Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 1013
 
About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Advertise Login 
     


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 266-271

To retrospectively review and assess the survival rate of newborns admitted over 3 years to a Newborn Intensive Care Unit at a Tertiary Care Institute in Northern India


1 Department of Pediatrics, Dr Rajender Prasad Government Medical College, Kangra, Himachal Pradesh, India
2 Department of Internal Medicine, Dr Rajender Prasad Government Medical College, Kangra, Himachal Pradesh, India

Date of Submission04-Jun-2020
Date of Decision09-Aug-2020
Date of Acceptance20-Aug-2020
Date of Web Publication01-Oct-2020

Correspondence Address:
Dr. Jyoti Sharma
Associate Professor, Department of Pediatrics, Dr Rajender Prasad Government Medical College, Tanda, Kangra - 176 001, Himachal Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_49_20

Rights and Permissions
  Abstract 


Objective: The aim of study was to study morbidity and mortality profile of newborns admitted to Sick Newborn Care Unit (SNCU) and to assess their survival rate over a period of 3 years. Materials and Methods: It was a observational retrospective study done over a span of 3 years from January 2017 to December 2019. The case records of all neonates admitted to SNCU during this period were scrutinized. The birth weight, gestational age at birth, morbidity profile, mortality profile were noted down. Results: Main causes of admission were found to be low birth weight (LBW), Prematurity, birth asphyxia, neonatal sepsis, and neonatal hyperbilirubinemia. Prematurity accounted for 46.3%, 47.42% and 45.34% of NICU admissions over 3 years. LBW newborns accounted for 52.81%, 49.11% and 42.63% of total admissions. Neonatal hyperbillirubinemia accounted for 40.71%, 47.79% and 52.69% of total admissions. Major causes of mortality were found to be sepsis, birth asphyxia and prematurity. Sepsis was observed to be cause of mortality in 33.01%, 37.72% and 23.32% of total deaths. Prematurity and hyaline membrane disease accounted for 30.62%, 23.17% and 33.18% of total deaths. Mortality rates were found to be very high in <1000 gm weight group (71.7%, 69.2%, 68.7%) over 3 years. Severe Birth asphyxia was found to be cause in 27.76%, 33.64% and 33.63% of total deaths. There was constant decline in mortality rate in all weight groups in LBW over 3 years. Overall Survival rate of newborns admitted was found to be 90.2%. Conclusion: Our study revealed that Prematurity, LBW, birth asphyxia, neonatal hyperbillirubinemia and sepsis were major causes for SNCU admission. Sepsis, birth asphyxia and prematurity were main contributors to mortality. Survival outcome of newborns mainly LBW and preterm has increased steadily over the last three years.

Keywords: Low birth weight, mortality, neonatal intensive care unit, neonate, prematurity, sepsis, sick new-born care unit, survival


How to cite this article:
Bajaj M, Sharma J, Mahajan S, Sharma M, Sharma PK. To retrospectively review and assess the survival rate of newborns admitted over 3 years to a Newborn Intensive Care Unit at a Tertiary Care Institute in Northern India. J Clin Neonatol 2020;9:266-71

How to cite this URL:
Bajaj M, Sharma J, Mahajan S, Sharma M, Sharma PK. To retrospectively review and assess the survival rate of newborns admitted over 3 years to a Newborn Intensive Care Unit at a Tertiary Care Institute in Northern India. J Clin Neonatol [serial online] 2020 [cited 2020 Oct 27];9:266-71. Available from: https://www.jcnonweb.com/text.asp?2020/9/4/266/297003




  Introduction Top


Perinatal period is a very critical period for a neonate as perinatal mortality is influenced by prenatal, maternal, and fetal conditions and by circumstances surrounding delivery. Perinatal deaths are associated with intrauterine growth restriction and conditions that predispose the fetus to asphyxia such as placental insufficiency; severe congenital malformations (CMFs) and overwhelming early-onset neonatal infections. The major causes of neonatal mortality are prematurity, low birth weight (LBW), and congenital anomalies all over the world. Mortality is observed highest during the first 24 h after birth.

Globally, neonatal deaths account for 44% of all deaths in <5 years' age group.[1] In India neonatal mortality contributes to almost two-thirds of the infant deaths and half of the under-five deaths.[2] Current neonatal mortality rate (NMR) in India is 22.7/1000 live births.[3] Seventy-five percent of neonatal deaths occur in the 1st week of life.[3] The major causes which contribute to neonatal mortality in developing countries such as India are prematurity, low birth weight, neonatal infections, and birth asphyxia. Together, these causes account for about 78% of all deaths.[4]

Most of the causes of morbidity and mortality in the neonatal period are preventable. These can be avoided by good antenatal and obstetric care and by early interventions in neonatal period.

Posting of skilled staff, pediatricians, anesthetists, and obstetricians in secondary care hospitals and in sick new-born care units (SNCUs) has played a major role in reducing the neonatal morbidity and mortality. These SNCUs are provided with equipment such as glucometers, radiant warmers, phototherapy units, oxygen concentrators, pulse oximeters and intravenous infusion pumps, continuous positive airway pressure machines, and ventilators. Further, the aim of these SNCUs is to strengthen the skilled staff with nurse to bed ratio of 1:1.2 and doctor to bed ratio of 1:4.[5] This study was done at SNCU/new-born intensive care unit (NICU) of a tertiary care institute to assess the survival rate and mortality rate of new-borns over the past 3 years.

Objectives of the study

  1. To study morbidity and mortality profile of new-born admitted to SNCU/NICU
  2. To assess the survival rate and mortality rate of new-borns admitted to SNCU/NICU over 3 years.



  Materials and Methods Top


This study was conducted at SNCU/NICU of a tertiary care teaching institute in Northern India which acts as a referral hospital for the nearby districts of this sub-Himalayan region. This government run hospital provides maternity and new-born services in the region in addition to the high percentage of referral of high-risk pregnancies and sick new-borns from other peripheral hospitals. The case records of all new-borns (inborn/outborn) admitted to NICU and SNCU from 2017 to 2019 were scrutinized.

Study design

It was an observational retrospective study done over a span of 3 years from January 2017 to December 2019.

Data analysis

Information regarding epidemiology, clinical presentation, morbidities, and outcomes was recorded from patient's files on preformed pro forma in SNCU software. Statistical analysis was done by using Microsoft Office Excel 10.

Inclusion criteria

All live new-borns <28 days old admitted at SNCU/NICU were included in this study.

Exclusion criteria

Babies admitted after 28 days of life were excluded from the study.


  Results Top


The total number of new-born admitted year wise were 2083, 2195, and 2395 out of which majority 81.94%, 76.94%, and 83.08% were inborn [Table 1].
Table 1: Admission data of newborns in newborn intensive care unit

Click here to view


Male neonates outnumbered females every year with admission percentage of 60.39%, 60.91%, and 63.13%, respectively, for the year 2017, 2018, and 2019 [Table 2].
Table 2: Gender wise distribution of admitted newborn

Click here to view


In our study, most of the admissions 53.77%, 52.61%, and 54.66%, over 3 years belonged to >37 weeks period of gestation (POG) wise [Table 3].
Table 3: Distribution of newborn according to period of gestation

Click here to view


LBW new-borns made up for 52.81%, 49.11%, and 42.63% of total admissions [Table 4].
Table 4: Distribution of newborn according to various birth weight groups

Click here to view


Neonatal jaundice (NNJ) accounted for 40.71%, 47.79%, and 52.69% of total admissions. CMF accounted for 6.33%, 4.51%, and 3.42% of total admissions. Sepsis accounted for 6.86%, 8.47%, and 5.88% of admissions [Table 5]. Other causes such as hypocalcemia, transient tachyponea of newborn, heart disease, neonatal seizure, persistent pulmonary hypertension of newborn made up for 12%, 5.51%, and 4.75% over 3 years.
Table 5: Morbidity profile of newborn admitted to sick newborn care unit/newborn intensive care unit at the time of admission

Click here to view


Major causes of mortality were sepsis, birth asphyxia, and prematurity. Sepsis was observed to be cause in 33.01%, 37.72%, and 23.32% of total deaths. Prematurity and hyaline membrane disease (HMD) made up for 30.62%, 23.17%, and 33.18% of total deaths. Severe birth asphyxia was found to be cause in 27.76%, 33.64%, and 33.63% of total deaths [Table 6].
Table 6: Mortality profile of newborns admitted year wise

Click here to view


Highest mortality rates were observed, i.e., 48.33%, 53.20%, and 53.81% in 1–3 days' group [Table 7].
Table 7: Duration Between time of admission (days) and death

Click here to view


Highest mortality rates of 67.95%, 68.18%, and 66.36% were observed in the age group of 1–6 days [Table 8].
Table 8: Distribution of newborn according to age of newborn at death

Click here to view


LBW accounted for 70.81%, 66.36%, and 66.36% of deaths overall. <1000 g (extremely LBW [ELBW]) constituted 13.41%, 8.18%, and 9.86% of overall mortality with very high mortality of 71.79%, 69.23%, and 68.75% in 3 years in this group. 1000–1499 g (very LBW) constituted 19.61%, 20.00%, and 21.97% of total deaths with mortality rate of 22.65%, 29.13%, and 32.88% with in this group. 1500–2499 g weight group accounted for 37.79%, 38.18%, and 33.63% of total deaths with mortality of 8.97%, 10.73%, and 8.92% in this group. However, mortality in weight group >2500 g was less 6.19%, 6.6%, and 5.6% [Table 9]a and [Table 9]b.


Click here to view


[Figure 1] shows constant decline in mortality rate in all weight groups over 3 years.
Figure 1: Graph comparing survival rate (percentage) according to birth weight over 3 years

Click here to view


Preterm were observed to have more mortality than term over 3 years. Preterm (<37 weeks POG) accounted for 58.37%, 50.45%, and 55.15% of deaths [Table 10].
Table 10: Gestation wise distribution of mortality profile of neonates

Click here to view


The overall survival rate was 90.20% for 3 years. It was 89.60%, 89.97%, and 90.60%, respectively, from 2017 to 2019.


  Discussion Top


Establishment of SNCU/NICU and skilled staff is one of the active interventions to reduce NMR at every level of health care. NMR, infant mortality rate (IMR) and under-5 mortality are majorly focused indicators of child health, which have showed a dramatic decrease post 2000. After the introduction of National Health Mission, SNCU/NICU's have been established at every district hospital. Repeated training of medical officers in Neonatal Resuscitation Program (NRP), posting of pediatricians, and highly skilled SNCU staff has helped greatly in reducing NMR and IMR.

In our study, inborn new-borns were more in number as compared to outborn new-borns which can be attributed to more deliveries being conducted at our hospital as it is a tertiary care hospital and a referral unit.

The average duration of stay (inborn/outborn) in NICU was 6.3/7.3 days, 6/7.4 days,

5.8/6.4 days over 3 years, and bed occupancy rate were around 84%, 86%, and 82%, respectively.

In our study, more male new-born were admitted in both inborn and outborn admissions as compared to females. Male: female ratio was found to be 1.5, 1.5, and 1.7 over 3 years which is in accordance with studies done by Das and Debbarma, Shakya et al., and Shrestha et al.[6],[7],[8] In our culture, male preponderance may be caused by social beliefs such that male babies are provided better care by their parents and brought to the hospital even with minor complaints, but female babies are usually neglected and are managed at home even if they are very sick.

Overall, the main causes of admission were found to be LBW, prematurity and related complications, birth asphyxia, neonatal sepsis, and neonatal hyperbilirubinemia.

Our study showed that LBW form 52.81%, 49.11%, and 42.63% of admissions with decrease of about 10% in the last year which is consistent with the range of 25.8%–50.4% reported from other studies.[9],[10]

Our study showed that prematurity (<37 weeks POG) was a major cause of admissions to NICU with admission percentage of 46%, 46%, and 44% which is consistent within the range of 25.8%–50.4% as reported from other studies.[9],[10] There is fall in admission rate by 2% over 3 years due to prematurity suggesting good antenatal care.

Our study showed that neonatal hyperbillirubinemia accounted for 40.71%, 47.79%, and 52.69%, of total admissions which is higher to the incidence observed in earlier studies done by Simiyu (35%)[11] and Shakya et al. (21.97%).[7] This can be attributed to the higher incidence of NNJ in this region. Thus, NNJ is now becoming major cause of admission these days to SNCU.

Our study showed that other main causes of admission included sepsis, birth asphyxia, CMFs, and RDS (HMD) mainly. All the results were comparable with study done by Yousuf et al.[12] except sepsis which is on the lower side as compared to other studies (20%–25%). However, there is a decrease by 1% in sepsis rate over 3 years which shows better implementation of protocols in NICU.

Our study showed that the most common causes of mortality in new-borns were sepsis (pneumonia/meningitis), birth asphyxia, RDS (HMD), and prematurity in this order.

In our study, the incidence of mortality caused by sepsis was comparable to a study done by Yousuf et al.(37%),[12] whereas the percentage of mortality caused by RDS, prematurity was markedly low. This can be attributed to good antenatal care, use of antenatal steroids, institutionalized deliveries, and good neonatal care. Mortality rate attributed to sepsis has come down by 10% over 3 years.

In our study, mortality attributed to birth asphyxia was found to be higher than other studies (8%–10%) which can be explained by reason that most of labor cases present to the institute in third stage due to the hilly and remote terrains not easily accessible.

Data from the time of admission and death showed that mortality rate in first 24 h was observed to be slightly less than that of 1–3 days of admission which is similar to study done by Demisse et al., who recorded up to 50% of all neonatal deaths within first 24 h of birth and 75% by 1 week of age.[13]

Mortality data according to weight showed that overall mortality percentage in LBW was the highest in weight group of 1500–2499 g which was comparable to the study done by Bansal.[14] In ELBW group, mortality rates were very high as compared to other studies showing 21%–45% mortality. However, data show that survival rate of ELBW has increased by 3%.

Mortality rate in preterm was more than term new-born which is comparable with other studies.[15],[16]

The overall survival rates of infants admitted in NICU at our hospital were 90.2% with improvement in 2019.


  Conclusion Top


Neonatal period is the most vulnerable period for the development of morbidity and mortality. Prematurity, LBW, perinatal asphyxia, NNJ, and sepsis are the major causes for SNCU admissions and also for morbidity and mortality. SNCU with skilled staff and good infrastructure can reduce both morbidity and mortality by early interventions.

Low-birth weight and prematurity were the significant contributors to mortality. Due to good antenatal care, mortality in LBW and premature neonates has been reduced significantly Neonatal sepsis can be prevented by enforcing strict hand hygiene and aseptic protocols. Birth asphyxia is an avoidable cause. NRP training and facility based new-born care has helped markedly in reducing it.

Survival outcome of new-borns has increased steadily over the last 3 years [Figure 1] and [Figure 2] which can be attributed to the increased number of hospital deliveries, skilled staff in SNCU/NICU, and good referral services.
Figure 2: Graph showing trend of survival rate over 3 years

Click here to view


What is already known?

Prematurity, low birth weight, sepsis, and birth asphyxia were the common causes of neonatal morbidity and mortality.

What this study adds?

  1. Neonatal hyperbilirubinemia is also an important indication for admission in NICU
  2. <1000 g birth weight (ELBW) new-borns have highest mortality rates
  3. Neonatal sepsis and birth asphyxia are the two preventable causes of neonatal mortality.


Limitations

Being retrospective design, it could not give any projections of cause-specific mortality for future. About 6%–8% of new-borns left against medical advice every year. Thus, actual rate of neonatal deaths may be higher than described in this clinical study.

Acknowledgment

The authors thank all the staff of NICU and residents posted during the study period for the care provided to the neonates.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levels and Trends in Child Mortality–Report 2013. Estimates Developed by the UN Inter-Agency Group for Child Mortality Estimation. New York: UNICEF; 2013.  Back to cited text no. 1
    
2.
Anurekha V, Kumaravel KS, Kumar P, Kumar S. Clinical profile of neonates admitted to a neonatal intensive care unit at a referral hospital in South India. Int J Pediatr Res 2018;5:2.  Back to cited text no. 2
    
3.
Shah HD, Shah B, Dave PV, Katariya JB, Vats KP. A step toward healthy newborn: An assessment of 2 years' admission pattern and treatment outcomes of neonates admitted in special newborn care units of Gujarat. Indian J Community Med 2018;43:14-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Million Death Study Collaborators, Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, et al. Causes of neonatal and child mortality in India: a nationally representative mortality survey. Lancet 2010;376:1853-60.  Back to cited text no. 4
    
5.
Sharma RK, Khan R, Anjum S. Study to evaluate the functioning of special care newborn unit (SNCU) established at a District Hospital. IJBR 2017;08:514-20.  Back to cited text no. 5
    
6.
Das D, Debbarma SK. A study on clinico-biochemical profile of neonatal seizure. J Neurol Res 2016;6:95-101.  Back to cited text no. 6
    
7.
Shakya A, Shrestha D, Shakya H, Shah SC, Dhakal AK. Clinical profile and outcome of neonates admitted to the neonatal care unit at a teaching hospital in Lalitpur, Nepal. J Kathmandu Med Coll 2014;3:144-8.  Back to cited text no. 7
    
8.
Shrestha SP, Shah AK, Prajapati R, Sharma YR. Profile of Neonatal admission at Chitwan medical college. J Chitwan Med Coll 2013;3:13-16.  Back to cited text no. 8
    
9.
Omoigberale AI, Sadoh WE, Nwaneri DU. A 4 year review of neonatal outcome at the University of Benin Teaching Hospital, Benin City. Niger J Clin Pract 2010;13:321-5.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Uganda Bureau of Statistics and Macro International Inc.: Uganda Demographic and Health Survey 2006. Calverton, Maryland, USA: Uganda Bureau of Statistics and Macro International Inc.; 2007.  Back to cited text no. 10
    
11.
Simiyu DE. Morbidity and mortality of neonates admitted in general paediatric wards at Kenyatta National Hospital. East Afr Med J 2003;80:611-6.  Back to cited text no. 11
    
12.
Yousuf S, Tali SH, Hussain I. Clinical profile and outcome of neonates admitted to a secondary level neonatal intensive care unit in North India. Asian J Pharm Clin Res 2017;10:339-40.  Back to cited text no. 12
    
13.
Demisse AG, Alemu F, Gizaw MA, Tigabu Z. Patterns of admission and factors associated with neonatal mortality among neonates admitted to the neonatal intensive care unit of University of Gondar Hospital, Northwest Ethiopia. Pediatric Health Med Ther 2017;8:57-64.  Back to cited text no. 13
    
14.
Bansal A, Comparison of Outcome of Very-Low-Birth-Weight Babies with Developed Countries: A Prospective Longitudinal Observational Study. Vol. 4. Department of Pediatrics, Punjab Institute of Medical Sciences, Jalandhar, Punjab, India; 2018. p. 254-248.  Back to cited text no. 14
    
15.
Ravindra BP, Raghavendraswamy K, Shreeshail B. Clinical profile and outcome of babies admitted to neonatal intensive care unit (NICU), Mc Gann Teaching Hospital Shivamogga, Karnataka: A Longitudinal Study. Sch J App Med Sci 2014;2:3357-60.  Back to cited text no. 15
    
16.
Bhatnagar M, Jiwane N. Clinical profile and outcome of babies admitted to special newborn care unit (SNCU): Retrospective observational study. Int J Sci Res 2016;5:64-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

Top
 
 
  Search
 
Similar in PUBMED
  Search Pubmed for
  Search in Google Scholar for
Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed85    
    Printed0    
    Emailed0    
    PDF Downloaded11    
    Comments [Add]    

Recommend this journal