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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 75-79

Late and moderately preterm babies in a Tertiary Childrens' Hospital in India: Its time we took a closer look


NICU, Rainbow Childrens Hospital, Hyder Nagar, Hyderabad, Telangana, India

Date of Web Publication10-Apr-2018

Correspondence Address:
Dr. Rajasri Rao Seethamraju
Rainbow Childrens Hospital, Opp Chermas, Hyder Nagar, Hyderabad - 500 072, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_5_18

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  Abstract 


Objectives: The late and moderate preterm (LMPT) babies form a significant proportion of Neonatal Intensive Care Unit (NICU) admissions. The aim of this study is to determine the disease patterns and outcomes of LMPT babies admitted to a tertiary childrens' hospital between January 1, 2017 and July 31, 2017. Material and Methods: This is a retrospective, observational study. Medical records of all neonates admitted during the study period were reviewed. The LMPT infants were analyzed for demographics and outcomes. Results: Of a total of 690 deliveries in the specified period in our hospital, 102 were LMPT neonates (14.8%). Of these, 39 (38.2%) were girls and 63 (61.7%) were boys. In this period, a total of 192 babies were admitted to our NICU of which 82 were LMPT babies (42.7%). 62 of the 82 were inborn (75.6%). Median weight among LMPT babies born in our hospital was 2.27 kg (interquartile range [IQR] 1.95–2.56) and median weight of the LMPT babies at admission to NICU was 2 kg (IQR 1.76–2.32). Preterm care was the most common reason for admission to NICU (67%). Respiratory distress was the main morbidity immediately after admission (28%) to NICU. Jaundice (59.75%) and hypoglycemia (10.9%) formed other main concerns. Median age for discharge was 35 weeks corrected gestational age (IQR 34–36). There was no mortality in the LMPT subgroup in the period specified. Conclusions: Researching and benchmarking our LMPT data have improved the confidence of our unit and will help develop guidelines specific to our population and health practices.

Keywords: India, late and moderate preterms, late preterm, late and moderate preterm, moderate preterm, well preterm


How to cite this article:
Seethamraju RR, Kharidehal N, Rayudu VK. Late and moderately preterm babies in a Tertiary Childrens' Hospital in India: Its time we took a closer look. J Clin Neonatol 2018;7:75-9

How to cite this URL:
Seethamraju RR, Kharidehal N, Rayudu VK. Late and moderately preterm babies in a Tertiary Childrens' Hospital in India: Its time we took a closer look. J Clin Neonatol [serial online] 2018 [cited 2018 Aug 18];7:75-9. Available from: http://www.jcnonweb.com/text.asp?2018/7/2/75/229668




  Introduction Top


For decades, the focus of all research in the field of neonatology was on babies who were very small or very preterm in keeping with the substantial mortality and morbidity associated with this cohort. Nearly 85% of preterm babies are born between 32 and 37 weeks gestation and most of these babies do not need too many interventions to survive. These bigger more mature preterm babies have therefore been looked after like we look after term babies. It is now recognized that the late and moderate preterms (LMPT) form a significant proportion of the Neonatal Intensive Care Unit (NICU) admissions and their outcomes are definitely better when compared to earlier gestations.

In general, there is a lack of standardization for terminology that describes babies born between 32 and 37 weeks. To remove confusing terms, such as “mild preterm”, “marginally preterm,” and “near term,” the National Institute of Child Health and Human Development (NICHD) in 2005[1] recommended that the term “late preterm” be used for the babies between 34+0 and 36+6 weeks, and this term was endorsed and adopted by many countries. However, the term “moderate preterm” still lacks consensus and has been used for various different gestational limits by researchers. Studies from the US [2] and Sweden [3] have used this for babies between 30 and 34 weeks of gestation. The recent study from Cleveland [4] labeled 29–33 weeks infants as moderately preterm.

The WHO in its fact sheet [5] classifies babies born between 32 and 37 weeks as moderate and late preterm babies. By inference, the babies born between 32+0 and 33+6 would be the moderately preterm babies. The LAMBS study [6] from the UK is the largest study that has specifically used this definition in their research. Indian data from this subgroup are yet to be available.

For this study, we choose to adhere to the definitions given by the WHO and NICHD and the LAMBS study for the moderate (32+0 and 33+6) and late preterm (34+0 to 36+6) babies. For the rest of this paper, they shall together be referred to as the LMPT babies.

India is one of the leading contributors to preterm birth worldwide. Understanding the morbidities of the LMPT subgroup, improving their care and benchmarking the Indian NICUs against available data is a useful investment.

Aim

To determine the disease, patterns and outcomes of LMPT babies, i.e., between 32+0 to 36+6 weeks gestation admitted to the neonatal unit and postnatal wards of the tertiary women and childrens' hospital between January 1, 2017 and July 31, 2017.


  Material and Methods Top


This is a retrospective, observational study. Ethical clearance was sought from the Ethics Committee of the organization and was deemed unnecessary as it was an observational study, and data collection was case notes based.

The labor ward register and the NICU admission register were used to identify all the LMPT neonates admitted to our hospital during the study. Medical records and the discharge summaries of all these LMPT neonates were reviewed retrospectively by the three researchers. Data collection included demographic details such as sex, admission and discharge gestation, weight, and centiles. The primary outcome that we looked at was mortality in this subgroup. The secondary outcomes were duration of hospital stay, morbidities during NICU and postnatal ward stay, and feeding practices.


  Results Top


Of a total of 690 deliveries in the specified period in our hospital, 102 were LMPT neonates (14.8%). Of these, 39 (38.2%) were girls and 63 (61.7%) were boys.

All 19 moderate preterm babies and 43 of the late preterm babies were admitted to the NICU while 40 late preterm neonates were cared for completely in the postnatal wards. In addition, there were 20 outborn LMPT babies admitted to our NICU.

[Figure 1] shows gestational distribution of deliveries in our hospital.
Figure 1: Gestational distribution of deliveries in our hospital

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Median weight among all LMPT babies born in our hospital was 2.27 kg (interquartile range [IQR] 1.95–2.56) and median weight of the LMPT babies at admission to the NICU was 2 kg (IQR 1.76–2.32). Preterm care was the most common reason for admission to the NICU (67%). Respiratory distress was the main morbidity immediately after admission (28%) to NICU. Jaundice (59.75%) and hypoglycemia (10.9%) formed the other main concerns.

[Table 1] shows the outcomes of the LMPT neonates born in our hospital after segregation into moderate and late preterm neonates
Table 1: Outcomes of the late and moderate preterm neonates born in our hospital after segregation into moderate and late preterm neonates

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Late and moderate preterms babies in Neonatal Intensive Care Unit

In the same period specified above, a total of 192 babies were admitted to our NICU of which 82 babies were between 32+0 and 36+6 weeks gestation at birth (42.7%). 62 of the 82 were inborn (75.6%). 74 of the 82 admissions were in the first 24 h (91.25%).

[Figure 2] shows gestation specific distribution at birth in NICU admissions.
Figure 2: Gestation specific distribution at birth in the Neonatal Intensive Care Unit admissions

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Among the 82 babies, only 23 required respiratory support after admission (28%). A total of six of the LMPT babies required surfactant (7.3%). A total of four babies required conventional mechanical ventilation whereas 19 required noninvasive support with continuous positive airway pressure and high-flow nasal cannula. There was no incidence of pulmonary hemorrhage, pneumothorax, or chronic lung disease among these babies. None of the babies required inotropic support. A total of 15 babies were found to have a murmur. Most of these were transitional flow murmurs. A total of three babies were found to have a patent ductus arteriosus (PDA), of which 2 were hemodynamically significant causing tachycardia and metabolic acidosis and therefore treated with a single course of paracetamol. None of the babies had intraventricular hemorrhage. There was bilateral flare reported in the first neurosonogram in two of the 82 babies which had normalized by the scan done at term. No baby developed necrotizing enterocolitis.

Feeds were started in 58 of the 82 babies in the first 24 h (70.7%). Of these 38 were started on formula feed (65%) and 20 (34.5%) were started on breast milk. Majority of those, who were fed between 24 and 96 h, were given breast milk. Time taken to full feeds in those who were given breast milk exclusively was a median of 6 days (IQR 3–7 days) whereas those that could be started on formula feeds in the first 24 h reached full enteral feeds in 1 day.

Median age for discharge from NICU was 35 weeks corrected gestational age (IQR 34–36). The median weight at discharge from NICU was 1.96 kg (IQR 1.8–2.18). A total of three babies were transferred to quaternary unit. The reasons for transfer were total anomalous pulmonary venous drainage in a 34 weeker, antenatal perforation of transverse colon in a 36 weeker, and an anorectal malformation at 36 weeks gestation that required multiple surgeries and prolonged stay. All three have been discharged and doing well.

[Figure 3] shows discharge outcomes of LMPT neonates admitted to NICU.
Figure 3: Discharge outcomes of late and moderate preterms neonates admitted to the Neonatal Intensive Care Unit

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  Discussion Top


More than 40% of our NICU admissions were LMPT infants in keeping with the usual trend for a relatively new unit. Our unit has an admission policy to admit all babies with gestation under 35 completed weeks and weight of 2 kg at birth to the NICU. Interestingly, more neonates admitted in this period were late preterm babies (majority from 34 weeks gestation) than the moderately preterm babies. This may reflect technological advances in obstetric surveillance and increased neonatal care, thereby improving the confidence of clinicians in delivering the high-risk babies at 34–36 weeks.[7]

There was no mortality in our hospital in the LMPT subgroup in the period specified. Among the immediate morbidities, need for respiratory support forms the major one, and when compared to the LAMBS study, we used noninvasive support in a higher percentage of babies and mechanical ventilation in a lesser percentage. The low incidence of a hemodynamically significant PDA in this cohort and the preference to treat with paracetamol (when compared to Ibuprofen) is in keeping with the available evidence [8],[9] Jaundice and hypoglycemia and percentage of septic screens were similar in the moderate preterms in both studies. More than half of the LMPT babies had a blood culture, and this reflects the lower threshold for these babies to get screened and started on antibiotics.[10]

Discharge from NICU too needs specific criteria to be met. The baby should be at least 34 weeks of corrected gestational age, at least 1.4 kg in weight, the mother or relatives should be able to fully orally feed the baby, the baby should maintain his/her own temperature, should have a normal clinical examination requiring no support, and demonstrate a steady weight gain. The median for discharge for the moderate preterm babies in our unit was 6 days when compared to 16 days in the LAMBS study. This reflects the fact that our cohort was more mature, and the babies were discharged as soon as they met the discharge criteria and sometimes even without a period of “rooming-in.” This finding showcases the socioeconomic and healthcare provision trends specific to India as compared to the National Health Service in the UK. Financial burden of health-care of “relatively well” children is an important cause of early discharge.

A total of 40 babies late preterm babies cared for on the postnatal wards received routine care like any other term baby and full oral feeds were started on day 1. They were discharged home with their mothers depending on whether the mum had a cesarean or a vaginal delivery. The median weight of discharge for these babies was 2.6 kg. It is interesting to note that seven of these babies got readmitted within 2 days for jaundice requiring phototherapy in the ward.

The feeding practices of the LMPT babies were the most encouraging with 80% getting started on feeds in the first 24 h including those admitted to NICU. However, we found that cesarean sections in this subgroup are definitely a hindrance to initiate feeding with breast milk both because of the morbidity and mobility issues in mum. On NICU, the time taken for full feeds in both breastfed and formula fed babies is less than a week on average; however, financial constraints may make parents opt for formula feeds to shorten duration of stay. Good counseling and support are needed in this situation to initiate and to maintain feeding with exclusive breast milk.


  Conclusions Top


Researching our late and moderately preterm infants has helped us showcase that they are a significant proportion of our NICU admissions, have a unique set of morbidities, and have a good prognosis. Benchmarking, some of our findings with international data such as the LAMBS study has improved confidence. Continued study of this group and comparison with other NICUs in the region may help us develop our own best practice guidelines.[11] Our feeding practices and promotion of breastfeeding need to be improved while keeping in mind the financial constraints of parents.

Strengths and limitations

We have studied all of the LMPT babies that were admitted to our hospital in the 7-month period. However, we looked at a short-time period and data collection was retrospective. Therefore, the conclusions we have drawn may not be fully representative. Secondly, ours is a single center study, and larger multicentric studies are needed from various centers in India to accurately reflect current trends and outcomes of the LMPT infants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raju TN, Higgins RD, Stark AR, Leveno KJ. Optimizing care and outcome for late-preterm (near-term) infants: A summary of the workshop sponsored by the national institute of child health and human development. Pediatrics 2006;118:1207-14.  Back to cited text no. 1
[PUBMED]    
2.
Escobar GJ, McCormick MC, Zupancic JA, Coleman-Phox K, Armstrong MA, Greene JD, et al. Unstudied infants: Outcomes of moderately premature infants in the Neonatal Intensive Care Unit. Arch Dis Child Fetal Neonatal Ed 2006;91:F238-44.  Back to cited text no. 2
    
3.
Altman M, Vanpée M, Cnattingius S, Norman M. Neonatal morbidity in moderately preterm infants: A Swedish national population-based study. J Pediatr 2011;158:239-440.  Back to cited text no. 3
    
4.
Trembath AN, Payne AH, Colaizy TT, Bell EF, Walsh MC. The problems of moderate preterm infants. Semin Perinatol 2016;40:370-3.  Back to cited text no. 4
    
5.
WHO Factsheet on Preterm Birth. Available from: www.who.int/mediacentre/factsheets/fs363/en. [Last updated on 2017 Nov].  Back to cited text no. 5
    
6.
Boyle EM, Johnson S, Manktelow B, Seaton SE, Draper ES, Smith LK, et al. Neonatal outcomes and delivery of care for infants born late preterm or moderately preterm: A prospective population-based study. Arch Dis Child Fetal Neonatal Ed 2015;100:F479-85.  Back to cited text no. 6
    
7.
Davidoff MJ, Dias T, Damus K, Russell R, Bettegowda VR, Dolan S, et al. Changes in the gestational age distribution among U.S. Singleton births: Impact on rates of late preterm birth, 1992 to 2002. Semin Perinatol 2006;30:8-15.  Back to cited text no. 7
    
8.
Nemerofsky SL, Parravicini E, Bateman D, Kleinman C, Polin RA, Lorenz JM, et al. The ductus arteriosus rarely requires treatment in infants & 1000 grams. Am J Perinatol 2008;25:661-6.  Back to cited text no. 8
    
9.
Terrin G, Conte F, Oncel MY, Scipione A, McNamara PJ, Simons S, et al. Paracetamol for the treatment of patent ductus arteriosus in preterm neonates: A systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2016;101:F127-36.  Back to cited text no. 9
    
10.
Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants. Pediatrics 2004;114:372-6.  Back to cited text no. 10
    
11.
Engle WA, Tomashek KM, Wallman C, Committee on Fetus and Newborn, American Academy of Pediatrics. “Late-preterm” infants: A population at risk. Pediatrics 2007;120:1390-401.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3]
 
 
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