Caring for tiny babies at Tygerberg Children’s Hospital has become a life’s mission for pioneering professor.
Caring for tiny babies, many weighing only a little more than a tub of margarine, has become Professor Gert Kirsten’s mission for the past few decades.
As the head of neonatology at Tygerberg Children’s Hospital for 20 years, Professor Kirsten and his team have boosted the survival rate for babies weighing less than a kilogram at birth, from 35% only a couple of decades ago to nearly 80% today.
With Kirsten retiring as head of the division, he’s had some time to reflect on his years and the challenges that still lie ahead for the neonatal wards.
Fresh from a stint at the world famous, high-tech Hospital for Sick Children in Toronto, Canada, Kirsten was plunged into the hurly burly of Tygerberg Hospital when he arrived in 1986.
“We were overwhelmed with patients.We realized we needed to keep mothers and their babies at their local hospitals as far afield as Upington and Springbok instead of transferring them to Tygerberg Hospital,” says Kirsten.
The solution was to get a small team of neonatal specialists, obstetricians, anaethetists and nurses together to visit hospitals throughout the region which stretched from the Namibian border in the North to George, Oudtshoorn and Graaff Reinet in the South.
Together they trekked around the rural areas, visiting hospitals and training nurses and doctors. This took a lot of the pressure off the central Tygerberg hub.
But there were still the serious cases to attend to – the achingly small babies, many weighing under a kilogram – who needed to be transferred to Tygerberg Children’s Hospital.
With a severe shortage of beds in the neonatal wards, mothers who came to hospital with their newborns were often sent home alone. But this created another problem. Apart from being unable to bond with their babies, the babies were not being breast-fed and being so tiny, were at high risk of infection.
“With outbreaks of infection due to over-crowding and formula milk feeding instead of breast milk, too many babies became seriously ill or were dying, and we needed to do something. We needed to get the mothers here.
“Breast milk contains anti-infective substances that provides immunity against infection,” explains Kirsten.
“But it was an uphill battle to persuade the administration that we needed to keep the mothers and babies in hospital for up to two months. Already, the wards were full. Administrators said: ‘This is a hospital, not a hotel’. But eventually, they changed their minds.”
Kirsten says he received tremendous support from the Western Cape Department of Health at that time and many young lives were saved.
Kangaroo Mother Care (KMC) where babies have skin-to-skin contact with their mothers,was also introduced at the hospital. By keeping them warm and close, babies often have a much higher survival rate. The babies, together with their mothers, remain at the hospital until they weigh 1.8 kilograms. For a 600-gram baby, this can take between two and three months.
KMC was introduced at a time when the government decided to close some of the nursing colleges. “Suddenly we had a huge problem, with a lack of nursing staff. Many took severance packages and went to the private sector. Mothers had to start doing things for themselves, changing nappies and giving one-on-one care in the KMC wards. They stepped in really well, and that helped a lot,” said Kirsten.
“Our policy is that the mother and the baby are a unit and you shouldn’t separate them,” believes Kirsten.
Within time, nurses in local hospitals were trained and KMC units were opened all over the Western Cape, further relieving the pressure on beds at the central hospital. Premature babies can be transferred back to the referring hospital once they reach a weight of 1200g.
The decision paid off. Kirsten says the infection rates came down and the survival rate shot up. With mothers and babies being discharged earlier, less money was spent on costly incubators, x-rays, antibiotics and drips.
But while celebrating their success, an obstacle lurked ahead.
The government’s introduction of free primary health care for pregnant mothers and children under the age of six in 1994 was widely welcomed, but this put pressure on other parts of the system. Costs were cut, with a directive that babies weighing less than a kilogram could not be admitted to neonatal intensive care units (NICUs).
“We had to come up with a solution to manage these most fragile of babies without the ICU facilities,” says Kirsten.
Using drip stands, Kirsten and his team developed a cheap home-built continuous positive airway pressure (CPAP) machine which could administer positive pressure to premature babies with respiratory distress syndrome due to surfactant deficiency.
A lack of surfactant causes respiratory problems especially in premature babies who have immature lungs.
The introduction of CPAP meant that premature babies with lung disease could now be managed in the neonatal ward instead of the NICU.
CPAP has since been introduced at Karl Bremer, Worcester, Paarl, Hermanus, Helderberg, Swartland, Ceres and Khayelitsha hospitals.
But as prospects looked brighter, the HIV epidemic tightened its grip. Far more sick mothers were being admitted to hospital in the mid 1990s. With many mothers very ill or dying, they were unable to provide expressed breast milk.
Caring South African organisations such as ‘Milk Matters’ stepped into the breach by setting up milk banks. Healthy breastfeeding mothers expressed their milk and supplied it for babies deprived of their own mother’s milk. This was a lifeline.
HIV-positive mothers who were well enough expressed their own milk for their babies.
“We bought hot plates and the mothers pasteurized the milk. The virus is very sensitive to heat and dies when exposed to boiling water. So we solved that problem. Every mother here did it for themselves,” says Kirsten.
The neonatal wards turned another corner when the government decided to introduce Anti Retroviral Therapy (ART) much earlier – when women were 14 weeks pregnant instead of just before birth. This helped to dramatically slice transmission rates from 14% to around 2%.
The attitude of mothers towards HIV also gradually changed for the better – and continues to improve.
Over the years, the hospital has also had to cope with waves of unexpected problems, such as the measles outbreak a few years ago, followed by the H1N1 phenomenon.
Recently doctors have been faced with a new and frightening threat…the drug, methamphetamine, also known as Tik.
“Tik is the next wave we’re dealing with,” says Kirsten.
When taken during pregnancy, Tik inflicts serious damage to the developing brain of a fetus. Worryingly, doctors have noticed that pregnant Tik-users often smoke it to dull labour pains, which can have devastating consequences.
In developed countries, six percent of babies weigh less than 2.5 kilograms. At Tygerberg Children’s Hospital, it’s four times as many. The reasons are numerous, but smoking, hypertension, alcohol and Tik have had a serious impact.
Despite this, Tygerberg Children’s Hospital boasts a neonatal survival rate on par with wealthy countries, yet without the benefit of state-of the art equipment and much bigger budgets.
Kirsten sees this as a team effort – from the medical staff to the provincial and city health departments to the mothers.
Kirsten credits the mothers, often as young as 14 years old, for showing great care for their babies and learning how to breast feed and care for them when they are at a very fragile weight.
“When I see them I’m often very proud. They come in here very vulnerable, but they leave as young mothers confident about how to look after their babies.”
During the time they stay in the KMC ward, the mothers spend time with dieticians, speech therapists and social workers and can also go for family planning.
While Tygerberg Children’s Hospital has made great strides, major challenges remain.
Kirsten says there is a dire shortage of neonatal beds as well as neonatal nurses to care for the rapidly increasing number of babies who are delivered at the hospital. A rising number of mothers from the Eastern Cape come to deliver their babies in Cape Town, while referral routes have also shifted, with many patients from the new Khayelithsa hospital being diverted to Tygerberg Children’s Hospital.
“We have 50,000 deliveries a year in our area, yet we only have eight NICU beds. You should have one NICU bed for every 2,000 deliveries,” says Kirsten.
The Tygerberg Children’s Hospital Trust is appealing to individuals and companies for funds to provide extra beds and life-saving equipment for the hospital, which admits 16,000 babies and children every year.
Kirsten has also called for more post-graduate training in neo-natal intensive care nursing. There are no courses in the Western Cape that offer post-basic training in neonatology except basic neonatal care during the midwifery course.
Kirsten said many of the nurses trained in neo-natal care are at risk of burnout as there are so few of them and are working extremely hard. There’s also a worry as many are close to retirement age.
“You need trained and skilled nurses to manage babies who are in NICU on ventilators. It’s no different to an adult on a ventilator in ICU. They’re as sick – and are often sicker, as their immunity is not as well developed and they are prone to infections,” says Kirsten.
Kirsten says his fervent wish upon retiring is to see more support for the neonatal wards and the NICU at Tygerberg Children’s Hospital, and the doctors and nurses who go beyond the call of duty for the babies they care for.
By Kim Cloete
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