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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 5  |  Issue : 3  |  Page : 168-173

Morbidity profile and mortality of neonates admitted in Neonatal Intensive Care Unit of a Central India Teaching Institute: A prospective observational study


1 Department of Pediatrics, Gandhi Medical College, Bhopal, Madhya Pradesh, India
2 Department of Pediatrics, AMU, Aligarh, Uttar Pradesh, India

Date of Web Publication28-Sep-2016

Correspondence Address:
Dr. Poorva Gohiya
F1, Doctors Quarters, Hamidia Hospital Campus, Bhopal - 462 001, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4847.191251

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  Abstract 

Introduction: Neonatal mortality contributes to 40% of infant mortality rate (IMR). Over the years, the IMR has reduced worldwide, as well as in India, but neonatal mortality rate has not decreased proportionately. We have taken up this study so as to ascertain the causes of morbidity prevalent in the neonates admitted in Neonatal Intensive Care Unit (NICU) of a teaching hospital. The teaching hospitals cater to a large population, being a referral center and having majority of facilities required for the adequate care of sick newborn babies. Materials and Methods: The study is conducted in NICU of a teaching hospital admitted within 24 h of birth in central India over a period of 1-year. Results: One thousand three hundred and eighty-eight newborns admitted within 24 h of birth were included in the study. About 63.4% were male neonates, (Male:female 1.7:1). The low birth weight babies were 63.5% in our study. Respiratory distress was present in 47.2% of neonates, meconium aspiration syndrome being the most common cause of respiratory distress. Neonatal sepsis accounted for morbidity in 45.10% of neonates, with Klebsiella being the most common organism grown in the blood culture. The incidence of congenital anomalies was 5.4% with cardiac anomalies being most common. The neonatal mortality was found to be 26.6% in our study. Neonatal sepsis and birth asphyxia were the two most common causes of neonatal mortality in the study. Extremely low birth weight neonates had the highest case fatality rate in the study, which indicates the need to develop an efficient group of professionals in teaching hospitals who will provide highly specialized and focused care to this cohort of vulnerable neonates. Conclusion: Our study has shown respiratory distress, perinatal asphyxia, and sepsis as the predominant causes of neonatal morbidity. All three are preventable causes, and our health-care programs should be directed toward addressing the risk factors in the community responsible for the development of these three morbidities. The preterm and low birth weight babies had significantly high mortality even with standard intensive care; therefore a strong and effective antenatal program with extensive coverage of all pregnant females specifically in outreach areas should be developed which will help in decreasing preterm deliveries and also lower the incidence of low birth weight babies.

Keywords: Birth asphyxia, early neonatal mortality, extremely low birth weight, prematurity


How to cite this article:
Malik S, Gohiya P, Khan IA. Morbidity profile and mortality of neonates admitted in Neonatal Intensive Care Unit of a Central India Teaching Institute: A prospective observational study. J Clin Neonatol 2016;5:168-73

How to cite this URL:
Malik S, Gohiya P, Khan IA. Morbidity profile and mortality of neonates admitted in Neonatal Intensive Care Unit of a Central India Teaching Institute: A prospective observational study. J Clin Neonatol [serial online] 2016 [cited 2019 Aug 25];5:168-73. Available from: http://www.jcnonweb.com/text.asp?2016/5/3/168/191251


  Introduction Top


Approximately, 3.1 million babies die worldwide in the 1st month of life, each year.[1] Majority of these deaths occur in developing world. Neonatal mortality accounts for 40% of total infant mortality rate.[2] Yet, 24 million more newborns have been saved worldwide because of the decline in neonatal mortality since 1990.[3]

The neonatal mortality rate (NMR) in India is 29 per 1000 live births.[3] The Millennium Development Goals (MDGs) 2015 have not been achieved which focused on decreasing NMR of India to <10. Although the time frame to achieve the MDGs has been extended, a significant work has been done in the area of improving neonatal mortality in India. In the year 2009, an estimated 3.3 million babies died in the 1st month of life (4.6 million neonatal deaths in 1990), and more than half of all neonatal deaths occurred in five countries of the world (44% of global live births) such as India 27.8% (19.6% of global live births), Nigeria 7.2% (4.5%), Pakistan 6.9% (4.0%), China 6.4% (13.4%), and Democratic Republic of the Congo 4.6% (2.1%). Between 1990 and 2009, the global NMR declined by 28% from 33.2 deaths per 1000 live births to 23.9.[2] We have undertaken this study to ascertain the predominant causes of morbidity and mortality in the neonates who are admitted in Intensive Care Unit so as to find out the burden of preventable causes, which in turn will help in formulating strategies for control of neonatal mortality.


  Materials and Methods Top


This is a prospective observational study done in the Neonatal Intensive Care Unit (NICU) of Department of Pediatrics in a Teaching Institute. A pretested proforma with standard definitions from National Neonatology Forum was used to register the cases after Institutional Ethical Committee cleared the study.

  • Study period: 1-year
  • Inclusion criteria:
    1. All (inborns and outborns) neonates admitted to NICU within 24 h of birth
    2. All newborns in whom parental consent was obtained for inclusion in the study.
  • Exclusion criteria:
    1. Newborns who were admitted at >24 h of life
    2. Newborns, whose parents did not give consent.


The data were statistically analyzed using the SPSS 18 (SPSS Inc., Chicago).


  Results Top


A total of 1388 newborns admitted within 24 h of birth were included in the study out of which 57.2% were intramural, whereas 42.8% were extramural. Male preponderance in both intramural and extramural babies (63.4%) was present in our study [Figure 1].
Figure 1: Sex distribution. Sex ratio - 1.7:1

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Of the 594 extramural babies, 217 babies were >2500 g, whereas 377 (63.4%) babies were <2500 g. In the intramural group also 63.6% babies were low birth weight [Figure 2].
Figure 2: Birth weight distribution

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About 45.10% of neonates had neonatal sepsis (early and late onset), 43% of extramural babies had neonatal sepsis. In the neonates with sepsis, the blood culture positivity was 48.46%. The most common organism isolated was Klebsiella (41.12%) followed by Staphylococcus aureus and  Escherichia More Details coli. Klebsiella was sensitive to ceftazidime (48%), amikacin (56%), meropenem (68%), and imipenem (64%). S. aureus was sensitive to ampicillin (44%), vancomycin (74%), 43.94% of neonates were admitted with birth asphyxia.

Respiratory distress was present in 47.2% of all the neonates studied. Meconium aspiration was the most common (26.56%) cause of respiratory distress in our study.

About 12.5% of neonates had neonatal convulsions, and the most common cause of convulsion was hypoxic-ischemic encephalopathy (HIE) (98.4%).

The incidence of congenital anomalies was 5.3%, i.e., 74 out of 1388 newborns. Congenital heart diseases accounted for 48.65% of all the anomalies. Neonatal sepsis was the most common cause of mortality accounting for 47.57% of cases followed by birth asphyxia. The difference in mortality rate due to sepsis and perinatal asphyxia was statistically significant with P < 0.0001. The case fatality rate was highest with extremely low birth weight (ELBW) babies.

The distribution of principal causes of morbidity is given in [Table 2].

Of the total 370 neonatal deaths, 263 were preterm. The relative risk of dying due to prematurity was 2.7 with 95% confidence interval (CI) 2.29-3.3 (P < 0.0001, odds ratio 3.861). The relative risk of dying due to low birth weight was 2.68 (CI 2.24-3.2) with P < 0.0001. Out of total deaths, 82.16% were early neonatal deaths. Discharge rate was found to be 40.56% in the study.


  Discussion Top


In the study, we have a high percentage (63.5%) of low birth weight babies as the study was done on admitted patients who required intensive care.

Sick neonates are referred to our unit from neighboring districts, and as low birth weight babies are prone to complications, this could be the reason for having a high proportion of low birth weight neonates. Studies done in other countries had a different incidence of low birth weight babies. In the study done by Omoigberale et al., the incidence of low birth weight was 26%.[4] In other studies,[5],[6],[7] it ranged between 20% and 55%. India accounts for 40% of the world's total burden of low birth weight babies. These are at-risk babies who need immediate neonatal care to prevent early mortality[2] and late neurodevelopmental morbidity thus focus should be on prevention of low birth weight babies with special reference to intrauterine growth restriction.

About 44.5% of total admitted neonates were preterm [Table 1]. The present study has a high incidence of preterm neonates as ours is a tertiary care NICU which acts a major referral center for high-risk neonates. Neonatal-perinatal database of India[8] has reported 32.7% incidence. Similar studies from countries such as Nigeria[4],[5] and Bangladesh[9] had 28% and 35.5% of preterms in their studies, respectively.
Table 1: Gestational age wise distribution of neonates


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Table 2: Neonatal Morbidity (not mutually exclusive)


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Respiratory distress (47.2%), neonatal sepsis (45.1%), HIE (43.94%), neonatal convulsions (12.5%), and hyperbilirubinemia (24.9%) were the top five neonatal morbidities in our study. The causes of morbidity were studied separately in intramural and extramural babies [Table 2].

Respiratory distress [Figure 3] due to different etiologies was present in 47.2% of neonates. Meconium aspiration syndrome as the cause of respiratory distress accounted for 26.56% of cases, followed by congenital pneumonia (23.97%). Respiratory distress syndrome (RDS) was the etiology of respiratory distress in 10.84% of neonates; other Indian studies[10] have reported the incidence of RDS from 6% to 15%. Congenital pneumonia was the cause of morbidity in 23.9% of neonates in our study. Studies from India, as well as other developing countries,[11] have reported the varied incidence of congenital pneumonia ranging from 20% to 32%. Transient tachypnea of newborn was the cause of respiratory distress in 4.58% of newborns. As respiratory distress is a major presenting symptom in both terms and preterms, its etiological diagnosis [Figure 4] helps us to direct resources toward the most prevalent cause in a particular institute.
Figure 3: Proportion of neonates having respiratory distress

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Figure 4: Causes of respiratory distress

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Neonatal sepsis was the cause of morbidity in 45.1% of admitted neonates. Different institution-based studies have found the incidence of neonatal sepsis ranging from 17.7% to 70%[4],[5],[6],[12] Blood culture positivity rate was 48.46% [Figure 5]. Klebsiella pneumoniae Scientific Name Search  was isolated from 41.12% of cultures, followed by S. aureus and E. coli. Klebsiella has been found as a predominant organism in other studies as well [Figure 6].[13],[14],[15],[16],[17]
Figure 5: Culture positive sepsis rate

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Figure 6: Distribution of organisms causing sepsis

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About 43.94% of babies were admitted with birth asphyxia; out of these, 50.32% of patient developed convulsions. Different institution-based studies have reported the incidence of birth asphyxia ranging from12.7% to 38.7%.[6],[18],[19]

Neonatal convulsions were documented in 12.5% of the neonates in our study. HIE was the cause of seizures in 98.4% of newborns; other causes were meningitis and hypocalcemia. Kumar et al.[20] in their study on neonatal convulsions found convulsions in 11.6/1000 live births, and the most common cause of seizures was HIE. In the studies done by Mwaniki et al.[21] and Simiyu D et al.,[22] birth asphyxia was the predominant cause of neonatal convulsions.

Around 24.9% of newborns had hyperbilirubinemia in our study, out of which 60% were preterm. ABO incompatibility and Rh incompatibility were present in 15% and 7.4%, respectively. The incidence of hyperbilirubinemia is high in our study as it is a hospital-based study with high-risk babies having various risk factors for developing hyperbilirubinemia. The incidence of hyperbilirubinemia was 35% in a study done by Simiyu.[22] About 39.6% in a study done by Owa and Osinaike[23] in Nigeria. South African countries have a higher incidence of hyperbilirubinemia as compared to India.

Congenital malformations were found in 5.3% of neonates in our study. Cardiac malformations were present in 48.65% of neonates with congenital malformations. A similar incidence of malformations was found in other studies.[24],[25],[26],[27] Sixty-five percent of the congenital malformations were found in low birth weight babies.

We recorded NICU mortality of 26.26% which is comparable to other studies done by different researchers.[6],[25],[26],[28] The incidence of early (<7 days of age) neonatal death was 82.16% in our study. In a study done by Udo et al.,[28] most of the deaths occurred within first 7 days of life. National Neonatal Perinatal Database[25] report stated 82% of mortality in the first 2 days.

Intraventricular hemorrhage, ELBW, sepsis, birth asphyxia, and RDS were the five major causes of mortality in our study. The causes of mortality were similar in intramural and extramural babies, and distribution is shown in [Figure 7] and [Figure 8]. Other studies which focus on mortality profile of NICU-admitted neonates had reported a similar mortality profile.[27],[28],[29] Case fatality rate was highest in extreme prematurity (80.95%).
Figure 7: Disease-wise fatality rates in intramural babies. IVH: Intraventricular hemorrhage, ELBW: Extremely low birth weight, RDS: Respiratory distress syndrome, Congenital M: Congenital malformations

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Figure 8: Disease-wise fatality rates in extramural babies. IVH: Intraventricular hemorrhage, ELBW: Extremely low birth weight, RDS: Respiratory distress syndrome, Congenital M: Congenital malformations

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The relative risk of dying due to low birth weight was 2.68 (CI 2.24-3.2) with P < 0.0001. The increased risk of mortality with low birth weight is found in many studies and being a preventable cause, the proportion of babies dying as a consequence of low birth weight can be reduced by focusing our public health programs on adolescent health and nutrition.


  Conclusion Top


Our study has shown respiratory distress, perinatal asphyxia, and sepsis as the predominant causes of neonatal morbidity. All three are preventable causes and our health-care programs should to be directed toward addressing the risk factors in the community responsible for the development of these three morbidities. The preterm and low birth weight babies had significantly high mortality even with standard intensive care; therefore a strong and effective antenatal program with extensive coverage of all pregnant females specifically in outreach areas should be developed which will help in decreasing preterm deliveries and also lower the incidence of low birth weight babies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

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