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Indian Pediatr 2013;50: 1088-1089 |
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Predictors of Mortality and Morbidity in
Extremely Low Birth Weight Neonates
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Eric C Eichenwald
Professor and Chair, Department of Pediatrics,
University of Texas Health Science Center, Houston, Texas, USA.
Email:
[email protected]
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I n this issue of Indian Pediatrics,
Mukhopadhyay and colleagues [1] report predictors of mortality and
morbidity in extremely low birth weight infants (ELBW) in a single
teaching hospital in India.
In a prospective analysis of 255 ELBW, > 23 weeks gestation infants, 149
infants with a mean gestational age of 29 (+2.6) weeks received
intensive care. Infants were not offered intensive care due to limited
resources, either because of lack of bed availability or inadequate
parental finances. Their unit protocols included most of the newer
evidenced-based therapies for this population, including early CPAP,
rescue surfactant, and early trophic feedings [2,3].
The incidence of death or major morbidity in this
cohort was high – almost half the babies provided intensive care died,
and 39% suffered major morbidities, the majority of which were severe
intraventricular hemorrhage. It is not clear from the report what the
incidence of major morbidity was amongst the survivors, an important
statistic to assess future resource utilization and social impact. Not
surprisingly in the analysis, birth weight < 800 grams, shock and the
need for mechanical ventilation predicted the risk of death. Birth
weight < 800 grams, lack of antenatal steroids, asphyxia, and mechanical
ventilation (all identified risk factors for intraventricular hemorrhage)
predicted major morbidity. Of particular note, small for gestational age
status, a fairly common finding in the cohort, was the most protective
against death, with an odds ratio of 0.39 (95% CI: 0.19 – 0.75).
So, what are the lessons of this report? In quality
improvement science, the old adage is "you can only manage what you
measure". Understanding local outcomes and risk factors for death or
morbidity is essential for protocols to improve care in both resource
rich and limited settings. While it is hard to know whether results from
this academic center are generalizable to the larger Indian perspective,
there do appear to be some more universal lessons. Only 22% of surviving
infants were < 28 weeks gestation, while representing over half
of those who died. These results suggest that resources and clinical
improvement efforts should be first devoted to larger, more mature
infants in whom the likelihood of mortality and major morbidity is much
less. It is important for the clinician to recognize that, as shown by
the data presented that the premature newborn < 28 weeks gestation who
requires prolonged mechanical ventilation is likely not to survive. In
contrast, the gestationally older baby who can be managed successfully
on CPAP has a higher likelihood of a good outcome. What clinical
improvements might influence better outcomes in these babies?
Antenatally, programs to promote increased administration of antenatal
glucocorticoids in a woman threatening to deliver preterm would likely
have a large impact as has been shown in developed countries. The
authors of the current report should be commended since almost three
quarters of women whose babies were admitted to intensive care did
receive steroids, though this proportion is likely to be much less
outside of the academic setting. If possible, establishing structures
and processes to shorten time to transfer to intensive care (10 hours in
this study), may also improve outcomes. It is likely that many of the
complications observed in this study (e.g. intraventicular hemorrhage,
asphyxia) might be influenced by this long interval to intensive care
via cold stress and delay in establishing adequate respiratory support.
Alternatively, programs to train local personnel in basics of
resuscitation, provision of warmth, and simple mechanisms to provide
CPAP support to preterm infants in respiratory distress would be
reasonable local goals [4,5]. Lastly, the incidence of sepsis was very
high in this cohort. It is likely that this represents both early and
late onset sepsis, for which there are established, low cost strategies
for prevention [6]. As has been observed in NICUs in resource rich
environments, attention to hand hygiene and umbilical and central line
care can have a significant impact on NICU acquired infections [7].
Clinical quality improvement is a journey, not a
destination. Understanding what we do, how we do it, and what our
outcomes are is a start – the next phase is what we need to do to move
the bar forward. This report is an excellent starting point.
Competing interests: None stated; Funding: Nil.
References
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Predic-tors of mortality and major morbidities in extremely low birth
weight neonates. Indian Pediatr. 2013;50:1119-23.
2. Lopez E, Gascoin G, Flamant C, Merhi M, Tourneux
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2013;13:165.
3. SUPPORT Study Group of the Eunice Kennedy Shriver
NICHD Neonatal Research Network, Finer NN, Carlo WA, Walsh MC, Rich W,
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