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.

SPECIAL CARE NEWBORN UNIT (NNF LEVEL II – A ACCREDITED)

GOVT. DIST. HOSPITAL NALGONDA

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

Cup Spoon

PALADAI

FEEDING METHODS

GAVAGE

SUPERVISED BREAST FEEDING

C P A P

Sound SPA

• 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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