Neonatal jaundice (NNJ) and hypoxic-ischemic encephalopathy (HIE) are common problems globally, but are most prevalent in low- and middle-income countries (LMICs) such as those in sub- Saharan Africa (SSA) [1
]. NNJ is a result of increased production of bilirubin and reduced excretory capacity of the immature liver of a baby during the first 28 days of life [3
]. HIE is characterized by a reduced oxygen or blood flow in the brain before, during, or immediately after birth [4
]. Both NNJ and HIE are major causes of brain damage [5
], leading to both short-term and long-term adverse neurobehavioral outcomes [6
In high-income countries (HICs), most children survive NNJ and HIE without significant morbidity due to availability of preventive strategies, early diagnosis, and advanced care and treatment. In contrast, in LMICs, especially in rural areas such as Kilifi, about 50% of mothers deliver their babies at home by unskilled birth attendants [9
]. Therefore, most children may experience a late diagnosis of NNJ or HIE depending on how soon the caregivers detect illness in their children and how fast they access hospital services. Accessibility to the hospital is further derailed by economic and infrastructural challenges [10
Moreover, survivors of these conditions are likely to be impaired in different developmental domains due to lack of proper guidelines for care and treatment [13
], lack of hospital facilities, and inadequate medical equipment and personnel [14
]. Given that most families have limited resources, survivors of NNJ and HIE may not be able to receive rehabilitative services which further accentuate the poor long-term outcomes.
Childhood infections are likely to interfere with the development of specific brain regions such as the prefrontal cortex and the subcortical ganglia regions that regulate behaviour and emotions and may develop mental health problems [15
] such as emotional and behavioural problems (EBPs). Emotional and behaviour problems manifest as both internalizing problems such as depressive, withdrawn, and anxiety symptoms and externalizing problems like attention problems, aggressive, conduct, and rule-breaking behaviours [16
]. Generally, children in SSA and Middle East countries have the highest levels of emotional problems and medium levels of behavioural problems as compared to children from other countries [17
]. Specifically, Kenyan children and adolescents are reported to have elevated EBPs in several domains as compared to other children from other countries based on multicultural norms [18
Although some degree of EBPs are expected in young children, persistent problems [19
] may indicate developmental problems which affect the quality of life of the affected children.[17
]. Quality of life is a subjective or objective measure of an individual’s well-being, including their physical, social, emotional functioning, as well as their economic status [20
]. Health-related quality of life (HRQOL) is a useful measure of general well-being, taking into account the physical, psychological, and the overall impact of health on an individual’s QoL [20
]. Despite EBPs and QoL being essential aspects of development, most studies on survivors of NNJ or HIE have focused on the neurocognitive outcomes while the mental health outcomes have received the least attention [21
], especially in school-aged children. The few studies on long-term mental health yielded equivocal results. While some reported elevated neurobehavioral problems, mental health disorders, and poor overall functioning of school-aged survivors of NNJ [23
] and HIE [26
], other studies did not find differences in mental health outcomes in school-aged survivors of NNJ compared to unaffected children [29
The long-term outcomes of NNJ and HIE are best understood using dynamic models of human development, such as the bioecological model of human development. According to this model, child development is influenced by both biological and environmental factors to which the child is exposed [31
]. A child’s development will be shaped not only by personal attributes and biomedical factors (e.g. neonatal insults, health status, and obstetric factors), but also by psychosocial environments (e.g. family environment, social-economic status, schooling), and the characteristics of his/her caregivers (e.g. caregiver mental health, level of education, and marital status). To identify strategic points of interventions for at-risk children, it is essential to study the relative contribution of each of these factors to the outcomes of survivors of NNJ or HIE.
While the literature presents some data on the mental health outcomes of survivors of NNJ and HIE, most of these studies are based on data from HICs [23
]. Despite the high burden of NNJ and HIE in SSA, there are no data on the mental health outcomes of school-aged children in this region who survive these conditions. Given the uniqueness of SSA countries, as previously discussed, it is vital to establish the burden of mental health and QoL in children who survived neonatal insults (NNI) in this part of the world. The quality of medical treatment and care, the living circumstances, and the family arrangements in LMICs in SSA may be dramatically different from those in other parts of the world, which raises the question to what extent available scientific knowledge on outcomes of NNI is applicable in SSA countries. Lack of data may impede the availability of needed policies, necessary care and treatment for school-aged survivors of NNJ or HIE who live with some degree of impairment. The limited data on the long-term mental health outcomes of neonatal insults in SSA could be attributed to a lack of research expertise and inadequate access to health care. Additionally, none of the studies has investigated the QoL and correlates of mental health and QoL outcomes of school-aged survivors of NNJ and HIE. In this study, we examined EBPs and QoL of school-aged survivors of NNJ and HIE and the correlates of mental health and QoL outcomes of school-aged survivors of NNJ and HIE born in Kilifi, Kenya.
We investigated mental health outcomes and QoL of school-aged survivors of NNJ and HIE and a community comparison group and the correlates associated with the mental health and QoL outcomes of survivors of NNJ and HIE. The findings indicate that the survivors of NNJ and HIE have comparable EBPs and QoL functioning as the community comparison group. Poor maternal mental health was associated with elevated EBPs in all the three broadband CBCL scales as well as with lowered quality of life in both survivor groups.
The findings of this study indicate that survivors of NNJ or HIE have mental health outcomes comparable to children without neonatal insults. Our results are consistent with the study by Vanborg et al. (2014), who reported that survivors of NNJ were not at an elevated risk of experiencing mental health problems compared to unaffected peers [30
]. Similarly, Van Handel et al. (2009) also reported no elevated EBPs in survivors of HIE using the CBCL [35
]. These findings, however, contradict other studies which reported more somatic and psychiatric symptoms [24
]; attention-deficit disorder [25
]; and autism spectrum disorder [23
] in survivors of NNJ and elevated neurobehavioral problems in survivors of HIE [26
Various factors may explain our observations. First, earlier studies indicate that Kenyan children in the general population have elevated EBPs (at least two times more in all the syndrome scales) compared to other multicultural standards [18
]. Therefore, the comparison group is experiencing higher mental health problems which are not significantly different from the survivors of NNJ and HIE. Second, the interpretation of these results should be understood in the broader perspective of developmental domains such as cognition, executive functions, and memory and the interplay between the individual characteristics and the environment. As children grow older, their brains may compensate for brain injury during the neonatal period—a phenomenon termed brain plasticity [47
]. Therefore, impairments reported during early childhood may resolve as children grow older. On the other hand, most of the survivors with severe outcomes may likely have died; therefore, those with severe outcomes may not have survived until school-age. Additionally, most of the neonates in this study did not have severe hyperbilirubinemia; thus, their mental health might not have been affected.
We found no significant differences in the QoL of survivors of NNJ and HIE when compared to healthy children. To the best of our knowledge, there are no studies that have investigated the QoL of school-aged survivors of NNJ and HIE, thus making it difficult for us to interpret the results in the context of earlier findings. However, investigations into the QoL of survivors of NNJ and HIE are vital as health is regarded as the state of complete physical, mental, and social well-being and not merely the absence of disease [49
]. Therefore, it is not only essential to understand the health status of individuals but also to understand and improve its quality. The finding that the survivors of NNJ and HIE have comparable QoL is encouraging as this indicates that despite the exposure to the neonatal insults these children can survive, function optimally, and thrive just as well as the unaffected children.
Although there are limited studies on the associations between maternal mental health and outcomes in survivors of NNJ or HIE, our finding that poor maternal mental health is associated with elevated levels of EBPs and lowered QoL in school-aged survivors of NNJ or HIE is consistent with other population-based studies [5
]. A possible explanation is that there is a complex causal association between the quality of parental care and EBPs outcomes in children. Researchers have suggested that poor maternal mental health may result in weaker attachments to the child and lack of responsiveness to their needs [57
]. Higher levels of mother’s negativity may, therefore, exacerbate a child’s poor emotions regulation and non-compliance, which may negatively affect emotional adjustment and externalizing behavioural problems. The finding that poor maternal mental health is associated with lowered QoL is similar to results reported by other studies with different populations [58
]. There is a possibility of shared methods variance in that caregivers with poor mental health may report poorer outcomes for their children. The EBP and quality of life data for children was collected from parents; consequently, caregivers with mental health problems perceived their children as presenting with more problems and having a lower quality of life.
Our finding that having seizures during admission was associated with elevated EBPs among survivors of HIE is similar to results in studies which have reported that EBPs are common in children with acute symptomatic seizures [46
The findings of this study should be cautiously interpreted, given the following limitations. First, the definition of NNJ included children with mild and moderate NNJ and few children had severe NNJ. Second, the mothers of the participants may have suffered recall bias, especially about the medical history of their children at the neonatal stage. Third, we could not perform subgroup analysis based on the severity of HIE as there was limited data on the Apgar score of the children with HIE. Fourth, as we used parental reports to explore the EBPs and QoL in their children, the responses of the parents could include a subjective component and be biased by the mental health state of the caregivers.
Additionally, parents may lack insights into their children’s mental health state. Teachers’ reports could have added more insights into the children’s mental health functioning as the classroom setting may give the teachers a better opportunity to detect mental health problems [60
]. Although QoL is regarded as a subjective measure and self-reports are generally preferred [61
], a study in the Kenyan population reveal that QoL children’s self-reports and parental reports are inconsistent [39
], making it important to include child report of QoL next to parent reports. However, the age of especially the younger children in this study might have hampered the validity of their reports [62
]. Lastly, since this is a cross-sectional study, we cannot infer any causal relationships between maternal mental health and children's EBPs. Future studies with longitudinal designs are needed to investigate further and understand this relationship.
Neonatal jaundice and HIE are common clinical problems that affect babies during the first days of life and are associated with child mortality and morbidity. Despite the high prevalence of NNJ and HIE in SSA, there is no data on long-term mental health and quality of life outcomes of survivors of NNJ or HIE in SSA. The current study examined the mental health and quality of life outcomes of school-aged survivors of NNJ, HIE, and a comparison group and the correlates of these outcomes in Kilifi, Kenya. We followed 375 participants (134 who survived NNJ, 107 who survived HIE, and 134 unaffected children) aged 6–12 years. We used the CBCL and PedsQL to assess the mental health and quality of life, respectively. Our results suggest that both the survivors of neonatal insults and the unaffected peers have comparably elevated mental health problems and quality of life outcomes. The association of poor maternal mental health to elevated EBPs and lowered QoL suggests a need for early psychosocial and clinical intervention for caregivers and their children to reduce the children’s risk for later development of EBPs and improve functioning in Kenyan children.
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