Study of Neonatal Morbidity and Mortality in Very Low Birth Weight Neonates admitted in Neonatal Intensive Care Unit in a Tertiary Care Centre

A Dissertation on

STUDY OF NEONATAL MORBIDITY AND MORTALITY

IN VERY LOW BIRTH WEIGHT NEONATES

ADMITTED IN NEONATAL INTENSIVE CARE

UNIT IN A TERTIARY CARE CENTRE

Dissertation submitted to

COIMBATORE MEDICAL COLLEGE COIMBATORE

in Partial fulfillment of the regulations for the award of the degree of M.D.PEDIATRIC MEDICINE

BRANCH

THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY CHENNAI- 600 032

CERTIFICATE

Certified that this dissertation entitled “STUDY OF NEONATAL MORBIDITY, MORTALITY IN VERY LOW BIRTH WEIGHT NEONATES ADMITTED IN NEONATAL INTENSIVE CARE UNIT IN A TERTIARY CARE CENTRE” is a bonafide work done by Dr. ABINAYA. G, M.D Post graduate student of Pediatric Medicine , Coimbatore Medical College & Hospital , Coimbatore – 641 018 during the

academic year 2016 – 2019.

Prof.Dr.V. Booma MD Professor and HOD of Pediatrics,

CERTIFICATE – II

This is to certify that this dissertation work titled “STUDY OF NEONATAL MORBIDITY, MORTALITY IN VERY LOW BIRTH WEIGHT NEONATES ADMITTED IN NEONATAL INTENSIVE CARE UNIT IN A TERTIARY CARE CENTRE” of the candidate Dr.ABINAYA. G, M.D with registration Number 201617301 for the award of

M.D Paediatrics, is personally verified by me from the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion 79 pages and result shows 3 % of plagiarism in the dissertation.

DECLARATION

I declare that this dissertation entitled “STUDY OF NEONATAL MORBIDITY AND MORTALITY IN VERY LOW BIRTH WEIGHT NEONATES ADMITTED IN NEONATAL INTENSIVE CARE UNIT IN A TERTIARY CARE CENTRE” has been conducted by me at NICU, Department of Pediatrics, Coimbatore Medical College and Hospital, under the guidance and supervision of my guide Prof.Dr.A.LAKSHMANASWAMY M.D., Dch., It is submitted in part of fulfillment of the award of the degree of M.D.Pediatrics for the MAY 2019 examination to be held under The Tamil Nadu Dr.M.G.R. Medical University, Chennai. This has not been submitted previously by me for the award of any degree or diploma from any other university.

ACKNOWLEDGEMENT

My sincere thanks to Prof.Dr.B.ASOKAN.M.S.Mch., DEAN, Coimbatore Medical College Hospital for allowing me to do this

ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to Prof.Dr.V.Booma MD, Professor of Pediatrics, Coimbatore Medical College and Hospital for permitting me to undertake this study and for her guidance, invaluable help, encouragement and support throughout the study.

I am extremely thankful to Prof. Dr. A.Lakshmanaswamy MD.DCh, Prof.Dr.M.Geethanjali, MD.DCh, Prof. Dr. D. Rajkumar, M.D., for their guidance, encouragement and support throughout the study.

I would like to thank our Registrar, Dr.B.R.Sasi Kumar,MD.DCh., for his valuable guidance and support in doing this study.

I extend my sincere thanks to Assistant Professors Dr.N.Kumar MD, Dr.M.Senthil kumar.MD, Dr.A.Umashankar, Dr.P.Thiyagarajan.MD.Dch, Dr.A.Uma Maheswari.MD, Dr.S.Jayaprakash.MD,Dr.C.Karthikeyan,M.D, Dr.P.Senthil kumar.MD.DM, Dr.V.K.Sathyan.MD.DM, Dr.C.Suganya M.D. for their invaluable suggestion, help and support throughout the study.

I sincerely thank Mr.JOSHVA ALLEN SHEPHERD, for helping me in statistical analysis.

I sincerely thank all the parents of the neonates who gave consent to include their neonates in this study.

ABBREVIATIONS

VLBW - Very low birth weight

NNH - Neonatal hyperbilirubinemia

WHO - World health organization

GA - Gestational age

NICU - Neonatal intensive care unit

IVH - Intraventricular hemorrhage

HMD - Hyaline membrane disease

AAP - American association of pediatrics

NRP - Neonatal resuscitation program

PDA - Patent ductus arteriosus

NEC - Necrotising enterocolitis

AOP - Apnea of prematurity

SGA - Small for gestation

AGA - Appropriate for gestation

IUGR - Intrauterine growth restriction

RDS - Respiratory distress syndrome

GDM - Gestational Diabetes mellitus

PROM - Premature rupture of membranes

PIH - Pregnancy induced hypertension

CONTENTS

SL.NO TITLE PAGE NO:

1. INTRODUCTION

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2. AIM & OBJECTIVES

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5. METHODOLOGY

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6. OBSERVATION & RESULTS

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7. DISCUSSION

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8. CONCLUSION

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9. RECOMMENDATIONS

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10. BIBLOGRAPHY

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11. ANNEXURE

PROFORMA

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CONSENT FORM

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1

INTRODUCTION

Prematurity (Gestational age (GA) < 37 weeks) is the major cause

of morbidity in neonates especially very low birth weight (VLBW)

neonates.

The WHO defines Very low birth weight neonates as birth weight

less than 1500g at birth irrespective of gestational age.

Birth weight is the most important determinant of perinatal,

neonatal and postnatal outcomes. It is dependent on the length of the

gestation and the intrauterine growth of the fetus.

The Incidence of VLBW babies is less than 2 % of the births

globally. In India, VLBW babies constitute 4 % to 7 % of live births and

approximately 30 % of Neonatal death. The VLBW rate is an accurate

predictor of the infant mortality rate. VLBW infants account for more

than 50% of neonatal death.

Neonatal mortality rate is an important contributing factor for

underfive mortality rate. Out of the 26 lakh neonatal deaths occurring

2

Figure 1 shows birth weight specific neonatal mortality in united states, 1950, 1985 and 2008.

The main reason for increasing morbidity & mortality in VLBW

neonates is due to their physiologic & metabolic immaturity. These

neonates are prone for increased risk of hypoglycemia, jaundice, infection

& re-hospitalization during their neonatal period. VLBW is one of the

most serious challenges in Maternal and Child Health in developing

3

Nearly half of neonates who survive to hospital discharge have

complications later which will affect the quality of their life.

Despite improvement in the neonatal care & facilities, neonatal

mortality remains high particularly in the developing countries.

By studying the factors associated with neonatal death, morbidity

& mortality in VLBW neonates can be reduced.

Hence my study will help to identify the factors contributing to the

morbidity and mortality in very low birth weight neonates admitted in

NICU. Necessary steps can be taken to reduce mortality in VLBW

neonates.

This kind of study has not been done in our hospital so far and it

4 CAUSE OF PRETERM BIRTH: FETAL

 Fetal distress

 Multiple gestation

 Erythroblastosis

 Non immune hydrops

PLACENTAL

 Placental dysfunction

 Placenta previa

 Abruptio placenta

UTERINE:

 Bicornuate uterus

 Incompetent cervix (premature dilation)

MATERNAL

 Pre eclampsia

5

 Infection( Listeria monocytogenes, group B streptococcus, urinary

tract infection, bacterial vaginosis, chorioamnionitis)

 Drug abuse

OTHERS

 Premature rupture of membranes

 Polyhydramnios

 Iatrogenic

 Trauma

PROBLEMS IN PREMATURE LOW BIRTH WEIGHT NEONATES RESPIRATORY SYSTEM:

- Respiratory distress syndrome

- Broncho pulmonary dysplasia

- Pneumothorax

- Congenital Pneumonia

- Apnea

CARDIOVASCULAR SYSTEM:

- Patent ductus arteriosus

- Hypotension

6 HEMATOLOGICAL

- Anemia

GASTROINTESTINAL SYSTEM:

- Poor gastro intestinal function

- Necrotizing enterocolitis

- Hyperbilirubinemia

METABOLIC:

- Hypocalcaemia

- Hypoglycemia

- Hypothermia

CENTRAL NERVOUS SYSTEM:

- Intraventricular hemorrhage

- Periventricular leukemia

- Seizures

- Retinopathy of Prematurity

- Deafness

7 RENAL:

- Hyponatremia

- Hypernatremia

- Hyperkalemia

- Renal tubular acidosis

- Edema

8

AIM & OBJECTIVES

To study the morbidity and mortality profile in very low birth

weight neonates in Neonatal Intensive Care Unit in Coimbatore Medical

College Hospital.

OBJECTIVES

1) To study the morbidity and mortality pattern in very low birth

weight neonates.

2) To study the maternal risk factors leading to very low birth

weight neonates.

3) To establish targeted preventive and advanced treatment

strategies in specific areas.

4) To plan for future research in areas of increased admission and

9

JUSTIFICATION OF THE STUDY

In recent trends, there is increasing number of babies born with

very low birth weight. These VLBW babies are at risk of developing

Hypoglycemia, Sepsis, Hyperbilirubinemia, Respiratory distress when

compared to term babies. By studying the risk factors leading to very low

birth weight and their morbidities, health professionals will be able to

anticipate and manage them accordingly. As a result, we will be able to

prevent complications in these neonates.

Identification of morbidity and mortality in VLBW neonates will

help us in formulating and implementing interventions to reduce neonatal

10

REVIEW OF LITERATURE

Jaiswal et al2., has done a prospective cohort study to compare early neonatal morbidity (Within 7 days of life) in late preterm infants

with term infants. This study was conducted at the Fernandez hospital,

Hyderabad. 363 of late preterm infants and 2707 of term infants were

included in the study. 257 (70.8 %) of late preterm and 788 (29.1%) of

term infants had requiring inpatient morbidities admission within first 7

days of life. Neonatal jaundice requiring phototherapy (55.1%) followed

by respiratory morbidity (10.5%) and hypoglycemic (8.8%) were the

frequent identified morbidities in late preterm infants, while neonatal

Jaundice (24.8%) was the most frequently identified morbidity in term

infants. Compared with term infants, late preterm infants were at 5.5

time’s higher risk for over all morbidity. Cesarean delivery, IUGR and

multiple pregnancy status significantly Contribute to neonatal

morbidities.

Schindler et al3., did a retrospective analysis of prospectively collected data of all 10 NICU’s in New South Wales and Australian

Capital Territory. All Live born infants less than 32 weeks gestation

11

The most common cause of death across all gestational groups was major

IVH followed by Acute Respiratory Illness and Sepsis.

Kabilan et al4., did a cross sectional retrospective study at level three SNCU between October 2016 and September 2017 in Govt. Stanley

medical College, Chennai, Tamil Nadu. There were 154 VLBW infants

registered. 75 Females (48.7%) and 79 (51.3%). Majority of them were

in the gestational age 33-36 weeks (n=68, 44.2%), small for gestational

age (n=89, 57.8), delivered through normal vaginal delivery(n=95,

61.7%),maternal age 21-30 (n=95, 61.6%), on antenatal steroids (n=59,

38.3%), maternal disease were present in 55 mothers (33%) and

gestational hypertension being more common (n=14, 9.6%). The mean

birth weight is 1.198 (SD= 0.211). The mean gestational age in weeks

was 31.9(SD= 3.095). This study reveals that birth weight and

mechanical Ventilation are the 2 major factors responsible for mortality

in VLBW babies. Major cause of morbidity was RDS (n=56, 33.6%),

birth asphyxia (n=54, 32.4%) and Sepsis (n=46, 27.6%). Mortality of

40.3% (n=62) observed in this study. Most of the death occurred due to

12

Ghulam Nabi Rather et al5., done a prospective study in the Department of Pediatrics and Neonatology at G.B. Pant General Hospital,

from April 2012 to March 2013. This was undertaken to study the

incidence, early neonatal morbidity and mortality in late preterm infants

(34-36 6/7 weeks). A total of 4100 neonates were included in the study.

Incidence of late preterm neonates was 11.58%.365 (76.8%) late preterm

neonates and 965(28.3%) term neonates were admitted. Compared with

term infants, late preterm infants were at significantly higher risk for

Sepsis, Jaundice, Hypoglycemia, Mechanical Ventilation and Perinatal

Asphyxia. Jaundice (41.6% compared to 15.3%), Hypoglycemia (16%

compared to 6.5%), Respiratory morbidities (11.2% compared to 2.1%),

sepsis (4.8% compared to 1.53%), Perinatal asphyxia (2.9% compared to

1.9%) were all significantly higher in late preterm babies as compared to

term babies. Early neonatal mortality in late preterm neonates was 2.5%

or 25/1000 live births.

Rasania M et al6 had done a retrospective cohort study using previously collected data from neonates who were admitted at SNCU of

Dhiraj hospital, Gujarat, India between January 2015 to December 2015.

It was done to study the morbidity profile and immediate outcome of late

13

168 late preterm and 1025 term neonates were included in the

study. Of 122 late preterm admitted in SNCU, 16.39% had birth

asphyxia, 28.6% had sepsis, 7.37% had RDS and 32.78% had

hyperbilirubinemia. Morbidities were relatively higher in out born late

preterm neonates. Need for respiratory support was significantly higher in

moderate preterm compared to late preterm (47.8% versus 5.95%).

Thapar K et al7., has done a study about morbidity and mortality of very low birth weight babies in a tertiary level NICU. It was an

observational study and conducted in NICU of SGRDIMS&R, Amritsar,

over the period of 18 months (1st October 2013 to 31st march 2015). A total of 75 VLBW infants were observed during this period and neonatal

outcome was assessed.

Sepsis (77.3%) was the major cause of morbidity in VLBW

neonates followed by HMD (66.7%) and Jaundice (65.3%). Sepsis along

with other factors play an important role in neonatal mortality (p=0.083).

Out of the total nine mortality, three cases were associated with IVH (p

value< 0.001). Pneumothorax was an associated factor in three cases (p

value <0.001). Sepsis, HMD, metabolic complications like hypoglycemia

14

Another study8 was conducted at the University Hospital of the Institute of Medical Science, Banaras Hindu University, India over a

period of three years. It was a retrospective cohort study and its objective

was to determine the Pediatrics of mortality in VLBW neonates. A total

of 260 VLBW newborn were enrolled. 96 babies (36.9%) died. Survival

rate increased with increase in birth weight and gestational age. Perinatal

asphyxia, Apnea, neonatal sepsis and shock are the factors directly

responsible for neonatal mortality. The presence of maternal bleeding and

failure to administer steroids to the mother when premature delivery is

anticipated are the antenatal predictors of mortality.

Sangamam et al9. conducted a cross sectional study to assess the perinatal morbidity and mortality among low birth weight babies and to

determine the associated maternal health and socio demographic factors.

This study was done in KMCT medical college, Kerala. All the babies

with birth weight > 1000 g but less than 2500 g and their mothers were

included in the study. A total of 1002 low birth weight babies, 982

mothers were included in the study. Very low birth weight babies < 1500

g had 10 times more mortality rates when compared to babies with birth

weight between 1.5- 2.5 kg. Preterm and growth restricted babies had the

worst perinatal outcomes. The most common perinatal complication was

15

Hyaline membrane disease (14.86 %). The most common maternal

complications associated with LBW were anemia (43.36%) and

hypertensive disorders of pregnancy (17.6%).

There were 49 early neonatal deaths accounting to 5.29% of live

babies. The major causes of neonatal death were hyaline membrane

disease (3.56%) and birth asphyxia (1.11%).

Ballot et al10 conducted 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. This study aimed to review morbidity and mortality in very low

birth weight (VLBW) infants in 2013 compared with similar data from

2006/2007. 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). The main

determinants of survival to discharge in 2013 were birth weight (odds

16

(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). The major cause of mortality was Extreme prematurity

17

METHODOLOGY

STUDY DESIGN:

Prospective Cohort Study

STUDY PLACE:

Neonatal Intensive care unit, Coimbatore Medical College

Hospital.

STUDY POPULATION:

All VLBW neonates admitted in Neonatal Intensive Care Unit.

STUDY PERIOD:

January 2017 – December 2017.

SELECTION CRITERIA: Inclusion Criteria:

All very low birth weight neonates admitted in NICU between

January 2017 to December 2017.

Exclusion Criteria:

1. Neonates with major congenital anomalies.

18

All VLBW neonates were included in the study after getting

written informed consent from the parents for using their neonates’

clinical data for the study purpose. Ethical committee clearance were also

obtained.

All VLBW neonates admitted in our NICU were enrolled in the

study. Relevant details were collected which includes maternal details

like their age , address , socioeconomic status, educational status,

maternal weight, risk factors (Hypertension, Anemia, Gestational

Diabetes mellitus, Multiple gestation, Chronic medical illness,

Hypothyroidism, HIV status, Hepatitis B, Maternal fever), order of birth,

gestational age , Antenatal steroids, premature rupture of membranes,

mode of delivery and Baby’s details include their sex, need of

resuscitation, Apgar score, gestational age, birth weight and their illness ,

need of mechanical ventilation and surfactant therapy were recorded.

ROUTINE CARE IN DELIVERY ROOM:

Low risk neonates may initially be placed on mother’s abdomen

after delivery. Secretions from mouth can be cleared using a bulb syringe

or soft catheter. Spontaneously breathing neonates with no distress do not

need any assisted method to clear their airway. Delayed clamping of cord

19

Apgar score is a routine method of systematically assessing

newborn infants immediately after birth. It was not designed to predict

the neurological outcome. The incidence of cerebral palsy is low in

neonates with Apgar scores of 0-3 at 5 minutes, but higher than in infants

with Apgar scores of 7-10. Low Apgar score and umbilical artery blood

pH predict neonatal death.

APGAR SCORING11

20 Need for Resuscitation at birth:

- Resuscitation is carried out based on NRP Protocol.

- Apgar at 1st and 5th minute of birth.

- Need for PPV / Chest compression.

- Temperature regulation is the foremost goal.

22 Thermoneutral environment (TNE)

TNE refers to a narrow range of environmental temperature at

which the basal metabolic rate (BMR) of the baby is at a minimum,

oxygen consumption is at least and baby maintains its normal body

temperature is called thermoneutral range of temperature.

Warm chain:

The warm chain is a set of ten interlinked steps carried out at birth and

later which will reduce the chances of hypothermia in all newborns

1. Thermal care in delivery room

2. Warm resuscitation

3. Immediate drying

4. Skin to skin contact

5. Breastfeeding

6. Bathing

7. Clothing and bedding

8. Rooming in

23 10. Training and awareness rising

Apart from routine procedures, extra care is necessary to prevent

hypothermia in preterm babies.

Preterm babies < 34 weeks should be nursed in Incubator which

decreases the insensible water loss.

Mechanism :

Convective heat loss dependent on air flow, the incubators reduce

the exposure of babies to air currents. Evaporative process of heat loss

will be limited by providing maximum possible relative humidity within

the incubator. Radiative heat losses are minimized by the hood on the

baby or by using double walled incubators.

Perinatal Asphyxia:

Definition according to ACOG guidelines include

a) Profound metabolic or mixed academia (pH < 7) in Umbilical

cord blood.

b) Persistence of low Apgar score less than 3 for more than 5

24

c) Signs of neonatal neurologic dysfunction ( e.g. : seizures,

encephalopathy, tone abnormalities)

d) Evidence if multiple organ involvement.

25

TABLE 1 : Organ system dysfunction in perinatal asphyxia CNS Hypoxic ischemic encephalopathy, intracranial

hemorrhage, seizures, long-term neurological sequelae

Cardiac Myocardial dysfunction, valvular dysfunction, rhythm abnormalities, congestive cardiac failure

Renal Hematuria, acute tubular necrosis, renal vein thrombosis

Pulmonary Delayed adaptation, respiratory failure, meconium aspiration, surfactant depletion, primary

pulmonary hypertension

GI tract Necrotizing enterocolitis, hepatic dysfunction

Hematological Thrombocytopenia, coagulation abnormalities

Metabolic Acidosis, hypoglycemia, hypocalcemia, hyponatremia

26 Respiratory Distress:

a) Tachypnea ( RR ≥ 60/min )

b) Retractions

c) Grunting

d) Scoring – Silverman & Down score chart.

27

FIGURE-712 - DOWNE’S SCORE:

Indications for respiratory support

Indications for CPAP in Preterm infant:

 Preterm infant with minimal respiratory distress and low

supplemental oxygen requirement.

 Requirement of Fio2 above 30 % by hood with respiratory

distress

 Fio2 above 40 % by hood

28

 Initial management of premature infants with severe respiratory

distress.

 Respiratory distress after extubation.

 To maintain lung volume after extubation.

Indications for Mechanical Ventilation:

 Prolonged Apnea

 Pao2 <50 mmHg or Fio2 above 80 %

 Paco2 above 60mmHg with persistent academia

 General Anaesthesia.

SURFACTANT THERAPY:

Surfactant Replacement Therapy must be considered in all preterm

infants with ~28 week gestational age with a clinical suspicion of RDS.

Use in infants of gestational age 24 to 27 weeks may be decided on a

case-by-case basis. Early rescue therapy where surfactant is administered

early but after the onset of respiratory distress, is very effective in

decreasing the incidence of RDS and mortality in preterm infants. An

29

Administration. The optimal dose of surfactant for RDS is 100

mg/kg body weight of phospholipid.

ASSESSMENT OF GESTATIONAL AGE

Gestational age can be assessed by 3 methods.

First trimester Ultra sonogram:

- Done at 6- 12 weeks of gestation.

- Most reliable method of assessing age of gestation.

First day of last menstrual period.

New Ballard Scoring:

- Used to assess Gestation age 20 – 44 weeks

- Score ranges from -10 to + 50

- Consist of two components

1. Physical Maturity

30

31

FIGURE-9 : NEUROMUSCULAR MATURITY

KANGAROO MOTHER CARE:

Kangaroo mother care is a method of care of preterm or low birth

weight (LBW) infants by placing them in skin to skin (STS) contact with

mother or other caregiver in order to ensure optimum growth and

32 Components of KMC 6-8

1. Kangaroo position

- The kangaroo position consists of skin-to-skin contact (SSC)

between the mother and the infant in a vertical position, between

the mother’s breasts and under her clothes

- The provider must keep herself in a semi- reclining position to

avoid the gastric reflux in the infant

- The kangaroo position is maintained until the infant no longer

tolerates it- as indicated by sweating in the baby or baby refusing

to stay in KMC position

- When continuous care is not possible, the kangaroo position can

be used intermittently, providing the proven emotional and

breastfeeding promotion benefits

- The kangaroo position must be offered for as long as possible

33 2. Kangaroo nutrition

- Kangaroo nutrition is the delivery of nutrition to “kangarooed”

infants as soon as oral feeding is possible.

- Goal is to provide exclusive or nearly exclusive breastfeeding

with fortification, if needed.

3. Kangaroo discharge and follow up

- Early home discharge in the kangaroo position from the neonatal

unit is one of the original components of the KMC intervention.

- Mothers at home require adequate support and follow up hence a

follow-up program and access to emergency services must be

ensured.

34 Hypoglycemia:

a) WHO defines hypoglycemia as Blood glucose of less than 45

mg/dl.

b) Blood sugars are monitored by using glucometer and plasma

glucose.

Indication for routine blood screening:

 Low birth weight infants

 Preterm infants

 Small for gestation

 Large for gestation

 Infant of Diabetic mother

 Any sick neonate – perinatal asphyxia, sepsis, shock

 Infants on total parental nutrition

 Infant born to mother receiving oral propranolol, Labetalol, oral

35 Neonatal Hyperbilirubemia:

a) Based on hour specific nomogram as per AAP guidelines,

phototherapy or exchange transfusion was given.

TABLE : 2 IMPORTANT RISK FACTORS FOR SEVERE HYPERBILIRUBINEMIA

Predischarge TSB or TcB measurement in high risk or high intermediate zone

Lower gestational age

Exclusive breastfeeding, especially if it is not going well and infant has excessive weight loss

Jaundice in the first 24 hours of age

Isoimmune or other hemolytic disease

Previous sibling with jaundice

Cephalohematoma or significant bruising

36

37

Suggested Use of Phototherapy and Exchange Transfusion in Preterm Infants <35 Weeks Gestational Age

38 Neonatal Sepsis:

a) Neonatal Sepsis is a clinical syndrome characterised by signs and

symptoms of infection in the first month of life.

b) Classified into two categories.

1) Early onset Sepsis (EOS).

2) Late onset Sepsis. (LOS)

Sepsis is recorded as

 Suspected sepsis- based on clinical symptoms and signs of

sepsis.Antibiotics given atleast for two days.

 Probable sepsis- based on positive screening test for sepsis. CRP

is taken as 10 mg/dl

 Culture positive sepsis

Risk Factors associated with early onset sepsis:

1) Low birth Weight (< 2500 g) or prematurity.

2) Febrile illness in the mother with evidence of bacterial infection

39

3) Foul smelling / meconium stained liquor.

4) Rupture of membranes > 24 hours.

5) Single unclean >3 sterile vaginal examinations.

6) Prolonged labor (sum of 1st & 2nd stage of labor ≥ 24 hours).

7) Perinatal Asphyxia (Apgar score < 4 at 1minute).

TABLE 3 : SEPSIS SCREEN:

COMPONENTS ABNORMAL VALUE

Total leukocyte count <5000/mm3

Absolute neutrophil count Low counts

Immature / Total neutrophil >0.2

Micro – ESR >15 mm in 1st hour

40

TRANSIENT TACHYPNEA OF NEWBORN:

The incidence of TTN is 0.3% to 0.6% of term deliveries and 1%

of preterm deliveries.

Risk factors for TTN include cesarean delivery with or without

labor, precipitous birth, and preterm birth. These conditions are thought

to result in delayed or abnormal fetal lung fluid clearance due to the

absence of the hormonal changes that accompany spontaneous labor. It is

characterized by

- Tachypnea

- Signs of mild respiratory distress

- Fio2 requirement < 40 %

- Signs of TTN persist for 12 to 24 hours in mild cases ; 72

hours in severe cases

- Chest radiograph reveals characteristic prominent perihilar

streaking (Sunburst pattern)

41

- Hyper aeration with widening of intercostal spaces, mild

cardiomegaly, widened and fluid-filled inter lobar fissure, and

mild pleural effusions may also be observed.

The radiographic findings in TTN usually improve by 12 to 18 hours and

resolve by 48 to 72 hours.

Treatment:

Treatment is mainly supportive with provision of supplemental

oxygen as needed. More severe cases may respond to continuous positive

airway pressure (CPAP) to improve lung recruitment

PATENT DUCTUS ARTERIOSUS:

PDA is commonly seen in preterm babies.

Clinical diagnosis of PDA:

- Bounding peripheral pulse

- Wide pulse pressure( 25 mm Hg )

- Hyperactive precordium

- Systolic murmur

42

Echocardiography is the gold standard for diagnosis as well as for

assessing severity of PDA. The features suggestive of patent ductus

arteriosus include

a) 2-D and color Doppler- short axis view: Direct visualization of

the ductus. In 2-D short axis view, in the presence of a patent

ductus, the appearance is classically described as ‘three-legged

stool’ appearance. In color Doppler, there is continuous flare in

the MPA.

b) Short axis view, Pulsed Doppler: Turbulence in main pulmonary

artery (MPA) due to left to right shunt jet flowing into MPA.

c) Four chamber view: Bowing of interatrial septum to right with

enlarged left atrium and left ventricle

d) Long axis view: LA/Ao ratio > 1.5:1

43

TABLE 4 : ECHOCARDIOGRAPHY - PDA Echocardiography

parameter* No PDA Mild Moderate Large Features of ductus arteriosus

Trans ductal diameter

(mm) 0 <1.5 1.5-3.0 >3.0

Ductal velocity Vmax

(cm/sec) 0 >2 1.5-2.0 < 1.5

Antegrade PA diastolic

flow (cm/sec) 0 >30 30-50 >50

Pulmonary overcirculation Left atrial /aortic root

width ratio 1.1 ± 0.2 <1.4:1 1.4-1.6 >1.6:1 Left ventricular/ aortic

root width ratio 1.9 ± 0.3 - 2.2 ± 0.4 2.27± 0.27

E wave/ A wave ratio <1 <1 1-1.5 >1.5

IVRT(ms) <55 46-54 36-45 <35

LVSTI 0.34 ± 0.09 - 0.26 ±

0.03 0.24 ± 0.07 Systemic hypoperfusion

Retrograde diastolic flow

(as % of forward flow) 10 < 30 30-50 > 50 Aortic Stroke Volume

(ml/kg) <2.25 - - >2.34

Left ventricular output

(ml/kg/min) 190-310 - - >314

44 Hemodynamically significant PDA:

Presence of PDA >1.5 mm with one of the following

- LA/Ao ratio >2.2:1

- Retrograde diastolic flow in descending aorta, celiac or

cerebral arteries > 30% of antegrade flow

- Left ventricular output > 320 ml/kg/min

RETINOPATHY OF PREMATURITY:

ROP is a vaso-proliferative disorder of the retina among

preterm infants. Neonates at less than 32 weeks of gestation are at risk of

developing ROP. Screening for ROP should be performed in all preterm

neonates who are born

< 34 weeks gestation and/or < 1750 grams birth weight ; in babies

34-366/7 weeks gestation or 1750-2000 grams birth weight if they have

risk factors for ROP. The first retinal examination should be performed

not later than 4 weeks of age or 30 days of life in infants born ~ 28 weeks

of gestational age. Infants born < 28 weeks or < 1200 grams birth weight

should be screened early, by 2-3 weeks of age, to enable early

45 FIGURE- 13

INTRAVENTRICULAR HEMORRHAGE:

IVH is common in preterm infants and the incidence is currently 15

to 20% in infants born at < 32 weeks of gestation.

46

TABLE-5 : VOLPE GRADING OF IVH

SEVERITY OF IVH FINDINGS

Grade 1 GMH with no or minimal IVH (10%

ventricular volume)

Grade 2 IVH occupying 10% - 50% of ventricular area on parasagittal view

Grade 3 IVH occupying > 50% of ventricular area on parasagittal view usually distends lateral ventricle (at the time of IVH diagnosis)

Grade 4 (separate notation)

Periventricular echodensity

APNEA OF PREMATURITY:

Apnea is defined as cessation of airflow for more than 20 seconds

accompanied by bradycardia or hypoxemia that is evident clinically

(cyanosis) or by oxygen saturation monitoring. Incidence of apnea

increases with decreasing gestational age. It is treated by caffeine

Caffeine- Loading dose of 20 mg/kg intravenous or orally over 30

minutes followed by maintenance dose of 10mg/kg of caffeine single

47 NECROTISING ENTEROCOLITIS:

NEC is the most common gastrointestinal emergency of the

neonate. Prematurity is the most common risk factor. Early enteral

feeding, bovine milk based products may increase the risk of NEC

48

RESULTS

A total of 382 VLBW neonates were included in the study. Out of 382

VLBW neonates, 199(52%) were males and 183(48%) were females.

TABLE 6 : AGE DISTRIBUTION

Gender

VLBW Neonates

n (%)

MALE 199 52%

FEMALE 183 48%

MALE 52%

Gender Distribution[N=382]

49

TABLE 7 : BIRTH LOCALITY

Locality

VLBW Neonates

n (%)

In Born 231 60%

Out Born 151 40%

Out of 382 VLBW neonates, 231(60%) were inborn and 151(40%) were out born.

In Born 60% Out Born

40%

50

TABLE 8 : MEAN BIRTH WEIGHT OF VLBW NEONATES MEAN BIRTH WEIGHT OF VLBW NEONATES

Mean SD Std. Error

MALE 1.250 0.120 0.008

FEMALE 1.274 0.125 0.009 Total 1.261 0.123 0.006

Mean birth weight was 1.25 kg in males and 1.27 kg in females with

standard deviation of 0.12.

Out of 382 VLBW babies, 195(51%) were born out of normal

51

TABLE 9 : MODE OF DELIVERY Mode of Delivery

Normal

VLBW Neonates

n (%)

LSCS 199 52%

FEMALE 183 48%

Among 382 VLBW neonates, 222(58%) were SGA, 92(24%) -AGA,

68(18%) were IUGR. The percentage of SGA babies were more among

them.

Normal 51% LSCS

49%

52

TABLE 10 : GESTATIONAL AGE

GA

VLBW Neonates

n (%)

SGA 222 58%

AGA 92 24%

IUGR 68 18%

Majority of VLBW neonates were in the gestational age group between

28-32 weeks (n = 224, 59%) and 32-34 weeks (n = 92, 24%)

0% 10% 20% 30% 40% 50% 60%

SGA AGA IUGR

53

TABLE 11 : GESTATIONAL AGE GESTATIONAL

AGE

VLBW Neonates

n (%)

< 28 weeks 24 6%

28-32 weeks 224 59%

32-34 weeks 92 24%

34-36 weeks 42 11%

The most common maternal risk factor associated with VLBW being

Gestational hypertension -210(55%) followed by Anemia – 63(17%),

Gestational diabetes mellitus- 8(2%), Hypothyroidism- 4(1%). 90 VLBW

54

TABLE 12 : MATERNAL RISK FACTORS

Maternal Risk

Factors Number (%)

No Risk 90 23.5

Gestational

Hypertension 210 55

Anemia 63 17

Hypothyroid 4 1

Gestational Diabetes 8 2

HIV 1 0.5

Multiple Gestation 0 0

Chronic Medical

Illness 0 0

55

Most of the mothers belong to low socioeconomic status. Table 13 shows

maternal age < 18 years were 10(2.5%) and most of the mothers were in

the age 18-21 years - 136(35.5%) followed by 194(51%) between 21-30

years, 42(11%) in the age > 30 years. Maternal hypertension being the

most common cause for VLBW babies. Only 2(0.5%) out of 382 were

meconium stained and 389(99.5%) had clear amniotic fluid. Antenatal

steroids coverage being 325(85%).

No Risk Gestatio nal Hyperte nsion Anemia Hypothy roid Gestatio nal Diabetes HIV Multiple Gestatio n Chronic Medical Illness Hepatitis B

Number 90 210 63 4 8 1 0 0 0

(%) 23.5 55 17 1 2 0.5 0 0 0

0 50 100 150 200 250

56

TABLE 13 : MATERNAL DETAILS Maternal Details

Maternal Age (Years) Number (%)

<18 10(2.5%)

18-21 136(35.5%)

21-30 194(51%)

>30 42(11%)

Maternal Disease

Gestational Hypertension 210(55%)

Anemia 63(17%)

Hypothyroid 4(1%)

Gestational Diabetes 8(2%)

HIV 1(0.5%)

Multiple Gestation 0

Chronic Medical Illness 0

Hepatitis B 0

Aminotic Fluid

Clear 389(99.5%)

Meconium Stained 2(0.5)

Antenatal Steroids 325(85%)

Table 14 depicts the findings from the study. Most of them were in the

gestational age 28-32(n = 224, 59%) and 32-34 weeks (n = 92, 24%) and

small for gestational age (n = 222, 58%).out of 382 VLBW neonates,

183(48%) were females and 197(52%) were males, 231 (60%) were

57

TABLE 14 : CHARACTERISTIC FEATURES OF THE STUDY

Characteristic Features of the Study

Number (%)

Gender

Female 183 (48%)

Male 197 (52%)

Gestational Age

<28 Weeks 24 (6%)

28-32 weeks 224 (59%)

32-34 Weeks 92 (24%)

34-36 Weeks 42 (11%)

Place of Birth

Inborn 231 (60%)

Outborn 151 (40%)

SGA 222 (58%)

AGA 92 (24%)

IUGR 68 (18%)

Table 15 shows 195(51%) normal vaginal deliveries and 187(49%) were

born by LSCS. Resuscitation at birth required for 24(6.3%).Surfactant

therapy was given for 43(11%), NCPAP for 62(16%), Mechanical

58

TABLE 15 : DELIVERY & INTERVENTIONS

Delivery & Interventions

Number (%)

Mode of Delivery

Normal 195 (51%)

LSCS 187 (49%)

Resuscitation

Required 24 (6.3%)

Surfactant 43 (11%)

NCPAP 62(16%)

Mechanical

Ventilation 71 (18.5%)

Table 16, shows the morbidity pattern in very low birth weight neonates.

The most common morbidity among VLBW neonates being sepsis (n =

133, 35%), RDS (n = 105, 27%), TTN (n = 85, 22%), Hypoglycemia (n =

47, 12%), NNH (n = 31, 8%). Perinatal asphyxia (n = 24, 6%), meningitis

(n = 24, 6%) were the other major morbidities.

59

TABLE 16 : MORBIDITY PATTERN IN VLBW NEONATES

Disease

VLBW Neonates

n (%)

SEPSIS 133 35%

RESPIRATORY DISTRESS SYNDROME 105 27% TRANSIENT TACHYPNEA OF

NEWBORN 85 22%

HYPOGLYCEMIA 47 12%

NEONATAL HYPERBILIRUBINEMIA 31 8%

ASPHYXIA 24 6%

MENINGITIS 24 6%

INTRAVENTRICULAR HEMORRHAGE 15 4%

SHOCK 15 4%

PNEUMONIA 10 3%

HYDROCEPHALUS 8 2%

PATENT DUCTUS ARTERIOSUS 6 2%

APNEA OF PREMATURITY 9 2%

NECROTISING ENTEROCOLITIS 7 2%

RETINOPATHY OF PREMATURITY 5 1%

INFANT OF DIABETIC MOTHER 5 1%

PNEUMOTHORAX 2 1%

60

SEPSI

S RDS TTN HYP OGLY CEMI A NNHASPH YXIA MENI NGITI S IVH SHO CK PNE UMO NIA HYD ROCE PHAL US

PDA AOP NEC ROP IDM PNE UMO

THO RAX

MAS

Series1 133 105 85 47 31 24 24 15 15 10 8 6 9 7 5 5 2 2

Series2 35% 27% 22% 12% 8% 6% 6% 4% 4% 3% 2% 2% 2% 2% 1% 1% 1% 1%

0 20 40 60 80 100 120 140

61

TABLE 17 : RDS BABIES REQUIRING SURFACTANT

Out of 382 VLBW neonates, 105 neonates had RDS. Among them, 43

neonates (41%) received surfactant therapy.

0 20 40 60 80 100 120

RDS

SURF 41%

RDS SURF

n 105 43

RDS REQUIRING SURFACTANT THERAPY

Disease RDS SURF %

62

TABLE 18 :NNH BABIES REQUIRING EXCHANGE TRANSFUSION

NNH babies requiring Exchange transfusion

Disease NNH EXCHANGE %

n 31 4 13%

31 VLBW neonates were admitted for neonatal hyperbilirubinemia. Out

of 31 neonates, exchange transfusion was done for 13% (n = 4), others

received phototherapy.

0 5 10 15 20 25 30 35

13%

NNH EXCHANGE

Series1 31 4

EXCHANGE TRANSFUSION IN NNH BABIES

EXCHANGE

63

TABLE 19 :OUTCOME

Outcome

VLBW Neonates

n (%)

SURVIVAL 287 75%

DEATH 95 25%

Table 19 shows that 285(75%) VLBW neonates survived and 95(25%)

neonates died.

Survival 75%

Death 25%

64

TABLE 20 : MORTALITY

Mortality Number (%)

Sepsis 49 52

RDS 38 40

Asphyxia 0 0

Meningitis 1 1

Pneumothorax 2 2

Pre-maturity 1 1

IVH 4 4

Table 20 shows the major cause of mortality in VLBW neonates were

found to be Sepsis 49 (52%), followed by Respiratory Distress syndrome

38 (40%). Other causes accounted to 8% of total VLBW neonatal death.

RDS 40%

Sepsis 52% Meningitis

1%

PneumoThorax 2%

IVH 4%

prematurity 1%

65

TABLE 21 : TIME OF DEATH

Duration

VLBW Neonates

n (%)

< 24 hours 7 7%

24 - 48 hours 11 12%

48- 72 hours 12 13%

3 Days 65 68%

Table 21 shows out of 95 neonatal death, 7(7%) occurred within 24 hours

of birth, 11(12%) between 24- 48 hours, 12(13%) between 48- 72 hours,

65(68%) occurred after 3 days.

Most of the VLBW neonates were died after 3 days (68%).

<24 Hrs

7% 24-48 Hrs _12%

48-72 hrs 13%

3 Days 68%

66

TABLE 22 :ASSOCIATION OF GENDER WITH OUTCOME

GENDER

OUT COME

TOTAL

SURVIVAL DEATH

MALE 135 64 199

FEMALE 152 31 183

TOTAL 287 95 382

No significant association of Gender with Outcome.

MALE FEMALE

ALIVE 47% 53%

DEATH 67% 33%

0% 10% 20% 30% 40% 50% 60% 70% 80%

67

TABLE 23 :ASSOCIATION OF BIRTH LOCALITY WITH OUTCOME

LOCALITY

OUT COME

TOTAL SURVIVAL DEATH

In Born 173 58 231

Out Born 114 37 151

TOTAL 287 95 382

Place of birth had no correlation with outcome of very low birth weight neonates.

In Born Out Born

ALIVE 60% 40%

DEATH 61% 39%

0% 10% 20% 30% 40% 50% 60% 70%

68

TABLE 24 :ASSOCIATION OF GESTATIONAL AGE WITH OUTCOME

Gestational Age

OUT COME

TOTAL SURVIVAL DEATH

<28wks 10 14 24

28-32wks 161 63 224

32-34wks 79 13 92

34-36wks 37 5 42

TOTAL 287 95 382

There is significant association of gestational age with outcome of very

69

TABLE 25 :ASSOCIATION OF MODE OF DELIVERY WITH OUTCOME

DELIVERY

OUT COME

TOTAL SURVIVAL DEATH

NORMAL 143 52 195

LSCS 144 43 187

TOTAL 287 95 382

Outcome of VLBW neonates was not affected by Mode of delivery.

NORMAL LSCS

ALIVE 50% 50%

DEATH 55% 45%

0% 10% 20% 30% 40% 50% 60%

70

TABLE 26 : Gestational Age with Time of Death Gestational

Age

Time of Death

48-72Hrs 3

Days Total < 24 Hrs 24 - 48 Hrs

28wks 2 3 1 8 14

28-32 4 5 9 45 63

32-34 0 3 2 8 13

34-36 1 0 0 4 5

TOTAL 7 11 12 65 95

There is significant association between gestational age and time of

death. 0% 10% 20% 30% 40% 50% 60% 70% 80%

< 24 Hrs 24 - 48 Hrs >72 Hrs 3 Days

28wks 29% 27% 8% 12%

28-32 57% 45% 75% 69%

32-34 0% 27% 17% 12%

34-36 14% 0% 0% 6%

71

DISCUSSION

This study includes 382 very low birth neonates admitted in NICU,

Coimbatore Medical College Hospital during the period from January

2017 – December 2017.

Out of 382 VLBW neonates, 199(52%) were males & 183 (48%)

were females; 231 (60%) were Inborn & 151 (40%) were Out born.

Their mean birth weight was 1.25 Kg in males & 1.27 kg in

females. 195(51%) were born out of Normal vaginal delivery & 187

(49%) were born by caesarean section.

Out of 382 neonates, 222(58%) were SGA, 92 (24%) were AGA

and 68(18%) were IUGR. SGA babies were among VLBW neonates.

Most of VLBW neonates were in the gestational age b/w 28-32

weeks (n=224, 59%) & (32-34 weeks (n = 92, 24%).

The most common maternal risk factor associated with VLBW was

gestational hypertension is 210 (55%) followed by anemia 63(17%).

Most of the mothers belong to low socio economic status (88.6%). This

leads to inadequate intake and increased risk of infections and leading to

72

In Jaiswal et al study, Neonatal jaundice requiring phototherapy (55.1%)

followed by respiratory morbidity (10.5%) and hypoglycemic (8.8%)

were the frequent identified morbidities in late preterm infants. In our

study, sepsis (35%) followed by RDS (27%), TTN (22%), NNH (8%).

Sepsis found to be the major morbidity in our study. Multiple gestation ,

IUGR and cesarean deliveries were found to be the risk factors for

morbidity in Jaiswal et al. study. But in our study, Gestational

hypertension (n =210, 55%) followed by anemia (n= 63, 17%) were the

major risk factors. Cesarean delivery and normal vaginal delivery were

found to be equal and does not contribute to morbidity in VLBW

neonates in our study.

The most common morbidity among VLBW neonates being sepsis

(n = 133, 35%) followed by RDS (n=105, 27%), TTN (n = 85, 22%),

hypoglycemia (n=47, 12%). In schinder et al. study, IVH followed acute

respiratory illness & sepsis were the most common cause of death.

In our study the major cause of mortality being Sepsis (n=49, 52%)

followed by RDS (respiratory distress syndrome) (n=38, 40%).

Kabilan et al. study reveals that birth weight & mechanical

ventilation are the two major factors responsible for mortality in VLBW

73

(n=54, 32.4%) and Sepsis (n=46, 27.6%). Most of the death occurred due

to RDS (n=43, 25.8%). RDS occurred in 90% of VLBW infants with

incidence of 33.6% and mortality rate of 76%. In our study, Sepsis and

RDS were the major cause of morbidity and mortality in VLBW

neonates. RDS accounts for 40% of mortality which is one of the major

cause of death in VLBW infants.

In Thapar K.et al study, sepsis was the major cause of morbidity

followed by HMD and Jaundice. Majority of them were in the gestational

age 33-36 weeks (n=68, 44.2%), small for gestational age (n=89, 57.8).

Similar to this study, Sepsis and RDS were the major cause of morbidity

in VLBW neonates in our study. But most of them were in the gestational

age between 28-32 weeks (n = 224, 59%) and 32-34 weeks (n = 92,

24%).

In Ghulam nabi et al. study, Jaundice was the major morbidity. But

in our study, jaundice constitutes 31(8%) of morbidity.

In Ballot et al study, major cause of mortality was Extreme

prematurity followed by HMD and NEC. In our study, Sepsis and RDS

74

In Sangamam et al. study, the most common morbidity was was

Hyperbilirubinemia (16.77%) followed by Hypoglycemia (14.99%) and

Hyaline membrane disease (14.86 %).The most common maternal

complications associated with LBW were anemia (43.36%) and

hypertensive disorders of pregnancy (17.6%). In our study, Sepsis and

RDS were the major morbidities among VLBW neonates. Maternal

hypertension and anemia being the most common risk factors leading to

VLBW in our study. Hypoglycemia accounts for 47(12%) of morbidity in

our study. Preterm infants are at risk of developing hypoglycemia after

birth, because they have immature hepatic glycogenolysis and adipose

tissue lipolysis, hormonal dysregulation and deficient hepatic

gluconeogenesis and ketogenesis.

In Rasania et al study, 16.39% had birth asphyxia, 28.6% had

sepsis, 7.37% had RDS and 32.78% had hyperbilirubinemia. Need for

respiratory support was significantly higher in moderate preterm (47.8%).

In our study, 35% had sepsis, 27% had RDS, 22 % had TTN followed by

hypoglycemia in 12%.

In another study done in Banaras university, Perinatal asphyxia,

75

neonatal mortality. In our study, Sepsis (n= 49, 52%), RDS contribute

40%, Prematurity 1%, IVH contribute 4% of mortality.

Out of 382 VLBW neonates, 105 neonates had respiratory distress

syndrome; 43 received surfactant therapy, 38 neonates with RDS

succumb to death.

Most of the VLBW neonates were in the gestational age group of

28-32 weeks and 32-34 weeks. Out of 382 VLBW neonates, 287 (75%)

were alive and 95 (25%) were died.

VLBW neonates (n = 71, 18.5%) were mechanically ventilated.

There was no association of gender, birth, locality and sex with outcome.

Gestational age and Mechanical ventilation had positive correlation with

outcome. As the gestational age decreases, both morbidity and mortality

increases.

Since RDS and sepsis are the major cause of mortality, quality of

care in the antenatal, perinatal and postnatal periods of newborn to be

improved.

We need to strengthen the ongoing trainings of health care

personnel like NRP and to provide appropriate antenatal education and

76

LIMITATION

This study was done in very low birth weight neonates weighing

1000- 1500 g. If babies weighing < 1000 g are also included, the results

would have been better.

77

CONCLUSION

Uplifting the socioeconomic status of women, Nutritional

counselling to reduce anemia should be considered to reduce the

incidence of very low birth weight babies. Antenatal steroid therapy

needs to be more vigorously implemented.

Sepsis and Respiratory distress syndrome were the major cause of

death.

Prematurity is the primary cause behind these neonatal death. This

emphasizes the need to prevent preterm deliveries. Effective preventive

strategies to decrease the preterm birth can only be the next big step to

78

RECOMMENDATION

By proper health education and strengthening of antenatal services

along with awareness of neonatal problems in low birth weight babies,

the incidence of very low birth weight and their complications can be

reduced.

FUTURE PERSPECTIVES:

 This include preventive strategies at many levels with special

emphasis on the prevention ,early detection and effective

management of Pregnancy Induced Hypertension(PIH) which is

found to be the leading cause of preterm delivery in our Centre.

Antenatal steroid therapy needs to be more rigorously

implemented.

 Policies at government level to implement strict Aseptic measures

in delivery rooms, Early CPAP administration, Good neonatal

transport facilities are essential to further raise our Neonatal health

79 WHAT THIS STUDY ADDS?

 Prematurity is the primary cause behind all the leading cause of

neonatal deaths.

 Preventing premature births is the single most important step in

reducing our neonatal mortality rate.

 Government policies aimed at implementing strict aseptic measures

in delivery rooms, Early CPAP administration, Good neonatal

transport facilities can make a great leap in raising our Neonatal

80

BIBLIOGRAPHY

1) Predictive ability of a predischarge hour-specifi c serum bilirubin

for subsequent signifi

2) cant hyperbilirubinemia in healthy term and near-term newborns.

Pediatrics 1999;103:6–14.)

3) Jaiswal A, Murki S, Gaddam P, Reddy A.

4) Early Neonatal Morbidities in Late Preterm infants, Indian

Pediatrics.2011; 48:607.11

5) Tim Schindler, Louise Koller Smith , Kei Lui, Barbare Bajuk ND

Srinivas Bolisetty , Causes of death in very preterm infants cared

for in Neonatal intensive care units : a population – based

retrospective cohort study , BMC Pediatrics,17,1,(2017)

6) Kabilan S,Kumar Ms . Morbidity and mortality pattern of very low

birth weight infants admitted in SNCU in a south Asian tertiary

care centre.

81

8) Ghulam Nabi Rather, Muzafar Jan, Wasim Rafiq,Imran

Gatoo,Sheikh Quyoom Hussain,Mohamad Latief. Morbidity and

mortality pattern in late preterm infants as a tertiary care hospital in

Jammu and Kashmir, Northern India. J Clinic Diagnos Res.2015;

9(12) : SC 01 – SC04

9) Rasania M, Muley P. Morbidity profile and immediate outcome of

late preterm neonates compared to term neonates in a rural tertiary

care hospital of Gujarat. Int J Contemp Pediatr 2017;4:1329-33.

10) Kaur A , Thapar K, Chhabra GS, Jaslean. Morbidity and Mortality

of very low birth weight babies in a Tertiary level NICU. J.Nepal

Pediatrics.Soc 2015;35(3) :257-263

11) Basu S, Rathore P, Bhatia BD . Predictors of mortality in very low

birth weight neonates in India. Singapore Med J . 2008 Jul ;

49(7):556.

12) Ballot DE, Chirwa T, Ramdin T, et al. Comparison of morbidity

and mortality of very low birth weight infants in a Central Hospital

in Johannesburg between 2006/2007 and 2013. BMC Pediatrics.

82

13) Apgar V. A proposal for a new method of evaluation of the

newborn infant. Curr Res Anesth Analg 1953;32:260-267.

14) Weiner, G.M., & Zaichkin, J. (2016). Textbook of neonatal

resuscitation. Elk Grove village IL: American Academy of

Pediatrics.

15) Silverman WC, Anderson DH. Controlled clinical trial on effects of

water mist on obstructive respiratory signs, death rate and necropsy

findings among premature in fants. Pediatrics 1956; 17: 1-4.

16) Wood DW, Downes’JJ, Locks HI. A clinical score for the

diagnosis of respiratory failure. Amer J Dis child 1972; 123: 227-9.

17) New Ballard score. (From Ballard JL, Khoury JC, Wedig K et al.

New Ballard score, expanded to include extremely premature

infants. J Pediatr 1991;119: 417-423.)

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19) The International Classification of Retinopathy of prematurity

83

PROFORMA

NAME:

AGE:

RESIDENCE:

CONTACT NO:

RURAL/URBAN/SEMI-URBAN:

OCCUPATION:

SOCIO-ECONOMIC STATUS:

EDUCATED/UNEDUCATED:

ANTENATAL VISITS:

1) BOOKED - YES/ NO

2) IMMUNISED – YES/ NO

HEMOGLOBIN:

BLOOD GROUP:

WEIGHT:

CONSANGUINITY: YES / NO

GRAVIDA: PARA: LIVE:

84 LMP: EDD:

RISK FACTORS:

1. ANEMIA -

2. HYPERTENSION -

3. DIABETES MELLITUS -

4. RH NEGATIVE -

5. MULTIPLE GESTATION -

6. HIV -

7. HEPATITIS – B -

8. SYPHILIS -

9. OTHER MEDICAL PROBLEMS -

10.HYPOTHYROID -

DRUG INTAKE:

ANTENATAL STEROIDS: YES / NO

MATERNAL FEVER:

FOUL SMELLING LIQUOR:

POSTNATAL HEMORRHAGE:

85 MODE OF DELIVERY:

1. CAESEREAN

2. LABOUR NATURAL

PRESENTATION: VERTEX / BREECH:

BABY’S DETAILS:

CRIED IMMEDIATELY AFTER BIRTH: YES / NO

BIRTH WEIGHT:

RESUSCITATION REQUIRED: YES / NO

(BAG & MASK VENTILATION / TACTILE STIMULATION /

ENDOTRACHEAL INTUBATION)

TERM / PRETERM (37 WEEKS):

APGAR SCORE:

PROBLEMS :

MECHANICAL VENTILATION:

86

CONSENT FORM

I have come to know that Dr.ABINAYA. G, Postgraduate in the Department of Paediatrics is conducting a study on the topic," STUDY OF NEONATAL MORBIDITY AND MORTALITY IN VERY LOW BIRTH WEIGHT NEONATES ADMITTED IN NEONATAL INTENSIVE CARE UNIT IN A TERTIARY CARE CENTRE" I understand that my child will not have to suffer any harmful consequences as a result of the study nor will I have any financial constraints.

It is understood that blood will be collected from my child for the purpose of conducting this study.

I also understand that I can withdraw myself from this study at any point of time and by doing so it will not affect the treatment in any manner. Understanding all these, I wholeheartedly agree to take part in this study.

Signature

Name of the Guardian: Relation: