The clinical risk index of babies (CRIB) score in India

Objective : To assess the usefulness of clinical risk index of babies (CRIB score) in predicting neonatal mortality in extremely preterm neonates, compared to birth weight and gestation.Methods : 97 preterm neonates with gestational age less than 31 weeks or birth weight less than or equal to 1500 g were enrolled for the prospective longitudinal study. Relevant neonatal data was recorded. Blood gas analysis results and the maximum and the minimum FiO₂ required by babies in first 12 hours of life were noted. Mortality was taken as death while the baby was in nursery. The prediction of mortality by birth weight, gestational age and CRIB score was done using the Logistic model, and expressed as area under the ROC curve.Results : The area under the ROC curve for birth weight, gestational age and CRIB score was almost the same, the areas being 0.829, 0.819 and 0.823 respectively. Hence CRIB score did not fare better than birth weight and gestational age in predicting neonatal mortality.Conclusion : The CRIB score did not improve on the ability of birth weight and gestational age to predict neonatal mortality in the study.     

需要机械通气的极低出生体重儿院内病死率及病死风险因素的前瞻性研究

目的：描述危重极低出生体重儿（VLBWI）的临床特征、接受治疗状况及其转归,评估其病死风险相关因素,评价CRIB、SNAPPE-II评分系统预测我国早产儿病死风险的价值。方法：对2010年1月至2011年10月间新生儿重症监护室（NICU）收治的127例需要机械通气的VLBWI进行前瞻性数据收集。结果：纳入患儿平均胎龄为31±2 周,平均体重为1290±170 g,男女比例为1.23∶1,超低出生体重儿占6.3%。接受肺表面活性剂（PS）治疗者占 48.0%;接受气管插管机械通气的患儿占49.6%。总的院内病死率为41.7%。低出生体重、多胎分娩、剖宫产、低PaO2/FiO2比值是病死的独立风险因素,OR值分别为1.611、7.572、4.062、0.133,P<0.05。SNAPPE-II和CRIB评分系统可较好地预测病死转归,ROC曲线下面积分别为0.806、0.777。结论：VLBWI总的病死率仍处于较高水平;低出生体重、多胎分娩、剖宫产、低PaO2/FiO2比值是VLBWI病死的高危因素。应用新生儿危重评分系统可对研究对象疾病危重程度进行量化。     

Assessing mortality risk in very low birthweight infants: a comparison of CRIB, CRIB-II, and SNAPPE-II

BACKGROUND: Illness severity scores are increasingly used for risk adjustment in clinical research and quality assessment. Recently, a simplified version of the score for neonatal acute physiology (SNAPPE-II) and a revised clinical risk index for babies (CRIB-II) score have been published. AIM: To compare the discriminatory ability and goodness of fit of CRIB, CRIB-II, and SNAPPE-II in a cohort of neonates < 1500 g birth weight (VLBWI). METHODS: Data from 720 VLBWI, admitted to 12 neonatal units in Lombardy (Northern Italy) participating in a regional network, were analysed. The discriminatory ability of the scores was assessed measuring the area under the receiver operating characteristic curve (AUC). Outcome measure was in-hospital death. RESULTS: CRIB and CRIB-II showed greater discrimination than SNAPPE-II (AUC 0.90 and 0.91 v 0.84, p < 0.0004), partly because of the poor quality of some of the data required for the SNAPPE-II calculation-for example, urine output-but also because of the relative weight given to some items. In addition to each score, several variables significantly influenced survival in logistic regression models. Antenatal steroid prophylaxis, singleton birth, absence of congenital anomalies, and gestational age were independent predictors of survival for all scores, in addition to caesarean section and not being small for gestation (for SNAPPE-II) and a five minute Apgar score of > or = 7 (for SNAPPE-II and CRIB). CONCLUSIONS: CRIB and CRIB-II had greater discriminatory ability than SNAPPE-II. Risk adjustment using all scores is imperfect, and other perinatal factors significantly influence VLBWI survival. CRIB-II seems to be less confounded by these factors.     

Validation of CRIB II for prediction of mortality in premature babies

Objective  

Validation of Clinical Risk Index for Babies (CRIB II) score in predicting the neonatal mortality in preterm neonates ≤32 weeks gestational age.     

新生儿危重病例评分与临床危险指数评分预测极低出生体重儿死亡风险的比较

目的探讨新生儿危重病例评分(NCIS)与新生儿临床危险指数(CRIB)评分对极低出生体重儿死亡风险评估的价值。方法对93例早产儿按不同胎龄、体重分组进行NCIS,其中42例胎龄<31周或出生体重<1.5kg者再进行CRIB评分,将两种评分结果进行比较。结果①胎龄越小、体重越轻,疾病危重评分分值越低,胎龄<31周或出生体重<1.5kg者明显低于≥31周或出生体重≥1.5kg者,其差异有显著性(P均<0.05雪;②死亡病例NCIS明显低于非死亡病例,CRIB评分明显高于非死亡病例,差异有显著性(P均<0.05雪;③NCIS与新生儿CRIB评分两者间呈负相关,r=-0.383,P<0.01。结论NCIS与CRIB评分均可较好地判断极低出生体重儿的疾病危重度,预测死亡风险,且两者相关性好。     

新生儿临床风险指数在早产低出生体重儿中的应用

新生儿临床风险指数（ clinical risk index for babies,CRIB ）是一种应用于早产低出生体重儿评估最初疾病严重程度,预测死亡风险率,评估各医疗机构的自身医疗质量,以及对各医疗机构之间进行客观医疗水平比较的评分系统,对我国日益发展的新生儿医学起着重要的作用。本文详细介绍了CRIB评分系统的来源及发展现状、具体评分细则以及CRIB的优点,对早产低出生体重儿死亡风险预测的准确性,并分析了其应用于预测早产低出生体重儿远期神经系统发育的价值。     

Early outcome of preterm infants with birth weight of 1500 g or less and gestational age of 30 weeks or less in Isfahan city,Iran

Background  

The outcome of preterm neonates has been varied in different hospitals and regions in developing countries. This study aimed to determine the mortality, morbidity and survival of neonates weighing 1500 g or less and with gestational age of 30 weeks or less who were admitted to referral neonatal intensive care units (NICUs) of two hospitals in Isfahan city, Iran and to investigate the effect of birth weight, gestational age and Apgar score on infant mortality.     

Role of score for neonatal acute physiology (SNAP) in predicting neonatal mortality

Objectives: To assess the validity of SNAP in predicting the outcome in terms of mortality and duration of hospital stay. The study was also undertaken to evolve the best cut-off SNAP scores for predicting mortality in different individual neonatal conditions.Methods: 295 consecutive newborn admitted to NICU during an eleven month period were evaluated with the investigations required as per the specifications of SNAP. Neonates who succumbed within 24 hours of admission and those who were shifted to the NICU for observation purposes were excluded.Results: In general, SNAP correlated well with mortality; the sensitivity and specificity of SNAP score >15 in predicting mortality were 63% and 95% respectively. The positive and negative predictive values were 72% and 92.5% respectively. Very low birth weight babies and ventilated preterm neonates had higher mortality and the best cut-off SNAP score for predicting mortality in these groups was 10. In all the other groups, SNAP score >15 correlated well with higher mortality. By using multiple regression analysis on three variables including birth weight, gestational age and SNAP, SNAP was found to show the best correlation with mortality. On correlating SNAP with duration of hospital stay, 76.8% of the surviving neonates with SNAP <16 stayed for <15 days, whereas the rest stayed longer despite low SNAP. All the 9 babies with SNAP >15 who survived stayed for >15 days.Conclusions: SNAP is a measure of illness severity and correlates well with neonatal mortality. SNAP may assist the clinician in explaining the probable outcome and therapeutic intervention needed and the cost of treatment to the parents. SNAP scores >10 in VLBW babies and >15 in others are associated with higher mortality.     

Use of the CRIB (clinical risk index for babies) score in prediction of neonatal mortality and morbidity.

A prospective study of the outcome of care of a regional cohort of very low birthweight (< 1500 g) and very preterm (< 32 weeks) infants was carried out. Its aims were to assess the ability of the CRIB (clinical risk index for babies) score, rather than gestational age or birthweight, to predict mortality before hospital discharge, neurological morbidity, and length of stay, and to access CRIB score as an indicator of neonatal intensive care performance. 676 live births fulfilled the criteria and complete data were available for 643 (95%). Compared with gestation and birthweight, CRIB was better for the prediction of mortality, was as good for the prediction of morbidity, and was not as good for the prediction of length of stay. CRIB adjusted mortality did not demonstrate better performance in units providing the highest level of care. Either the CRIB score was not sensitive to performance or the level 3 hospitals in this study were performing badly. On the basis of this analysis purchasers and providers of neonatal intensive care cannot yet rely on the CRIB score as a performance indicator.     

CRIB,CRIB‐II,birth weight or gestational age to assess mortality risk in very low birth weight infants?

AIM: The mortality risk of very low birth weight (VLBW) (<1500 g) infants has been estimated by the Clinical Risk Index for Babies (CRIB). Superior discriminatory power has been claimed for the revised CRIB-II score based on birth weight, gestational age, sex, temperature and base excess (BE) at admission. This analysis compared the power of CRIB, CRIB-II, birth weight and gestational age to predict death prior to discharge. METHODS: Of 1485 consecutive VLBW infants admitted between January 1, 1991 and December 31, 2006, who survived for >or=12 h, CRIB and CRIB-II calculations were possible in 1358 infants (92%). Predictive power of variables was assessed by comparing areas under receiver operator characteristics curves (AUC). RESULTS: CRIB (AUC [95% confidence intervals] 0.82 [0.78-0.86]) performed significantly better than birth weight (0.74 [0.69-0.79]) or gestational age (0.71 [0.66-0.76]), while CRIB-II (0.69 [0.64-0.74]) was rather inferior to CRIB and did not differ significantly from birth weight or gestational age. No substantial changes were seen when substituting worst BE during the first 12 h of life for BE at admission when calculating CRIB-II. CONCLUSIONS: CRIB-II does not result in improved estimation of mortality risk in VLBW infants as compared to CRIB, birth weight or gestational age.     

Can severity‐of‐illness indices for neonatal intensive care predict outcome at 4 years of age?

Aim: To test four neonatal severity-of-illness indices (CRIB, NTISS, SNAP, SNAP-PE) for their ability to predict short- and long-term outcome in very low-birthweight infants receiving neonatal intensive care.

Methods: Data on 240 newborns with birthweights below 1500 g from two Swedish neonatal units were collected. The predictive values of the indices for an adverse outcome in the neonatal period and at 4 y of age were compared with those of gestational age and birthweight.

Results: An early adverse outcome (in-hospital death, severe haemorrhagic-ischaemic brain lesion, retinopathy, chronic lung disease) was better predicted with CRIB (area under ROC curve (Az) = 0.87) and SNAP-PE (Az = 0.86), while SNAP-PE was best for predicting late problems (deviations in growth and psychomotor development, neurosensory impairment, difficulties in concentration, and impairment in vision, and hearing,) (Az = 0.63). All indices predicted the early outcome better than the outcome at the 4-y follow-up. Severity-of-illness indices can be used as instruments to follow and improve the level of neonatal intensive care, but unfortunately seem to be of little value in long-term follow-up.

Conclusion: CRIB and SNAP-PE indices are better in predicting hospital mortality than birthweight. None of the systems can predict adverse outcome at 4 y of age.     

伊朗伊斯法罕新生儿重症监护中心新生儿气胸的发病因素、发生率和死亡率调查

目的：该研究旨在调查伊朗伊斯法罕新生儿重症监护中心(NICU) 住院新生儿气胸的发病因素、发生率和死亡率。方法：738 例入住NICU的新生儿中,43例发生了气胸。回顾性分析气胸患儿的临床资料,包括胎龄、出生体重、Apgar评分、出生方式、母亲年龄、产次、围产期窒息、出生时复苏、气胸发生部位、机械通气情况、肺表面活性物质治疗、肺部疾病等。结果：气胸患儿平均胎龄为31周,出生体重为1 596 g。12例（28%）患儿胎龄小于28周。28例（65%）出生体重低于1 500 g。共43 例(5.8%)新生儿发生了气胸。97%的气胸为单侧（n=63),双侧气胸仅占3%（n=2）。呼吸窘迫综合征(40/43, 93%)和机械通气(37/43, 86%)是导致气胸发生的常见原因。共28例(65%)患儿死亡。死亡患儿与幸存患儿出生体重、胎龄及胸管留置时间差异有统计学意义。需要肺表面活性物质治疗的气胸患儿死亡率显著增加,与无需表面活性物质治疗的气胸患儿比较差异有统计学意义。结论：该研究中气胸的发生率与死亡率高于其他报道,其原因可能是该研究中新生儿出生体重和胎龄都较低。呼吸窘迫综合征和机械通气是导致新生儿气胸发生的常见原因。患儿胎龄越小,体重越低,肺部疾病越严重,死亡率则越高。     

Lessons from improved neonatal survival at Chandigarh

We observed a significant fall in neonatal mortality in babies weighing less than 2 kg during 1986 as compared to 1973 (7.94% vs 12.88%; p less than 0.005), and in preterm babies the mortality fell from 26.88 to 11.5% (p less than 0.001) during 1986. This was achieved despite 2-3 fold increase in the high risk babies and without any increase in the number of neonatal special care beds or nurses. Effective utilisation of the facilities was made possible through: (a) reduction in admissions to neonatal special care unit of babies with birth weight more than 1500 g; (b) early discharge of babies to home from NSCU; (c) involvement of the mothers in the care of their high risk babies: and (d) care of babies with sucking difficulties and asymptomatic birth asphyxia outside NSCU. All babies discharged home at less than 2 kg weight, and living in Chandigarh were followed for 3 months and 98.2% were doing well. This observation highlights the judicious use of neonatal special care facilities and mothers for the care of high risk neonates.     

Early predictors of mortality in very low birth weight neonates.

OBJECTIVE: To evaluate early predictors of mortality in very low birth weight neonates. SETTING: Teaching hospital. DESIGN: Case control study. METHODS: Hospital born very low birth weight newborns (500-1500 g) enrolled for study and followed up till death or 28 days. Infants' birth data and data on physiologic alterations, investigation and interventions in the first 24 hours of life and CRIB score were analyzed for their ability to predict neonatal mortality. RESULTS: 115 subjects were enrolled into the study of which 47 died in the neonatal period. The factors significantly associated with early neonatal mortality included birth weight, gestation, low Apgar scores, need for assisted ventilation at birth, need for supplemental oxygen and mechanical ventilation in the first 24 hours, presence of shock, hypoxia and acidosis (p < 0.05). The factors associated with late neonatal mortality were birth weight and gestation only. Multivariate analysis of these factors showed that besides low birth weight, shock, need for mechanical ventilation, acidosis and high alveolar-arterial oxygen gradients were significant predictors of neonatal mortality. When compared with the CRIB score, birth weight <1200g proved to be an equally good predictor of mortality risk. CONCLUSION: VLBW neonates with disturbed cardio-pulmonary physiology during the first 24 hours of life, especially those in need of mechanical ventilation, are at an increased risk of early neonatal mortality.     

Measuring New Born Foot Length to Identify Small Babies in Need of Extra Care: a Cross-Sectional Hospital Based Study

Objective

The neonatal mortality rate (NMR) continues to remain quite high, one important cause being preterm deliveries. The main obstacle in the pathway towards decreasing NMR is identification of babies in need of extra care. To analyze the utility of newborn foot length as a proxy measure for birth weight and gestational age.

Methods

A cross-sectional study done in a hospital of eastern India with 351 babies during 4 months. Right foot length of each recorded using a plastic, stiff ruler.

Findings

48.1% babies were preterm, 51.8% low birth weight (LBW) and 33.3% very low birth weight (VLBW). Foot length less than 7.75 cm has 92.3% sensitivity and 86.3% specificity for identification of preterm neonates. For identification of LBW babies (<2500 gm) a foot length less than 7.85cm has 100% sensitivity and 95.3% specificity. Foot length less than 6.85 cm has 100% sensitivity and 94.9% specifity for identification of VLBW babies (<1500 gm).

Conclusion

Foot length may be used in the identification of LBW and preterm babies who are in need of extra care.     

Early neonatal mortality in Caxias do Sul: a cohort study

OBJECTIVES: To establish the profile of neonates in Caxias do Sul city, and to study early neonatal mortality, its causes and related variables.METHODS: This cohort study enrolled 5,545 newborns, which were followed up to 7 days after birth. The probability of early neonatal mortality was calculated and multiple logistic regression was performed to relate all studied variables to the outcome of early neonatal death.RESULTS: The observed probability of early neonatal mortality was 7.44 per thousand live births. The incidence of premature births and low birth weight was 9.4% and 8.1%, respectively. Fifty five percent of the neonates were born through cesarean section, which were related to socioeconomic and educational level. Previous history of neonatal mortality, maternal age > 35 years, gestational age, Apgar score < 7, male sex and low birth weight were related to early neonatal death. The main cause of death was hyaline membrane disease, followed by congenital cardiopaties, extreme preterm and abruptio placentae.CONCLUSION: Even though the observed probability of early neonatal mortality was low, some deaths may have been avoided if better prenatal and delivery care, as well as newborn assistance had been offered.     

Gestational age assessment in preterm neonates weighing less than 1500 grams

Postnatal assessment of gestational age in preterm neonates traditionally has been performed using the methods of Dubowitz and Ballard. This study was designed to determine the accuracy of these methods in a sample of very low birth weight preterm neonates. Dubowitz and Ballard examinations were done on 110 preterm neonates within the first 72 hours of life by a neonatologist masked to the gestational age assessed antenatally. Mean birth weight was 1066 +/- 256 g (SD). These data were compared with gestational age assessments using last menstrual period and best obstetric estimate calculated by an obstetrician unaware of the neonatal examination. Mean gestational age using last menstrual period was 28.3 +/- 2.9 weeks. Mean differences between last menstrual period and Dubowitz/Ballard were -2.8 +/- 2.1 weeks and -2.6 +/- 2.2 weeks, respectively. Results using best obstetric estimate were similar. An ophthalmologist examined lens vessels of 89 neonates. A similar pattern toward overestimation of gestational age interval by Dubowitz/Ballard was seen at each lens vessel grade. The Dubowitz and Ballard examinations are inaccurate methods of assessing gestational age in preterm neonates with birth weights less than 1500 g.     

The use of CRIB (clinical risk index for babies) score in auditing the performance of one neonatal intensive care unit

The CRIB (clinical risk index of babies) score was developed to overcome the disadvantages of birthweight-specific comparisons between neonatal units. The aims of this study were to assess the ability of CRIB score compared to birthweight and gestational age to predict hospital mortality in very low birthweight infants and to use CRIB score in auditing one unit's performance during a prolonged time period. The charts of 335 infants with birthweight ≤ 1500 g born between 1980 and 1995 were reviewed retrospectively. CRIB predicted hospital mortality significantly better than birthweight and gestation and performed equally well, whether the infants were treated with synthetic surfactant or not. When adjusting for CRIB score there was a significant improvement in the unit's performance, probably owing to the introduction of surfactant. As small samples tend to be associated with wide confidence intervals, use of CRIB is recommended in comparing risk adjusted mortality in a single unit over several years, as in this study, or between large groups of neonatal units over shorter periods.     

An illness severity score and neonatal mortality in retrieved neonates

The Clinical Risk Index for Babies (CRIB) score is a simple tool to measure clinical risk and illness severity in very low birth weight infants. The aim of this study was to determine if a modified CRIB score (MCRIB) used at first telephone contact with a transport service differentiated between retrieved infants who did or did not die in the neonatal period and hence might be a useful triage tool. A retrospective cohort study of 2504 infants, median gestational age 36 weeks and birth weight 2782 g, transported by the New South Wales Newborn and Paediatric Emergency Transport Service (NETS) was performed. MCRIB was calculated at four time points during the retrieval process. The MCRIB score at the time of the first call and the change in the MCRIB score over the retrieval process were related to outcome (neonatal death or survival). The mean MCRIB score at the time of first call was higher in those infants who died during the neonatal period (4.37) than in those who survived (2.63), (P<0.0001). MCRIB performed better (area under the receiver operator characteristic curves of 0.72) with regard to predicting mortality than gestational age (0.56) or birth weight (0.52). The mean MCRIB score fell progressively from the time of first call to admission at the accepting NICU (P<0.0001); infants whose MCRIB score increased were more likely to die (P<0.0001). Conclusion: these results suggest an illness severity score, applied at the time of first call to a transport service would be helpful in setting priorities for retrievals.Abbreviations CRIB Clinical Risk Index for Babies - MCRIB Modified Clinical Risk Index for Babies - NETS New South Wales Newborn and Paediatric Emergency Transfer Service - NICUS Neonatal Intensive Care Unit Study - ROC receiver operator characteristic - SNAP Score for Acute Neonatal Physiology - VLBW very low birth weight     

Low Apgar score and mortality in extremely preterm neonates born in the United States

Aim: To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates. Methods: Infant birth and death certificate data from the US National Center for Health Statistics for 2001–2002 were analysed. Primary outcome was 28‐day mortality for 690 933 neonates at gestational ages 24–36 weeks. Mortality rates were calculated for each combination of gestational age and 5‐min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age. Results: Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30–36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0–3 vs. 7–10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks. Conclusion: Low Apgar score was associated with increased mortality in premature neonates, including those at 24–28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.