Improvement of Surgical Care for Newborns in Conditions of a Large City

The dissertation is devoted to the improvement of surgical care for newborns with congenital anomalies and other surgical pathology in conditions of a large city. The study is based on the medical and social and organizational aspects of specialized care provision and is aimed at developing an optimal organizational model of surgical care based on a neonatal surgery center. The clinical material covers a 27-year observation period.

In the work, a comprehensive epidemiological analysis of the prevalence and structure of congenital anomalies in Saint Petersburg was conducted, and their role in the structure of morbidity, disability, and mortality of the population was investigated. The clinical and medical and social characteristics of newborns hospitalized in a pediatric surgical inpatient department were examined, and the quality of life of parents of children with congenital anomalies was studied. Principles of surgical care organization were developed according to the following stages: antenatal diagnosis, transport to a hospital, inpatient treatment, and rehabilitation treatment.

Relevance of the study. Under contemporary conditions characterized by a significant decline in the birth rate, the quality of health of newborns and infants acquires particular importance. The first year of life, especially the neonatal period, is the most critical stage of human ontogenesis. The complexity of this ontogenetic stage is determined by the intensity of morphological and functional restructuring accompanying the child's adaptation to extrauterine life. The roots of many chronic diseases lie in the perinatal and neonatal periods of ontogenesis. Currently, the critical features of neonatal ontogenesis and the first year of life are combined with unfavorable social, biological, and ecological factors. Against the background of a sharp decline in the birth rate and a shortening of life expectancy, a progressive deterioration in the health of children and adolescents, as well as women of reproductive age, is observed (Ignatyeva R.K., 1994; Vel'tishch Yu.E., 1994; Baranov A.A., 1994 and 2000; Al'bitskiy V.Yu. et al., 1997 and 2001; Vasil'eva T.V., 2001; Shapkayts V.A., 2001; Roberton N.R.C., 1998; Hageman J.R., 1998). One of the primary directions of modern neonatology is the study of surgical pathology in newborns, in particular, congenital anomalies (CA).

The number of children with surgical pathology in the neonatal period is constantly increasing. In Russia, approximately 100,000 children with congenital anomalies are born annually; nearly 10% of them die within the first year of life (Ailamazyan E.K., 1993). In the structure of causes of mortality in children under one year of age, congenital anomalies occupy a leading position alongside conditions of the perinatal period (Zelinskaya D.I., 1996). CA rank second only to intrauterine hypoxia and birth asphyxia, sharing second place with respiratory distress syndrome and other respiratory conditions (19.2%) (Katkova I.P. et al., 1995). In a number of regions of Russia, CA have risen to first place in the structure of causes of neonatal and infant mortality. In the structure of surgical diseases, the largest group comprises children with CA of the gastrointestinal tract, lungs, diaphragm, and kidneys. The next, significantly smaller group consists of children with surgical infections: enterocolitis, peritonitis, abscesses. The third group includes children with such surgical conditions as tumors, traumatic diaphragmatic relaxation, and injuries of internal organs, among others. The severity of a sick child's condition is often exacerbated by the combination of congenital anomalies and congenital diseases. Conditions arising in the perinatal period that determine a high frequency of developmental disorders and childhood pathology require a shift in emphasis in scientific and practical activity toward the earliest periods of life (Vel'tishch Yu.E., 1994).

If congenital anomalies do not lead to the death of a child, they frequently become a cause of persistent decline in working capacity in later life, and a reduction in social adaptation of the child is often observed. CA rank third in the structure of causes of childhood disability (Zelinskaya D.I., Kobrinskiy B.I., 2000). Children with disabilities due to congenital anomalies accounted for 19.2% of the total number of children with disabilities in 2001 (Bokeria JI.A. et al., 2003). Developmental anomalies substantially influence the formation of the patient's personality and his characteristic traits. The birth of a child with a congenital anomaly generally has an unfavorable effect on the reproductive function of the family and its psychological climate (Zdorovtseva N.V., 1991).

Unfortunately, only in recent years have works devoted to the diagnosis and treatment of congenital anomalies and surgical pathology in newborns begun to appear, and comprehensive medical and social studies in this field are rare. There are very few neonatal surgery centers in our country, and as a result, children in the first year of life, including newborns, are treated in general surgical departments, which leads to significant mortality, reaching up to 100% for certain types of anomalies.

Goal of the study. On the basis of research into the medical and social and organizational aspects of surgical care for newborns with congenital anomalies and other surgical pathology, to develop an optimal organizational model of surgical care for newborns based on a neonatal surgery center in conditions of a modern large city.

To achieve the stated goal, the following tasks were set:

1. To study the prevalence and structure of congenital anomalies in Saint Petersburg.

2. To present an analysis of mortality in different age and sex groups from this class of diseases.

3. To provide a medical and social characterization of newborns hospitalized in a pediatric surgical inpatient department.

4. To conduct a study of the quality of life of parents of children with congenital anomalies.

5. To carry out a clinico-statistical analysis of the provision of specialized medical care to newborns with congenital anomalies in a pediatric surgical inpatient department.

6. To provide a scientific analysis of the features of managing newborns with congenital anomalies in contemporary conditions.

7. To study the current state of organization of surgical care for newborns with congenital anomalies in conditions of a modern large city.

8. To develop an optimal organizational model of surgical care for newborns based on a neonatal surgery center.

Scientific novelty of the study lies in the fact that for the first time in our country, principles for the organization of a Neonatal Surgery Center were developed. For the first time, a comprehensive epidemiological analysis of the place of CA in the structure of morbidity, disability, and mortality of a metropolis population was conducted. For the first time, the clinical and medical and social characteristics of newborns hospitalized for congenital anomalies and other surgical pathology were studied in detail. For the first time, the quality of life of parents of children with congenital anomalies was studied. Based on extensive (27-year) clinical material, the study demonstrates the necessity of organizing specialized departments for newborns with surgical pathology.

Scientific and practical significance of the study is determined by its results, which made it possible to present to government authorities and management bodies, as well as practical healthcare institutions, objective, scientifically grounded information on the prevalence and structure of congenital anomalies in Saint Petersburg. The implementation of the set tasks made it possible to provide a scientific rationale for the activities of a neonatal surgery center. Principles of surgical care for newborns were developed according to the following stages: antenatal diagnosis, transport to a hospital, inpatient treatment, and rehabilitation treatment. An individual staffing schedule for a neonatal resuscitation department was developed. Algorithms for the diagnosis and treatment of various types of surgical pathology in newborns were proposed and piloted. The implementation of the developments in the dissertation in the practice of Children's Surgery Centers in the country may contribute to the improvement of surgical care for newborns and a reduction in mortality from congenital anomalies.

The materials of the dissertation have been implemented in practical activities of: the Committee of the Federation Council of the Federal Assembly of the Russian Federation on Science, Culture, Education, Healthcare, and Ecology; the Committee on Healthcare of the Administration of Saint Petersburg; the Saint Petersburg City Clinical Children's Hospital No. 1; the Izhevsk City Clinical Children's Hospital No. 2; the Moscow City Clinical Children's Hospital No. 13 named after N.F. Filatov; and the Irkutsk City Ivan-Matrenin Clinical Hospital. The materials of the study are used in the educational process of Saint Petersburg State Medical University named after Academician I.P. Pavlov (departments of public health and healthcare, and pediatric surgery); the Saint Petersburg State Pediatric Medical Academy; the Izhevsk State Medical Academy; the Irkutsk State Institute of Advanced Physicians' Training; and have been included in the textbook "Neonatology," recommended by the Federal Educational and Methodological Association of the Ministry of Health and Social Development of the Russian Federation for students studying in the specialty "Pediatrics."

Main provisions of the dissertation to be defended:

1. Diseases of Class XVII of the ICD — "Congenital anomalies (malformations), deformations, and chronic disorders" have significant medical and social importance today due to their relatively high prevalence among the population of Saint Petersburg (primarily among children), negative trends, a major role in the structure of mortality, hospitalized morbidity, and especially disability among children and adolescents.

2. The formation of congenital anomalies is determined by a complex of unfavorable medical and social, medical-biological, and clinical factors identified in the present study.

3. The birth of a child with congenital anomalies significantly affects the quality of life of other family members. The obtained data determine the necessity and possible approaches to organizing socio-psychological assistance to families, allowing rehabilitation efforts to be directed in the most effective manner to improve family adaptation to the new situation.

4. In recent decades, substantial changes have occurred in the provision of care for newborns with surgical pathology, both in clinical and organizational approaches. Their implementation has made it possible to significantly reduce mortality and expand the list of correctable congenital anomalies.

5. The three-tier system of care for newborns with surgical pathology, developed in the present study, including the creation of Children's Surgery Centers, with the application of proposed algorithms for each group of congenital and acquired pathology, has proven its effectiveness and can be recommended for use in all regions of the Russian Federation.

Personal contribution of the author to the conducted research. The author independently conducted an analytical review of domestic and foreign literature on the studied problem, compiled the research program, developed statistical recording forms, and collected medical and social and clinico-statistical information. The planning, compilation of the mathematical-statistical processing program, and the processing itself were carried out with the personal participation of the author. Intermediate results of the study were systematically reviewed by scientific consultants. The analysis, interpretation, presentation of obtained data, formulation of conclusions, and practical recommendations were mainly performed personally by the author. The author's share of participation in data collection was up to 100%, in mathematical-statistical processing — over 80%, and in the generalization and analysis of the material — 100%.

Dissertation defense (habilitation). The main materials of the dissertation were reported at the sessions of: the Congresses of the European Association of Pediatric Surgeons (Graz, 1995; Madrid, 1997; Budapest, 2001; Tours, 2003); the scientific-practical conference "Biomedical and Biosocial Problems of Integrative Anthropology" (Saint Petersburg, 1999); the scientific-practical conference "Pediatrics at the Turn of the Centuries: Problems, Development Paths" (Saint Petersburg, 2000); the scientific-practical conference "Current Problems of Pediatric Surgery" dedicated to the 70th anniversary of the Izhevsk State Medical Academy and the 45th anniversary of the pediatric surgical service of Udmurtia (Izhevsk, 2003); the II Russian Congress "Modern Technologies in Pediatrics and Pediatric Surgery" (Moscow, 2003); the scientific-practical conference "Hospital Pediatrics in the 21st Century. Problems, Development Paths" (Saint Petersburg, 2003); and the World Congress of Pediatric Surgery (Zagreb, 2004).

Under the topic of the dissertation, 30 scientific works have been published.