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Survival Rates And Prevalence Of Morbidities In Very Low Birth Weight Neonates Admitted to Level - II
Special Newborn Care Unit
Dr. Damera Yadaiah,
District Hospital, Nalgonda,
Telangana, India.
METERNAL HEALTH AND NEWBORN SURVIVAL
“The health and wellbeing of the fetus
is dependent upon the health and
nutrition of the mother (not the
father!) because she is both the
seed as well as the soil where in
baby is nurtured for 9 months.”
- Meharban Singh
Mothers are the creators and austainers of progeny
Situation which needs to improve
• 20th Feb 2018, UNICEF report.
• 26 lakh babies die worldwide within 28 days of birth,
i.e. 7000 deaths every day,
6.4 lakh neonatal deaths occur in India.
• 12th worst among the 52 lower middle income countries.
• Birth weight is a significant determinant of newborn survival. LBW is an underlying factor
in 60–80% of all neonatal deaths.
• LBW infants are approximately 20 times more likely to die, compared with heavier babies
(Kramer 1987). One-third of LBW babies die within the first 12 hours after delivery.
Mortality among Very low birth weight infant (VLBW < 1500g) is a major contributor to the
Neonatal Mortality Rate (NMR) in both developing and developed countries.
– The survival rate of VLBW infants in INDIA is about 63%.
Primary Objective
• To evaluate the morbidities and mortality in VLBW
babies admitted to level - II SNCU in a district
hospital.
Inclusion criteria
All infants with birth weight ≤ 1500 gm or weight at admission
≤ 1500 gm
Admitted to the SNCU within the first 24 hours.
• Weight was recorded at admission using an electronic weighing scale with
a precision of 10grams.
• Gestation was estimated from the mothers LMP or from the New Ballard
examination at admission.
• All infants were managed in the SNCU as per the standard protocols.
• All the nurses in the SNCU were trained and were certificated as per the
FBNC module.
• Respiratory distress management was either using oxygen or nasal CPAP.
• Caffeine was used only for infants with apnoea.
• Those requiring ventilation were referred to nearest medical college or to
a private Level III as per the request of the patient.
Methods
• Feeding was either tube or spoon and was with either
mothers own milk or preterm formula.
• Infection control practices were in place and babies were
screened for signs of infections at-least twice a day.
• C-reactive protein,
• Blood counts,
• Micro ESR
• Blood cultures- outsourced ( were done only when screen
was positive or on strong clinical suspicion).
• Lumbar punctures were rarely performed.
Cont…
• For treatment of jaundice no specific charts were used and
jaundice was treated with phototherapy and exchange if
TSB > 1% of the birth weight.
• Mothers were encouraged to participate in baby care and
in skin to skin contact. KMC was practiced for all infants
when they were stable and were on spoon feeds.
• Bedside KMC was done for babies with O2 dependency.
• The infants were discharged home if they are accepting
spoon feeds or direct breast feeds, breathing in room air,
gaining weight consecutively for 3 days and mother was
confident in taking care of the newborn.
Cont…
• Standard definitions were used for most neonatal morbidities.
• Cranial ultrasound was done for all the babies
• Portable x-ray machine was available in the unit and diagnosis
of RDS was confirmed from the chest x-ray.
• Ultrasound abdomen was rarely done in any of the infants.
• Blood culture, 2D echo, CT and MRI Brain were done as and
when necessary.
Cont…
• The data (DEO) was collected prospectively in a database
(SNCU Software) available in the unit.
• For this study, demographic and neonatal data on mortality
and morbidity was extracted from case files and from SNCU
software.
Cont…
The data extracted included Birth weight, Gestational age estimation, Sex of the newborn, Growth status, Mode of delivery, Antenatal steroid coverage, Need for resuscitation at birth, Congenital anomalies, Respiratory Distress Syndrome, Seizures, Necrotising enterocolitis, Anaemia, Hypoglycaemia, Jaundice, Apnoea, Retinopathy of prematurity and Broncho-pulmonary dysplasia
Statistics
• Data on morbidity and mortality are represented in percentages.
• Sample size: No prior sample size estimation was done for the
study.
Results
• A total of 511 VLBW neonates were admitted during the study
period.
• Median birth weight - 1344 (183) grams
• Mean gestational age - 32.7(1.54) weeks.
Table 1: Outcome in relation to Birth Weight
Outcome
< 1000 gm
1001-1500 gm
Total No.
Survival
36 (72%)
374 (81.1%)
410 (80.2%)
Referral/ LAMA
3 (6%)
12 (2.6%)
15 (2.9%)
Deaths
11 (22%)
75 (16.2%)
86 (16.8%)
Birth or admission weight < 1000 gms - 50.
Mortality -16.8% (86)
Referred to higher centre -15 (2.9%).
Table 2: Age at Mortality
Hospital duration
Survivors, N= 390
Death, N = 86
<1 day
4 (1%)
40 (46.5%)
2-7 days
59 (15.1%)
31 (36%)
>7 days
327 (83.8%)
15 (17.4%)
Forty (46.5%) neonates succumbed to death within 1 day
31 (36%) between 2 to 7 days of life.
Table 3: Morbidities in the VLBW Infants
Morbidities
Total No. of Newborns
Respiratory distress
439 (85.7%)
Screen positive sepsis
399 (78%)
NNJ
277 (54.2%)
Apnoea
154 (30.1%)
The mean duration of hospital stay was 26 days (SD ± 20).
Discussion
• Increasing numbers of very preterm and VLBW infants are surviving because of advances in both perinatal and neonatal care over the past two decades.
• In this study survival to hospital discharge was 80.2%. This is the one of the best survival of VLBW Infants reported from a SNCU(Level - II) in India.
Improved facilities and infrastructure in NICU (NHM Guidelines)
Good nurse to patient ratio (14 nurses employed for 20 SNCU beds)
Availability of Doctors round the clock (at least one Pediatrician available on
each shift)
Good Infection control practices.
Availability of CPAP machine with disposables may also have increased the
survival of babies with respiratory distress and may have been contributed
to decreased referral and death in this study.
Exclusive Breast Feeding or Expressed Breast Milk.
Kangaroo Mother Care.
Rational Use of Antibiotics.
Good Developmental supportive cate
We assume this survival is achieved in our SNCU even in the absence of
facilities for Mechanical Ventilation, ABG, Blood culture, Surfactant or TPN
for the following reasons:
SATISFIES FIVE SENSES
VISION
TASTE
TOUCH
SMELL
EYE TO EYE CONTACT
MOTHER’S HEART SOUNDS
BREAST MILK
SKIN TO SKIN COONTACT
MOTHER’S ODOUR
HEARING
Kangaroo Mother Care
Maturation of oral feeding skills and the choice of initial feeding method in LBW infants
Gestational age
Maturation of feeding skills Initial feeding method
< 28 weeks No proper sucking efforts No propulsive motility in the gut
Intravenous fluids
28 – 31 weeks
Sucking bursts develop No coordination between suck/swallow and breathing
Oro-gastric (or naso-gastric) tube feeding with occasional spoon/paladai feeding
32-34 weeks
Slightly mature sucking pattern Coordination between breathing and swallowing begins
Feeding by spoon/paladai/cup
>34 weeks
Mature sucking pattern More coordination between breathing and swallowing
Breastfeeding
• There are no study done in level - II care non-teaching hospital SNCU and
no studies available to compare morbidities in VLBW neonates separately
in such SNCU.
• The survival to discharge in our study in the SNCU(80.2%) is similar to that
reported from tertiary care neonatal hospital of India.
• The data from this study supports the conceptualization of SNCUs and
universalisation of level - II care at SNCU in a District Hospital.
• Improvement in maintenance and trained manpower in
SCNU further reduces neonatal mortality to single digit and
helps in achieving millennium development goal.
Conclusions
• Survival rate among VLBW neonates in other district hospitals,
SNCUs and Medical colleges varied from 50- 70% (17,19, 32).
• Survival from tertiary care NICUs of country reported survival
of VLBW infants between 80% -90% (15, 16).
• The survival rates and morbidities rates reported in the study
are comparable to many of the tertiary care hospital and the
results shown here will help in conceptualizing the SNCU care.
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