potentially avoidable deaths – what could neonatologists do better ? malcolm battin chair ne...
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Potentially Avoidable Deaths – What Could Neonatologists Do Better ?
Malcolm Battin
Chair NE Working Group
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Neonatologist’s role
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Neonatologist’s role
Might include :
• Clinical Practice • Advocacy• Research or clinical review • Education
• Aim to improve mortality
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Primary Neonatal Death Classification (PSANZ-NDC) 2009
Top 3 causes account for 77 % of neonatal deaths
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NND classification (Page 32)
Extreme prematurity 31.3%
• 1.5 % births < 32 wks GA• 0.4% births 24-27 wks GA
• Lower range GA 20 wks (T. 17) • 114/165 (87%) deaths <24/40 (T. 21)
• 20/165 deaths (12.1%) 24-27/40 (T. 21)• Plus respiratory, neurological, gastro (NEC)
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01020
3040506070
8090
100
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2008
%501-1000 g 1001-1500 g
Survival of NW inborn babies by BW
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01020
3040506070
8090
100
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2008
%501-1000 g 1001-1500 g
Survival of NW inborn babies by BW
Liggins & Howie
1st surfactant report
OSIRIS in NZ HFOV/CPAP/Trigger
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A progressive ceiling on potential developmental outcomes ?
Wolke (Lagercrantz 2008)
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When Does Neonatal Death Occur ? Time of death
0
10
20
30
40
50
60
70
80
90
100
<1 2-7 8-14 15-21 22-28
Days
Perc
en
tag
e
20-23
24-27
>28/40
Data from Table 6
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Prematurity
• Concept of borderline in viability
• Individualised approach < 24 weeks
• Audit of neurodevelopmental outcomes
• Publication of results for scrutiny !
• Spontaneous preterm birth & APH as antecedent causes associated with deprivation
• Prematurity associated neonatal death risk highest in teenage mothers
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Teenage mothers• Half of teenage mothers whose babies died
were Maori • risk increased across ethnicities
• Half of teenage mothers whose babies died in highest deprivation quintile.
• 45 % of teenage mothers whose babies died were smokers
• More contact health system after birth• NICU nurses support
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Maternal age (Figure 18)
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Canadian studies what people know about risk associated with maternal age
• 1,044 women, after first live-born, aware link with conception difficulties – 85.%
• * Multiple birth 24%, c.section 18.8%, preterm delivery 22% and LBW 11%
• Further survey 20-45 yrs without children• > 70% recognized link to conception • < 50 % knew that advanced maternal age
increased the risk of stillbirth, c. section, *multiple birth and preterm delivery
Tough 2002 and 2007
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NND classification Page 32
• Congenital abnormality 23.6%• Potentially avoidable – complex issue• Some benefit scale or special service
• Neurological 22% • NE Working Group
• Infection 6.6% • Cardio-respiratory 6% • Gastrointestinal 4.4%
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Neonatal Encephalopathy or Hypoxic Ischemic Death 2010 data collection
• Thank you for completing forms• Please keep it up for 2011
• 5 % of babies had 1 min Apgar ≥ 9• 23 % of babies had 5 min Apgar ≥ 7• 15 % either no resus or oxygen only • Cooling – not all babies• Investigation, counseling for family
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Contributory Factors (T33)
Neonatal deaths
n=182
Contributory factors
n %
Yes 61 34
No 103 57
Not stated 18 10
Potentially avoidable
35 19
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Organisation/people/skills
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Perinatal Mortality 2009
• Neonatal deaths with no obstetric antecedent are considerably more frequent in babies of Maori mothers
• Seven cases of SUDI deaths• Four had a mother who smoked• 6 were co-sleeping • 10 cases in 2008
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Conclusion
Some contribution clinical practice
Major benefit is working across disciplines
Communication, best practice, lack of skills and knowledge