|Year : 2019 | Volume
| Issue : 3 | Page : 155-161
Clinical profile and outcome of newborns admitted to a secondary-level neonatal intensive care unit in tribal region of Odisha
Prateek Kumar Panda1, Pramod Kumar Panda2
1 Department of Paediatrics, AIIMS, New Delhi, India
2 Department of Paediatrics, District Headquarter Hospital, Koraput, Odisha, India
|Date of Web Publication||6-Aug-2019|
Dr. Pramod Kumar Panda
District Headquarter Hospital, Koraput, Odisha
Source of Support: None, Conflict of Interest: None
Introduction: Neonatal deaths constitute major proportion of under-five mortalities in India. Secondary-level neonatal intensive care units (NICUs) currently provide care to majority of sick newborns in India. Only few clinical studies have described the management outcome of newborns admitted into these secondary-level NICUs in India. Methods: The current study was conducted in Koraput District Headquarter Hospital and associated Medical College Hospital located in tribal regions of Odisha catering to 13.8 lakhs population of predominantly lower socioeconomic status. The study included in-depth retrospective case record analysis of all the NICU admissions in 3 months between April and June 2018, after a broad overview of all admissions in 3 years between July 2015 and June 2018. Predesigned pro forma was used to document clinical profile, indication for admission, microbiological characteristics of neonatal sepsis, and outcome in terms of discharge, death, referral, or left against medical advice. Results: Of 4127 total NICU admissions between July 2015 and January 2018, 3159 (76%) newborns were discharged. The most common indications for admissions in inborn babies were prematurity and related complications (23%), birth asphyxia (19%), and neonatal hyperbilirubinemia (18%). For outborn newborns, along with these causes, neonatal sepsis (20%) was another important cause of NICU admission. Escherichia coli and Klebsiella species were predominant microorganisms to be isolated in blood culture. About 11% of newborns received kangaroo mother care, with median duration of 6 days. Predominant causes of death among newborn babies were prematurity-related complications (51%) and neonatal sepsis (37%). Conclusion: Prematurity-related complications, birth asphyxia, neonatal hyperbilirubinemia, and sepsis are the predominant indications for admission to a secondary-level NICU in India. About three-fourth of neonates can be treated successfully within the existing infrastructure.
Keywords: Clinical profile, neonatal intensive care unit, newborns, secondary level
|How to cite this article:|
Panda PK, Panda PK. Clinical profile and outcome of newborns admitted to a secondary-level neonatal intensive care unit in tribal region of Odisha. J Clin Neonatol 2019;8:155-61
|How to cite this URL:|
Panda PK, Panda PK. Clinical profile and outcome of newborns admitted to a secondary-level neonatal intensive care unit in tribal region of Odisha. J Clin Neonatol [serial online] 2019 [cited 2019 Aug 20];8:155-61. Available from: http://www.jcnonweb.com/text.asp?2019/8/3/155/264034
| Introduction|| |
Newborn health is now considered as high-level national priority globally. The current neonatal, infant, and under-five mortality rate in India are 24, 32, and 34/1000 live births, respectively. Thus, neonatal mortality constitutes the major proportion of under-five mortality in India as well as other countries. After the introduction of the National Rural Health Mission (NRHM), especially Janani Suraksha Yojana in 2005 for improvement in maternal and child health, there has seen a tremendous growth of neonatal intensive care in India. The proliferation of secondary- and tertiary-level neonatal intensive care units (NICUs) has led to dramatic improvement in median survival rates of 58% and 88% among extremely low birth weight (LBW) and very LBW newborns, respectively.
The India Newborn Action Plan launched in September 2014, for accelerating the reduction of preventable newborn deaths and stillbirths in the country has a goal of attaining “Single Digit Neonatal Mortality Rate (NMR) by 2030.” However, unfortunately, there is a deep divide across the 29 states of India in the availability of level of neonatal care. Many tribal and rural regions in low performing states such as Odisha and Bihar still have the lack of even basic newborn care facilities. With NMR of 44/1000 live births, Odisha is far behind the national average. According to a recent National Institution for Transforming India Aayog report in June 2019 comparing the overall performance of states on health indicators, Uttar Pradesh, Bihar, and Odisha were the worst performed. The structured clinical study describing the outcome and variables of neonatal care in states like Odisha are scanty in the published literature.
The National Neonatology Forum of India stratifies neonatal care into three levels as follows: Level I includes basic resuscitation and healthy newborn care, Level II includes care of preterm newborn >32 weeks gestational age (GA) (subdivided into IIA and IIB based on brief ventilation of <24 h and continuous positive airway pressure (CPAP) support), and Level III includes care of extreme preterm newborns. Under the NRHM, sick neonatal care units (SNCUs) are established as secondary-level NICUs, generally at district level hospitals. Ideally, these should possess 12–20-bedded units, with 4 trained doctors, and 10–12 nurses and support staff with the provision of 24 × 7 services to sick newborns, except assisted ventilation, and major surgeries. Neonates who require higher intensive care are referred to tertiary level NICUs at apex centers. In a country like India, where the majority of neonatal care occurs in secondary-level NICUs, it is a priority for health-care officials to divert the resources for improvising these SNCUs to bring down the NMR.
Quite a few studies in India have described in detail the morbidity profile of tertiary care NICUs. However, there are few clinical studies to show the morbidity and mortality profile of SNCUs. The neonatal morbidity profile also had a paradigm shift over the past two decades, as the primary cause of neonatal mortality is now prematurity and associated complications, unlikely birth asphyxia and neonatal sepsis, which constituted the major chunk of neonatal mortality few decades before. Hence, it is high time, a clinical study should be performed in a secondary care NICU to reveal the true picture of neonatal morbidity and mortality in community by avoiding referral bias, which is a major shortcoming of clinical studies from tertiary care units.
| Methods|| |
The current study was conducted in August 2018 in District Headquarter Hospital and associated Saheed Laxman Naik Medical College, Koraput, Odisha, after obtaining ethical clearance from concerned authority. This hospital is the only SNCU in this tribal and most underdeveloped district of Odisha, with a population of 13.8 lakhs. However, the catchment area of this SNCU also covers nearby three underdeveloped districts: Nabrangpur, Malkanagiri, and Rayagada. Most people in the district are of lower socioeconomic status, with a considerable proportion being below poverty line proposed by the Government of India. The economy of the district mainly depends on agriculture, and it continues to be one of the most backward districts of India according to the recent report of the Ministry of Panchayati Raj. The population in this area has poor access to health-care services as compared to other regions of Odisha. The neonatal and under-five mortality rates in this area are high and institutional delivery rate is low, as compared to state standards.
This SNCU has 20 beds, with the doctor-to-bed ratio of 1:6 and nurse-to-bed ratio of 1:3. It is equipped with capacity for thermoregulation, intravenous hydration and medications, Katori spoon feeding, nasogastric tube feedings, phototherapy equipment [Figure 1], oxygen concentrators for use with nasal cannula and headbox [Figure 2], blood product transfusion facility, biochemical and microbiological laboratory, X-ray and ultrasound facility, and two CPAP machines. Neonates requiring prolonged mechanical ventilation or other superspecialty care are referred to a tertiary care NICU (MKCG medical college, Berhampur), located at a distance of about 200 km. During the study, there was no other SNCU in these four districts that had all these similar capabilities to care for sick neonates.
|Figure 1: Newborn receiving phototherapy while being nursed inside the sick neonatal care unit|
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|Figure 2: Newborn receiving oxygen support with head box while being nursed inside the sick neonatal care unit|
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The SNCU in this hospital accepts both inborn and outborn newborns with GA >28 weeks and weight more than 1000 g, up to a corrected GA of 48 weeks. The admission criteria of this SNCU allows admitting newborns with birth weight <1800 g, GA <35 weeks, multiple deliveries (twins and triplets), major life-threatening malformations, birth asphyxia requiring endotracheal intubation and/or requiring bag and mask ventilation for at least 5 min, meconium aspiration syndrome, respiratory distress syndrome (RDS), transient tachypnea of newborn and other newborns with respiratory distress since birth and newborns with central cyanosis (not improving with oxygen therapy). Other important clinical indications include neonatal seizures, significant birth injury, history of prolonged rupture of membrane in mother >24 h due to increased risk of early-onset neonatal sepsis (EONS), if the mother is sick and unable to provide adequate care to the newborn, babies born to diabetic mother, especially if the mother is a poorly controlled diabetic and the baby is macrosomic, babies born to mother with Rh isoimmunization in pregnancy, babies with neonatal hyperbilirubinemia requiring phototherapy and babies with hypoglycemia, polycythemia, lethargy, or neonatal sepsis.
The primary objective of the present study was to determine the clinical presentation and discharge rate of newborn babies from SNCU in DHH, Koraput. Secondary objectives were to determine the treatments (drugs, respiratory supports, kangaroo mother care, phototherapy, blood product transfusion, etc.) received by these babies, and clinical and microbiological characteristics of neonatal sepsis in this SNCU.
The adequate sample size to fulfill the primary objective was calculated to be 316, using the formula n = Z2 × P (1 − P)/d2. Here, n is the sample size, Z is the statistic corresponding to the level of confidence (3.84 in our case with 95% confidence interval), P is expected prevalence (according to Prinja et al. in 2013, discharge rate from another SNCU in Odisha was 71%), and d is precision (5% in our case).
In the first stage, a broad overview of all admissions in the 3 years between 2015 and 2018 was performed in a predesigned pro forma to find out the average admission and discharge rate of the SNCU under study. In the 3 years previous to the study between July 2015 and June 2018, a total of 4127 Newborns were admitted to this SNCU, of which 3176 newborns (77%) were discharged, 446 (10%) newborns expired, 268 (6.5%) neonates were referred to tertiary care NICU and caregivers of 238 (6%) neonates left against medical advice (LAMA). A total of 1278, 1113, and 1736 newborns were found to be admitted to this SNCU in 2015–2016, 2016–2017, and 2017–2018, respectively. Of these, 76%, 72%, and 81% of newborns were completely cured and discharged successfully in these 3 years, respectively. Overall trend of admissions, discharge, and death rates over the past 3 years are illustrated in [Table 1]. Thus, with an average admission rate of 114 newborn babies per month in this SNCU, clinical data of newborn babies admitted in recent most 3 months before the study initiation period, i.e., from April to June 2018 were included for detailed retrospective chart review
|Table 1: Admission and discharge trends over 3 years (from July 2015 to June 2018)|
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Case record analysis of all the SNCU admissions in 3 months between April and June 2018 was followed by entering patient characteristics including clinical and demographic variables, admitting complaints, and outcome in a predesigned pro forma. Maternal risk factors, resuscitation required at birth, hematological, biochemical parameters, and results of microbiological and radiological investigations were also recorded. In neonates with multiple indications for admission, predominant, and most antecedent indication for admission was determined by mutual discussion and final consensus opinion of investigators. In case of outborn neonates, whenever insufficient data were found in our case records, resuscitation details, feeding issues before hospitalization, and care received in newborn stabilization units at primary health centers were collected by contacting doctors, auxiliary nurse midwives (ANMs), and Accredited Social Health Activists (ASHAs). Every effort was made to collect the missing data by telephonically contacting the concerned persons, whenever personal interview or direct document review was not feasible. Follow-up information at 1 and 4 weeks after discharge were also collected from our center and also contacting ANMs and ASHAs. In spite of these, those babies left with inadequate clinical details were excluded from the final analysis. STROBE checklist was followed to ensure the quality of the study.
Data collected in predesigned pro forma were transferred to Microsoft Excel spreadsheet. Continuous variables were expressed either as mean with standard deviation or median with interquartile range. Categorical variables were expressed as frequency (in percentage) with 95% of confidence interval. For determining the statistical significance of the difference between two variables Chi-square test/Fisher's exact test and Student's t-test/Wilcoxon rank sum test were used for categorical and continuous variables, respectively. All the statistical analysis was carried out using the latest version of the SPSS (Statistical Package for Social Sciences for Windows, Version 24.0., SPSS Inc., Chicago, USA).
| Results|| |
A total of 561 neonates were admitted during the study, with an average duration of SNCU stay being 8.7 ± 2.1 days and bed occupancy rate of around 83%. Five neonates with inadequate clinical details were excluded from the final statistical analysis. Demographic variables, inborn/outborn distribution, and outcome (death, discharge, or referral to higher center) are demonstrated in [Table 2]. Discharge rate was higher for inborn neonates as compared to that of outborn neonates (81% vs. 69%, P = 0.03) and term neonates as compared to preterm neonates (86% vs. 54%, P = 0.04). A number of children admitted with various clinical indications and their outcomes are demonstrated in [Table 3]. Children with multiple clinical indications had lower discharge rate as compared to their counterpart (82% vs. 64%, P = 0.01). Clinical profile and outcome of preterm neonates are described in [Table 4].
|Table 2: Sociodemographic profile of neonates admitted between April and June 2018 and their final outcome|
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|Table 3: Various indications for admission in neonates admitted between April and June 2018 and outcome of each individual subgroups|
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|Table 4: Clinical profile and outcome of preterm neonates admitted between April and June 2018|
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Clinical and microbiological characteristics of babies with neonatal sepsis are described in [Table 5]. A number of neonates in whom at least one risk factor for neonatal sepsis was identified was more in EONS as compared to late-onset neonatal sepsis (LONS) (91% vs. 78%, P = 0.04). Among the children with neonatal sepsis, those having meningitis and hemodynamic instability have a lower discharge rate as compared to their counterparts (47% vs. 79%, P = 0.001). Predominant causes of death in our SNCU and their relative distribution are demonstrated in [Table 6]. A total of 287 (51%) of all neonates admitted had respiratory distress. Of these, 172 (59%) and 31 (11%) could be managed successfully with oxygen support only and oxygen along with CPAP, respectively. Relative distribution of various etiologies of respiratory distress and their clinical outcome is described in [Table 7].
|Table 5: Clinical profile and outcome of neonates admitted with sepsis between April and June 2018|
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|Table 7: Relative distribution of various etiologies for respiratory distress in neonates|
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Total 494 neonates (89%) could be traced on follow-up at 1 week after admission, and all of them had no fresh health-care issues. At 4 weeks after admission, 361 (65%) newborns could be traced, and out of them 234 (76%) were found to be healthy with adequate weight gain without any fresh health-care issues. Rest of neonates predominantly has feeding issues and nasal blockade at follow-up, which was managed on outpatient basis. Readmission rate was only 3% (15 neonates), with the predominant cause of readmission being LONS.
| Discussion|| |
While comparing the results of this study with the few published studies describing morbidity and mortality profiles of various secondary-level NICUs in India, similarities were noticed. Prinja et al. described four secondary-level NICUs (Vaishali, Guna, Bhubaneswar, Shivpuri) in three different states of India in 2013. All four NICUs had a discharge rate between 60% and 80%, comparable to our clinical study. Predominant causes of admission were also similar to our SNCU: prematurity-related complications, birth asphyxia, neonatal sepsis, and neonatal hyperbilirubinemia. The relative distribution of these morbidities among the neonates was also similar to our SNCU.
Overall, SNCU neonatal treatment cost was found to be INR 4581 (USD 101.8) and INR 818 (USD 18.2) per neonate treatment and per bed-day treatment, respectively, in this study. Thus, secondary-level NICUs are cost-effective alternatives for neonates not requiring mechanical ventilation or surgical intervention. Being nearby to home, it also helps in reducing logistic concerns of caregivers. However, easily accessible and timely neonatal transport to tertiary care NICUs are also need of the day.
Yousuf et al. reported 85% successful discharge out of 336 neonates from a secondary level of NICU in Bathinda, Punjab, in 2017. Hyperbilirubinemia, sepsis, and perinatal asphyxia were the most common reasons for admission. Neogi et al. studied the functioning of eight SNCUS in rural districts of India within 2 years of establishment in 2009. The case-fatality rate was found to be reduced by 40% within 1 year of their functioning. Proportional mortality due to sepsis and LBW declined significantly over 2 years (LBW <2.5 kg). The major reasons for admission and the major causes of deaths were birth asphyxia, sepsis, and LBW/prematurity in this study. The units had a varying nurse: bed ratio (1:0.5–1:1.3). The bed occupancy rate ranged from 28% to 155% (median 103%), and the average duration of stay ranged from 2 days to 15 days (median: 4.75 days). Repair and maintenance of equipment were found to be a major concern.
However, tertiary level NICUs reported higher discharge rates from various parts of India.,,,, Sridhar et al., in 2015, in a retrospective study on 1487 neonates in a Tertiary Care Teaching Hospital in Mandya, Karnataka reported around 5% referral to other centers and 7% mortality, which is less as compared to our study. The major causes of morbidity were neonatal sepsis (28%), RDS (23%), and birth asphyxia (17%). Most of the deaths were due to RDS (43%), birth asphyxia (37%), and neonatal sepsis (8%) like our clinical study.
Patil Ravindra et al., in 2014, in a cross-sectional study in tertiary care NICU in Shivamogga, Karnataka described around 82% discharge rate and 10% mortality rate among 1041 neonates. The most common specific morbid reason for admission was RDS (37%) followed by neonatal jaundice (13%) and meconium aspiration syndrome (13%). In this study, also common causes for mortality were prematurity, RDS, birth asphyxia, and sepsis. Hedstrom et al. in a rural NICU in 2008 in Uganda, Iyer et al. in 2015 and Malik et al. in 2016 in two central Indian NICUs also showed similar clinical profile in 809, 1580, and 1388 newborn admissions, respectively,,
Barkiya et al. in 2016 described similar causes with a better outcome of about 85%, in 102 term and preterm newborns with respiratory distress in a tertiary care NICU in Kunnur, India. Sanuja et al. in 2017 described 586 neonates with suspected sepsis in a tertiary care NICU. The incidence of culture-positive sepsis (21.5%) was higher than our study. The common organisms were Gram-negative organisms in both EONS and LONS, like our study. However, in contrast to our findings, Gram-positive organisms such as Staphylococcus aureus and Acinetobacter (19%) was also a major contributor in neonatal sepsis in this study.
Being a retrospective chart review, this study is subjected to the lack of accuracy related to missing data and documentation errors. About 14% of newborns admitted were either referred to higher center or LAMA. Thus, the actual rate of neonatal death may be higher than described in this clinical study. Prospective studies and collaboration with the referral center to determine the clinical outcome of referred neonates will help in providing further accurate information in this regard.
| Conclusion|| |
Preterm birth-related complications, birth asphyxia, neonatal hyperbilirubinemia, and neonatal sepsis are the predominant clinical indications for admission to a secondary-level NICU in tribal regions of Odisha. About three-fourth of newborns admitted can be treated successfully even in a secondary-level NICU by quality neonatal care, within the existing health-care infrastructure. Common causes of mortality in these SNCUs are preterm birth-related complications and neonatal sepsis. Multicentric, prospective studies are required to identify the targets to reduce neonatal mortality in SNCUs and planning public health measures accordingly.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]