Abstract
Background
Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina which occurs in premature babies due to defective vasculogenesis. There are established screening guidelines to enhance its early identification and prompt treatment. The aim of the study was to determine the level of awareness of the screening protocols for retinopathy of prematurity (ROP) among paediatricians in Nigeria.
Methods
A questionnaire was administered to paediatricians and residents in paediatrics attending a continuous professional development (CPD) course in Benin City, Nigeria. Information on their knowledge of risk factors, screening guidelines and treatment modalities for ROP was obtained.
Results
There were a total of 48 participants. The mean age of the participants was 34.5 ± 4.5 years of which 25 (52.1%) were females. A majority, 46 (95.8%) knew some risk factors for ROP. Fourteen (29.2%) participants knew the ROP screening guidelines while 10 (20.8%) had partial knowledge of these guidelines. Knowledge on the use of laser as a treatment modality of ROP was shown by 18 (37.5%) participants. The major reason given for not screening for ROP was being unaware of a referral centre in Nigeria in 43 (89.6%) participants.
Conclusion
The majority of paediatricians attending a CPD course in Nigeria though aware of retinopathy of prematurity, are currently poorly informed on the management of this condition and the need for screening. There is need to enlighten paediatricians in Nigeria on retinopathy of prematurity in order to prevent this treatable cause of blindness in children.
Keywords: Retinopathy of prematurity, Paediatricians, Need for screening, Nigeria
Introduction
Retinopathy of prematurity (ROP), previously called retrolental fibroplasias, is a vasoproliferative disorder of the retina which occurs principally in premature children due to defective vasculogenesis1. The survival of premature and low birth weight babies with modern and effective neonatal care increases the incidence of retinopathy of prematurity. Retinopathy of prematurity is one of the causes of avoidable blindness targeted by the World Health Organization in the Vision 2020-Right to Sight initiative2. There is a wide variation in the incidence of ROP in various countries which is closely linked to their level of development3-6. Reports indicate a steady decline in industrialized countries, an upsurge in middle income countries and low incidence in low income countries5,6. The low incidence in low income countries has been attributed to high infant mortality rates and poorly equipped neonatal intensive care units7. In order to reduce the prevalence of retinopathy of prematurity, screening guidelines of at risk babies have been recommended in order to institute appropriate interventions to reduce the incidence of blindness form this treatable condition8,9. Pediatricians who are responsible for the care of these neonates ought to be well informed and implement the recommended protocol to achieve a complete win-win situation in the saving of both lives and sight of these babies for a more productive life. This is important as the number of blind years in a child increases the burden of care to the families affected and society at large10,11. The study was performed to determine the level of awareness and retinopathy of prematurity screening protocol/guidelines among pediatricians in Nigeria in compliance with international screening guidelines for ROP. This is relevant with an upsurge in the number of assisted births and in-vitro fertilization in the country and improved neonatal care in a bid to ensure survival of the babies, thus assessing how prepared paediatricians are to tackle the sequel of improved neonatal care12.
Reports
MATERIALS AND METHODS
A questionnaire modified from previous studies10,13 was administered to paediatricians and residents in paediatrics drawn from across the country attending a continuous professional development (CPD) course in Benin City, Nigeria. Information on demographics, education and practice profile, knowledge of risk factors, dilatation drops, screening guidelines and treatment options, risks of screening and treating preterm babies with retinopathy of prematurity (ROP) was obtained. Also obtained were responses on the number of premature babies seen per month, awareness and referral scheme to ophthalmologist and barriers for referring babies for ROP screening. Responses obtained were analyzed using Graphpad Instat Software V2.05a and P value <0.05 taken as significant.
RESULTS
There was a total of 48 respondents with a mean age of 34.5 ± 4.5 years, range 28-45 years; of which 25(52.1%) were females. There were 7(14.6%) qualified paediatricians while residents in training were 41(85.4%). Most of the respondents, 46(95.8%) were in government employment. Among them, 13(27.1%) saw between 1-10 preterm babies per month while 46(95.8%) knew some risk factors for retinopathy of prematurity (ROP). The most common risk factor identified by respondents for ROP was supplemental oxygen exposure in 40(83.3%). Fourteen (29.2%) participants knew the ROP screening guidelines. Referral for ROP screening was routinely undertaken by 14(29.2%) respondents. The major reason given for not screening for ROP was being unaware of a referral centre in the country in 43(89.6%) participants. Knowledge on the use of laser or cryotherapy as a treatment modality of ROP was recorded in 18(37.5%) and 7(14.6%) participants respectively. A summary of the responses is presented in Table 1. There was no statistically significant difference in the responses concerning knowledge of screening guidelines and ROP screening between the paediatricians and residents in paediatrics (P>0.05).
Table 1: Knowledge, Attitude and Clinical practices of Paediatricians about Retinopathy of Prematurity
| Questions | Predominant responses (%) | Other responses (%) |
| Number of preterm seen per mth | 1-10(27.1), 11-20(25.0)No response/idea(25.0) | 31-40(10.4), 21-30(8.3)>50(4.2) |
| Time of screening in age | 1 mth(47.9%) | 6wks(10.4), 2mths(6.3)3mths(20.8), 6mths(4.2)No response/idea(10.4) |
| Birth weight criteria | <1.5kg(39.6) | <2.0kg(16.7), <2.5kg(22.9<1.0kg(14.6), No response/idea(6.3) |
| Gestational age criteria | <32wks(25.0)<28wks(10.4) | 30 wks(6.3), 34 wks(12.5)33wks(2.1), <35wks(8.3)<36wks(14.6), <37wks(10.4)<38wks(2.1), No response/idea(8.3) |
| *Risk factors | Oxygen therapy(83.3) Prematurity(58.3)LBW(12.5) | Asphyxia(8.3), Phototherapy(8.3)Acidosis(4.2), Blood transfusion(4.2)Mechanical ventilation(4.2)RDS(4.2), Hypoxia(2.1)Apnoea(2.1), Sepsis(2.1), Hypercapnia(2.1)Maternal cpx DM,HTN(2.1)Retinal detachment/haemorrhage(2.1)Trauma(2.1), No response/idea(4.2) |
| *Knowledge of Rx modalities | No response/idea(58.3) | Laser(37.5), Cryotherapy(14.6)Surgery(4.2), Wrong answers(10.4) |
| When Rx starts | No response/idea(33.3)Immediately(41.7) | 3 mths(2.1), Infancy(2.1) |
| Risks of Rx | No response/idea(50.0)No risk(37.1) | Yes(22.9), Blindness(8.3)Nerve injury(2.1), Infection(2.1)Retinal detachment(2.1) |
| Success of Rx in prevention of blindness | No response/idea(45.9)Good12(25.0) | Satisfactory(14.6)Poor(10.4)Very good(4.2) |
| Number of babies seen with ROP blindness | None(62.5)No response/idea(35.4) | Between 1-3(2.1) |
| Number of babies seen with ROP but not blind | No response/idea(50.0) None(43.8) | Between 1-4(4.2) |
| Availability of referral services for ROP | None(35.4) No response/idea(33.3) | Yes(31.3) |
| Do you refer for ROP screening*Mode of referral to ophthalmologist | No(62.5)Yes(29.2)Discharge slip(25)Provide written brochure(10.4) | No response(8.3)Inform parents verbally(4.2)Nurse/assistant inform verbally(2.1) |
| *Barriers to screening/referral | Not aware of referral centre(89.6)Parent not agreeing(18.8)No protocol(14.6) | Ophthalmologist not available 4(8.3)Not needed as babies don’t have ROP(8.3)Too expensive(6.3) |
| Key: Mth(s)=month(s), Wks= weeks, Cpx=complications, Rx=treatment, DM=diabetes mellitus, HTN=hypertension, LBW=low birth weight, *=Multiple responses | ||
Discussion
Guidelines have been established to enhance early identification and prompt treatment of babies with retinopathy of prematurity8,9. This has been done to improve the quality of life of survivors. These screening guidelines have been modified in different countries to suit their peculiar needs and adapt to regional variations in presentation14-18. Paediatricians who are the primary caregivers of babies with prematurity ought to be aware of the screening protocol for ROP to improve the quality of care and lives of these babies following survival10-12,18. Indeed monitoring for risk factors and clinical features of ROP in babies are prognostic indicators in these babies17.
Although a majority of the paediatricians (95.8%) had some knowledge of the risk factors for ROP, only 29% of them had good knowledge of the screening guidelines. This may be as a result of only few(2%) of them have managed babies with ROP blindness which may be due to low survival rate of the very preterm babies as a consequence of inadequate neonatal services. This in turn may have contributed to their poor knowledge of available treatment modalities as almost 60% indicated they had no idea, low referral rate for ROP screening (29.2%) and knowledge of available referral centres in Nigeria. Indeed some cited lack of an established protocol as the reason for not referring babies for screening. Generally, the knowledge and practice guidelines among paediatricians in this study is poor in comparison with previous studies10,19,20 due possibly to reasons earlier outlined.
There was no statistically significant difference in the responses concerning knowledge of screening guidelines and screening practice for ROP between the paediatricians and residents (P>0.05). This suggests a low level of emphasis placed on ROP in the training of residents in paediatrics. This has implications in the readiness by paediatricians to address the challenges of ROP that could arise following better neonatal care.
There are currently no established guidelines or screening protocol for ROP in Nigeria. A blind school study performed about two decades ago in Northeastern Nigeria recorded an incidence of 0.5%21. An isolated pilot study carried out in a tertiary health centre in South West Nigeria, also about two decades ago reported an incidence of 5.5% in babies weighing about 1,500g or less than 31 weeks gestational age22. This figure may have been higher if majority of the preterm babies had not died. However, a more recent study performed in South-south Nigeria with improving neonatal care reported an incidence of 47.2% and babies requiring treatment referred to a center about 800 miles away23. This rise in incidence carries the risk of another ‘epidemic’ of the disease if appropriate measures for screening, detection, prompt treatment and prevention are not instituted.
Conclusions
Retinopathy of prematurity is an important and emerging disease in Nigeria. Paediatricians and other caregivers should be educated to improve their awareness of ROP. Its prevalence should be documented, national guidelines for screening and prompt treatment of babies at risk developed, and facilities for screening and treatment made readily available.
Acknowledgment
Special thanks go to Drs Subhadra Jalali, Padmaja Rani Kumari, at the LV Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India for their professional assistance.
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
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