Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.

! !

Morbidity Pattern and Hospital Outcome of Neonates

Admitted in Tertiary Care Hospital, Nepal
Deepeshwara Nepal, Sumit Agrawal, Sushan Shrestha and Ajit Rayamajhi
Department of Paediatrics, Kanti Children's Hospital, Maharajgunj, Kathmandu, Nepal

Correspondence:
Deepeshwara Nepal
Kanti Children’s Hospital, ABSTRACT
Maharjgunj,
Kathmandu, Nepal Introduction: The first 28 days of life, neonatal period is crucial as
Email: [email protected] neonates are susceptible to sepsis, birth asphyxia, hypoxic injuries
and its consequences which may lead to lifelong morbidity. Knowing
the causes of morbidity and mortality is an essential step to improve
neonatal health. The aim of this study is to describe the pattern and
causes of neonatal admission, immediate hospital outcome in the
form of improved, died or left against medical advice and factors
DOI: 10.3126/jnps.v40i2.29469 associated with its outcome.
Submitted on: 2020-06-15 Methods: This was a retrospective hospital based study carried out
Accepted on: 2020-07-03 in Neonatal Intensive Care Unit (NICU) of Kanti Children’s Hospital,
Kathmandu, Nepal over a period of six months (February 2019 to
July 2019 AD). Neonatal details including age, sex, gestational age,
birth weight, and maternal age and parity, mode of delivery, place of
delivery, neonatal morbidities and neonatal outcomes were recorded
in a predesigned performa. Results were expressed as mean,
percentage and p value. P- value was calculated by using chi-square
Acknowledgements: We would like to
thank neonatal intensive care unit and
test.
record section of Kanti Children’s Results: A total of 163 neonates were admitted during the study
Hospital period, among which 106 (65%) were males. The mean birth weight
Funding: Nil was 2483.96 ± 812.63 gm. Among admitted newborns 130 (79.8%)
Conflict of Interest: None declared had good outcome, babies born to young mothers (< 20 years of age)
Permission from IRB: Yes had poor outcome which is statistically significant with p value of
0.002. Neonates whose birth weight were < 1000 gram had
significantly poor outcome (0.001).
Conclusion: Common causes of NICU admission were neonatal
To cite this article: Nepal D, Agrawal S, sepsis, neonatal hyperbilirubinemia, prematurity and perinatal
Shrestha S, Rayamajhi A. Morbidity asphyxia. Babies born to young primipara mothers, extremely low
Pattern And Hospital Outcome Of birth weight, extremely premature babies and babies undergoing
Neonates Admitted In Tertiary Care mechanical ventilation had poor outcome.
Hospital, Nepal. J Nepal Paediatr Soc.
Key words: morbidity; mortality; neonates; prematurity; sepsis
2020;40(2):107-13

This work is licensed under creative common attribution 3.0 license

J Nepal Paediatr Soc Vol 40 Issue 2 May-Aug 2020 !107

 Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.
! !
INTRODUCTION service, it receives only extramural cases) admitted
Neonatal period (the first 28 days of life) is crucial in NICU during the study period were included.
in human life as they are vulnerable to high Data on age (at time of hospital admission), sex,
morbidity and mortality. Advancement in perinatal gestational age, birth weight, maternal age, parity
and neonatal care have reduced Neonatal Mortality and neonatal morbidity in terms of final diagnosis
Rate (NMR) in developed countries, but these rates were recorded in a predesigned performa.
are still high in developing countries.¹ Every Diagnosis was mainly clinical which was supported
Newborn Action Plan recently endorsed by World by laboratory findings, radio-imaging and
Health Assembly calls for NMR < 10/1000 live echocardiography whenever indicated. Neonatal
birth.² But NMR of Nepal is 21/1000 live birth sepsis was diagnosed as per WHO clinical criteria
accounting 65.5% and 54% of infant and under 5 defined in Integrated Management of Childhood
mortality rate respectively.³ Worldwide the major and Neonatal Illness (IMNCI) along with septic
direct causes of neonatal mortality are preterm birth screening including complete blood count, C
(27%), infection (26%), perinatal asphyxia (23%) reactive protein, micro ESR and blood culture.
and congenital anomalies (7%).²A previous study Neonatal sepsis was further divided into early onset
done in Nepal showed sepsis as the leading cause neonatal sepsis (EONNS) when sepsis occurred
of hospital admission and mortality (34.5%) within 72 hours of life and late onset neonatal
followed by prematurity (23%) and perinatal sepsis (LONNS) when it occurred after 72 hours to
asphyxia (23.3%).4 As disease pattern vary from 28 days of life. Meningitis was diagnosed with
place to place and with time, even in the same cerebrospinal fluid (CSF) analysis. Pneumonia was
place, regular neonatal auditing is vital but it is diagnosed on the basis of clinical features along
lacking in our country.⁵ There are limited hospital with chest X ray (CXR) findings. Perinatal
asphyxia was diagnosed based on the criteria set by
based data regarding morbidity and mortality
WHO and National Neonatology Forum of India.
pattern of newborn in Nepal. Evidence based data
on neonatal morbidities, mortalities and Neonatal jaundice (NNJ) was diagnosed when the
rise of bilirubin required need of phototherapy
interventions especially facility based care are vital
according to American Academy of Paediatrics
for formulating neonatal preventive health
strategies to reduce neonatal mortality. So we guidelines for phototherapy for neonatal jaundice
35 weeks or above and NICE (National Institute for
undertook this study to see the common causes of
Health and Care Excellence) guidelines for < 35
admission and the root cause of mortality which
weeks gestation period. Preterm was defined when
will help us prioritise the areas in neonatal health.
the baby was born before the completion of 37
The aim of this study is to describe the pattern and
weeks of gestation on the basis of last menstrual
causes of neonatal admission, immediate hospital
period, which was further categorised as extremely
outcome in the form of complete improvement,
preterm (< 28 weeks), very preterm (28 to < 32
death and LAMA (Left against medical advice) and
weeks), moderately preterm (32 to < 34 weeks) and
factors associated with its outcome.
late preterm (34 to < 37 weeks). Birth weight was
METHODS further categorised as extremely low birth weight
(Less than 1000 gm), very low birth weight (1000
This was a retrospective hospital based study
to 1499 gm), low birth weight (1500 to 2499 gm)
conducted at NICU of Kanti Children’s Hospital,
and normal weight (> 2500 gm). Congenital heart
Kathmandu, Nepal, over the period of six months
disease (CHD) was diagnosed with
(February 2019 - July 2019). Data were retracted
echocardiography. Meconium aspiration syndrome
from medical record section of the hospital after
(MAS) was diagnosed when there was history of
obtaining ethical approval from IRC of our
meconium stained liquor with typical CXR along
institute, which is the only Government tertiary
with respiratory distress and exclusion of other
care children’s hospital and receives sick children
possible causes. Respiratory distress syndrome
including neonates from all over Nepal. A total of
(RDS) was diagnosed when there was respiratory
163 extramural neonates (as there is no maternity
distress along with typical CXR finding in preterm
J Nepal Paediatr Soc Vol 40 Issue 2 May-Aug 2020 !108
 Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.
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Table 1. Neonatal outcome versus socio-demographic and other clinical parameters and its significance

S.N. Characteristics Outcome Total p-value OR

(95%CI)
Good outcome Poor outcome
n (%) n (%)
1 Age on admission
< 24 hours 19 (65.5%) 10 (34.5%) 29 (100%) 0.059
24 to 72 hours 38 (82.6%) 8 (17.4%) 46 (100%)
72 hours to 7 days 34 (91.9%) 3 (8.1%) 37 (100%)
7 to 28 days 40 (78.4%) 11 (21.6%) 51 (100%)
2 Mother’s age *
< 20 years 8 (50%) 8 (50%) 16 (100%) 0.002
20 to 35 years 110 (82.1%) 24 (17.9%) 134 (100%)
> 35 Years 10 (100%) 0 10 (100%)
3 Parity
Primi 67 (78.8%) 18 (21.2%) 85 (100%) 0.902 0.952
Multi 63 (80.8%) 15 (19.2%) 78 (100%)
4 Sex
Male 82 (77.35%) 24 (22.65%) 106 (100%) 0.365 0.677
Female 48 (84.2%) 9 (15.8%) 57 (100%)
5 Place of delivery
Institutional 121 (80.6%) 29 (19.4%) 150 (100%) 0.292 1.937
Non- institutional 9 (69.2%) 4 (30.8%) 13 (100%)
6 Mode of delivery
Spontaneous vaginal 75 (75.7%) 24 (24.3%) 99 (100%) 0.253
delivery
Lower segment caesarean 50 (84.7%) 9 (15.3%) 59 (100%)
section
Instrumental 5 (100%) 0 5 (100%)

neonates. Outcomes were divided into two groups value value was calculated using chi-square test. A
as good outcomes and bad outcomes. Good p - value of < 0.05 was considered significant.
outcomes meant babies discharged with complete
recovery, whereas poor outcome included both RESULTS
mortality as well as those babies who were A total of 163 neonates were admitted during the
discharged against medical advice (LAMA). Babies study period. Mean birth weight of the neonates
who went into LAMA were either in a very bad was 2483.96 ± 812.631 gm and the duration of
medical condition or had some financial burden due hospital stay was 14.74 ± 13.035 days. There was a
to the possibility of prolonged NICU stay or some significant relationship between mother’s age and
form of family problems. The primary causes of outcome with a p-value of 0.002. Newborns born to
mortality were classified according to WHO, ICD young primi mothers (< 20 years) had highest
10 version: 2010 criteria. Statistical analysis was mortality. All the newborns born to elderly mothers
done using SPSS (statistical package of social (> 35 years) had excellent outcome. Neonates who
sciences) version 20.0.as mean, percentage and p were admitted within 24 hours of life were more
likely to die than other age group (P-value 0.059).

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 Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.
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Table 2. Neonatal outcome vs. diagnosis Table 3. Outcome of neonates according to gestation
and birth weight
SN Diagnosis Outcome Total
n (%) Variables Admission Death P
Good Poor
N (%) N (%) value
outcome outcome
n (%) n (%) Gestational age
1 Early onset 51 10 61 < 28 weeks 2 (1.2) 1 (3.4) 0.19
neonatal sepsis (83.6%) (16.4%) (100%)
28 < 32 weeks 22 (13.5) 7 (24.1)
2 Neonata 53 4 57
jaundice (93%) (7%) (100%) 32 < 34 weeks 9 (5.5) 3 (10.3)
3 Preterm 39 13 52 34 < 37 weeks 19 (11.7) 3 (10.3)
(75%) (25%) (100%)
37 < 40 weeks 68 (41.7) 10 (34.5)
4 Late onset 37 11 48
neonatal sepsis (77%) (23%) (100%) ≥ 40 weeks 43 (26.4) 5 (11.6)

5 Pneumonia 32 10 42 Birth weight (gm)

(76.2%) (23.8%) (100%) < 1000 3 (1.8) 3 (10.3) 0.001
6 Perinatal 32 7 39 1000 - 1499 21 (12.9) 4 (13.8)
asphyxia (82%) (18%) (100%)
1500 - 2499 46 (28.2) 10 (34.5)
7 Mechanical 12 20 32
ventilation (37.5%) (62.5%) (100%) ≥ 2500 93 (57.1) 12 (41.4)
8 Congenital heart 26 4 30
disease (86.7%) (13.3%) (100%) Among the 163 admitted cases, EONNS was the
9 Respiratory 13 7 20 commonest diagnosis seen in 61 newborns
distress (65%) (35%) (100%) followed by NNJ. Among the diagnosis good
syndrome outcome was seen in 100% cases of hypocalcaemia
10 Neonatal seizure 7 4 11 followed by NNJ (93%). Neonates who were
(63.6%) (26.4%) (100%) ventilated mechanically had the highest poor
11 Neonatal 5 1 6 outcome (20 out of 32 i.e. 62.5%). There was
meningitis (83.3%) (16.7%) (100%) increasing trends of mortality rate as gestation age
12 Meconium 5 1 6 decreased. Mortality rate was significantly high in
aspiration (83.3%) (16.7%) (100%) ELBW category (p-value = 0.001). Among the 163
syndrome newborns, 129 (79%) were discharged with
13 Hypoglycemia 4 1 5 complete recovery as shown in figure 1.
(80%) (20%) (100%)
14 Hypocalcaemia 3 0 3
(100%) (100%)
Improved Death LAMA

This could have been due to the early presentation

of more severe diseases in this population. Male 3%
babies outnumbered females with respect to 18%
admissions (106 vs. 57) and poor outcome (24 vs.
9), but it was not statistically significant (p-value
0.365 and odds ratio 0.677). Likewise there was no
significant differences in final outcome as regard to 79%
place of delivery, mode of delivery and parity of
mothers. (Table 1)
Figure 1. final outcomes of neonates

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 Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.
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DISCUSSION abs ence of antenatal checkup and poor
This study is dedicated to acknowledge the socioeconomic condition. Surprisingly maternal
neonatal health problems in Nepal, a country poor age of more than 35 years was associated with very
in resources. In our geographic condition and good outcome (100% survival), it might be due to
limited resources, all newborns referred to our small sample size, or biological maturity and
hospital are at critical stage. In order to achieve excessive concern for their babies and hence
SDG by 2030 in neonatal health we have to presented to the hospital early in the course of
improve our neonatal health status. Though illness.
management of premature and VLBW babies There were total of 32 cases (19.6%) that required
require high skilled manpower, sophisticated mechanical ventilators due to various reasons with
equipment and vigilant hospital management, highest mortality rate (62.5%) in this particular
simple interventions like KMC, early initiation and
group. Thus requirement of mechanical ventilators
exclusive breastfeeding can help a lot when is one of the bad prognostic factors for survival.
implemented properly. Knowing the existing Other workers reported lower mortality rate in their
pattern of neonatal morbidity and mortality in
studies.9,17 Another study from western region of
hospital setup like ours which represent the sickest our country, Pokhara showed even higher (87.5%)
population of neonates from all over the country
mortality rate.⁶ This study showed that preterm
plays the key role in determining appropriate
babies who were born before 37 weeks of gestation
measures to be applied by national health authority
were more likely to die as compared to those who
and stakeholders to improve the current situation
were born after 37 weeks of age (p-value = 0.19).
and to meet the SDG goal of neonatal health of the
Poor outcome was significantly higher in ELBW
country.
babies as compared to normal weight babies (P-
Even though we received babies in most critical value 0.001).
stage in their diseases, good outcome was observed
Perinatal asphyxia comprised 39 (23.9%) cases,
in 130 (79.8%) cases with only 33 (20.2%) cases
among them seven (18%) cases had poor outcome.
having poor outcome which comes even low (16%)
Likewise 21 (12.8%) cases of neonatal sepsis had
when we exclude LAMA cases. Studies from
poor outcome. So neonates requiring mechanical
various parts of country showed high variability of
ventilators, preterm babies, ELBW babies, perinatal
neonatal mortality ranging from 3.32% -
asphyxia, neonatal sepsis, home deliveries, and
24.74%.6,11 Likewise similar type of variation in
babies born to young mothers are predictors of poor
neonatal mortality were observed in different
outcome noted in our study. Neonatal sepsis was
countries which ranged from 7.16% - 36.6%.¹2-16
the leading cause of death (41%) followed by birth
These variabilities in mortality within the country
asphyxia (37.2%) and prematurity (11.5%) in
and also outside might be due to various reasons
another study from eastern part of the country.¹8
including severity of illness during admission, time
Similar types of contributing factors for neonatal
lapse between illness and hospital arrival,
death were found in other studies.13-15
percentage of extramural cases, availability of
medical equipment and skill of the medical experts. Regarding neonatal morbidity, sepsis stands as the
leading cause (53.9%). Even though we received
Male babies being predominant in both hospital
only extramural referral cases EONNS occupy
admissions (77.35%) as well as in poor outcomes,
almost one third (31%) of study population whereas
(22.65%) raise the issues of biological vulnerability
LONNS constituted 22.6%. Slightly less percentage
of male neonates, similar finding were observed in
(32.6%) of NNS was found in other studies from
other studies.6-12 Neonates born to young mothers
different parts of the country.6,8,9 So it clearly
who were less than 20 years have highest mortality
indicates that we have to seriously think about the
rate which is statistically significant (p-value
preventive measures like good ANC coverage,
0.002). This might be due to poor nutritional status,
maintenance of good hygiene and strict aseptic
low maternal education, lack of family support,

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 Original Article Morbidity Pattern and Hospital Outcome of Neonates; Nepal D et al.
! !
precaution during delivery. So, we have to improve CONCLUSIONS
our antenatal, intrapartum and postnatal service Neonatal sepsis, neonatal hyperbilirubinemia,
delivery. perinatal asphyxia, LBW babies and prematurity
Neonatal jaundice requiring phototherapy was were the leading causes of NICU admissions. All of
these causes except neonatal hyperbilirubinemia
observed in 57 (34.9%) neonates. Similar
incidences were reported in other studies both in were most common cause of neonatal death. All of
NICU and NIMCU setup (36.2 - 54%).19-21 these conditions seemed to be preventable. This
Though neonatal hyperbilirubinaemia was second study was done to know the recent neonatal
common morbidity, it was the least common cause morbidity and mortality pattern in NICU setup
of neonatal mortality that too was due to co-morbid which helps to lay the foundation in prioritising
condition with NNS. Prematurity was the third these common conditions in national neonatal
health strategy and develop facility based
most common cause of morbidity 52 (31.9%),
similar incidence are reported from other intervention package. There is highly unacceptable
studies.22-24 trend of newborn deaths in Nepal which can be
prevented by ranking the common conditions and
Perinatal asphyxia was another common cause of implementing appropriate measures accordingly.
NICU admission accounting for 39 (24%) cases
which were almost similar to that of other This is a single cantered hospital based
studies.10,20 Such high prevalence clearly shows that retrospective study. It would be more logical to
we have to really focus on improving the skills of conduct multi centred (including primary,
skilled birth attendant, and health personnel who secondary and tertiary care hospitals) prospective
perform neonatal resuscitation. We have to study including both intramural and extramural
cases which would perhaps give a better picture of
strengthen our heath care facility especially level 2
and 3 neonatal care units; it is high time to think of neonatal care in the country.
newer intervention like therapeutic hypothermia to
prevent lifelong neurological sequelae of our
neonates.

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