Table 1

Key discussions and decisions from local expert advisory group

ConditionDiscussion pointsDecision 
Birth weight <2000 g New guidelines are being produced by the Ministry of Health, which will indicate that all newborns <2000 g should be admitted for kangaroo mother care (KMC).2000 g should be applied as the definition for low birth weight requiring admission as KMC and neonatal units are typically co-managed.
Large for gestational age/foetal macrosomia All neonates >4000 g should be admitted for investigation of aetiology, and other support as required (such as feeding to prevent hypoglycaemia). However, this care is usually provided on the postnatal ward rather than the newborn unit.Acknowledge in the framework but do not include in overall estimation.
Neonatal encephalopathy Minor neonatal encephalopathy does not necessitate neonatal inpatient care and carries no long-term risk of neurological disability.Only Sarnat grades II and III42 should be included in estimation.
Neonatal respiratory diseases Neonatal respiratory distress syndrome (RDS) and transient tachypnoea of the newborn (TTN) are difficult to differentiate in many clinical settings in Kenya, and are often classified predominantly on gestational age. Management is largely consistent across these groups. Although meconium aspiration syndrome (MAS) is a distinct clinical entity, respiratory support management is similar to that of RDS and TTN.A composite outcome of ‘neonatal respiratory diseases was created’, comprising all neonates with RDS, TTN and MAS requiring inpatient care. It was recognised, however, that ultimately distinguishing the different aetiologies of neonatal respiratory diseases will be important for health services.
Late-onset neonatal sepsis Most neonates >7 days old with severe infection are likely to be admitted to the paediatric ward rather than the newborn unit, and so, from a health service provision perspective, should not be counted in our framework.Attempts should be made to separately estimate early-onset (<7 days old) and late-onset neonatal sepsis.
Jaundice A large number of jaundice cases will resolve without treatment. Jaundice requiring treatment is likely to be in the first week of life and be provided as an inpatient in the neonatal unit. On the other hand, jaundice in older neonates is likely to be investigated±treated as an outpatient or on the paediatric ward.Only ‘jaundice requiring inpatient treatment’ in the first week of life should be included in the framework.
Major congenital malformations Defining which congenital malformations require inpatient neonatal care is complex. Some malformations that might be diagnosed in the neonatal period in a high-resource setting may present later in the Nairobi population due to a combination of delayed diagnosis and care-seeking behaviours.Only congenital malformations likely to result in mortality or severe morbidity without neonatal inpatient care (most commonly for surgical intervention) should be included in the framework. For details, see online supplementary appendix 1.
Miscellaneous conditions There are other conditions that require inpatient care, potentially large in number but each with a low individual incidence and high level of uncertainty around their estimates, which should be acknowledged.These conditions (specifically including birth trauma resulting in fracture or acute anaemia, and renal and musculoskeletal congenital malformations) should be acknowledged in the framework but not included in the overall estimation.