Outborn Infants Research Articles

Demographics, clinical characteristics and neonatal outcomes in a rural Ugandan NICU.

BackgroundNinety-six percent of the world’s 3 million neonatal deaths occur in developing countries where the majority of births occur outside of a facility. Community-based approaches to the identification and management of neonatal illness have reduced neonatal mortality over the last decade. To further expand life-saving services, improvements in access to quality facility-based neonatal care are required. Evaluation of rural neonatal intensive care unit referral centers provides opportunities to further understand determinants of neonatal mortality in developing countries. Our objective was to describe demographics, clinical characteristics and outcomes from a rural neonatal intensive care unit (NICU) in central Uganda from 2005–2008.MethodsThe NICU at Kiwoko hospital serves as a referral center for three rural districts of central Uganda. For this cross sectional study we utilized a NICU clinical database that included admission information, demographics, and variables related to hospital course and discharge. Descriptive statistics are reported for all neonates (<28 days old) admitted to the NICU between December 2005 and September 2008, disaggregated by place of birth. Percentages reported are among neonates for which data on that indicator were available.ResultsThere were 809 neonates admitted during the study period, 68% (490/717) of whom were inborn. The most common admission diagnoses were infection (30%, 208/699), prematurity (30%, 206/699), respiratory distress (28%, 198/699) and asphyxia (22%, 154/699). Survival to discharge was 78% (578/745). Mortality was inversely proportional to birthweight and gestational age (P-value test for trend <0.01). This was true for both inborn and outborn infants (p < 0.01). Outborn infants were more likely to be preterm (44%, (86/192) vs. 33%, (130/400), P-value <0.01) and to be low birthweight (58%, (101/173) vs. 40%, (190/479), P-value <0.01) than inborn infants. Outborn neonates had almost twice the mortality (33%, 68/208) as inborn neonates (17%, 77/456) (P-value <0.01).ConclusionsUnderstanding determinants of neonatal survival in facilities is important for targeting improvements in facility based neonatal care and increasing survival in low and middle income countries.

PC.06 Outcome of infants with birth weight less than 500 grams in a tertiary neonatal unit

BackgroundAdvances in obstetric and neonatal practice have potentially increased survival at the limits of viability and in severely growth restricted infants. In the UK, the proportion of liveborn infants weighing...

Maternal Haemoglobin and Short-Term Neonatal Outcome in Preterm Neonates

ObjectiveTo determine whether there is a significant association between maternal haemoglobin measured before delivery and short-term neonatal outcome in very preterm neonates.Study designWe included prospectively all live births occurring from 25 to 32+6 weeks of gestation in a tertiary care centre between January 1st 2009 and December 31st 2011. Outborn infants and infants presenting with lethal malformations were excluded. Three hundred and thirty-nine mothers and 409 infants met the inclusion criteria. For each mother-infant pair a prospective record of epidemiologic data was performed and maternal haemoglobin concentration recorded within 24 hours before delivery was retrospectively researched. Maternal haemoglobin was divided into quartiles with the second and the third one regarded as reference as they were composed of normal haemoglobin values. Short-term outcome was defined as poor in case of death during hospital stay and/or grades III/IV intraventricular haemorrhage and/or periventricular leukomalacia and/or necessity of ventriculoperitoneal shunt.ResultsThe global rate of poor short-term neonatal outcome was 11.4% and was significantly associated with low maternal haemoglobin values. This association remained significant after adjustment for antenatal corticosteroids therapy, gestational age, parity, mechanism of preterm birth, mode of delivery and birth weight (aOR = 2.97 CI 95% [1.36–6.47]). There was no relation between short-term neonatal outcome and high maternal haemoglobin concentration values.ConclusionWe show that low maternal haemoglobin concentration at delivery is an independent risk factor for poor short-term neonatal outcome in very preterm neonates. This study is one of the first to show such an association within the preterm population.

Delivery room surgery: an applicable therapeutic strategy for gastroschisis in developing countries

The survival rate of infants with gastroschisis has improved significantly. It is over 90% in developed countries, but 50% in developing countries. This study aimed to investigate the factors improving the survival rate of infants with gastroschisis in developing countries. Neonates meeting the inclusion criteria, who presented to our center since the establishment of delivery room surgery, were enrolled into this retrospective study. Data were evaluated specifically to determine the role of delivery room surgery in reducing the mortality and morbidity of infants with gastroschisis and to identify factors optimizing the conditions of outborn infants. A total of 64 infants were identified. The overall survival rate of the infants was 60.9%. The survival rate of infants in inborns was 76.5%, and the survival rate of infants in outborns was 43.3%. Infants of the outborn group took more time to reach full enteral feeding, and were more likely to require a prolonged stay in hospital when compared with those of the inborn group. Logistic analysis identified that the surgical technique, the presence of sepsis and intestinal necrosis could be expected to influence the outcome of gastroschisis. The strategy of delivery of patients in a center prepared to perform delivery room closure of gastroschisis appears to improve the survival of patients with gastroschisis. Further reduction in mortality rates will depend on improved conditions of outborn infants.

Survival of Newborn Infants With Severe Respiratory Failure Before and After Establishing an Extracorporeal Membrane Oxygenation Program*

Severe hypoxic respiratory failure is a leading cause of neonatal mortality in Chile. Extracorporeal membrane oxygenation improves survival in neonates with hypoxic respiratory failure. To determine the impact of the establishment of a Neonatal Extracorporeal Membrane Oxygenation Program on the outcome of newborns with severe hypoxic respiratory failure in a developing country. Data of newborns (birthweight > 2,000 g and gestational age ≥ 35 wk) with hypoxic respiratory failure and oxygenation index greater than 25 were compared before and after extracorporeal membrane oxygenation was available. Extracorporeal membrane oxygenation was initiated in infants with refractory hypoxic respiratory failure who failed to respond to inhaled nitric oxide/high-frequency oscillatory ventilation. Data from 259 infants were analyzed; 100 born in the pre-extracorporeal membrane oxygenation period and 159 born after the extracorporeal membrane oxygenation program was established. Patients were similar in terms of risk factors for death for both periods except for a higher oxygenation index and a greater proportion of outborn infants during the extracorporeal membrane oxygenation period. Survival significantly increased from 72% before extracorporeal membrane oxygenation to 89% during the extracorporeal membrane oxygenation period (p < 0.01). During the extracorporeal membrane oxygenation period, 98 of 159 patients (62%) with hypoxic respiratory failure were rescued using inhaled nitric oxide/high-frequency oscillatory ventilation, whereas 61 (38%) did not improve; 52 of these 61 neonates were placed on extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survival rate to discharge was 85%. After adjusting for potential confounders, the severity of the pretreatment oxygenation index, a late arrival to the referral center, the presence of a pneumothorax, and the diagnosis of a diaphragmatic hernia were significantly associated with the need for extracorporeal membrane oxygenation or death. The establishment of an extracorporeal membrane oxygenation program was associated with a significant increase in the survival of newborns more than or equal to 35 weeks old with severe hypoxic respiratory failure.

Community-genotype strains of methicillin-resistant Staphylococcus aureus with high-level mupirocin resistance in a neonatal intensive care unit

AimThe aim of this study was to investigate the genotypes of mupirocin-resistant methicillin-resistant Staphylococcus aureus (MR-MRSA) isolates in our neonatal intensive care unit (NICU) and their potential source. Study designOne hundred one MRSA isolates obtained from 59 inborn and 42 outborn infants were identified and their antimicrobial susceptibility determined. Using pulse-field gel electrophoresis (PFGE) analysis, MR-MRSA isolates obtained from the neonatal patients in the NICU were compared with those from adult hospitalized in the same hospital and with community-associated MRSA (CA-MRSA) isolates recovered from different hospitals in Korea. ResultsOverall, 47% of CA-MRSA and 79% of healthcare-associated MRSA isolates exhibited high-level mupirocin resistance (HLMR). Forty-five percent of the outborn infants were considered to have CA-MRSA at the time of admission to our NICU. Most HLMR-MRSA isolates from neonates were grouped into a single cluster by PFGE analysis, and which included CA-MRSA isolates with HLMR recovered from outborn infants who were already colonized when they were transferred to our NICU. They belonged to the same PFGE group as the community-genotype strains isolated from different hospitals in Korea. HLMR-MRSA isolates from adults patients were classified as different clones. None of the attending staff in the NICU were nasal carriers. ConclusionCommunity-genotype strains of MRSA with HLMR may be imported to our NICU through obstetrics clinics and contribute to MRSA colonization or infection in facilities with a high rate of admission of outborn infants.

PP.42 Investigation of Neonatal Encephalopathy: The Lost Placental ‘Black Box’

BackgroundAfter an aeroplane crash, recovery of the ‘black box’ is a high priority for investigators; analysis of recorded parameters frequently identifies cause or contributing factors. The placenta likewise provides an...

Predicting death or major neurodevelopmental disability in extremely preterm infants born in Australia

BackgroundThe aim of this study was to determine if the National Institute of Child Health and Human Development (NICHD) calculator, designed to predict mortality or neurosensory disability in infants 22–25...

It is not the ride: inter-hospital transport is not an independent risk factor for intraventricular hemorrhage among very low birth weight infants

The purpose of this study was to evaluate the relationship between intraventricular hemorrhage (IVH), inter-hospital transport and known potential risk factors for IVH. Very low birth weight (VLBW <1500 g) infants admitted to a large regional neonatal intensive care unit within 48 h of life from 2005 to 2010 were identified. Logistic regression and proportional odds logistic regression models were used to compare inborn versus outborn patients with respect to IVH (any vs none) and IVH grade, respectively. Logistic regression was used to quantify the association between outborn status and mortality. A total of 758 infants were included in the study (inborn=568, outborn=190). Outborn infants were found to have greater IVH severity than inborn (odds ratio (OR): 1.52; P=0.012). After accounting for 20 clinical and demographic variables in a multivariable model, the association between outborn status and IVH lacked statistical significance (OR: 1.14; P=0.56). Significant predictors of IVH grade included vaginal delivery (OR: 2.16; P<0.001), patent ductus arteriosus (OR: 1.65; P=0.005), 5-min Apgar (OR: 0.85; P=0.005) and gestational age (OR: 0.98; P=0.012). Sixty-nine (9.1%) of the infants died. After adjusting for potential confounders, the relationship between mortality and outborn status was not significant (OR:1.26; P=0.516). Significant predictors of mortality included gestational age (OR: 1.03; P=0.04) and 5-min Apgar (OR:1.22; P=0.02). Although VLBW infants transported during the first 2 days of life have higher rates of IVH than infants born at a tertiary care facility, this relationship may be explained by associations with underlying clinical variables rather than transport itself.

Variations in Transport Outcomes of Outborn Infants among Canadian Neonatal Intensive Care Units

Outborn infants born at community hospitals and transported to tertiary neonatal intensive care units (NICUs) for treatment account for 20% of all tertiary NICU admissions in Canada. Little is known about variations in their outcomes. The Transport Risk Index of Physiologic Stability (TRIPS) is a validated score of neonatal physiological status that can identify differences between transport teams' outcomes. To examine regional variations in outcomes among outborn infants transported to Canadian tertiary NICUs using TRIPS. Transport teams prospectively collected data for all outborn infants admitted to 25 Canadian NICUs during 2006 to 2007. Singleton outborn infants ≥ 32 weeks' gestation admitted to NICUs for at least 24 hours who died or who were transferred to another NICU within 24 hours were examined for overall incidence of mortality, major morbidity, and change in TRIPS score. Complete transport data were available for 2313 (72.9%) of 3193 eligible infants. There were significant variations in interhospital and interprovincial outcomes. Factors significantly affecting change in TRIPS score were gender, pretransport TRIPS score, composition of transport team and distance traveled. Significant variation exists in transport outcomes in Canada. Further investigation is required to optimize infant transport systems, processes, and clinical care.

Assessing Outcome in Interhospital Infant Transport: The Transport Risk Index of Physiologic Stability Score at Admission

To evaluate the performance of the Transport Risk Index of Physiologic Stability (TRIPS) score at admission for early mortality prediction. The study included all consecutive outborn infants admitted to a single neonatal intensive care unit (NICU) over a 3-year period. The data collected included demographic variables, 7-day NICU mortality, and severe (≥ grade 3) intraventricular hemorrhage (IVH), TRIPS score at admission, and Score for Neonatal Acute Physiology II (SNAP-II) and SNAP-Perinatal Extension-II (SNAPPE-II) scores. A total of 175 neonates were enrolled. TRIPS at admission discriminated 7-day mortality from survival with a receiver operating characteristic (ROC) area of 0.80, and predictive performance of TRIPS for severe IVH showed a ROC area of 0.67. The TRIPS had good calibration for all strata (p = 0.49). For gestational age (GA) >32 weeks, the area under the curve (AUC) for TRIPS was 0.71, whereas the AUC for GA ≤32 weeks was 0.99 for 7-day mortality. Predictive performance of TRIPS for 7-day mortality was similar to that of SNAP-II and SNAPPE-II. TRIPS score at admission had a good performance to discriminate high-risk patients for 7-day mortality, mainly infants with GA ≤32 weeks. TRIPS might be a useful triage tool if applied at the time of first contact with a transport service.

Surgical Management of Extremely Low Birth Weight Infants with Neonatal Bowel Perforation: A Single-Center Experience and a Review of the Literature

Background: Necrotizing enterocolitis (NEC) and focal intestinal perforation (FIP) are major causes of morbidity in infants with extremely low birth weight (ELBW). Objective: To evaluate the surgical procedures applied, and the survival and long-term outcome of ELBW infants with NEC and FIP in a single-center study. Methods: Inborn and outborn ELBW infants (<1000 g) with NEC and FIP were analyzed retrospectively from 2002 to 2007. Data collected include surgical procedures, survival as well as complications, length of partial parenteral nutrition and hospital stay. The short-term and long-term outcomes after 2–7 years were assessed and compared with a matched control group. Results: Out of 280 ELBW infants, 28 underwent surgery, 19 because of FIP and 9 for NEC. Fourteen infants in the FIP group were treated with primary laparotomy and 5 with peritoneal drainage (PD). In the NEC group, only 1 infant was treated with PD. PD was used for unstable patients and was always followed by secondary laparotomy after stabilization. Five of 28 (18%) surgically treated ELBW infants and 4 (14%) matched controls died. The following complications occurred in the surgical group: complete (n = 1) or minor wound dehiscence (n = 4), stoma prolapse (n = 5), parastomal hernia (n = 2), stoma fistula (n = 1), and wound infection (n = 2). Dependency on parenteral nutrition was significantly shorter in infants with FIP, while there were no differences in time to stoma closure and length of hospital stay between those with FIP and those with NEC. Eleven of 23 (47.8%) surviving patients with FIP or NEC showed developmental delay, compared with 9 of 24 (37.5%) in the controls. Conclusions: The management of EBLW infants with NEC and FIP remains challenging. Our treatment approach was associated with low mortality. Developmental delay seems to be caused by extreme prematurity rather than NEC- or FIP-related bowel perforation.

The Respiratory Morbidities in Late-preterm Infants Compared with the Early-preterm and Term Infants throughout the First Year of Life

Purpose: We examined the respiratory morbidities in late-preterm infants compared to those of the early-preterm infants and term infants throughout the first year of life. Methods: Data were retrospectively collected for 87 late-preterm, 72 early-preterm, and 608 term infants who were admitted to NICU and the nursery of Busan St. Mary's Medical Center from Jan 2007 to Oct 2009. Results: There were significant differences in the proportions of the out-born infants, twin pregnancy, small for gestational age, and Caesarean section in the three groups (P<0.05). Late-preterm and early-preterm infants had longer duration of hospitalization, larger proportions of respiratory distress syndrome, mechanical ventilation at birth, oxygen therapy after 48 hours of birth, oxygen dependency at 28 days, and continuous positive airway pressure support at 28 days compared to term infants during the neonatal period (P=0.000). Late-preterm infants and early-preterm infants were re-admitted more often than term infants during the first year of life (P=0.000). Also Late-preterm and early-preterm infants had increased chance of respiratory tract illness than term infants (P=0.001). Conclusion: In this study, we demonstrated that there are higher chances of respiratory morbidities in the late-preterm infants than the term infants either during the neonatal period or throughout the first year of life, although early-preterm infants showed greatest respiratory morbidities.

Impact of Implementing 5 Potentially Better Respiratory Practices on Neonatal Outcomes and Costs

We implemented 5 potentially better practices to limit mechanical ventilation (MV), supplemental oxygen, and bronchopulmonary dysplasia in newborn infants born before 33 weeks' gestation. The methods used in this study included (1) exclusive use of bubble continuous positive airway pressure (bCPAP), (2) provision of bCPAP in the delivery room, (3) strict intubation criteria, (4) strict extubation criteria, and (5) prolonged CPAP to avoid supplemental oxygen. We excluded outborn infants and those with major anomalies and obstetric complications from analysis. Demographics were similar in 61 infants born before and 60 born after implementation. For infants born at 26 to 32(6/7) weeks' gestation, intubation (first 72 hours) decreased from 52% to 11% (P < .0001) and surfactant use decreased from 48% to 14% (P=.0001). In all infants, the mean ± SD fraction of inspired oxygen requirement (first 24 hours) decreased from 0.27 ± 0.08 to 0.24 ± 0.05 (P=.0005), days of oxygen decreased from 23.5 ± 44.5 to 9.3 ± 22.0 (P=.04), and days of MV decreased from 8.8 ± 27.8 to 2.2 ± 6.2 (P=.005). Hypotension decreased from 33% to 15% (P=.03). The percentage of infants with bronchopulmonary dysplasia was 17% before and 8% after (P=.27). Nurse staffing ratios remained unchanged. Implementation of these potentially better practices reduced the need for MV, surfactant, and supplemental oxygen as well as reduced hypotension among infants born before 33 weeks' gestation without adverse consequences. The costs for equipment and surfactant were lower.

Therapeutic hypothermia in the neonate – from best research to best practice

BackgroundTherapeutic hypothermia is recommended as the standard of care for the management of hypoxic-ischaemic encephalopathy (HIE) (REF). The true value of clinical trials lies in their translation into universal practice.AimTo...

Congenital diaphragmatic hernia (CDH) in wales 1989–2010

AimsTo determine the incidence, co-morbidities and outcome of congenital diaphragmatic hernia (CDH) in Wales.MethodsThis retrospective database review used 2 data-sets-CARIS (Congenital Anomaly Register & Information Service, Wales) to determine incidence,...

Demographic Profile of Infants with Stage 5 Retinopathy of Prematurity in North India: Implications for Screening

Purpose: To study demographic profile of infants presenting as stage 5 retinopathy of prematurity (ROP) at a tertiary referral center of North IndiaMethods: A retrospective review of consecutive infants with stage 5 ROP from 1999–2008. Various parameters retrieved included the inborn (born at level III nursery of our institute) /outborn (born outside study center) status, birth weight, gestational age, age at presentation, screening details,treatment details and reasons for consultationResults: Sixty -six infants are included. All infants were outborn (born outside study center). Mean birth weight was 1250.23 ± 486.45 g and gestational age at birth was 28.5 ± 2.2 weeks. Ten (15.1%) infants were above 1500g birth weight. Median age at presentation was 7 month (range, 2–84 months). Fifty-seven (86.4 %) infants were never screened for ROP and 2(3%) were lost to follow-up after single screening. Seven (10.6%) infants had screening and treatment. Forty-nine (74.2%) infants were self-referred (i.e brought by parents on their own) and 17(25.8%) were referred by ophthalmologists. Pediatricians referred none of the infants.Conclusion: Our study shows that lack of screening is responsible for stage 5 ROP in outborn infants. More needs to be done to spread awareness about the disease. Broader screening guidelines are needed to ensure screening for infants>1500 g birth weight.

Psychosocial parental support programs and short-term clinical outcomes in extremely low-birth-weight infants

Objective. To describe the association between an individualized psychosocial parental support (PPS) program and short-term clinical outcomes of extremely low-birth-weight (ELBW) infants admitted to the neonatal intensive care unit (NICU).Methods. Medical records of ELBW infants (<1000 g) hospitalized in the NICU at Miami Children's Hospital between July 2006 and June 2008 were reviewed. Outborn infants admitted during their first 72 h of life and discharged home were included. Parents were divided in two groups according to their participation status in the PPS program. Neonatal outcomes in both groups were compared.Results. Forty-one infants were included (n = 41). Mean gestational age was 26.7±2 weeks, and birth weight was 860±125 g. Median length of stay (LOS) was 96 days (quartile range: 76–112 days). PPS was provided to 33.3% of these infants' parents. The median LOS in the PPS group was significantly lower than in control group (86 vs. 99 days; p < 0.05). No other differences in short-term neonatal outcomes were found.Conclusions. The addition of individualized psychosocial parent support programs to standard care in the NICU may reduce LOS in surviving infants discharged home. Further larger and randomized prospective studies are needed.

Predisposing Factors to Neonatal Septicaemia at Ahmadu Bello University Teaching Hospital, Zaria Nigeria

The study aimed at identifying the risk factors for neonatal septicaemia in Zaria.Consecutive newborns admitted into the Special Care Baby Unit of Ahmadu Bello University Teaching Hospital, Zaria with the presumptive test diagnosis of neonatal septicaemia between 25 May, 2004 and 31 May, 2005 were studied. History of events in the antenatal and neonatal periods was obtained and physical examination was done. Blood, urine, cerebrospinal fluid and swabs of body discharges were taken for culture and sensitivity studies. The data were analysed using Epi Info version 6 software. Associations were tested using Chi square, with Yates correction, or Fisher's exact tests where appropriate, while statistical significance was set at p < 0.05.A total of 211 neonates, consisting of 69 in-born and 142 out-born infants were studied. There were 122 (57.8%) males and 89 (42.2%) females; giving a male: female ratio of 1.4:1. Seventy-five (35.5%) of the newborns had bacteriologically proven septicaemia consisting of 54 (38.0%) of the outborn and 21 (30.4%) of the inborn babies (p = 0.3535); 42 males and 33 females (p = 0.8011). The male: female ratio of newborns with culture-proven septicaemia was 1.2:1. The predisposing factors that were associated with culture-proven septicaemia were lack of antenatal care (p = 0.0234), prolonged rupture of membranes (p = 0.0085), prolonged labour (p = 0.0032), preterm delivery (p = 0.0125) and perinatal asphyxia (p = 0.0078).The risk factors in neonates with septicaemia in this study emphasise the need for timely improvement in the implementation of existing public health strategies.

Challenges and outcomes of management of anterior abdominal wall defects in a Nigerian tertiary hospital

Abdominal wall defect presents a great challenge when it is large, ruptured, or associated with other anomalies. To review the challenges and outcome of management of anterior abdominal wall defects (AAWD). A retrospective review of omphalocele and gastroschisis managed over 8 years at our institution. Omphalocele (n=49) and gastroschisis (n=7) constituted 2.4% of total admission. The median age was 23.5 hours, with male-female ratio of 1:1.1. Term infants were 91.7% and more than 75% weighed above 2.5 kg. The mean maternal age was 28.5±5.87 years and mean parity was 3.1±2.0, with P values of 0.318 and 0.768, respectively. More than 92.9% of infants were out-born, 46 pregnancies (82.1%) were booked, and 51 (91.1%) had at least one ultrasound scan, but only 1 (1.8%) was diagnosed with gastroschisis. Ruptured omphalocele were 11 (6 major, 5 minor) in number, 3 of which presented with enterocutaneous fistula, and 3 (6.1%) were syndromic omphalocele. Positive blood culture confirmed septicaemia in 21 cases (37.5%). Surgical repair was done in 35 cases (62.5%), 44.6% as emergency, and 17.9% as elective. Non-operative management was done in 21 patients (37.5%) and 5 (8.9%) were discharged against medical advice. Median length of hospital stay was 10 days (mean, 15.98±14.38). Postoperative complication rate was 32.1% and overall mortality was 30.4%, with the highest case fatality among gastroschisis (57.1%) and omphalocele major (32.1%). There were large numbers of out-born infants due to poor prenatal diagnosis in spite of high instances of antenatal ultrasound scan. Many patients presented with complications that resulted in poor outcome.