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Comparison of morbidity and mortality of very low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013 BMC Pediatrics Sample (2015) 15:20 doi:10.1186/s12887-015-0337-4 Daynia E Ballot (
[email protected]) Tobias Chirwa (
[email protected]) Tanusha Ramdin (
[email protected]) Lea Chirwa (
[email protected]) Irma Mare (
[email protected]) Victor A Davies (
[email protected]) Peter A Cooper (
[email protected]) Sample
ISSN Article type
1471-2431 Research article
Submission date
11 November 2014
Acceptance date
19 February 2015
Article URL
http://dx.doi.org/10.1186/s12887-015-0337-4
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Comparison of morbidity and mortality of very low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013 Daynia E Ballot1* * Corresponding author Email:
[email protected] Tobias Chirwa2 Email:
[email protected] Tanusha Ramdin1 Email:
[email protected] Lea Chirwa1 Email:
[email protected] Irma Mare3 Email:
[email protected] Victor A Davies1 Email:
[email protected] Peter A Cooper1 Email:
[email protected] 1
Departments of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa 2
Department of Public Health, University of the Witwatersrand, Johannesburg, South Africa 3
Department of Surgery, Faculty of Health Sciences, University of the Witwatersrand, Private Bag 3, Wits, 2050 Johannesburg, South Africa
Abstract Background Health protocols need to be guided by current data on survival and benefits of interventions within the local context. Periodic clinical audits are required to inform and update health care protocols. This study aimed to review morbidity and mortality in very low birth weight (VLBW) infants in 2013 compared with similar data from 2006/2007.
Methods We performed a retrospective review of patients’ records from a neonatal computer database for 562 VLBW infants. These neonates weighed between 500 and 1500 g at birth, and were admitted within 48 hours after birth between 01 January 2013 and 31 December 2013. Patients’ characteristics, complications of prematurity, and therapeutic interventions were compared with 2006/2007 data. Univariate analysis and multiple logistic regression were performed to establish significant associations of various factors with survival to discharge for 2013.
Results Survival in 2013 was similar to that in 2006/2007 (73.4% vs 70.2%, p = 0.27). However, survival in neonates who weighed 750–900 g significantly improved from 20.4% in 2006/2007 to 52.4% in 2013 (p = 0.001). The use of nasal continuous positive airway pressure (NCPAP) increased from 20.3% to 62.9% and surfactant use increased from 19.2% to 65.5% between the two time periods (both p < 0.001). Antenatal care attendance improved from 54.4% to 70.6% (p = 0.001) and late onset sepsis (>72 hours after birth) increased from 12.5% to 19% (p = 0.006) between the two time periods. Other variables remained unchanged between 2006/2007 and 2013. The main determinants of survival to discharge in 2013 were birth weight (odds ratio 1.005, 95% confidence interval 1.003–1.0007, resuscitation at birth (2.673, 1.375–5.197), NCPAP (0.247, 0.109–0.560), necrotising enterocolitis (4.555, 1.659–12.51), and mode of delivery, including normal vaginal delivery (0.456, 0.231–0.903) and vaginal breech (0.069, 0.013–0.364).
Conclusions There was a marked improvement in the survival of neonates weighing between 750 and 900 g at birth, most likely due to provision of surfactant and NCPAP. Provision of NCPAP, prevention of necrotising enterocolitis, and control of infection need to be prioritised in VLBW infants to improve their outcome.
Keywords Infant, Very low birth weight, Premature, Neonatal mortality
Background In 2013, neonatal mortality accounted for almost 45% of deaths in children younger than 5 years of age [1]. Only 27 of 138 developing countries are likely to achieve the fourth Millennium Development Goal of reducing under-5 mortality by two thirds before 2015, and South Africa is not among these countries [2]. The neonatal mortality rate in South Africa is lower than the global average but is approximately five-fold that in some European and Scandinavian countries [2]. Preterm birth is the most important cause of neonatal mortality [3]. In 2013, complications relating to prematurity were the second largest cause of death in children younger than 5 years old, with infectious causes accounting for approximately half of these deaths [1]. Most neonatal deaths occur within the first week of life and two thirds could be prevented by provision of adequate health care [1].
To achieve the Every Newborn target of less than 10 neonatal deaths per 1000 births by 2035, the most important causes of neonatal death need to be determined [4]. Very low birth weight (VLBW) neonates (birth weight 750 g at birth with HMD who showed signs of respiratory failure. Ventilation (IPPV) was provided to those infants >900 g who showed evidence of respiratory failure on NCPAP or became apnoeic. Newborns who were below the weight cut-off were occasionally provided with support at the discretion of the attending medical staff.
Neonatal database and ethical approval Detailed information, including birth factors, therapeutic interventions, complications of prematurity, and clinical outcome, was collected upon discharge from hospital for each patient. This information was entered into a neonatal database that was maintained for the purpose of clinical audits and quality control. This database was managed using Research Electronic Data Capture tools hosted at the University of the Witwatersrand [14]. Data for each eligible VLBW patient were obtained from the computer database and analysed. Each case was de-identified for the purpose of confidentiality. Ethical approval for the study was obtained from the Human Research Ethics Committee of the University of the Witwatersrand.
Definitions Standard definitions as per the VON [10] were used. NEC was considered as modified Bell’s stage 2 or 3 [15] and peri-intraventricular haemorrhage (IVH) was classified using Papile’s staging [16]. At the time of the study, the neonatal unit of the CMJAH did not submit data to the VON. Maternal HIV referred to mothers who were HIV positive and not necessarily those on anti-retroviral treatment or those who had AIDS. Chorioamnionitis was defined as premature and/or prolonged rupture of the membranes, fever, and foul-smelling liquor in mothers. Neonates were considered to be small for gestational age if the birth weight was below the 10th percentile on the Fenton growth charts [17]. Resuscitation at birth was defined as the need for bag mask ventilation, chest compressions, or intubation and ventilation. Severe IVH was considered to be either grade 3 or 4. Sepsis was classified as culture-proven bacterial or fungal sepsis only; suspected sepsis or clinical sepsis was classified as no sepsis. Birth defects were defined as life-threatening anomalies at birth. Respiratory failure was defined as oxygen saturation below 88% in 60% supplemental oxygen, respiratory acidosis (pH 60 mmHg), or clinical marked respiratory distress. Ventilatory support referred to the most invasive level each neonate received (i.e., those who were treated with both NCPAP and IPPV were classified in the IPPV group). Neonates who were transferred out to regional hospitals for KMC were classified as survivors.
Statistical analysis Statistical analysis was performed using SPSS (IBM Corp released 2013 IBM SPSS Statistics for Windows Version 22.0, Armonk NY). Data are described using standard statistical methods. Frequency tables and percentages with 95% confidence intervals were used for categorical variables. Continuous variables (normally distributed) are summarised using mean and standard deviation (SD). Results are reported as mean (±SD). Obstetric and labour room information is reported per neonate (not per mother) to allow for multiple pregnancies and to concur with the aim of the study. Univariate analysis was performed using cross tabulations with the chi square test to compare categorical variables. Continuous variables were normally distributed and thus compared using unpaired t-tests. A p value less than 0.05 was considered significant. Various demographic and birth factors, complications of prematurity, and therapeutic interventions were compared between 2006/2007 and 2013. Ventilatory support was different among the various birth weight categories. Therefore, neonates were stratified into weight groups as follows: 750 g and in surfactant use in all weight categories between 2006/2007 and 2013. There was a marked increase in the use of NCPAP and surfactant between 2006/2007 and 2013. Significantly fewer neonates with HMD received NCPAP and were provided with surfactant in 2006/2007 than in 2013 (both p < 0.001). Most neonates who were treated with NCPAP (94.6%; 335/354) received surfactant therapy. There was also a significant increase in late onset sepsis from 12.5% in 2006/2007to 19% in 2013 (p = 0.006). One neonate was discharged home on oxygen.
Table 2 Complications of prematurity and therapeutic intervention for VLBW infants who were admitted to the CMJAH Variable HMD Surfactant IPPV NCPAP PDA Ligation of Patent Ductus Arteriosus (PDA) Blood Transfusion Late onset sepsis NEC NEC surgery Other surgery Pneumothorax Severe IVH Cystic periventricular leukomalacia (PVL) Severe ROP Discharged on human milk feeds *percentage of babies screened. **percentage of those discharged.
2013 (Total 562) Number (%) [95%CI] 470 (83.6)[80.3 – 86.5] 368 /470 (78.3)[74.4 – 81.8] 98/470 (20.9) [17.4 – 24.8] 354/470 (75.3) [71.2 – 79.0] 54 (9.6) [7.4-12.3] 3 (0.5) [0.18- 1.5] 146 (26) [22.8 – 29.8] 107 (19) [16 – 22.5] 41 (7.3) [5.4 – 9.8] 10 (1.8) [0.97 – 3.3] 11 (2.0) [1.1 – 3.4] 4 (0.7) [0.28 – 1.8] 22/297 (7.4)*[4.9 – 11] 2 /297(0.6)* [0.12 – 2.7] 3/144 (2.1)* [0.71 – 5.9] 126/413 (30.5)** [26.3 – 35.1]
2006/2007 (Total 463) Number (%)[95%CI] 295 (63.7) [59.2 – 68] 89/295 (30.2)[25.2-35.6] 97/295 (32.9) [27.8 – 38.4] 94 /470(31.9) [26.8 – 37.4] 26 (5.6) [3.9 – 8.1] 106 (22.9) [19.2 – 26.6] 58 (12.5) [9.1 – 16.6] 26 (5.6) [3.7 – 7.8] 20 / 321(6.0)* [3.9 – 9.1] 4 /321(1.2)* [0.3 – 2.5]
P Value
