cause- specific neonatal deaths dr.abdulrahman alnemri assistant professor paediatric consultant...
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Cause- Specific Neonatal Deaths
Dr.AbdulRahman Alnemri
Assistant professor paediatric
Consultant Neonatologist
1st international NEONATOLOGY conference 17-19 November 2008
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غافر
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Background
Each year 4 million children die in the first 4 weeks of life
Global average of 30-36/1000 Live Birth Geneva WHO report,2005
Many neonatal deaths are preventable with existing low-cost intervention
Planners and policy makers required reliable cause-of –death information
Int J Epidemiol 2003;362-65-70
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The reduction of child mortality has been included among the Millennium Development Goals(MDG-4) that the United Nations has set to be attained by year 2015.
With out reduction in global NMR MDG-4 will not be achieved
Strategies, which address inequalities both within a country and between countries, are necessary if there is going to be further improvement in global perinatal health.
Report of the Secretary General. New York, NY: United Nations; 2001. UN document A756/3264 million neonatal deaths: when? where? Why? Lancet 2005;365:891-900
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Causes of Neonatal Deaths
WHO report before 2005 provide little detail with respect to perinatal-neonatal causes of death WHO,the world helth
Report:2004Geneva
Neonatal infection the single largest cause of deaths globally national inst of science2003,pp.1-333
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Estimating the cause of 4 million neonatal death in the year 2000
NMRs ranged from 2 to 18 per 1000 live births. Based on 193 countries; the major causes Infection (sepsis/pneumonia, tetanus, and
diarrhea 35% Preterm birth 28% Asphyxia 23% 98% information on cause of death is lacking
because of inadequate vital registration (VR)
International Journal of Epidemiology 2006;35:706–718
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The estimated distribution of causes for 4 million neonatal deaths for the six WHO regions in the year 2000. Size of circle represents number of deaths in each region. Afr = Africa, Amr = Americas, Emr = Eastern Mediterranean, Eur = Europe, Sear = Southeast Asia, and W pr = Western Pacific
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1. El Shafei AM, Sandhu AK, Dhaliwal JK. Perinatal mortality in Bahrain. Aust N Z J Obstet Gynaecol 1988;28:293–98.
2. Ebrahim AH. Perinatal mortality in Ministry of Health Hospitals- Bahrain, 1985 and 1996. J Bahrain Med Soc 1998;10:95–99.
3. Kishan J, Soni AL, Elzouki AY, Mir NA. Perinatal mortality and neonatal survival in Libya. J Trop Pediatr 1988;34:32–33.
4. el-Zibdeh MY, Al-Suleiman SA, Al-Sibai MH. Perinatal mortality at King Fahd Hospital of the University Al-Khobar, Saudi Arabia. Int J Gynaecol Obstet 1988;26:399–407.
5. Asindi AA, Archibong E, Fatinni Y, Mannan N, Musa H. Perinatal and neonatal deaths. Saudi Med J 1998;19:693–97.
6. Dawodu A, Varady E, Verghese M, al-Gazali LI. Neonatal audit in the United Arab Emirates: a country with a rapidly developing economy. East Mediterr Health J 2000;6:55–64.
7. Yassin KM. Indices and sociodemographic determinants of childhood mortality in rural Upper Egypt. Soc Sci Med 2000;51:185–97.
8. Campbell O, Gipson R, el Mohandes A et al. The Egypt National Perinatal/Neonatal Mortality Study 2000. J Perinatol 2004;24:284–89.
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Mortality rates in Canadian neonatal intensive care units
• Canadian Medical Association or its licensors 22 JANV. 2002; 166 (2)
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YearIMR
(NMR)
Rank % Change Date
200347.94(12.7)
73 -72.38 % 2003 est.
200413.24
(11)145 0.00 % 2004 est.
200513.24 144 -3.25 % 2005 est.
2006 12.81 144 2006 est.
Source: CIA World Factbook - Unless otherwise noted, information in this page is accurate as of November 1, 2006
Infant and NMR in Saudi Arabia
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Date FIFA Ranking position
Mar 2008 50
Feb 2008 50
Jan 2008 57
2007 61
2006 64
2005 33
2004 28
2003 26
2002 38
2001 31
2000 36
1999 39
1998 30
1997 33
1996 37
1995 54
1994 27
1993 38
Saudi Arabia average position from FIFA World
Ranking creation is 38
http://www.fifa.com/
The Gulf Area countries are on track to meet most of the Millennium Development Goals,
although the speed of improvement has slowed since the 1990s.
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Neonatal Mortality RateNorth Saudi Arabia
NMR account for 60% of all infant deaths
(65.6%) occured in the neonatal period Three main causes of death were identified:
perinatal causes, genetic disorders and infection 44% of infant deaths considered as preventable
Avery’s Neonatology: Pathophysiology& Management of the Newborn. 6th ed. Philadelphia,Pa: Lippincott Williams & Wilkins;2005:459–489
JELLY A. E. (1) ; WARNASURIYA N. (1) Saudi medical journal 1998, vol. 19, no2, pp. 136-140
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South Saudi Arabia Department of Pediatrics, Abha Maternity Hospital, Abha
The major death determinants were low birth weight (LBW)/ prematurity, congenital malformation and birth asphyxia.
Respiratory insufficiency (89.9% of cases) and sepsis (36% of cases) were the main causes of neonatal deaths in low birth weight infants.
Ann Saudi Med 1997;17(5):522-526.
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Causes of neonatal deaths in ACH
Causes of deathNo. of infants % of total (n=169)
Low birth weight 77 45.5
Congenital malformation 52 30.8
Infection 23 13.6
Birth asphyxia 13 7.7
Meconium aspiration syndrome
2 1.2
Inborn error of metabolism 2 1.2
Ann Saudi Med 1997;17(5):522-526.
South Saudi Arabia
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Factors contributing to death in 77 LBW infants.
Conditions No. of cases
Hyaline membrane disease 33
Sepsis 23
Necrotizing enterocolitis 14
Pulmonary hemorrhage 4
Intraventricular hemorrhage 3
Persistent pulmonary hypertension
3
Undetermined 10
Ann Saudi Med 1997;17(5):522-526.
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East P of Saudi Arabia. Neonatal vital statistics: a 5-year review 81-86
The overall neonatal mortality rate declined from 15.6 to 8.1/1000 live births (LB), and after excluding lethal malformations mortality fell from 14.0 to 5.6/1000 LB
Congenital malformations, RDS, and asphyxia were the 3 most common causes of death.
These conditions and severe immaturity account for 74% of deaths.
Dawodu AH Al Umran KAl Faraidy AAnn Trop Paediatr. 1988 Sep;8(3):187-92.
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CAUSE-SPECIFIC INFANT MORTALITY RATE IN QATIF AREA, EASTERN PROVINCE, SAUDI ARABIAHussain Abu Srair, FRCP(C), FAAP; Joshua A.
Owa, FNMC (Nig), FWAC; Hussain Ahmed Aman, MD
70.3% of the deaths occurred in the neonatal period
Major causes of IMR were premature delivery (39.1%) Infections (25%) Birth defects (18.8%) Difficult delivery (4.7%)
Ann Saudi Med 1995;15(2):156-158
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Do you know any study?
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CAPITAL OF Saudi Saudi Med J. 2008 Jun ;29 (6):879-883 18521470
OBJECTIVE: To describe and monitor the causes of neonatal and postneonatal deaths in the Neonatal Intensive Care Unit (NICU) over a 10-year-period. METHODS: This is a descriptive study of all infants who died in the NICU from January 1995 until December 2004 at Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia. Data were collected prospectively on all infants admitted to NICU. The cause of death for each infant was discussed and determined by at least 2 consultant neonatologists. Deaths were classified according to the modified Wigglesworth's classification of perinatal death. RESULTS: During the study period, there were 79871 live births and 526 deaths, in which 446 84.2% were inborn deaths and 80 15.8% were outborn. Of the inborn deaths, 251 infants died between 1-6 days, 103 died between 7-27 days, and 92 died after 27 days. Lethal malformations led to death in 36%, prematurity and its complications in 42%, hypoxic ischemic encephalopathy in 5%, while other specific diagnoses, combined, led to death in 17% of the cases. CONCLUSION: Prematurity and its complications followed by congenital malformations were the leading causes of death.
Majeed-Saidan et,al
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Prematurity and LBW Rate
1. Spain 1%2. Finland , Sweeden, Ireland 4%3. Jordan, Japan, Egypt 5%4. Oman 6%5. UK., USA,Chile 7%6. Kuwait 7%
7. AFHSR 15.5%
Unicef Report 2000
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Neonatal Deaths At Armed forces Hospital Programme Southern Region
(AFHSR) a sex-year review
Dr.AbdulRAhman Alnemri,MDDr.Ibrahim Alhefzi,MDDr.Khaled Rashid,MD
Dr.Ahmad HellalDr.Suliman Alfifi, MD
1st international NEONATOLOGY conference 17-19 November 2008
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The estimated distribution of causes for 4 million neonatal deaths for the six WHO regions in the year 2000. Size of circle represents number of deaths in each region. Afr = Africa, Amr = Americas, Emr = Eastern Mediterranean, Eur = Europe, Sear = Southeast Asia, and W pr = Western Pacific
International Journal of Epidemiology 2006;35:706–718
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•AFH SR NICU, is the tertiary centre in the region accommodate up to 40 newborns • There are 3 levels of care IC, IMC& feeder and grower
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Objective
To describe trend in neonatal mortality in AFH Southern region between
1st January 2001 to 31st Dec 2006 Determine the major causes of death in different
birth weight group The data could be used to plan the future direction
of perinatal neonatal care at Armed Force hospitals south regions
Compare the outcome with Armed force hospitals programme.
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METHODS
Descriptive analysis of data of all neonates died IN neonatal intensive care unit at AFHSR from January 2001 to Dec 2006
All perinatal and neonatal data collected from the maternal and neonatal medical records * The “underlying cause of death” is derived from
the diagnosis listed on each death certificate according to International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ( 4th edition, Craig D. Puckett: volume 1,2,3 channel publishing Ltd
* Lotus approach 97 data program
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METHODS In cases where the cause of death was in
doubt, case notes were reviewed with the doctor who certified the death of the neonate to arrive at a consensus direct cause of death
Exclusion criteria (D.R. DEATHS + STILL BIRTH)
The birth weight of 6-year study period was grouped into 3 groups
1) ELBW infants below 1000gm
2) VLBW infants 1000 -1499gm
3) Near term infant more than or equal to 1500gm
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General Statisticyr Birth St.birth C.PMR END LND
2001 5599 67 12.2 20 11
2002 5708 42 7.18 18 6
2003 6265 41 5.74 20 4
2004 6322 52 9.4 21 11
2005 6567 48 8.5 21 14
2006 6923 72 11.8 16(3.7) 6
Total 37384 53.7 9.6 19 8.6
The average perinatal mortality rate was 14 per 1000 total births and the neonatal mortality rate was 9.6 per 1000 live-births
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year T. admission T D (%)
2001 594 40 (6.5)
2002 686 31 (4.5)
2003 833 35 (4)
2004 780 34 (4.3)
2005 675 50 (7.4)
2006 784 57 (7.3)
Total 4352 (11.6%) 247 (5.7)
General Statistic NICU Mortality Review
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Inborn Vs out-bornNICU Death
5.00%
15.50%
22.40%
4.60% 4.90%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Inborm Outborn *KKU Abha KKUH RKH
*Saudi med. j 2003, vol. 24, no12, pp. 1374-1376
58 out-borne neonate Mortality (9) 15.5%
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CORRECTED MORTALITY
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
200120022003200420052006
*
58% ELBW*
26%
41%22.5%
32.5%
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MORTALITY EAR DISTRIBUTION
0
5
10
15
20
25
30
35
40
Jan
Feb Mar Apr
May Ju
nJu
lyAug
Sep Oct
NovDec
2007
2006
2005
2004
2003
2002
2001
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Mortality with gestational age
62%
38%
<34wk
35-42wk
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Early Mortality
58%42%
Early
Late
MEAN 3.6 DAYSMEAN 23 DAYS7- 45 DAYS
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Causes of all neonatal death
0%
10%
20%
30%
40%
50%
60%
70%
Prematurity
MCA
BA+MAS
Card
Surgical
sepsis
unExp
Prematurity < 34wk , MCA multiple cong anomalies, BA+ birth asphyxiaThe major death determinants were low birth weight (LBW)/prematurity, stillbirth, congenital
malformation and birth asphyxia Saudi medical journal , 1998, vol. 19, no6, pp. 693-697
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Admission on birth weight
B. wt Total admission
Deaths M R(%)
ELBW
< 1000gm
234 85 36%
1000-1499 405 40 10%
> 1500gm 3713 122 3.3%
Total 4352 247 5.7%
Exclude multiple congenital and lethal deaths Corrected M R = 3.4%
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ELBW Mortality(< 1000gm)
0%
5%
10%
15%
20%
25%
30%
35%
40%
MR
2001
2002
2003
2004
2005
2006
Total deaths 85 Average Mortality Rate 36%
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Mortality by B wt
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<500gm 500-599 600-699 700-799 800-899 900-999
% Mortality
MEAN 670 GM
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ELBW Deaths (< 1000gm)
36%64%
Late Early
77% <750gm
Total 85/234 MR 36%
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Causes of Deaths in ELBW
39%36%
25%
10%
4%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Resp F*
IVH
SEPSIS
NEC
Un det
•PHE 37%•PNX 12%
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Causes of Deaths in ELBW(<1000gm)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Early Death Late Daeth
Resp F
IVH
Sepsis
NEC
Un Exp
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Major Risk Factor
Antenatal careAntenatal SteroidGrowth RetardationMale SexMode of DeliveryMultiple pregnancyEthnic groupIn born Vs out born
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Survival
5min Abgar < 7 83 (55.7%)
Male 60 (40.3%)
Female 89
SVD 112 (75%)
C section 37 (25%)
Booked 97 (65%)
Un-booked 52 (35%)
Full steroid 97
No 52
AGA 122 (82%)
IUGR 27 (18%)
5min Abgar <7 55 (64.7%)
Male 51 (60%)
Female 34 P 0.0037
NSVD 70 (82%)
C. section 15 P 0.1949
Booked 18 P <0.1
Un booked 67 (78.8%)
full 24 P <0.0023
No 61 (72%)
AGA (>10th 18 P 0.0185
IUGR (<10th 67 (78%)
Deaths
Total 149 Total 85
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Comparison of The Survival Rate of ELBW Infants (500 – 999 gm)
0
20
40
60
80
100
RKH JAPAN FINLAND AUST. VIC NZ AFHSR KKUH
Country
Sur
viva
l (%
)
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Low Birth Wt
1000 gm to 1499 gm
< 34wk
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Mortality in 1000-1499 gmB wt Total
admDeaths %
1001-1099 74 10 13.5
1100-1199 57 7 12.3
1200-1299 90 9 10
1300-1399 77 7 9
1400-1499 107 7 6.5
Total 405 40 9.8
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
1099 1199 1299 1399 1499
Mortality
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Causes of Death in VLBW infant (1000-1499 gm)
Cause No %
Prem 25 62.5%
MCA 15 37.5%
0%
10%
20%
30%
40%
50%
60%
70%
Permat Resp NEC
Permat
MCA
Resp
Sepsis
NEC
IVH
Resp. f
PHE
13 52%
Sepsis 9 36%
NEC 2 8%
IVH 1 4%
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Prenatal- Neonatal Death
71%
29%
Early Late
PHEPNEUMXIVH
SEPSISNECMCA
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Survival Rate of VLBW InfantsRKH Experience 1998 - 2004
93
95
90
95
80
100
1000-1249 1250-1499
Birth Weight (gm)
Sur
viva
l (%
)
RKH KFSR
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Near Term
>1500 gm> 34 wks
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Deaths in Near-term infant Mortality
Total admissions = 3713 85% OF TOTAL ADDMISSION Deaths = 122 (64 early 58 late) 35 (28.6%)* lethal anomalies M R = 33 / 1000 live birth (3.3%)
** DNR
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0%
5%
10%
15%
20%
25%
30%
35%
40%
TOTAL
IUGR
BA
RD
IDM
MCA
JAUND
SURG
FEED P
Near Term Admission
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Mortality Rate in Near Term infants>1500gm
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
1500-2000 2001-2500 2500 t mr
B. Wt Total No. deaths
MR
1500-2000
739 38 4.3%
2001-2500
824 32 3.5%
>2500 2150 52
(42.6%)
2.4%
Total 3713 122 3.3%
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B. wt. based Mortality Distribution
31%
26%
43%
1500-2000
2001-2500
>2500
L A*
LA * 35 infant with Lethal Anomalies40% IUGR
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Lethal anomalies DNR
Diagnosis NO
CNS anomalies 10
Trisomy 18 11
Trisomy 13 4
thantophoric dysplasia 5
Potter Syndromes 5
Total 35
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Cuases No (%)
MCA 45 (37%)
B. Asp +PPHN 37 (30%)
IEM WITH L ACID 13(10.5%)
D. hernia 9(7.5%)
COMP. CHD 9 (7.5%)
Hydropes 4 (3%)
Sepsis 4 (3%)
AWD 1 (1.5%)
Total 122
0%
10%
20%
30%
40%
Causes of deaths
MCA B AS IEM D H
CHD HYDR SEPSIS
MCA = Multiple congenital Anomalies
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Risk Factors
The risk factors independently associated near term death included
low birth weight (IUGR) P value < .001complications during labour p .001 lethal deformities P value 0.001Infection 0.1
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2007
ChangesSeparate the unit coverage
IsolationFeeding protocol
Inodomethacine prophylaxis
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0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
Mortality
2001
2002
2003
2004
2005
2006
2007
CORRECTED MORTALITY
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Summary Total live birth 37384 Total Admission 4352 = 11.6 % of T. Birth Total Death 229 (5.3%) Prematurity is the major cause of mortality(61%) especially
ELBE 45% IVH responsible for early death (45%) while sepsis is the major
killer in late death (50%) Multiple congenital anomalies is the 1st cause of death in near
term infant >34wks of gestation 37% Followed by Prenatal asphyxia with or with out
PPHN 30% Poor antenatal care, multiple congenital anomalies ,
multiple pregnancy are major risk factors need to be evaluated
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Conclusion
The perinatal neonatal services cooperationNational registryPrematurity 15.5%Antenatal steroid Sepsis and IVH are the major contributing
causes for mortality in ELBW infantCongenital anomalies is very high (6 -8/1000 Live Birth)Need revaluation of the service annually
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Acknowledgment
CoauthorsAll NICU rotating residents & Registrars
NICU Head nurse and all Unit nursesMRS. Zahoor Abdullah AssiriMRS. Farah
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