outcome of low birth weight babies admitted to special care … · gestational age at birth...
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Outcome of Low Birth Weight
Babies admitted to Special
Care Nursery-PMGH
PROSPECTIVE DESCRIPTIVE STUDY
(2017-2018)
MMED 2- Maylin Kariko-Siko
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Introduction
2.9 million newborns die annually from
prematurity, birth asphyxia, serious
bacterial infection and congenital
malformations. (K. M. Milner et al, 2015)
15.1 million neonates survive these
problems every year, and are at
increased risk of adverse
neurodevelopmental outcome (K. M.
Milner et al, 2015)
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Improving outcomes beyond survival for high-risk
newborns in resource-limited settings is an
emerging challenge globally recognized.
Global estimates demonstrate the scale of this
challenge and significant gaps in morbidity
outcome data in high mortality contexts
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At PMGH we manage a substantial number
of preterm neonates
Annual report 2017 (Jan-Dec) - PMGH
admitted 1813
◦ 212 Premature babies: 11.7% of newborns (3rd
leading cause of admissions to SCN)
Information on long-term outcomes for high-
risk neonates is scarce.
Data needed to improve systems of care
and early intervention for these high-risk
neonates.
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Aims
To document the early follow-up
outcome of LBW babies admitted to
the SCN
1. Nutritional status
2. Developmental milestones
3. Head circumference
4. Anaemia
5. Vaccination status
6. Morbidities
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Methodology Type – prospective descriptive observational cohort study
Timeline – January 2017 to July 2018
Site – Special Care Nursery and Neonatal Consultation Clinics, PMGH
Population Definition – Babies born with birth weights of less then 2kg
Follow Up Age – At ≥6 months of chronological age (contact numbers taken from mothers)
Method of Data Collection – two separate forms for admission and follow up
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Study population
Inclusion
1. Birth Weight <2kg (ELBW/VLBW/LBW)
2. Any gestation at birth
3. Delivered at PMGH or referred in
Exclusion
1. No chart or Lost to follow up
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Definition of Terms
Low Birth Weight – in this study < 2kg
Birth weight categories 1. LBW – 1.5 to 2kg
2. VLBW – 1.0 to 1.49kg
3. ELBW - < 1kg
Gestational age (GA) categories (Dubowitz)
1. Term – ≥38 wks
2. Near term – 36 to 37 wks
3. Pre-term - < 36 wks
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Primary Outcomes (outcome from nursery)
Death
Survival
Follow-up outcomes (after discharge from
nursery)
Survived to follow up
Likely survived but lost to follow up
Known to have died after discharge from
hospital
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Nutrition: ◦ Z-scores weight for length and weight
for age at ≥ 6 months.
Developmental Milestones:◦ the proportion of children at ≥ 6 months
with up to date or delayed milestones (Denver Developmental Screening Tool)
Anaemia:◦ the proportion of infants at ≥ 6 months
with Hb less than 10g/dL (WHO standardized definition)
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Head Circumference Assessment: ◦ WHO head circumference percentiles
according to growth standards
Vaccination status◦ Fully vaccinised/partially
Infectious disease morbidity:◦ the number of hospital admissions from
infections in the first 6 months or more, after initial hospital discharge
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Data were entered into spreadsheet and
analysed using Stata Version 14 and
Microsoft Excel
Ethical clearance
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Flow of Patients-outcomes
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81 babies
◦ Male 48 (59%)
◦ Female 33 (41%)
Method of delivery
◦ 9 (12%) caesarean section
◦ 71 (88%)Normal vaginal delivery
Head circumference: median 29 cm (IQR
27.5- 31cm)
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Birth weight
Median birth weight: 1.495 kg (IQR 1.3 to
1.715 kg).
1.2%
49.4% 49.4%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
ELBW (<1Kg) VLBW (1- 1.499Kg) LBW (1.5-1.99Kg)
Birth weight categories
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Gestational age (by Dubowitz)
Median gestational age: 34 weeks
IQR 32 - 35.5 weeks
Range 29 - 38 weeks
61, 75.3%
17, 21.0% 3, 3.7%
Gestational age at birth (Dubowitz Score)
Preterm (GA<36) Near term(GA 36-37) Term (GA≥ 38)
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Median length of hospital stay: 19 days
(IQR 10-39 days).
Longest: 112 days
Median weight at discharge was 1.54kg
(IQR 1.48 to 1.68 kg)
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Follow-up
39 of 81(48%) babies followed up to 6
months or more
26 lost to follow up (32%) but believed to
be alive
Deaths: 16 known deaths (20%)
◦ 13 while in hospital
◦ 3 after discharge to home.
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Median chronological age at follow up was 9 months (IQR 8-11 months).
Median corrected age at follow up was 7.5 months (IQR 6-10.5 months).
Median weight at follow up was 7.8kg (6.3-8.5 kg), and height 66.5 cm (IQR 63-72 cm).
Majority who were followed up were well-nourished:
◦ Mean weight-for-height z-score: -0.3(standard deviation 1.2)
◦ Median WFH z-score was 0 (IQR -1 to 0)
◦ Median WFA z-score was 0
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Head circumference
◦ Mean head circumference: 43.4 (SD 2.19).
◦ According to WHO centiles for HC, the median HC was at the 41st centile (IQR 3-75)
◦ 75% of children had HC in the normal range
◦ 25% had some degree of microcephaly (<3rd centile)
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Nutrition-type of feed
20 (51%) were still breast fed by their
mothers
18 had been weaned from breast milk,
artificial milk introduced
For those weaned off breast milk: median
age of weaning (from breast milk) was 2
months (IQR 1-5 months).
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Follow up-cont
5 children developed anaemia after
discharge
33 of 39,(85%) children seen at follow-
up were fully vaccinated, and 6 (15%)
partially vaccinated.
15 (38%)had admissions to children's
ward
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
18, 47%
10, 29%
9, 24%
8, 23%
20, 53%24,
71%29,
76%
27,77%
Delayed Up-To-Date
Developmental Milestones
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Discussion
This project was carried out to determine the
outcome of the high risk babies at PMGH
first study in our resource limited setting, the focus
group were all LBW <2kg, of varying gestational
ages.
Given this situation, the out comes were still similar
to other studies done in terms of their
developmental outcomes.
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despite some babies having some
deficiency in the four domains of
developmental milestones, overall most
were up to date only gross motor being the
most commonly delayed domain.
Denver Developmental Screening Test is
not the ideal test
Head circumference: According to WHO
centiles for head circumference, majority
(75%) had HC in the normal range
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Nutritionally- majority well nourished. Those followed up thrived well despite being born small. 20 still breastfed, others were weaned early and introduced artificial milk at median age of 2 months (IQR 1-5).
Observed –result of long hospital stay and lack of lactation from mothers
5 children developed anaemia after discharge,- low detection
15 (38%) admissions to the children’s ward, mostly for respiratory and gastrointestinal infections: increased vulnerability to community acquired infections
High vaccination coverage- regular check and administration
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Follow ups were done at the hospital
consultation clinics and those that were not
followed up had reasons- not captured
Deaths – 20 % during initial admission. ?Few
deaths post discharge
Deaths portrays reality of challenges faced
Do we send babies home when they are still
too small (1.54kg median weight)?
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Limitations
Lack of awareness at start of project
Assessment of milestones done using
Denver tool.
Difficult to follow up
Study structure was complex and needed
more than one researcher to carry out
series of follow up
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Conclusion
Care and follow up of LBW babies are vital for
survival
Lost to follow up group of babies in the
community require special attention
Outcomes here were achieved with supported
therapeutic practices (CPAP, oxygen therapy,
phototherapy & KMC) and regular follow up at
a central location.-room for improvement
Guideline not yet available but needed
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Recommendations
Maximise on our current available resources to
improve outcomes of survival and beyond
Set up proper metric systems of follow up, user
friendly to our setting
Decentralise the follow up of low birth babies
Need for bigger well organized study needed to
properly document outcomes- to change practices
of care where necessary
? Consider weight at discharge
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Acknowledgements
My Heavenly Father- wisdom/knowledge
Professor Trevor Duke
Dr Gamini Vali
Husband and son
Family
Committed Mothers and their babies
Fellow colleagues/friends
Nurses and staff of the consultation clinics
Nigel Uaiz
MBBS V student Jethro Huafolo
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References
K. M. Milner, E. F. G. Neal, G. Roberts, A. C. Steer
& T. Duke (2015) Long-term neurodevelopmental
outcome in high-risk newborns in resource-limited
settings: a systematic review of the literature,
Paediatrics and International Child Health, 35:3,
227-242
Ballot,E D, Potterton J, Chirwa T et al. (2012).
Development outcome of very low birth weight
infants in a developing country. BMC Pediatrics
Miller K.M, Robert G, Steer AC et al. Early
childhood developmental outcomes for high risk
newborns in Fiji – an observational study
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Thank you