Clinical Risk Index For Babies Research Articles

The Accuracy of Clinical Risk Index for Babies (CRIB-II) for Predicting Mortality of Severely-ill Preterm Neonates

Background: In Pakistan neonatal mortality rate is 47.3 among 1000 live births. Predictors of neonatal mortality risk can be used to prioritize the care for neonates and to improve the outcome. Objective: To determine the accuracy of clinical risk index for babies (CRIB-II) for predicting mortality of severely ill preterm neonates. Study Design: A Cross Sectional Study. Settings: NICU, Department of Pediatrics Unit I and Unit II, Mayo Hospital, Lahore Pakistan. Duration: From January 22, 2016 to July 30, 2016. Methodology: 200 cases fulfilling the selection criteria (Gestational age 26­34 weeks, Preterm admitted in NICU within 12 hours of birth), were included in the study by nonprobability, Consecutive Sampling. Babies with lethal malformations were excluded. Data required for CRIB II score was collected and analyzed by SPSS. Results: Out of the 200 cases, 102 patients were male (51 %). Age varies from 1 hour to 9 hours of life with mean of 5.8. Gestational age ranges from 28 weeks to 33 weeks with mean age is 30 weeks. Patients had following diagnosis with number of cases: Respiratory distress syndrome 54; Early onset sepsis 30; PT, JNN, EOS 22; Mild Asphyxia 18; Prematurity 14; RDS, EOS 14; Moderate Asphyxia 10; prematurity, Jaundice neonatorum 8; IUGR 8; Early onset sepsis, DIC 4; PT, NEC, EOS 4. CRIB score has sensitivity of 77.7 %, specificity of 65.4 %. It has positive predictive value of 64.8 %, negative predictive value of 78.2 % & clinical accuracy of 71%. Conclusion: CRIB II score has clinical accuracy of 71 % determining prognosis of severely ill preterm neonates in term of mortality.

Predictive ability of neonatal illness severity scores for early death in extremely premature infants

Background The predictive ability of neonatal illness severity scores for mortality or morbidity in extremely premature infants has not been extensively studied. We aimed to evaluate the ability of neonatal illness severity scores [Clinical Risk Index for Babies II (CRIB II), Score for Neonatal Acute Physiology II (SNAP-II), and SNAP-Perinatal Extension II (SNAPPE-II)] in predicting mortality and short-term morbidity of extremely premature infants. Methods This retrospective study involved 171 infants with gestational age (GA) between 22 and 27 weeks who were admitted to the NICU during 2010–2017. Predictive ability of neonatal illness severity scores for mortality and short-term morbidity (bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular hemorrhage, necrotizing enterocolitis, and gastrointestinal perforation) was assessed by comparing their area under the receiver operating characteristic curve. Results The overall mortality rate was 11.1%. Mortality at 23 weeks’ gestation was higher than that at 24–27 weeks’ gestation (p < .01, adjusted residual 4.5). Neonatal illness severity scores were significantly higher in infants who died than in those who survived (p < .01). CRIB II (AUC 0.93, 95% CI 0.85–1.00), SNAP-II (AUC 0.90, 95% CI 0.76–1.00), and SNAPPE-II (AUC 0.95, 95% CI 0.91–0.99) appeared to be excellent predictors and were superior to birth weight (AUC 0.88, 95% CI 0.80–0.95) or GA (AUC 0.84, 95% CI 0.72–0.96) alone in predicting early death (died on <28th postnatal day). CRIB II, SNAP-II, and SNAPPE-II were better predictors of early death than mortality in extremely premature infants. Neonatal illness severity score and short-term morbidity were not strongly associated. Conclusions The neonatal illness severity scores were excellent predictors of early death in extremely premature infants and might be useful for selecting extremely preterm infants who need intervention.

Comparative study of clinical parameters in newborns with hypoxic ischemic encephalopathy and severity of MRI abnormalities

Background: Hypoxic Ischemic Encephalopathy (HIE) is a leading causes of developmental impairment among infants. Scores for Neonatal Acute Physiology Perinatal Extension (SNAPPE) and Clinical Risk Index for Babies (CRIB) scores are known to correlate with future developmental outcomes in sick newborns. NICHD score ≥ 2 is defined as moderate to severe brain injury. Objective: To address the hypothesis that SNAPPE and CRIB scores are significantly higher for newborns that have increased severity of injury as shown by MRI findings. Additionally, clinical parameters like CRP(C- reactive protein), blood glucose levels and oxygenation status could predict the severity of brain injury. Design/Methods: …

The Clinical Risk Index for Babies II for Prediction of Time-Dependent Mortality and Short-Term Morbidities in Very Low Birth Weight Infants

Background: A simple predictive indicator of mortality and morbidities is essential to assess neonatal illness severity and plan proper management. Objective: This study aimed to test the time-dependent performance of the Clinical Risk Index for Babies (CRIB) II in predicting mortality and major short-term morbidities among very low birth weight infants (VLBWIs). Methods: This population-based prospective study from 67 Korean Neonatal Network centers performed between 2013 and 2016 included 5,296 VLBWIs with CRIB II calculation and 6,398 infants with CRIB II calculation but without the base excess (CRIB II-BE). A regression model predicting time-dependent mortality and morbidities using the CRIB II score was designed. The discriminate ability of the CRIB II and CRIB II-BE scores in predicting mortality and morbidities was explored using receiver-operating characteristic analysis. Results: CRIB II performed significantly better in predicting mortality than did gestational age or birth weight alone. The time-dependent performance of CRIB II was good in the first 30 days (area under the curve [AUC], 0.8435) and at 31–90 days (AUC, 0.8458). However, it was poor after 90 days (AUC, 0.6576). Specific CRIB II cutoffs were associated with severe intraventricular hemorrhage (AUC, 0.81), bronchopulmonary dysplasia (AUC, 0.77), and mortality or major morbidities (AUC, 0.80), respectively. The model using CRIB II-BE showed similar performance in predicting mortality and morbidities to that of the CRIB II model. Conclusion: Certain CRIB II cutoffs were significantly associated with time-dependent mortality, particularly within the first 90 days after birth as well as with short-term morbidities.

Incidence and severity of transient hypothyroxinaemia of prematurity associated with survival without composite morbidities in extremely low birth weight infants

This study investigated the incidence of transient hypothyroxinaemia of prematurity (THOP) associated with survival without composite morbidities and the predictability of THOP severity in extremely low birth weight infants (ELBWIs). We retrospectively reviewed the medical records of 546 ELBWIs who underwent initial thyroid function tests within 14 postnatal days, with 156 ELBWIs from 2000 to 2005 (period I) and 390 from 2006 to 2013 (period II). The infants were stratified into 23–24, 25–26 and 27–28 weeks’ gestation subgroups within each period; the initial thyroxine (T4) level, mortality, clinical characteristics and composite morbidities, including bronchopulmonary dysplasia, intraventricular haemorrhage, necrotizing enterocolitis, and retinopathy of prematurity were analysed. The predictive value of the initial T4 level, Apgar score at 5 min, and clinical risk index for babies II (CRIB II) score for estimating mortality and survival with or without composite morbidities was assessed. Comparing period II and period I, the incidence of THOP was significantly decreased along with significantly increased survival without composite morbidities in ELBWIs at 25–28 weeks’ gestation. The severity of THOP showed significant associations with mortality and composite morbidities. The initial T4 level was most effective for predicting outcome compared with Apgar and CRIB II scores.

Delayed cord clamping is associated with improved dynamic cerebral autoregulation and decreased incidence of intraventricular hemorrhage in preterm infants.

Delayed cord clamping (DCC) improves neurologic outcomes in preterm infants through a reduction in intraventricular hemorrhage (IVH) incidence. The mechanism behind this neuroprotective effect is not known. Infants born <28 wk gestation were recruited for longitudinal monitoring. All infants underwent 72 h of synchronized near-infrared spectroscopy (NIRS) and mean arterial blood pressure (MABP) recording within 24 h of birth. Infants with DCC were compared with control infants with immediate cord clamping (ICC), controlling for severity of illness [clinical risk index for babies (CRIB-II) score], chorioamnionitis, antenatal steroids, sedation, inotropes, and delivery mode. Autoregulatory dampening was calculated as the transfer function gain coefficient between the MABP and NIRS signals. Forty-five infants were included (DCC; n = 15, paired 2:1 with ICC controls n = 30). ICC and DCC groups were similar including gestational age (25.5 vs. 25.2 wk, P = 0.48), birth weight (852.3 vs. 816.6 g, P = 0.73), percent female (40 vs. 40%, P = 0.75), and dopamine usage (27 vs. 23%, P = 1.00). There was a significant difference in IVH incidence between the DCC and ICC groups (20 vs. 50%, P = 0.04). Mean MABP was not different (35.9 vs. 35.1 mmHg, P = 0.44). Compared with the DCC group, the ICC group had diminished autoregulatory dampening capacity (-12.96 vs. -15.06 dB, P = 0.01), which remained significant when controlling for confounders. Dampening capacity was, in turn, strongly associated with decreased risk of IVH (odds ratio = 0.14, P < 0.01). The results of this pilot study demonstrate that DCC is associated with improved dynamic cerebral autoregulatory function and may be the mechanism behind the decreased incidence of IVH. NEW & NOTEWORTHY The neuroprotective mechanism of delayed cord clamping in premature infants is unclear. Delayed cord clamping was associated with improved cerebral autoregulatory function and a marked decrease in intraventricular hemorrhage (IVH). Improved dynamic cerebral autoregulation may decrease arterial baroreceptor sensitivity, thereby reducing the risk of IVH.

Adrenal function of extremely premature infants in the first 5 days after birth.

Background There is limited data on adrenal function in the early days after birth in extremely premature infants. The relationship between plasma adrenocorticotrophic (ACTH) and cortisol hormone is central to the integrity of the hypothalamic-pituitary-adrenal (HPA) axis yet there are no studies examining this relationship in prematurity. Methods The aim of this study was to examine the relationship between early morning plasma cortisol and ACTH concentrations during the first 5 days after birth in infants born at less than 28 weeks' gestation and to identify any independent factors that determine plasma cortisol levels in these infants during extreme prematurity. We prospectively studied early morning plasma ACTH and cortisol concentrations in infants born below 28 weeks' gestation during the first 5 days of birth. Plasma cortisol was measured without extraction, using DPC Immulite® 2000 using a solid phase 2 site chemiluminescent immunometric assay. ACTH was measured using a radioimmunoassay. Spearman's correlation was used to examine the relationship between cortisol and ACTH. Multiple regression analysis was used to examine the relationship between plasma cortisol and clinical risk index for babies (CRIB) score, antenatal dexamethasone, mode of delivery and gestation. Results There were 95 infants (53 males) of mean gestation 25.3 ± 1.3 standard deviation (SD) (range 23-27 + 6) weeks. The mean birth weight was 809 ± 17.0 g. The mean plasma cortisol was 400.5 ± 42.6 nmol/L and the mean plasma ACTH was 4.5 ± 0.9 pmol/L. Early morning plasma cortisol correlated significantly with gestation (R = 0.4, p = 0.005). Early morning plasma ACTH did not correlate with early morning plasma cortisol (R = -0.12, p = 0.7). Multiple regression analysis showed that gestation was the only independent determinant of early morning plasma cortisol concentration (beta coefficient = -0.4, p = 0.04). Conclusions The relationship between early morning plasma ACTH and plasma cortisol is either not established or is impaired in infants of less than 28 weeks' gestation in the first 5 days after birth. The plasma cortisol level is mainly determined by gestation and is not directly related to illness severity, antenatal steroids or plasma ACTH in these infants in the first 5 days after birth.

SURVIVAL UNTIL DISCHARGE OF VERY-LOW-BIRTH-WEIGHT INFANTS IN TWO CROATIAN PERINATAL CARE REGIONS: A RETROSPECTIVE COHORT STUDY OF TIME AND CAUSE OF DEATH.

SUMMARYWe investigated mortality, causes, timing and risk factors for death until hospital discharge in very-low-birth-weight (VLBW) infants born in two Croatian perinatal care regions. This retrospective study included 252 live born VLBW infants. The mortality rate until hospital discharge was 30.5% (77/252). VLBW infants who died had by 4 weeks lower gestational age (GA) than surviving infants (median GA, 25 vs. 29 weeks), lower birth weight (BW) (mean BW, 756.4 vs. 1126.4 g), lower 5-minute Apgar score (median 5 vs. 8) and were more often resuscitated at birth (41.6 vs. 19.4%; p<0.001 all). Infants who survived were more often small-for-gestational age (SGA) (28.0 vs. 15.6%; p=0.04) and more often received continuous-positive-airway-pressure (CPAP) in delivery room (13.1 vs. 2.6%; p=0.01). Multivariate logistic regression revealed that parameters influencing death until hospital discharge were 5-minute Apgar score (OR 0.780, 95% CI 0.648-0.939) and higher Clinical Risk Index for Babies (CRIB) score (OR 1.677, 95% CI 1.456-1.931). ROC analysis showed that CRIB score (AUC 0.927, sensitivity 92.2, specificity 81.1; p<0.001) was the strongest predictor of death until hospital discharge. In infants who died within 12 hours, death was most commonly attributed to immaturity and in those surviving >12 hours to necrotizing enterocolitis.

Comparison between Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) and Clinical Risk Index for Babies (CRIB) in Prediction of Neonatal Mortality in Neonatal Intensive Care Unit (NICU) of Tanta University Hospital

AbstractBackground: Survival of the newborns who are admitted to the NICUs do not depend exclusively on birth weight and gestational age, but also on other perinatal factors and phys-iological conditions of the individual infants, in particular severity of their disease. More than one decade ago, the score for the neonatal acute physiology (SNAP), later the SNAP-perinatal extension (SNAP-PE) scores and clinical risk index for babies (CRIB) scores were proposed to be used in assessing severity, with sufficient precision to allow their application for quality assessment.Aim of Study: Was to compare between two neonatal mortality risk scores, SNAP-PE II and CRIB, in predicting the neonatal mortality in NICU of Tanta University Hospital (TUH ) over a period of one year and to measure the incidence of neonatal deaths in NICU of TUH over a period of one year.Patients and Methods: This was a prospective cohort study which was carried out on 500 newborns admitted to NICU of TUH over 1 year period. (From February 2016 to February 2017). All neonates were followed-up in NICU till their death or discharge. Neonates who had one of the following criteria were excluded: Newborn who died or was discharged in less than 24 hours after admission to our NICU, Infants whose APGAR score was not known, those who were admitted for observational purposes and those with were inevitably lethal congenital malformations. SNAP-PE II and CRIB scores applied to all the neonates in this study during the first 12 hours after their admission to NICU.Results: Area under the curve of both scores was nearly similar, meaning accuracy of both of them in predicting neonatal mortality.Conclusion: Both SNAP-PE II and CRIB scores have good sensitivity for predicting neonatal mortality which was slightly higher in SNAP-PE II score.

Risk-adjusted mortality of VLBW infants in high-volume versus low-volume NICUs

ObjectiveTo examine whether the number of very low birthweight (VLBW) infants treated annually in neonatal intensive care units (NICUs) (hospital volume) has an effect on their in-hospital mortality under the...

Coupling between mean blood pressure and EEG in preterm neonates is associated with reduced illness severity scores.

Hypotension or low blood pressure (BP) is a common problem in preterm neonates and has been associated with adverse short and long-term neurological outcomes. Deciding when and whether to treat hypotension relies on an understanding of the relationship between BP and brain functioning. This study aims to investigate the interaction (coupling) between BP and continuous multichannel unedited EEG recordings in preterm infants less than 32 weeks of gestational age. The EEG was represented by spectral power in four frequency sub-bands: 0.3–3 Hz, 3–8 Hz, 8–15 Hz and 15–30 Hz. BP was represented as mean arterial pressure (MAP). The level of coupling between the two physiological systems was estimated using linear and nonlinear methods such as correlation, coherence and mutual information. Causality of interaction was measured using transfer entropy. The illness severity was represented by the clinical risk index for babies (CRIB II score) and contrasted to the computed level of interaction. It is shown here that correlation and coherence, which are linear measures of the coupling between EEG and MAP, do not correlate with CRIB values, whereas adjusted mutual information, a nonlinear measure, is associated with CRIB scores (r = -0.57, p = 0.003). Mutual information is independent of the absolute values of MAP and EEG powers and quantifies the level of coupling between the short-term dynamics in both signals. The analysis indicated that the dominant causality is from changes in EEG producing changes in MAP. Transfer entropy (EEG to MAP) is associated with the CRIB score (0.3–3 Hz: r = 0.428, p = 0.033, 3–8 Hz: r = 0.44, p = 0.028, 8–15 Hz: r = 0.416, p = 0.038) and indicates that a higher level of directed coupling from brain activity to blood pressure is associated with increased illness in preterm infants. This is the first study to present the nonlinear measure of interaction between brain activity and blood pressure and to demonstrate its relation to the initial illness severity in the preterm infant. The obtained results allow us to hypothesise that the normal wellbeing of a preterm neonate can be characterised by a nonlinear coupling between brain activity and MAP, whereas the presence of weak coupling with distinctive directionality of information flow is associated with an increased mortality rate in preterms.

Incidence, risk factors, and outcome of neonatal acute kidney injury: a prospective cohort study.

Acute kidney injury (AKI) is common in neonates admitted to the neonatal intensive care unit (NICU). AKI is associated with increased morbidity and mortality and a greater long-term risk of chronic kidney disease. To study the incidence and outcome of neonatal AKI in a single Saudi Arabian center, level 2\3 NICU. This single-center prospective cohort study included all infants who received level II or III NICU care during 2015 (January to December). We excluded infants who survived less than 48h after admission, had evidence of congenital renal anomalies, or had insufficient data. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Both AKI and non-AKI neonates were prospectively followed up until NICU discharge. Outcomes studied included mortality and length of NICU stay. The results of adjusted risk analyses were expressed as relative risk (RR) with 95% confidence interval (95% CI). The incidence of AKI (modified neonatal KDIGO stages) was 56% (120/214 patients). Compared with neonates without AKI, those with AKI had a lower birth weight (2202 ± 816 vs. 1570 ± 776g; p < 0.001) and a lower gestational age (35 ± 3 vs. 32 ± 4weeks; p < 0.001). After adjustment for potential confounders, only gestational age (RR, 4.8; 95% CI, 3-9) and perinatal depression (RR, 10; 95% CI, 2-46) were significantly associated with an increased risk of AKI. For infants with gestational age < 32weeks, only the Clinical Risk Index for Babies (CRIB II) score was associated with an increased risk of AKI (RR, 1.9; 95% CI, 1-3). After adjustment for gestational age, AKI was significantly associated with mortality (RR, 5.4; 95% CI, 2-14), but not with the length of hospital stay (LOS) (p = 0.133). However, the AKI group had a significantly longer LOS (mean difference: 14days; 95% CI, 5.5-23days), and 33 patients (27.5%) with AKI were discharged with abnormally high serum creatinine levels (> 65μmol/L). AKI occurred in more than half of all NICU admissions, was associated with an increased risk of mortality, and had a higher incidence among smaller and sicker infants. Therefore, close monitoring of renal function during hospitalization and after discharge is warranted in such infants.

Correlation between Perfusion Index and CRIB Score in Sick Neonates Admitted to a Tertiary Center.

The study was to determine the correlation of Perfusion Index (PI) and Clinical Risk Index for Babies (CRIB) score, in assessing the severity of illness in sick neonates. This was a cross-sectional study conducted at a tertiary care Neonatal Intensive Care Unit (NICU). All eligible neonates, both term and preterm, admitted to the high-dependency unit of the NICU were included, after parental consent. Relevant details of history and examination were collected with a structured proforma. Severity of illness was assessed using CRIB score within 12 h of admission. PI was recorded within 24 h of admission, and babies were examined for the presence or absence of shock and their outcome was documented. The correlation coefficient between PI and CRIB score was derived. A total of 200 eligible newborns were enrolled. The mean gestational age of the neonates was 34 weeks. The median [interquartile range (IQR)] CRIB score was 1.00 (0.00, 3.00), and PI was 1.400 (0.93, 2.30). The Spearman's rank correlation coefficient between PI and CRIB score was -0.41 with p value <0.05. The median PI of neonates with CRIB score ≤5, 6-10 and >10 was 1.50, 0.74, 0.67, respectively (p value <0.0001). The median (IQR) PI of babies with shock and without shock was 0.63 (0.43, 0.84) and 1.58 (1.19, 2.41), respectively, with p value <0.001. PI has a negative correlation with CRIB score and can be used to assess the severity of illness in sick neonates.

Predicting mortality in extremely low birth weight infants: Comparison between gestational age, birth weight, Apgar score, CRIB II score, initial and lowest serum albumin levels.

We explored GA, BW, Apgar score, CRIB II score, and serum albumin levels as univariate predictors of mortality in extremely low birth weight infants. Medical records of 564 extremely low birth weight infants were reviewed retrospectively. The infants were grouped as survivors (group I), expired ≤ 7th postnatal day (group II), and expired > 7th postnatal day (group III). The predictive value for mortality of gestational age, birth weight, Apgar scores at 1 and 5 min, clinical risk index for babies II score, and first and lowest serum albumin levels was assessed by calculating the associated area under the curve (AUC) in receiver operating characteristic (ROC) curves. The overall survival and mortality rates of groups I, II, and III were 81.0% (457/564), 7.6% (43/564), and 11.4% (64/564), respectively. Birth weight, Apgar scores at 1 and 5 min, and first serum albumin levels were significantly higher, while the clinical risk index for babies II score was significantly lower in group I when compared to groups II and III. Gestational age and lowest serum albumin level in group I were significantly higher than group III, but not group II. However, gestational age, birth weight, and clinical risk index for babies II score showed gestational age dependent variations regardless of survival or mortality. Apgar score at 5 min (0.756) and lowest serum albumin level (0.771) demonstrated the highest AUC of the ROC curve in predicting mortality in group II and III, respectively. In conclusion, Apgar score at 5 min and lowest serum albumin level were the most effective predictors for mortality in extremely low birth weight infants during ≤ 7th and > 7th postnatal days, respectively.

Outcomes of very low birth weight infants born by vaginal delivery versus cesarean section

The optimal mode of delivery for very low birth weight (VLBW) infants remains controversial. Despite lacking evidence of benefts regarding neonatal outcomes, cesarean section delivery is becoming more prevalent, particularly in early gestational ages. In our retrospective, multicentr study data were collected for very low birth weight infants born in two Croatian perinatal regions in a 3 – year period (2014. – 2016.). The fnal cohort consisted of 255 very low birth weight infants. The rate of delivery via cesarean section was 74.1% (189/255) and is one of the highest reported in the literature so far. Infants born vaginally were born at an lower gestational age, had lower 1- and 5-minute Apgar scores, lower birth weights, and prognosis as expressed by higher Clinical risk index for babies (CRIB) scores and were more ofen born following chorioamnionitis and had higher mortality rate until 7 days of hospitalization. Univariate logistic regression analysis showed that cesarean section reduced the risk of death before 7 days of life (OR 0.34 95% CI 0.182-0.667). This signifcance was lost afer multivariate analysis. In infants surviving afer 7 days of hospitalization, rates of short-term neonatal morbidity (severe intracranial hemorrhage, cystic periventricular leukomalacia (cPVL), late-onset sepsis, necrotizing enterocolitis, kidney injury and retinopathy of prematurity requiring interventions) were not signifcant when comparing infants born vaginally and those born following cesarean section.

Posição canguru em recém-nascidos pré-termo de muito baixo peso: estudo descritivo

Descrever o número de períodos em que recém-nascidos pré-termo de muito baixo peso estiveram em posição canguru durante internação na unidade neonatal e buscar relações entre variáveis maternas e neonatais com a realização da posição canguru. Estudo descritivo retrospectivo com todos os recém-nascidos pré-termo admitidos em 2012, com peso de nascimento igual ou inferior a 1500g e idade gestacional menor que 31 semanas, classificados como pacientes de maior risco clínico, segundo o Clinical Risk Index for Babies. Foram investigados 38 sujeitos, cujo período de hospitalização variou entre 18 a 136 dias. O início da posição canguru ocorreu em média aos 30,8 dias de vida pós-natal (DP=18,5) e a quantidade de períodos em que estiveram em posição canguru foi em média 10,7 vezes. A ocorrência da posição canguru foi menos frequente que as oportunidades advindas da presença materna e esteve relacionado ao maior oferecimento de leite em livre demanda.

Challenges Faced in Translating the Benefits of Surfactant Replacement Therapy to a Resource-Limited Setting.

Aim To determine the challenges, if any, in translating the benefits of surfactant replacement therapy (SRT) to a resource-limited setting. Method This was a retrospective descriptive study comparing the outcome of 75 cases who received surfactant and 69 controls who did not at the University Hospital of the West Indies during the period 2001 to 2011. Descriptive analyses were performed. Statistical significance was taken at the level p < 0.05. Results Only 13% of neonates with respiratory distress syndrome received surfactant therapy. The median time of surfactant administration was 16.5 hours (interquartile range: 6-37 hours). The mean ± standard deviation time between repeat doses was 19.1 ± 14 hours. There was no difference in mortality between cases (67%) and controls (59%) (p = 0.32). However, the cases who survived were less mature (28.3 ± 2 weeks) and less clinically stable (CRIB II [Clinical Risk Index for Babies] score: 8.2 ± 3) than their controls who survived (30.0 ± 2 weeks; CRIB II score: 6.0 ± 3) (p = 0.01). There was no difference in mean gestational age or CRIB II scores between nonsurviving cases and controls. A high incidence of sepsis, pneumothoraces, and pulmonary hemorrhage was noted in both cases and controls. Conclusion SRT did not improve the overall outcome in preterm neonates treated with RDS. Challenges encountered in optimizing SRT included affordability and accessibility of surfactant, supportive equipment, and supportive therapies, as well as a high incidence of complications related to prematurity.

Outcome of very-low-birth-weight babies managed with nasal continuous positive airway pressure, with or without surfactant, in a high-care nursery

Background. Very-low-birth-weight (VLBW) infants who require nasal continuous positive airway pressure (NCPAP) are managed in neonatal intensive care units (NICUs) in developed countries, while in low-resource settings this is not always possible. The failure rate of NCPAP provided outside NICUs is not well known. Objectives. To determine the failure rate, assessed as the need for invasive medical ventilation (iMV) and mortality on NCPAP in VLBW infants managed in a high-care nursery (HCN) within the first 72 hours of life. Methods. Records of VLBW infants managed with NCPAP, at Chris Hani Baragwanath Hospital, were reviewed for infant characteristics, need for iMV and mortality on NCPAP. Clinical risk index for babies (CRIB) was calculated for each infant. Comparisons were made between those who needed iMV and those who did not, and between survivors and non-survivors on NCPAP. Results. A total of 325 VLBW infants were managed with NCPAP in the HCN. Mean (standard deviation) birth weight was 1 120 (184)g, 98.5% were of gestational age (GA) <34 weeks and 14.9% were small for GA (SGA). Thirteen percent died while on NCPAP and 33% of survivors required iMV – an overall failure rate of 43%. Factors associated with iMV were high CRIB score ( p <0.001), lower Apgar score ( p =0.013), lower PaO2 ( p =0.022) and high base deficit ( p =0.034). Those who died were more likely to have extremely low birth weight ( p <0.001), lower GA ( p <0.001), high CRIB score ( p <0.001) and base deficit ( p <0.001). On multivariate analysis, the predictors for need of iMV were low Apgar score ( p =0.033), SGA ( p =0.042) and CRIB score ( p =0.005), while that of mortality on NCPAP was birth weight. Conclusion. Although failure rate of NCPAP in VLBW infants managed in HCN is high, a significant proportion of VLBW infants benefit from this intervention.

Diagnosis and Risk Factors of Acute Kidney Injury in Very Low Birth Weight Infants

Acute kidney injury (AKI) is common in critically ill premature infants. There is a lack of consensus on the diagnostic definition of AKI in very low birth weight (VLBW) infants. The primary aim of this study was to determine the incidence and risk factors for AKI in VLBW infants using the AKI network (AKIN) and pRIFLE (pediatric Risk, Injury, Failure, Loss, End-Stage) criteria and to evaluate whether Clinical Risk Index for Babies (CRIB II) score is a predictor of AKI. The secondary objective was to determine the extent of agreement between the AKIN and pRIFLE criteria in the diagnosis of AKI in VLBW infants. This was a retrospective chart review of 115 VLBW (< 1500g) infants born in an academic center with a Level 3B neonatal intensive care unit. Multiple congenital anomalies, transfer to other centers, or death within the first 2weeks were the exclusion criteria. Relevant data were collected and analyzed in the first 2weeks postnatally. AKI incidence, according to AKIN and pRIFLE criteria, was 20.1% and 22.6%, respectively. As per the interrater reliability analysis, there was a fair agreement between the two criteria (kappa=0.217). AKI was nonoliguric. The length of stay was significantly longer in the AKI group. Prenatal nonsteroidal anti-inflammatory drug exposure, lower gestational age, lower birth weight, respiratory distress syndrome, mechanical ventilation, patent ductus arteriosus, hypotension, late onset sepsis, and higher CRIB II scores were significantly associated with AKI. Our regression analysis found CRIB II scores to be an independent risk factor for AKI (odds ratio=1.621; 95% confidence interval, 1.230-2.167; p=0.001). The determination of AKI using the pRIFLE and AKIN criteria yielded different results. pRIFLE appears to be more sensitive in VLBW infants. A high CRIB II score was recorded for AKI. Future studies are necessary to develop a uniform definition and identify the risk factors to improve the outcomes in this population.

Protocole donneur unique : pratiques transfusionnelles et facteurs de risque des transfusions multiples en réanimation néonatale

In France since 2002, the single-donor transfusion protocol, using four pediatric units from the same adult donor's packed red blood cells (PRBCs) in multiply transfused newborns, is recommended in preterm neonates to reduce the risks of infection and alloimmunization. This protocol is controversial, however, because it causes the transfusion of stored blood, which could have adverse consequences. Before the new recommendations of the French Haute Autorité de santé (National authority for health) in 2015, we conducted a national practice survey in 63neonatal intensive care units (NICU) and a retrospective study of the characteristics of 103children transfused within our unit, to better target beneficiaries. The practice survey showed that 30% of French NICUs no longer used the protocol in 2014, due to logistical or financial problems, or concerns about the transfusion of stored blood. The practices were heterogeneous. Few NICUs used a written protocol. In our NICU, the use of single-donor protocol involved the use of units stored for more than 20days in half of the cases beginning with the third unit used. Six-term newborns were mainly transfused once, which does not seem to warrant the single-donor transfusion protocol. The use of this protocol caused the loss of 50% of the manufactured units, which go unused. In multivariate analysis, two factors were predictive of multiple transfusion within our population of 95premature neonates undergoing transfusion: low-term and a high Clinical Risk Index for Babies (CRIB) score. The risk of multiple transfusions would be reduced by about 15% for each additional week of gestation and approximately 16% per point within the CRIB score. These variables integrated into a statistical model predict the risk of multiplying transfusions. According to the ROC curve, a calculated risk higher than 50% is the appropriate cut-off value to transfuse with the single-donor transfusion protocol. This would limit its indications, saving more than 130pediatric units of blood for 100transfused children. A prospective study in our department will allow internal validation of this test.