Transcript Morbidity and mortality of VLBW infants in Johannesburg

Daynia E. Ballot
Department of Paediatrics and Child Health
University of the Witwatersrand / CMJAH
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SA will not meet MDG 4 – to decrease < 5
mortality by 2/3 by 2015
Neonatal mortality
◦ 40% of deaths in children < 5 years
 VLBW infants – high risk of mortality
 PPIP – extreme multi-organ immaturity most common
cause of neonatal death at CMJAH
 Need to focus on VLBW survival to improve neonatal
mortality
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VLBW survival in Jhb 2006/7 70.5%.
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Resource constraints - ELBW infants denied ICU
on the basis of anticipated poor outcome and
prolonged hospitalisation (Social Justice)
Neonatal ICU one of the top ten costs to medical
aids in SA
Neonatal care continually evolving
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Surfactant and NCPAP
INSURE
Breastfeeding
KMC
PMTCT
Neonatal survival and outcomes are improving
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Vermont Oxford Network (VON) is a non-profit
voluntary collaboration of health care professionals
working together as an interdisciplinary community
to change the landscape of neonatal care.
Founded in 1988, VON is now comprised of teams
of health professionals representing neonatal
intensive care units and level I and II care centres
around the world, in support of our mission
AIM: to improve the quality and safety of medical
care for newborn infants and their families through
a coordinated program of research, education, and
quality improvement projects.
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Research Electronic Data Capture
Van der Bijlt University
Data collected on discharge for purposes of
clinical audit and quality improvement
◦ Vermont Oxford Network
◦ Perinatal Problem Identification Program
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Data checked for completeness and accuracy
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6 beds in labour ward nursery
14 bedded PICU / NICU – shared
35 bedded “high care” ward
◦ NCPAP and INSURE
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20 “low care” beds
15 KMC beds
Paediatric surgery
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< 750 grams – no ventilatory support except
supplemental oxygen. No surfactant
>750 grams – Early rescue surfactant
(INSURE) and NCPAP
> 900 grams – IPPV if required
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To evaluate current VLBW morbidity and
mortality at CMJAH
◦ To inform health care protocols and improve
outcome of VLBW infants
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Neonatal computerised database (REDCAP)
kept for clinical audit
Review of patient records from neonatal
database
01/01/2013 to 31/12/2013
All babies 500g to 1500g
Admitted to neonatal unit within 48 hours of
birth
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A total of 562 infants were included in the
analysis (20 died in the delivery room)
Mean birth weight 1117.1 grams (SD 249)
Mean gestational age 29.2 weeks (SD 2.8)
More females (54.8% - 308)
90 multiple gestation (16.2%)
Mean duration of stay 24.8 days (SD 21.8)
Variable
Number (%)
VON (%)
Antenatal steroids
220 (39.1)
80.5
Antenatal care
397 (70.6)
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Inborn
472 (84)
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Born outside a health facility
33 (5.9)
Multiple gestation
90 (16)
27.5
C-section
311 (55.4)
72.2
SGA
99 (15.6)
23.3
Any initial resuscitation
415 (73.8)
88.5
14 (2.5)
12.8
Maternal hypertension
130 (23.1)
29.0
Maternal HIV
160 (28.5)
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6 (1.1)
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Chorioamnionitis
Maternal syphilis
Variable
Total (%)
VON (%)
Surfactant
368 (65.5)
60.1
Mechanical Ventilation
98 (17.4)
60.9
NCPAP alone
290 (51.6)
49.2
Ligation of Patent Ductus
Arteriosus (PDA)
Late onset sepsis
3 (0.5)
5.4
107 (19)
12.8
NEC
41 (7.3)
5.4
NEC surgery
10 (1.8)
3.1
11 (2)
7.2
Other surgery
Blood transfusion
Pneumothorax
147 (26.1)
4 (0.7)
4
22 (3.9)
7.8
Cystic periventricular
leukomalacia (PVL)
2/297 (0.67)
2.8
Severe ROP
3/144 (2.1)
6.1
Breastmilk feeds on discharge
126 (22.4)
Severe IVH
Home Oxygen
1 (0.17)
Variable
Odds Ratio (95% CI)
Birthweight
Resuscitation at birth
Nasal CPAP without mechanical ventilation
NEC
Birth defect
P Value
1.01 (1.00 – 1.029)
< 0.001
0.25 (0.10 – 0.619)
0.002
4.88 (1.58 – 15.04)
0.006
0.05 (0.01 – 0.23)
< 0.001
0.03 (0.01 – 0.90)
0.043
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Multiple logistic regression excluding babies
< 750 grams (no NCPAP or IPPV) showed that
significant predictors of mortality were:
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birthweight (p< 0.001)
maternal HIV status (p = 0.024)
resuscitation at birth (p = 0.002)
NCPAP without mechanical ventilation (p = 0.028)
NEC (p = 0002).
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Overall survival increased slightly from 70.5%
to 73.4% between 2006/7 and 2013 (VON
2012 88%)
◦ Significant increase in survival of ELBW infants from
34.9% to 47.2%
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Most significant predictor of survival was
birth weight
Other associations were resuscitation at birth,
NCPAP without ventilation, NEC, maternal HIV
status and birth defects
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Integrated program to address these
problems should improve outcome
(Antenatal steroids)
Neonatal resuscitation
PMTCT
NCPAP
Promote breastfeeding
Measures to reduce NEC - including
Antibiotic stewardship
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Low technology, inexpensive
Does not require ICU
Can be implemented in level 2 (regional
hospitals)
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Other points to note:
◦ Low incidence of pneumothorax
◦ Less IPPV and more surfactant use than in the VON
◦ Less severe ROP and PVL
 Although not all babies screened
◦ Only one baby discharged on home oxygen
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Low rate of severe complications may reflect
relatively low survival
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Survival is improving – especially in ELBW
infants
Low technology interventions can improve
outcome
◦ appropriate for developing resource limited country
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Need to work on improving survival
◦ NB continue monitoring rates of complications and
handicap
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Need good data on long term outcome
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Importance of ongoing clinical audit
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Benchmarking
Quality improvement
Collaborative research (local and international)
MMED projects
Local solutions for local problems – need
accurate current local data
Vermont Oxford Neonatal network
PPIP
Egyptian neonatal network
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Egyptian Neonatal Network for Training
Pediatricians (ENNTP) is a project aiming to
establish a national network of trained Egyptian
Pediatricians capable to use electronic health
records and conduct leading multi-disciplinary,
collaborative research dedicated to the
improvement of neonatal health and health care
to international standards.
Five collaborating neonatal intensive care units
from different Egyptian Universities (Mansoura,
AlAzhar, Ain Shams, Tanta and Alexandria) join
the ENNTP project.
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My co- consultants
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Dr Ramdin
Dr Chirwa
Dr White
Prof Davies
Prof Cooper
Sr Pat Hanrahan, Mr Rapola and Mr Reineke
for data management
To PMG for sponsoring our participation in
the VON
Our patients