth and low birthweight remains a significant chal... more Background Neonatal mortality due to preterm birth and low birthweight remains a significant challenge in Pakistan. Kangaroo mother care (KMC) is a unique, low-cost intervention proven to reduce neonatal mortality and morbidity and increase exclusive breastfeeding rates. However, KMC has not been attempted in community settings in Pakistan. We aim to implement and evaluate the effectiveness of a community-based KMC package to reduce neonatal morbidity and mortality among preterm and low birthweight (LBW) infants, which will provide evidence for policy development and the large-scale implementation of KMC across the country. Objective The primary objective of this trial is to reduce neonatal mortality among preterm and LBW infants. The secondary objectives are growth (measured as weight gain), reduced incidence of possible serious bacterial infection, and increased exclusive breastfeeding and continued breastfeeding practices. Methods We designed a community-based cluster randomized ...
Journal of Ayub Medical College, Abbottabad : JAMC, 2020
BACKGROUND Retinopathy of prematurity (ROP) is a preventable and treatable vasoproliferative diso... more BACKGROUND Retinopathy of prematurity (ROP) is a preventable and treatable vasoproliferative disorder of the retina which develops mostly in preterm babies. It is a leading cause of childhood blindness and more common in under developed countries. Prevalence of the severe ROP is 7.7% in Pakistan. We reviewed the characteristics of preterm babies with severe ROP to evaluate the predictors of sight threatening ROP. METHODS Our study was conducted at the NICU of Aga Khan University Hospital which is a tertiary care private sector hospital in Karachi. Ninety-seven cases of severe ROP were found out of which 83 cases were enrolled. Data on determinants for ROP were collected including gestational age, birth weight, weight gain at two and four weeks, h/o blood transfusion, supplementary oxygen, presence of PDA and its treatment. Data analysis was done by using SPSS version 20.0. RESULTS Frequency of severe ROP in our cohort was 5.95%. Mean gestational age for severe ROP was 28.27±1.79 and...
We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (L... more We compared the impact of management of severe acute malnutrition (SAM) by lady health workers (LHWs) at a community level with the standard CMAM program provided at the health facility. A two-arm cluster randomised controlled trial was conducted in a rural district in sindh Pakistan. The primary outcome was recovery from SAM and secondary outcomes were relapse, defaulter and mortality rate. A total of 829 children were recruited in the trial (430 in intervention and 399 in control groups). No significant difference was noted in recovery rate between the intervention and control groups (79.2% vs 85.6%, p = 0.276). Similarly, no significant differences were noted in relapse (p = 0.757), weight gain (p = 0.609), deaths (p = 0.775) and defaulter rate (p = 0.324) across the groups. Compliance of RUTF was significantly higher in the control group (93%) than in the intervention group (87%), p < 0.000. Our results showed no impact of SAM treatment on performance indicators of CMAM (recovery, relapse, death and default) between the standard CMAM programme performed at the health facility by the government and NGO staff and the programme performed at health house level by the LHWs in Pakistan. We recommend further robust trials in other settings to confirm our results.
Background: Pakistan is experiencing a rapid nutrition transition with a shift from underweight t... more Background: Pakistan is experiencing a rapid nutrition transition with a shift from underweight to overweight and obesity. This paper will examine the role of household socioeconomic position (SEP), community SEP and urbanicity on the nutritional status (underweight, overweight and obesity) of Pakistani women. Methods: We analysed data on 34,391 women aged ≥20 years enrolled in 2011 National Nutritional Survey of Pakistan (NNS). The NNS is a nationally representative survey employing a multistage stratified cluster sampling design. We assessed household SEP through a wealth index constructed using items from household possessions, utilities and housing conditions. We assessed the relationship of urbanicity, household and community SEP with categories of body mass index (BMI) using multinomial logistic regression where normal BMI (18.6-22.5 kg/m 2 ) was the reference category. Results: Overall, 15% of women were underweight (BMI<18.5 kg/m 2 ), 14% were pre-overweight (BMI 23.00-24...
Background Puerperal sepsis (PS) is one of the major causes of maternal death, contributing to 26... more Background Puerperal sepsis (PS) is one of the major causes of maternal death, contributing to 26 000 deaths per year in developing countries. Early recognition and treatment are essential to managing PS but numerous social, cultural and technical barriers prevent or delay access to care and necessary medical attention. Through this qualitative study, we identified barriers to care seeking for puerperal sepsis among recently delivered women in Matiari, Pakistan. Methods We conducted 20 in-depth interviews among recently delivered women with and without sepsis and their family members. Key informant interviews were conducted with 14 healthcare providers and traditional birth attendants. The themes used for content analysis were knowledge of danger signs, factors affecting care seeking and local treatment practices for postpartum sepsis. Results Recently delivered women, their family members and traditional birth attendants were unaware of the word PS or the local translated term for ...
Objective Central line associated bloodstream infection (CLABSI) is an important cause of morbidi... more Objective Central line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions. Design This was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative. Setting A tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. Patients All patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission. Interventions CPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment. Main outcome measures CLABSI rates pre...
Objectives The objectives of impact evaluation were to assess the prevalence and impact of nutrit... more Objectives The objectives of impact evaluation were to assess the prevalence and impact of nutrition-based supplementation on stunting in children under-five year of age. Methods Baseline and endline surveys on a sub-set of population in 2014 and 2017 were conducted in two districts of Sindh, Pakistan. Children 6–23 months received a daily ration of 50 g/day of lipid based nutrient supplement-medium quality (LNS-MQ). Children aged 24–59 months received a micronutrient powder sachet containing the RDA for 15 micronutrients every alternate day for at least 6 months. Results 2195 children at baseline and 2923 at endline were included in analysis. A significant reduction of 10% (45% at baseline; 40% at endline; P = 0.003) was observed in the stunting prevalence among children 6–59 months in intervention areas, but only a 2% reduction (52% at baseline; 51% at endline; P = 0.46) was noted in control areas. There was a significant reduction of 8% in the prevalence of underweight in interve...
IntroductionIn 2016, 2.6 million children died during their first month of life. We assessed the ... more IntroductionIn 2016, 2.6 million children died during their first month of life. We assessed the effectiveness of an integrated neonatal care kit (iNCK) on neonatal survival and other health outcomes in rural Pakistan.MethodsWe conducted a community-based, cluster randomised, pragmatic, open-label, controlled intervention trial in Rahim Yar Khan, Punjab, Pakistan. Clusters, 150 villages and their lady health workers (LHWs), were randomly assigned to deliver the iNCK (intervention) or standard of care (control). In intervention clusters, LHWs delivered the iNCK and education on its use to pregnant women. The iNCK contained a clean birth kit, chlorhexidine, sunflower oil, a continuous temperature monitor (ThermoSpot), a heat reflective blanket and reusable heat pack. LHWs were also given a hand-held scale. The iNCK was implemented primarily by caregivers. The primary outcome was all-cause neonatal mortality. Outcomes are reported at the individual level, adjusted for cluster allocatio...
To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and fol... more To determine the prevalence and possible factors associated with anaemia, and vitamin B12 and folate deficiencies in women of reproductive age (WRA) in Pakistan. A secondary analysis was conducted on data collected through the large-scale National Nutrition Survey in Pakistan in 2011. Anaemia was defined as haemoglobin levels <12 g/dL, vitamin B12 deficiency as serum vitamin B12 levels of <203 pg/mL (150 pmol/L) and folate deficiency as serum folate levels <4 ng/mL (10 nmol/L). A total of 11 751 blood samples were collected and analysed. The prevalence of anaemia, vitamin B12 deficiency and folate deficiency was 50.4%, 52.4% and 50.8%, respectively. After adjustment, the following factors were positively associated with anaemia: living in Sindh province (RR 1.07; 95% CI 1.04 to 1.09) P<0.00, food insecure with moderate hunger (RR 1.03; 95% CI 1.00 to 1.06) P=0.02, four or more pregnancies (RR 1.03; 95% CI 1.01 to 1.05) P<0.00, being underweight (RR 1.03; 95% CI 1.00 t...
Background The preferred timing of umbilical-cord clamping in preterm infants is unclear. Methods... more Background The preferred timing of umbilical-cord clamping in preterm infants is unclear. Methods We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. Results Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were av...
Hemi-truncus arteriosus is a rare congenital cardiovascular malformation. It usually presents in ... more Hemi-truncus arteriosus is a rare congenital cardiovascular malformation. It usually presents in infancy and leads to development of progressive pulmonary vascular disease, heart failure, and death. We report a case of hemi truncus arteriosus in a 12-day-old neonate who was successfully managed at our institute.
BackgroundDespite evidence for the benefits of vitamin A supplementation (VAS) among children 6 t... more BackgroundDespite evidence for the benefits of vitamin A supplementation (VAS) among children 6 to 59 months of age, the feasibility of introduction and potential benefit of VAS in the neonatal period in public health programmes is uncertain.ObjectiveThe primary objective was to evaluate the feasibility and effectiveness of early neonatal VAS (single dose of 50 000 international units within 48–72 hours after birth) delivered through the public sector Lady Health Worker (LHW) programme in rural Pakistan and to document its association with a reduction in mortality at 6 months of age.MethodsA community-based, cluster randomised, placebo-controlled trial was undertaken in two districts of rural Pakistan. LHWs dispensed vitamin A/placebo in identical capsules to newborn infants within 48–72 hours of birth. Follow-up visits were undertaken at 1 week of age and every 4 weeks thereafter until 6 months of age.ResultsOf a total of 15 433 consecutive pregnancies among eligible women of repro...
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