Clinical Profile and Outcome of Neonates Admitted to Neonatal Intensive Care Unit ( NICU ) at a Tertiary Care Centre in Eastern Nepal

Address for correspondence Dr. Gauri Shankar Shah Professor and Head Department of Paediatrics and Adolescent Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal Email: gaurishankarshah@live.com How to cite this article ? Shah GS, Yadav S, Thapa A, Shah L. Clinical Profi le and Outcome of Neonates Admitted to Neonatal Intensive Care Unit (NICU) at a Tertiary Care Centre in Eastern Nepal. J Nepal Paediatr Soc 2013;33(3):177-181.


Introduction
N eonatal period (0-28 days of life) is the most susceptible period of life due to different diseases, which in most cases are preventable 1 .Almost 50% of deaths in our country occur in the neonatal period 2 .Though considerable improvement in the survival of newborn in developed countries has been made but the mortality rate is still very high in the developing countries 3 .One of the Millennium Development Goals is to reduce the number of deaths in children under 5 years to two third by the year 2015, and to achieve this goal a substantial reduction in neonatal deaths will be required especially in the developing countries 4 .In the developed countries, the main cause of morbidity and mortality in the neonatal period is congenital abnormalities which are mostly non-preventable, but in the developing countries the common causes such as infections, jaundice, birth asphyxia and pneumonia predominate 5 .The neonatal disease pattern is a sensitive indicator of availability, utilization and effectiveness of mother and child health services in the community.Of the 130 million neonates born every year Globally, about 4 million die in the fi rst 4 weeks of life 6 . .Most of the neonatal deaths (99%) occur in the lower to middle income countries and half of them occur at home.The risk of a newborn dying is 24 per 1,000 live births in the fi rst week of life, 3 per 1,000 per week during the rest of the fi rst month, and 0.12 per 1,000 per week after the fi rst year of life 7 .The neonatal mortality of Nepal as per NDHS 2011 data is 33 per 1,000 live births 8 .Most of the causes of neonatal mortality and morbidity are preventable 9 .The pattern of neonatal diseases vary from place to place 10 .The major causes of neonatal deaths globally were estimated to be infections (35%), preterm births (28%) and asphyxia (23%) 11 .A study previously done in Nepal shows asphyxia as the leading cause of hospital admission (22%) followed by prematurity (20%) and sepsis (17%) with mortality due to these three causes being 7%, 3% and 5%, respectively 1 .All these diseases can be prevented by good obstetric and perinatal care.The aim of this study was to identify the common causes for admission to the NICU and its outcome.

Materials and Methods
A retrospective study conducted at the Neonatal Intensive Care Unit (NICU), Department of Pediatrics and Adolescent Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal from January 2012 to December 2012.A total of 361 neonates admitted to NICU were included in the study.Our NICU is of level III having facilities of mechanical ventilation, arterial blood gas monitoring, central oxygen line, warmers, phototherapy, multichannel patient monitor etc which are needed for care of sick neonates.The data of all the neonatal admissions were documented and analyzed as per follows; Age, Gender, Place of delivery, Cause of admission, Birth Weight and Final outcome.Diagnosis was mainly clinical with specifi c laboratory or radiological fi ndings.Sepsis and meningitis were diagnosed on clinical grounds along with C-reactive protein (CRP), complete blood count (CBC), positive blood culture and cerebrospinal fl uid (CSF) examination.Congenital heart disease was diagnosed on ECG changes, Chest X-Ray and then confi rmed by Echocardiography.Birth Asphyxia was diagnosed clinically and hypoxic ischemic encephalopathy (HIE) by Sarnat and Sarnat Staging.Diagnosis of prematurity was clinical or based on WHO defi nition for prematurity (live born neonates delivered before 37 weeks from 1st day of last menstrual period) and using new Ballard scoring.Low birth weight was defi ned as when birth weight was less than 2500 g.Neonatal jaundice was diagnosed by assessing serum bilirubin level along with G6PD estimation in males.Pneumonia was diagnosed mainly on clinical examination and radiological fi ndings.

Discussion
Being a tertiary-care centre, we get many neonates in advanced stage of the disease or complicated by their illness.Males predominate as study subjects, which is similar to other studies 1,12 .This may be because of the fact that males get more attention on part of caregivers and brought to the hospital for seeking health services.
Sepsis accounted for about one-third cases requiring admission in our NICU.A much higher incidence (41.3%) has been reported by Jan et.al. 12and lower incidence (6.4-10.5%)by other authors in their studies 13,14 .The variation in occurrence of sepsis depends upon the health practices being followed in the community and awareness of health professionals and parents providing the neonatal care.Since early and late neonatal sepsis accounted for equal percentage of patients in our study, so predisposing factors during antennal, intrapartum and postnatal period are equally important and should be taken into consideration in its prevention.
Prematurity was found to be the next common cause (23.8%) for admission.This is similar to the incidence reported from South Africa 15.Conversely, a much higher incidence (34.6-48.2%)has been reported from other neighboring countries 13,16 .Preterm neonates really require very close attention and advanced care because of their inherent handicaps and complications.Their higher incidence in developing world is a major concern, so preventive aspects should be taken in to consideration beside establishment of NICU in different regions of the country.
Birth asphyxia (20.2%) accounted for the third most common cause of admissions to our NICU and mostly (82.2%) in HIE stage II and III.The incidence is almost similar to that of Butt et.al. 17and much lower than reported from South Africa 15 .Thus occurrence of high incidence of birth asphyxia and mostly in severe stages indicate the level of neonatal care existing in our heath sector especially in the community.So adequate attention is to be paid in training of heath workers who can effectively reduce the incidence as well as its severity and decrease the load of NICU admissions at tertiary care level.Meconium aspiration syndrome was found in 8.3% of cases, which also require urgent attention at the time of birth in the form of tracheal suctioning if the baby is depressed.However, this can be performed effi ciently in inborn neonates where trained resident staff attends the delivery.Prakash and Das 18 reported the incidence in 3.67% of their cases.
Neonatal hyperbilirubinemia is the cause of admissions in 4.7% of neonates.Much higher incidence (36.2-54%) has been reported in other studies 12,17,19 .The NICU admissions in neonatal hyperbilirubinemia is mainly done for exchange transfusion and phototherapy.
However, it can be curtailed by early detection, bilirubin monitoring and effective phototherapy.
Congenital anomalies found were Jejunal atresia, anal atresia, and tracheosephageal fi stula, which needed immediate surgical interventions.Rest was minor malformations and were accompanying feature with some other illness requiring therapy.
Methicillin resistant staphylococcus aureus was detected in 43.3% of cases followed by pseudomonas species, Klebsiella pneumoniae, Enterococcus, Acinetobacter.Other authors reported Staphylococcus aureus, Coagulase Negative Staphylococcus (CoNS) and Klebsiella pneumoniae as the three predominant pathogens in their studies.However, they did not mention regarding methicillin resistance in Staphylococcal isolates 20,21 .
Overall mortality observed was 20.2%.Those who required mechanical ventilation had higher mortality (36.1%) than the cases not on ventilation therapy (13.25).Thus it appears that need for ventilation is itself a risk factor for mortality.Other workers have reported higher mortality rate (25.8-34%) 18,22 .However, Jan et al 12 found much lower mortality (8.3%) in their audit report.The mortality dependes upon the stage of the disease and facilities available in a particular NICU.Moreover, attempt should be made to keep it at low as possible.

Conclusions
Thus, it appears that triad of sepsis, prematurity and birth asphyxia is major cause of NICU admissions at our centre.Need for ventilation adversely affected the outcome.This can be reduced by improving antenatal care of pregnant women, timely interventions and of high risk pregnancies to tertiary care centre.

Table 1 :
Distribution of study subjects

Table 2 :
Outcome of neonates

Table 3 :
Procedures performed in study subjects

Table 4 :
Distribution of congenital abnormalities

Table 5 :
Distribution of organisms from blood