Cause- Specific Neonatal Deaths

Dr.AbdulRahman Alnemri

Assistant professor paediatric

Consultant Neonatologist

1st international NEONATOLOGY conference 17-19 November 2008

04/19/23 2

غافر

04/19/23 3

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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

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

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

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 (%

)

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

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

2007

ChangesSeparate the unit coverage

IsolationFeeding protocol

Inodomethacine prophylaxis

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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