Predictors of mortality in very low birth weight neonates in India

INTRODUCTION: Very low birth weight (VLBW) neonates constitute approximately 4-7 percent of all live births and their mortality is very high. The objective of the present study was to determine the predictors of mortality in VLBW neonates. METHODS: A retrospective cohort of VLBW neonates admitted over three years was studied. Exclusion criteria were: (1) neonates weighing less than 500 g and with gestational age less than 26 weeks; (2) presence of lethal congenital malformations; and (3) death in the delivery room or within 12 hours of life. The outcome measure was in-hospital death. Medical records were reviewed and data was analysed. Univariate analysis and logistic regression analysis were done to determine the predictors of mortality. RESULTS: A total of 260 cases were enrolled, of which a total of 96 (36.9 percent) babies died. The survival rate was found to increase with the increase in birth weight and gestational age. Univariate analysis showed maternal per vaginal bleeding, failure to administer steroid antenatally, Apgar score less than or equal to 5 at one minute, apnoea, gestational age, neonatal septicaemia and shock are the factors directly responsible for neonatal mortality. Logistic regression equation showed maternal bleed (1.326), apnoea (3.159), birth weight (0.037), gestational age (0.063), hypothermia (1.132) and shock (3.49) predicted 65 percent of mortality in VLBW babies. CONCLUSION: Common antenatal and perinatal predictors of mortality in VLBW infants in India include maternal bleed, failure to administer antenatal steroids, low Apgar score, apnoea, extreme prematurity, neonatal septicaemia and shock.     

Outcome of extremely low birthweight infants at the University Hospital of the West Indies, Jamaica

OBJECTIVE: To describe the early outcome of extremely low birthweight infants delivered at the University Hospital of the West Indies. METHODS: A two-year retrospective review of the charts of all live, inborn extremely low birthweight infants admitted to the neonatal unit between January 1, 2002 and December 31, 2003 was conducted Differences between survivors and non-survivors were determined using analysis of variance and predictors of outcome were determined using multiple regression models. RESULTS: During the study period, 47 extremely low birthweight infants were admitted to the neonatal unit. The mean +/- SD birthweight and gestational age of these infants were 780 +/- 137 g and 27 +/- 2 weeks respectively. Twenty (43%) infants survived Babies (19; 58%) of gestational age > or = 27 weeks had increased survival compared to those < 27 weeks, (1; 7%; p = 0.001) and babies weighing > or = 750 g had increased survival (17, 65%) compared to those weighing < 750 g, (3, 14%; p < 0.001). Infants delivered by Caesarean section had improved survival 15 (58%) over those delivered vaginally (5, 24%; p = 0.02). All six (100%) infants whose mothers did not receive prenatal steroids died while 18 (50%) infants whose mothers received prenatal steroids died (p = 0.02). Significant factors associated with outcome were offered and gender was entered into a multiple regression model; gestational age and female gender remained independent predictors of survival. CONCLUSION: Obstetric measures for the prevention of preterm delivery need to be optimized in order to decrease the morbidity and mortality associated with extremely low birthweight infants.     

The urban-remote divide for Indigenous perinatal outcomes

OBJECTIVE: To determine whether remoteness category of residence of Indigenous women affects the perinatal outcomes of their newborn infants. DESIGN AND PARTICIPANTS: A population-based study of 35 240 mothers identified as Indigenous and their 35 658 babies included in the National Perinatal Data Collection in 2001-2004. MAIN OUTCOME MEASURES: Australian Standard Geographical Classification remoteness category, birthweight, Apgar score at 5 minutes, stillbirth, gestational age and a constructed measure of perinatal outcomes of babies called "healthy baby" (live birth, singleton, 37-41 completed weeks' gestation, 2500-4499 g birthweight, and an Apgar score at 5 minutes >or= 7). RESULTS: The proportion of healthy babies in remote, regional and city areas was 74.9%, 77.7% and 77.6%, respectively. After adjusting for age, parity, smoking and diabetes or hypertension, babies born to mothers in remote areas were less likely to satisfy the study criteria of being a healthy baby (adjusted odds ratio [AOR], 0.87; 95% CI, 0.81-0.93) compared with those born in cities. Babies born to mothers living in remote areas had higher odds of being of low birthweight (AOR, 1.09; 95% CI, 1.01-1.19) and being born with an Apgar score < 7 at 5 minutes (AOR, 1.63; 95% CI, 1.39-1.92). CONCLUSIONS: Only three in four babies born to Indigenous mothers fell into the "healthy baby" category, and those born in more remote areas were particularly disadvantaged. These findings demonstrate the continuing need for urgent and concerted action to address the persistent perinatal inequity in the Indigenous population.     

Risk factors associated with chronic lung disease in Malaysian very low birthweight infants

To determine the significant risk factors associated with development of chronic lung disease (CLD) in Malaysian very low birthweight (VLBW, < 1501g) infants. A prospective observational study was carried out at the Sarawak General Hospital (SGH) in Kuching, over a period of 29 months from 1 April 2003 to 31 August 2005. Infants with birthweight between 600g to 1500g admitted to this hospital were recruited. The progress of these infants was followed till discharge. CLD was defined as the persistent need for oxygen therapy to maintain oxygen saturation above 88% at 36 weeks of postmenstrual age. Of the 224 infants recruited, 36 (14.8%) had CLD. Logistic regression analysis showed that lower birth weight (adjusted odds ratio (OR) = 0.996, 95% confidence intervals (CI) = 0.994, 0.998; p = 0.001), male infants (adjusted OR = 3.9, 95% CI = 1.6, 11.7; p = 0.02), chorioamnionitis (adjusted OR = 9.0, 95% CI = 1.6, 50.8; p = 0.01), severe respiratory distress syndrome of grades 3 or 4 (adjusted OR = 4.6, 95% CI =1.6, 13.2; P = 0.005) and patent ductus arteriosus (adjusted OR = 4.3, 95% CI = 1.5, 12.8; p = 0.007) were significant risk factors associated with development of CLD. A number of treatable conditions are associated with development of CLD in Malaysian VLBW infants.     

Very low birthweight and normal birthweight infants. A comparison of continuing morbidity

One hundred and forty-eight (95.5%) of 155 consecutive two-year survivors of 227 very low birthweight (VLBW, less than 1501 g) infants and 50 (83.3%) of 60 infants of normal birthweight who were selected at random, all of whom were born at the Royal Women's Hospital, Melbourne from October 1980 to March 1982, were seen at the age of two years. Social, psychological and health data were compared between the groups. The mean Bayley Mental Developmental Index scores of VLBW children were significantly lower; the prevalence of major handicaps and poor growth (height and weight below the 10th percentile), and the number of hospital readmissions, wheezing episodes, major and minor congenital anomalies and postnatally-acquired malformations (for example, abnormally shaped skull) were significantly greater in VLBW children. There was a trend for a greater number of episodes of otitis media, lower respiratory tract infections and surgical procedures per child in VLBW children. Extremely low birthweight children (birthweight less than 1000 g) contributed significantly to this morbidity. Parents of VLBW children perceived significantly more problems with infant vomiting and behavioural disturbances at two years of age. The children of mothers of limited education, or immigrant status and non-fee paying or lower socioeconomic families had lower mean Bayley Mental Developmental Index scores but similar handicap rates and health status in both weight cohorts.     

Maternal psychological distress and parenting stress after the birth of a very low-birth-weight infant

CONTEXT: Few studies document how parents adapt to the experience of a very low-birth-weight (VLBW; <1500 g) birth despite societal concerns about the ethics and justification of intensive care for these infants. OBJECTIVE: To determine the degree and type of stress experienced over time by mothers whose infants vary in degree of prematurity and medical and developmental risk. DESIGN: Longitudinal prospective follow-up study of a cohort of mothers of high- and low-risk VLBW and term infants from birth to 3 years. SETTING: All level III neonatal intensive care units from a large midwestern metropolitan region. PARTICIPANTS: Mothers and infants prospectively and consecutively enrolled in a longitudinal study between 1989 and 1991. High-risk VLBW infants were diagnosed as having bronchopulmonary dysplasia, and comparison groups were low-risk VLBW infants without bronchopulmonary dysplasia and term infants (>36 weeks, >2500 g). MAIN OUTCOME MEASURES: Standardized, normative self-report measures of maternal psychological distress, parenting stress, family impact, and life stressors. RESULTS: Mothers of VLBW infants (high risk, n = 122; low risk, n = 84) had more psychological distress than mothers of term infants (n=123) at 1 month (13% vs 1%; P = .003). At 2 years, mothers of low-risk VLBW infants did not differ from term mothers, while mothers of high-risk infants continued to report psychological distress. By 3 years, mothers of high-risk VLBW children did not differ from mothers of term children in distress symptoms, while parenting stress remained greater. Severity of maternal depression was related to lower child developmental outcomes in both VLBW groups. CONCLUSIONS: The impact of VLBW birth varies with child medical risk status, age, and developmental outcome. Follow-up programs should incorporate psychological screening and support services for mothers of VLBW infants in the immediate postnatal period, with monitoring of mothers of high-risk VLBW infants.     

Survival of low-birthweight infants in a Queensland provincial centre

Survival figures over a five-year period of low-birthweight infants (2000 g or less at birth) in two intensive care nurseries in Rockhampton , Queensland, are presented. The units were level 2 nurseries with some level 3 amenities . All live-born infants born in Rockhampton and infants retrieved from outlying areas were included in the study. The survival rate was nil for infants of less than 501 g at birth, 40% for those weighing between 500 and 751 g, 45% for those weighing 750 to 1001 g, 85% for those weighing 1001 to 1501 g and 91% for those weighing 1500 to 2001 g at birth. These results compare favourably with those for some level 3 intensive-care units.     

Neonatal sepsis in very low birthweight infants at the University Hospital of the West indies

A retrospective review was conducted on the charts of all very low birthweight (VLBW) infants with culture proven sepsis admitted to the neonatal unit of the University Hospital of the West Indies (UHWI) during the period January 1, 1995 to December 31, 2000. During the study period, 22 VLBW infants were admitted to the neonatal unit with culture proven sepsis, 16 (73%) survived and 6 (27%) died As birthweight and gestational age increased, outcome improved There was no difference in survival based on age at presentation. Neonates with early onset disease had a significantly longer mean duration of rupture of membranes than those with late onset disease (p = 0.009) and babies with late onset disease had a significantly lower mean Hb level than those with early onset disease (p = 0.000). Predominant isolates were Klebsiella sp (10, 37%), Streptococcus Group D (4, 15%), Escherichia coli (3, 11%) and Group B Streptococcus (3, 11%). Klebsiella sp accounted for 8/13 (62%) of late onset infections. Complications included anaemia, thrombocytopenia, bleeding and multi-organ failure. Strategies aimed at prevention, such as limiting the excessive use of broad-spectrum empiric antibiotics and the periodic review and continuous reinforcement of infection control policies will help decrease the mortality and morbidity associated with nosocomial infection in the VLBW infant.     

Contribution of twin pregnancy to perinatal mortality and fetal growth retardation; reversal of growth retardation after birth.

A survey of factors associated with perinatal mortality in 511 twins and fetal growth retardation and its reversal in 262 twins is presented. The incidence of stillbirth was almost 50% higher in twins than in singletons and the neonatal mortality was six times as high. Eighty percent of the neonatal deaths occurred in infants born prior to or at 30 weeks of gestation; 93% of the deaths were in infants weighing less than 1500 g and 75% occurred within 48 hours of birth. Fetal malnutrition was the main cause of stillbirth, and respiratory distress syndrome and asphyxia neonatorum were the main causes of neonatal death. One quarter of the twins had fetal growth retardation, a prevalence 10 times that in singletons. In almost all, the growth retardation was reversed by high-energy feedings. Although twins represented only 1% of all pregnancies and 2% of live births, they composed 12% of infants with early neonatal death and 17% of growth-retarded infants. A program is suggested for reduction of twin mortality and morbidity.     

Babies born under 1000 g--perinatal outcome.

Improved survival of very pre-term infants is a result of advances in obstetric and neonatal medicine. To provide relevant data for a Northern Ireland population group, we evaluated mortality and morbidity of extremely low birthweight (ELBW; < 1000 g) infants from a tertiary referral neonatal unit. Seventy-seven ELBW infants were admitted on the first day of life during the period April 1990 to April 1992. Mean (SD) gestational age (GA) was 26.2 (2.1) weeks and birthweight (BW) was 781 (132) g. The degree of severity of initial illness was high, with a mean (SD) CRIB (clinical risk index for babies) score of 7.4 (4.2). Fifty (65%) babies survived, being discharged home at a mean (SD) age of 95 (34) days. Survivors were more likely to have received maternal steroid therapy or been born in this hospital. Ten (20%) of the survivors had evidence of severe neonatal brain injury or cranial ultrasonography--Papile grade 3 or 4 intraventricular haemorrhage (IVH) or periventricular leucomalacia (PVL). Survival rate of ELBW infants without severe brain injury was 54% overall; this ranged from 0% in ELBW infants born at 23 weeks GA and 33% at 24 weeks GA to 85% at 27 weeks GA.     

Is sudden infant death syndrome still more common in very low birthweight infants in the 1990s?

OBJECTIVE: To determine the rate of sudden infant death syndrome (SIDS) in very low birthweight children (VLBW) relative to children with low (LBW) and normal birthweights. DESIGN, SETTING AND SUBJECTS: Cohort study of consecutive live births in Victoria, 1993-1997 inclusive. MAIN OUTCOME MEASURES: All sudden unexpected deaths in early childhood over this five-year period; all deaths from SIDS (defined as a sudden unexpected death without a definite pathological explanation); and the proportion of SIDS in live births in three birthweight subgroups (VLBW, 500-1499 g; LBW, 1500-2499 g; and normal birthweight, > 2499 g). RESULTS: There were 316,028 live births (with known birthweight) in Victoria over the five-year period; 224 (0.71 per 1000 live births) died unexpectedly. In 10 of these deaths there was a definite pathological explanation, giving a rate of SIDS of 0.68 per 1000 live births. The rate of SIDS in VLBW children was 2.52 per 1000 live births, lower than the rate reported before the 1990s. The rate of SIDS in VLBW children was not significantly different from the rate in LBW children of 1.98 per 1000 live births (difference per 1000 live births, 0.53; 95% CI, -1.45 to 2.52), but was significantly higher than the rate in normal birthweight children of 0.59 per 1000 live births (difference per 1000 live births, 1.93; 95% CI, 0.06-3.79). CONCLUSIONS: The rate of SIDS in VLBW children has fallen in the 1990s, along with the overall fall in the rate of SIDS, but remains higher than that in normal birthweight children.     

Neonatal intensive care and cost effectiveness.

During the past decade the rate of death among newborns weighing less than 1500 g at birth has decreased by approximately half. This dramatic reduction has resulted from the application of research findings and technologic advances, but it has proved expensive. Perhaps as a consequence of articles demonstrating the costs as well as the recognition that the overall prevalence of disabilities in infants is relatively unchanged, neonatal intensive care has recently been viewed as a possible area for cost containment. We reviewed the literature on the cost of neonatal intensive care and the limited information on other expensive medical programs and found that the cost of neonatal intensive care compared favourably, especially for infants whose birth weight was 1000 to 1500 g. Better information on the outcome of infants of very low birth weight and comparable rigorous studies of the cost effectiveness of other expensive medical programs are required, and other less easily quantified factors must be considered before decisions are made to limit neonatal intensive care on the basis of gestational age or birth weight.     

Immunization levels among premature and low-birth-weight infants and risk factors for delayed up-to-date immunization status. Centers for Disease Control and Prevention Vaccine Safety Datalink Group.

CONTEXT: Studies have noted that health care professionals may not conform to proper immunization schedules for premature and low-birth-weight infants in the United States. Little is known about the success of current efforts to immunize these high-risk infants. OBJECTIVE: To describe current immunization practices for premature and low-birth-weight infants and ascertain risk factors for poor immunization status, using large population-based data sources. DESIGN AND SETTING: Cohort and case-control analyses of immunization data tracked from March 1991 through March 1997 for 3 large health maintenance organizations (HMOs) participating in the Centers for Disease Control and Prevention's Vaccine Safety Datalink project. PARTICIPANTS: A total of 11580 low-birth-weight and premature infants were enrolled from birth to age 2 months; 6832 of these were continuously enrolled from birth to age 24 months. At age 2 months, there were 173373 full-term, normal-birth-weight infants enrolled as controls; at age 24 months, there were 103 324. MAIN OUTCOME MEASURES: Age-specific immunization status by prematurity and birth weight (<1500 g, 1500-2500 g, born at <38 weeks' gestation with birth weight of >2500 g, or full-term with normal birth weight) and patient characteristics associated with up-to-date status. RESULTS: At each age, infants weighing less than 1500 g at birth had lower up-to-date immunization levels than other infants. At age 6 months, 52% to 65% of infants weighing less than 1500 g were up-to-date at each of the 3 HMOs compared with 69% to 73% of those weighing 1500 to 2500 g, 66% to 80% of premature infants weighing more than 2500 g, and 65% to 76% of full-term, normal-birth-weight infants. By age 24 months, 78% to 86% of infants weighing less than 1500 g were up-to-date, significantly less than heavier infants, who had levels of 84% to 89%. Well-child preventive care strongly predicted immunization status, while concomitant pulmonary disease did not. CONCLUSIONS: Our data suggest that infants born prematurely are vaccinated at levels approaching that of the general population, but levels of vaccination for very low-birth-weight infants lag slightly behind.     

Outcome of term breech presentation

Three hundred and ninety five cases of breech presentation at Harare Maternity Hospital, Harare revealed that caesarean section either electively or in labour resulted in good fetal outcome. Vaginal breech delivery was associated with a perinatal mortality of 74 per 1,000. Fifty four (25%) out of 216 infants delivered vaginally required admission to the Neonatal Unit and thirteen of these had a five minute Apgar Score of 5 or less. Various reasons for this unacceptably high morbidity and mortality are discussed in order to develop a protocol for management of breech presentation in a developing country. The protocol includes the advocation of external cephalic version.     

75例极低出生体重儿甲状腺激素检测及其临床意义

目的：探讨极低出生体重儿甲状腺激素的变化和临床意义。方法：选择2009年11月到2010年12月问入住本院新生儿重症监护室病区,共75例极低出生体重儿,按出生体重分为500—1000g、1001—1500g两组,对照组30例为健康足月新生儿。生后3～7天测定血甲状腺激素FT3、FT4、TSH水平,异常者7～10d后复查,记录典型甲状腺功能低下临床表现发生率。对连续2次FT3、FT4低下者予以小剂量口服左甲状腺素。结果：体重500—1000g组、1001—1500g组的FT3、FT4水平低于对照组,体重越低者FT3、FT4水平越低。3组间TSH水平无统计学差异;甲状腺素水平异常波动比例达65／75（86．7％）,但临床表现不典型;以单纯FT3降低、FT3和FT4均降低、单纯嘎降低为3种主要表现类型。64．6％（42／65）异常者2次复查恢复正常水平,接受甲状腺激素治疗者仅32．3％（21／65）。结论：极低出生体重儿易出现暂时性甲状腺激素水平异常,多数可自行恢复,少数异常者需小剂量甲状腺素治疗。     

The impact of the establishment of a neonatal intensive care unit on the outcome of very low birthweight infants at the University Hospital of the West Indies

A retrospective analysis of the outcome of inborn very low birthweight infants admitted to the neonatal unit of the University Hospital of the West Indies pre- (period 1) and post- (period 2) establishment of a neonatal intensive care unit was conducted. During the study, 250 infants were admitted to the neonatal unit, 132 (53%) during period 1 and 118 (47%) during period 2. There was improved survival during period 2 when 81 (69%) infants survived compared to period 1 when 73 (55%) survived (p = 0.02). This increased survival was due to an increase in survival of infants weighing 750-999g in period 2 when 17 (65%) infants survived compared to 9 (29%) in period 1 (p < 0.05). There was an increase in the number of infants ventilated in period 2, 39 (33%) compared to 12 (9%) period 1 (p < 0.001). Infants who were ventilated in period 2 were less likely to die than those ventilated in period 1 (OR 0.05, CI 0.01, 0.66). After controlling for gender, weight, gestational age and ventilation, infants born in the second time period were less likely to die than those born in the first time period (OR 0.33, CI 0.14, 0.76). The establishment of a neonatal intensive care unit has resulted in improved survival of very low birthweight infants; further improvement in survival of these infants will be dependent on increased accessibility to surfactant therapy, initiation of total parenteral nutrition and availability of trained personnel.     

小于胎龄极低出生体质量儿晚发型败血症危险因素分析

目的 探讨新生儿重症监护室小于胎龄极低出生体质量儿(VLBWI)晚发型败血症的危险因素。方法 回顾性分析安徽医科大学第一附属医院新生儿重症监护室2009年1月至2014年12月收治的胎龄<34周、出生体质量<1500 g、住院时间>7 d VLBWI的相关临床资料,分析其中小于胎龄VLBWI晚发型败血症临床特点、实验室结果、危险因素及预后等。结果 296例纳入本研究的VLBWI中,小于胎龄儿组165例,其中发生晚发型败血症者56例,经单因素分析结果显示,小于胎龄VLBWI晚发型败血症危险因素包括极早产(胎龄<32 周)、超低出生体质量(出生体重<1000 g)、胎膜早破>18 h、预防应用抗菌药物>7 d、经外周中心静脉插管>7 d、经鼻持续气道正压通气、机械通气、留置胃管>7 d、静脉营养时间及住院时间长等。有统计学意义的变量进入logistic多元回归分析显示,其独立危险因素为留置胃管>7 d和胎膜早破>18 h。结论 在VLBWI中小于胎龄儿更易发生晚发型败血症,今后临床工作中应对这一特殊群体采取个性化预防措施,凡胎膜早破>18 h者需动态连续监测血象指标,尽早开始经口肠道微量喂养,缩短留置胃管时间。     

Postponing or preventing deaths? Trends in infant survival, Georgia, 1974 through 1981

Trends in survival were examined for infants in five birth-weight groups (500 to 999 g, 1,000 to 1,499 g, 1,500 to 1,999 g, 2,000 to 2,499 g, and greater than or equal to 2,500 g). The study population consisted of infants born in Georgia from 1974 through 1981. Survival to the first birthday increased for all birthweight groups. Improvements in postneonatal survival occurred concurrently with improvements in neonatal survival, except for infants with birth weights of 500 to 999 g. Between 1974-1975 and 1980-1981, the proportion of deaths that were attributed to perinatal conditions but occurred during the postneonatal period increased from 1.1% to 4.7%. These observations suggest that advances in perinatal care have led to postponement rather than prevention of a few infant deaths, although overall many more deaths were prevented. For infants with birth weights of less than 1,500 g, lower mortality among those admitted to newborn intensive care units was the major contributor to improved survival. Our findings indicate that both neonatal and postneonatal mortality should be examined in evaluating the effects of perinatal care.     

Perinatal and infant mortality

Australia's infant mortality rate fell below 10/1000 live births for the 1st time in 1983 (9.6/1000). Internationally, Australia ranks 12th in infant mortality among countries with populations over 2.5 million. Contributing to this relatively poor international standing has been the high incidence of low birthweight infants, high postneonatal mortality in disadvantaged population groups such as the Aborigines, and the completeness of registration of infant mortality in Australia. There is a legal requirement that perinatal deaths from at least 20 weeks gestation or 400 gm birthweight be registered. In 1983, the national perinatal mortality rate was 12.2/1000 births. The greatest reduction in neonatal mortality has been among infants weighing 1000-2499 gms. Most of the recent improvement in the low birthweight component of the neonatal death rate is attributable to the better survival of these infants, not a major reduction in the incidence of low birthweight. Several proposals are made for improving the data on perinatal and infant mortality in Australia. These deaths should be routinely linked to the maternal and fetal or neonatal data in the perinatal morbidity data collections to facilitate identification of risk factors. Also, pregnancies terminated after diagnosis of fetal abnormalities should be included in these perinatal data collections. Steps such as educating the community about the adverse effects of alcohol and smoking in pregnancy, increased planning of pregnancy, better detection of high risk pregnancies, and regionalization of the care of pregnant women at high risk of complications could contribute to further reductions in infant and perinatal mortality in Australia.