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Background: Audit of disease and mortality patterns provides essential information for health budgeting and planning, as well as a benchmark for comparison. Neonatal mortality accounts for about 1/3 of deaths < 5 years of age and very low birth weight (VLBW) mortality for approximately 1/3 of neonatal mortality. Intervention programs must be based on reliable statistics applicable to the local setting; First World data cannot be used in a Third World setting. Many neonatal units participate in the Vermont Oxford Network (VON); limited resources prevent a significant number of large neonatal units from developing countries taking part, hence data from such units is lacking. The purpose of this study was to provide reliable, recent statistics relevant to a developing African country, useful for guiding neonatal interventions in that setting.Methods: This was a retrospective chart review of 474 VLBW infants admitted within 24 hours of birth, between 1 July 2006 and 30 June 2007, to the neonatal unit of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Binary outcome logistic regression on individual variables and multiple logistic regression was done to identify those factors determining survival.Results: Overall survival was 70.5%. Survival of infants below 1001 grams birth weight was 34.9% compared to 85.8% for those between 1001 and 1500 grams at birth. The main determinant of survival was birth weight with an adjusted survival odds ratio of 23.44 (95% CI: 11.22 – 49.00) for babies weighing between 1001 and 1500 grams compared to those weighing below 1001 grams. Other predictors of survival were gender (OR 3. 21; 95% CI 1.6 – 6.3), birth before arrival at the hospital (BBA) (OR 0.23; 95% CI: 0.08 – 0.69), necrotising enterocolitis (NEC) (OR 0.06; 95% CI: 0.02 – 0.20), hypotension (OR 0.05; 95% CI 0.01 – 0.21) and nasal continuous positive airways pressure (NCPAP) (OR 4.58; 95% CI 1.58 – 13.31).Conclusions: Survival rates compare favourably with other developing countries, but can be improved; especially in infants < 1001 grams birth weight. Resources need to be allocated to preventing the birth of VLBW babies outside hospital, early neonatal resuscitation, provision of NCPAP and prevention of NEC. © 2010 Ballot et al; licensee BioMed Central Ltd.
This was a retrospective record review of all neonates with a birth weight < 1501 grams admitted to the neonatal unit of CMJAH within 24 hours of birth from 1 July 2006 to 31 June 2007. All inborn neonates were admitted directly to a labour ward nursery, so statistics included inborn babies who died shortly after birth. VLBW babies who were delivered at outlying primary level hospitals or clinics and those who were born before arrival in hospital (BBA) were also admitted to the neonatal unit. Data was entered from hospital records onto a Microsoft Access (2003) database. Maternal information obtained from the delivery records included age, parity, gravidity, antenatal care, administration of antenatal steroids, syphilis screening and treatment, human immunodeficiency virus (HIV) screening and prophylaxis, place of delivery, fetal presentation and mode of delivery. HIV screening followed a protocol of voluntary counseling and testing; mothers could refuse to be tested. Prophylaxis was only given to infants where mothers were proven to be HIV positive. Polymerase chain reaction (PCR) testing to confirm HIV infection in the neonate was only done from 6 weeks of chronological age. Neonatal intensive care unit (NICU) admission was not determined by HIV exposure. The baby's weight, Apgar scores and details of delivery room resuscitation were also obtained from the delivery records. Gestational age was determined from a combination of maternal history (expected date of delivery, height of fundus, first trimester ultrasound) and the Ballard score, which was done by attending clinical staff. The birth weight was plotted on Fenton [23] growth charts to determine whether the baby was appropriate for gestational age (AGA), small for gestational age (SGA) or large for gestational age (LGA). Information was available on all patients until hospital discharge. Neonatal records were reviewed by the primary author (DEB) and the final diagnoses assigned by the attending clinical staff were confirmed using the available clinical information and results of investigations. The neonatal information included duration of hospital stay, respiratory diagnosis (including hyaline membrane disease (HMD)), duration of oxygen therapy, pneumothorax, neonatal jaundice (NNJ), phototherapy, exchange transfusion, patent ductus arteriousus (PDA) and treatment, necrotizing enterocolitis (NEC) and management, intraventricular haemorrhage (IVH) and grade, periventricular leukomalacia (PVL), hypotension, infection and causative organism blood results, retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD) (defined as oxygen requirement at 28 days of age), congenital anomalies, whether KMC was done and final outcome (discharge or death). IVH was graded according to Papile [24] the diagnosis of NEC was given if the baby had modified Bell's stage 2 or 3 [25]; ROP was diagnosed by an ophthalmologist; PDA was confirmed on echocardiogram by a paediatric cardiologist. The cause of death was reviewed by the primary author (DEB) and classified according to the PPIP classification http://www.ppip.co.za. The PPIP was established in 1999 in South Africa as a national tool for perinatal death audit. In order to have manageable data, the single most likely cause of death is listed – major categories include prematurity, asphyxia, infection and congenital anomaly. Each category is further subdivided into sub-categories; prematurity is subdivided into extreme immaturity, HMD, IVH, NEC and pulmonary haemorrhage. No postmortem examinations were done on the study patients. Details of ICU admissions include indication for ventilation, dates and type of ventilatory support, (IPPV or NCPAP) and surfactant therapy. Babies who received both NCPAP and IPPV were classified as needing ventilator assistance for the purposes of analysis. Babies were managed according to the unit policies at the time. Ventilatory support was offered to babies above 900 grams birth weight, due to severely limited tertiary resources. Babies were not routinely intubated or given NCPAP in the delivery room; ventilatory support (including NCPAP) was commenced when the infant showed signs of respiratory failure. All babies, irrespective of birth weight, were provided with standard neonatal care (nursed in an incubator, given supplemental oxygen, intravenous fluids, antibiotic therapy, blood transfusion, phototherapy as needed and KMC). Surfactant therapy was only given as rescue therapy to babies on ventilatory support, usually to those patients who did not wean rapidly from supplementary oxygen. A second dose of surfactant could be given if the baby had responded to the initial dose and then deteriorated again. NCPAP was introduced to the neonatal unit March 2006. During the period of the study, there was no rooming in facility, so mothers could only do KMC intermittently during the day. KMC was introduced once a baby was in room air and tolerating full enteral feeds. Cranial ultrasound was done during the first week of life by a paediatric neurologist and, if indicated, repeated after 1 to 2 weeks and just prior to discharge. Babies who died within the first 72 hours may not have undergone a cranial ultrasound. Screening for retinopathy of prematurity was done by an ophthalmologist at 36 weeks post conceptional age. If babies were discharged prior to this age, an outpatient appointment was booked for the ophthalmology clinic. Babies were discharged home once they had established enteral feeds, were off supplemental oxygen, maintaining temperature and had achieved a weight of 1600 grams. Some babies were discharged to regional step down facilities for weight gain, close to the time of discharge home. Statistical analysis was done on a personal computer using SPSS version 17 (SPSS Inc. http://www.spss.com). Continuous variables were summarised using mean and 95% confidence intervals, while categorical variables were summarised as ratios and percentages. For the purposes of analysis, babies transferred out and those discharged home directly were combined as "survivors" and compared to those babies that died during their hospital admission. Cross-tabulations of categorical variables with survival were produced and statistical associations between these categorical variables and survival outcome were done using the Chi-Square test of association. Normally distributed continuous variables were compared using the unpaired t test and the Mann-Whitney U test was used to compare discrete variables and those continuous variables that were not normally distributed. Binary outcome logistic regression was done on individual variables to predict survival. Those variables which were significant at the univariate analysis were entered into a multiple logistic regression using the backward selection procedure. All the statistical tests were conducted at 5% significance level. The study was approved by the ethics committee of the University of the Witwatersrand for research on human subjects.
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