|Year : 2020 | Volume
| 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
Mohit Bajaj1, Jyoti Sharma1, Swati Mahajan2, Milap Sharma1, Pradeep Kumar Sharma1
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 Submission||04-Jun-2020|
|Date of Decision||09-Aug-2020|
|Date of Acceptance||20-Aug-2020|
|Date of Web Publication||01-Oct-2020|
Dr. Jyoti Sharma
Associate Professor, Department of Pediatrics, Dr Rajender Prasad Government Medical College, Tanda, Kangra - 176 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
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|| |
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. In India neonatal mortality contributes to almost two-thirds of the infant deaths and half of the under-five deaths. Current neonatal mortality rate (NMR) in India is 22.7/1000 live births. Seventy-five percent of neonatal deaths occur in the 1st week of life. 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.
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. 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
- To study morbidity and mortality profile of new-born admitted to SNCU/NICU
- To assess the survival rate and mortality rate of new-borns admitted to SNCU/NICU over 3 years.
| Materials and Methods|| |
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.
It was an observational retrospective study done over a span of 3 years from January 2017 to December 2019.
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.
All live new-borns <28 days old admitted at SNCU/NICU were included in this study.
Babies admitted after 28 days of life were excluded from the study.
| Results|| |
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].
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].
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].
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|
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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|
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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].
Highest mortality rates were observed, i.e., 48.33%, 53.20%, and 53.81% in 1–3 days' group [Table 7].
Highest mortality rates of 67.95%, 68.18%, and 66.36% were observed in the age group of 1–6 days [Table 8].
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.
[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|
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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].
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|| |
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.,, 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.,
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., 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%) and Shakya et al. (21.97%). 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. 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%), 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.
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. 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.,
The overall survival rates of infants admitted in NICU at our hospital were 90.2% with improvement in 2019.
| Conclusion|| |
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.
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?
- Neonatal hyperbilirubinemia is also an important indication for admission in NICU
- <1000 g birth weight (ELBW) new-borns have highest mortality rates
- Neonatal sepsis and birth asphyxia are the two preventable causes of neonatal mortality.
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.
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
Conflicts of interest
There are no 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], [Table 8], [Table 9], [Table 10]