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Brief Reports Indian Pediatrics 2003; 40:991-995 |
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Maternal and Neonatal Profile and Immediate Outcome in ELBW Babies |
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Arvind Sehgal, Sucheta Telang, S.M. Passah and M.C. Jyothi From the Division of Neonatology, Department of Pediatrics, Lady Hardinge Medical College and Associated Smt. Sucheta Kriplani, and Kalawati Saran Children’s Hospital, New Delhi 110 001, India. Correspondence to: DR. Arvind Sehgal, c/o Dr. S.S. Verma, PO BOX 2025, Berala, New South Wales, 2141, Australia. E-mail: [email protected] Manuscript received: March 26, 2002, Initial review completed: July 22, 2002; Revision accepted: May 8, 2003. Abstract:
Babies weighing less than 1000 grams at birth comprise a unique subclass of the neonatal population. Although these infants constitute less than 1% of all live births, they occupy most neonatal care beds and spend longest time in nursery, consuming large amounts of hospital resources. There has been a dramatic increase in survival rates of this population from a dismal 10% to 50-60%(1). The purpose of this study was to analyze the maternal and neonatal demographic and clinical profile of pre-term infants less than 1000 grams birth weight in our nursery and assess their immediate outcome. Realizing that survival in these newborns is improving, the limits of viability may be redefined, since data relating to profile and outcome of extremely low bith weight (ELBW) babies from developing tropical countries is scarce. Subjects and Methods The study was conducted at the Neonatal Intensive Care Unit of the Smt. Sucheta Kriplani Hospital, New Delhi, India, which is a well-equipped unit with facilities for mechanical ventilation and parenteral nutrition. Approximately 15000 deliveries take place at the center annually. Only inborn babies with no sepsis risk factors in mother are admitted in this unit. The study population comprised of consecutive live births weighing between 500-1000 grams at birth, delivered over a period of twelve months between August 2000 and 2001. It was designed as a retrospective analysis of case records of all ELBW babies admitted during the study period. The following maternal data was analyzed: parity, antenatal care status, incidence of anemia, pregnancy induced hypertension (PIH), antepartum hemorrhage (APH), previous pre-term delivery, drug intake during pregnancy etc. The gestational age of the babies was determined by a combination of mother’s expected date of confinement and physical and neurological examination of the newborn using New Ballard Scoring. Neonatal profile was assessed for various diseases typical to this population and their respective manage-ment. Feeding practices were evaluated and duration of stay in survivors and causes of death in non-survivors was recorded. Indirect ophthalmoscopy with cycloplegic refraction was performed by the ophthalmologists for screening for retinopathy of prematurity (ROP). Continuous variables are expressed as mean ± S.D. Significance was tested using Chi square test and Student’s ‘t’ test wherever applicable and P values greater than 0.05 were considered non-significant. Results During the study period, a total of 52 ELBW babies were born alive of which 28 were males and 24 females. All of them were admitted to the neonatal intensive care unit. The overall survival rate was 57% (30/52) and about half the deaths took place within 48-72 hours of birth. Mortality was higher in females as compared to males (58% vs 28%) (P<0.05). The overall mean gestational age was 27.8 ± 3.1 weeks (range 26-33 weeks), while in survivors and non-survivors it was 28.5 ± 3.8 and 27.0 ± 2.9 weeks respectively (P >0.05). The overall mean birth weight was 831±160 grams (range 675-1000 grams) while in survivors and non-survivors it was 870±121.4 and 780±140 grams respectively (P<0.01). Sixty three per cent babies were small for gestational age (SGA) while the rest were appropriate for gestational age (AGA). The highest mortality was seen in babies less than 28 week gestation and those weighing less than 800 grams (55%). Forty four percent mothers did not receive adequate antenatal care (ANC) and babies born to them had unfavorable outcome (mortality 14/23,60%) as compared to those with optimal antenatal care (8/29, 27%, P<0.01). Antenatal steroids were given to 15 mothers. Amongst maternal risk factors, anemia (taken here as Hb < 10 g/dL) was the commonest (65%) followed by previous pre term delivery. Table I shows the various maternal risk factors present in our study. Table I Infant Birth Data and Maternal Risk Factors for Pre-maturity
*Includes 4 twins, 1 triplets and 1 quadruplets. ** RHD= 2,Uncontrolled diabetes =1,Trauma=1, Drugs (clomiphene =1). Hb= Hemoglobin, ANC = Antenatal care, PIH = Pregnancy induced hypertension, BP= Blood pressure.
Detailed description of neonatal morbidity is presented in Table II. Fourteen babies underwent exchange transfusions and two of them developed features of kernicterus. Seven babies had blood culture proven sepsis and Klebsiella species were the commonest to be isolated. Two babies were oxygen dependent for more than 28 days. Twenty-five babies were mechanically ventilated out of which ten survived. Twenty-four (46%) babies were given parenteral nutrition with dextrose solutions (8%-12%) and amino acid infusions (1 to 2.5 g/kg/day). In most babies, enteral feeds were started between 3rd and 7th day after birth. Majority of the babies took more than four weeks to reach full feeds (~200mL/kg/day), median 33 days (range 17-44 days). Most (80%) were fed with both EBM and formula, through infant feeding tube, till sucking and rooting reflexes were well established. The discharge weight in majority of the survivors was between 1500 grams and 1550 grams (median 1530 grams, range 1400 to1640 grams), while the average weight gain was ~16 grams /day. The mean duration of hospital stay was 34 days (range 25 to 43 days). The most common immediate cause of death was respiratory failure. HMD (63%), sepsis (32%), IVH/ICH (27%), pulmonary hemorrhage (18%) and NEC (9%) were the main contributors to mortality (with multiple causes in some). ROP screening could be done in 35 of the 52 babies during their stay in nursery and was normal in 22 of them. The incidence of ROP was highest in babies of less than 28 weeks gestation (71%) and those weighing less than 800 grams at birth (62%). Table II Clinical Profile of ELBW Neonates.
HMD=Hyaline membrane disease, RDS=Respiratory distress syndrome, ICH/IVH=Intracranial/intraventricular hemorrhage, A/S=Apgar score, ICROP=International Classification of Retinopathy of Prematurity.
Discussion The survival rate in our study is comparable to other similar studies (1, 2) though there are few reports of ~70 % survival(3). In a recent Indian study(4) on very low birth weight (VLBW) babies (<1.5 kg), 17% mortality was reported, majority being less than one kg(4). Gender difference in our study favored males, which was in contrast to another study(5), which had reported both improved survival and decreased neuro-developmental morbidity in girls as compared to boys. Gestational age and birth weights in survivors was higher as compared to non-survivors while the overall values of these variables were similar to an earlier study(6). The increase in survival from 45% at 26 weeks to 75% at 32 weeks is reflective of the fact that those with higher gestational age and growth retardation had more mature organs and were better equipped to withstand the transition from intrauterine to extrauterine life. These findings are in conformity to work previously reported(7,8). Those born to mothers with inadequate ANC had a higher risk of having an unfavorable outcome. Amongst the Indian population, a very high incidence of maternal anemia has been noticed and is a known cause of prematurity and growth retardation. Neonatal compli-cations in our study were typical of what would be expected in the ELBW group. The high incidence of neonatal jaundice and HMD/RDS is comparable to previous data(9). Major contributors to mortality were respiratory insufficiency due to HMD, pulmonary hemorrhage and ICH, as has been the finding of previous studies(10). Gestational age and clinical condition of the baby determined initiation of feeds. These were initiated in hemodynamically stable babies, to prevent NEC, beginning with "trophic feeding". All efforts were made to give expressed breast milk; otherwise special low birth weight formulas were given. Non-nutritive sucking at the breast was initiated gradually and with increasing maturity; feedings with a special utensil called "palade" were started. With these practices, an average weight gain of ~16 grams per day was achieved which concurs with the expected intra-uterine accretion rate of ~15 gm/kg/day. The mean duration of stay of survivors and discharge weight was quite low mainly because we discharge babies at a lower weight, due to limited availability and pressing requirements for beds at NICU. The discharged infants receive follow up from a multi-disciplinary team to monitor growth, neurologic status, vision (ROP screening) and hearing (BERA analysis). ROP was detected in about 1/3rd of those screened. In previous studies on similar populations(6) the incidence has ranged from 23-40%. Although about 60% babies received antibiotics during their stay in the nursery, culture proven sepsis was documented in 13 % cases of which Klebsiella species were the commonest. The incidence of sepsis in other studies has ranged from 20%-30%(1,8). These studies had included babies in whom maternal risk factors for sepsis were present while the present study had excluded such cases. In our institution, outborn babies and those inborn but with maternal sepsis risk factors like prolonged rupture of membranes >18 hours, maternal pyrexia ³ 38ºC, unclean vaginal examination, loose motions etc. are admitted in a separate neonatal set up. The authors admit the unintended bias regarding this aspect. These results represent the period when exogenous surfactant therapy was not being used in the unit, the main limiting factor being the cost involved. There is dearth of scientific data on this subgroup of neonates from our country. The predominant population in our study was of small for gestational age babies, had lower survival rates, were predominantly fed on breast milk, and were discharged early with lower discharge weights. This is quite different from the spectrum that is prevalent in the developed world. A comprehensive compilation of data from multiple centers win India would give a real picture regarding the status of these newborns in our country. Contributors: AS and SMP designed the study, AS did the data collection, AS, SMP, ST analyzed results, AS, MCJ, ST drafted and edited the manuscript. AS will be the guarantor of the study. Funding: None. Competing Interest: None stated.
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