Original Article

CLINICAL RISK INDEX FOR BABIES (CRIB SCORE) AS A PREDICTOR OF

NEONATAL MORTALITY
Zarmast Khana, Nasir Zulfiqarb, Hamid Mahmoodc, Amara Waqard, Awais Gohare
a
Assistant Professor, Pediatrics, Shifa International Hospital, Islamabad.
b
Associate Professor, Surgery, Sir Syed Institute of Medical Sciences, Karachi.
c
Professor, Biochemistry, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad.
d
Director Quality Enhancement Cell, Gulab Devi Hospital, Lahore.
e
University of Lahore, Lahore.

ABSTRACT:

OBJECTIVE: It is very important to predict the outcome among preterm and very low birth weight
babies as mortality rates are quite high. CRIB score is used to predict the outcomes in preterm
neonates. The objective of this study was to determine the strength of CRIB score in detecting
neonatal mortality in babies presenting with very low birth weight.
STUDY DESIGN: Cross-sectional study.
SUBJECTS: A total of 254 newborns with birth weight of between 500 to 1500 grams and
gestational age of ≤35 weeks were included. The study was conducted over a period of 6 months in
neonatology department of Shifa International Hospital, Islamabad.
METHODS: CRIB score was obtained through a prospective way in all neonates and its association
was assessed with mortality during neonatal intensive care unit (NICU) stay.
RESULTS: The percentage of male and female newborn subjects was 54.3% (n=138) and 45.7%
(n=116) respectively. Mean gestational age was 33.3 weeks ± 1.04 and mean birth weight of study
population was 1129.9 grams ± 210.6. Mean CRIB score among the study population was 6.3 ± 3.1
and overall mortality was found to be 54.7% (n=139). Mean CRIB score was found to be 8.27 ± 2.1
among mortality group and it was 3.87 ± 3.4 among newborns who were discharged (P<0.05).
Mortality was present in 4.3% (n=4) of neonates with CRIB score between 1-5, 87.1% (n=121)
who had CRIB score between 6-10 and 100% (n=14) of neonates who had CRIB score between 11-
15 (P<0.05).
CONCLUSION: Significantly higher mortality was noted among neonates with higher CRIB scores.
KEYWORDS: CRIB score, Neonatal mortality, Premature birth.

INTRODUCTION: with neonatal care in ICU[4]. A need was felt by

the health care providers to develop a clinical
Preterm deliveries and babies with very low risk index for babies (CRIB) to find out quality of
birth weight (VLBW) are at risk of developing life pattern of infants and other risk
severe morbidity and mortality[1,2]. Very low assessments in order to detect high mortality
birth weight infants are in a need of advance rate in the neonatal deaths[5].
medical care, as common interventions and The CRIB score was published by the
treatments cannot save their life[3].There
are international neonatal network in year 1993. It
more than 6.2 million prenatal deaths around formed the basis to collect data from the
the world each year. Most of them occurs parents within 12 hours after the birth of their
between a period of 7-28 days of their early life.
More than 74% of the prenatal deaths occurs Corresponding Author:
due to very low birth weight of the infants. The Zarmast Khan
other major causes are birth asphyxia and Assistant Professor,
Pediatrics, Shifa International Hospital,
infections in the hospital. This high morbidity
Islamabad.
and mortality rate has raised questions for the
Email: [email protected]
health. Professionals who are actively involved

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 KHAN Z., ZULFIQAR N., et al. CLINICAL RISK INDEX FOR BABIES (CRIB SCORE)

neonates. Initially CRIB score has included 6 DURATION:

variables which were differentiated in to four
levels[6]. With the advancement in prenatal Six months.
medication and sophistication of the
instruments for the neonatal intensive care SAMPLE SIZE:
units, the rate of neonatal morbidity and
mortality rates have become low. The objective The sample size was calculated by using WHO
of this study is to find out different variables calculator with the statistical assumptions of
which are related to high morbidity in very low 95% power and 5% alpha error, prediction of
birth weight infants[7]. More commonly used mortality 21.0% from previous literature. The
variables to identify the risk factors, which may sample size came out to be 254 neonates.
aggravate the high rate of mortality are
considered to be gestational age and birth SAMPLING TECHNIQUE:
weight[8,9].
It has been estimated that 131 million babies Non-probability consecutive sampling
are born and more than 15 million die before technique.
their 10th birthday. There is approximation of 8.1
million babies who cannot complete their first STUDY DESIGN:
year of life. Different countries have set their
development goals as per world summit for Cross sectional study.
children, United Nations Millennium
Declaration [10] and United Nations special SAMPLE SELECTION:
session on children[11], the preterm birth rate is
variable throughout the world from Africa to INCLUSION CRITERIA:
Europe, which is 5% in Europe and 18.2% in
Africa[12] of these preterm births, 84% usually 1. Neonates with gestational age ≤ 35 weeks.
occurs between 31 to 36 weeks of gestational 2. Weight at birth between 500-1500 grams.
age. The mortality rate is very high in low- 3. Neonates born on the same day and shifted
income countries as compared to high income to Shifa International Hospital, Islamabad.
countries where preterm birth rate is low[13]. 4. Newborns delivered in Shifa international
Keeping in mind the high mortality rates after hospital, Islamabad.
preterm birth and very low birth weight, it is
very important to assess these babies with DATA COLLECTION PROCEDURE:
special attention and top most care. If the
outcome is predicted within first few hours after Study was conducted in nursery and neonatal
birth, the clinicians may intervene timely and intensive care unit of Shifa International
with proper management, serious morbidity Hospital, Islamabad having more than 1500
and mortality rates may be reduced. We admission per month including inborn and
planned to determine the strength of CRIB babies delivered in Shifa International Hospital,
score in predicting neonatal mortality. Islamabad. All neonates delivered here in
nursery were given serial numbers and CRIB
OBJECTIVES: score was calculated by a trained neonatologist
and all babies were followed till their presence in
To determine the strength of CRIB score in hospital to know outcome. Arterial blood gas
detecting neonatal mortality in babies (ABG's) analysis was done with 12 hour
presenting with very low birth weight. interval. Informed consent was taken from the
parents or caretakers. Two hundred and fifty
MATERIALS AND METHODS: four patients fulfilling inclusion criteria were
registered.
SETTING: The details regarding birth weight (kg),
Department of Neonatology, Shifa International gestational age started from last menstrual
Hospital, Islamabad. period (ballard score and from early scans) and

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congenital malformations, all were recorded in Value of <0.05 was considered as significant.
a pretested structured proforma The Data was depicted in tables and graphs.
assessments was made according to the 6
clinical parameters of CRIB score. The total RESULTS:
score was entered in the proforma. Patients
were followed on daily basis until the final DEMOGRAPHY OF THE SELECTED
outcome i.e. complete or partial recovery or POPULATION:
death. All the information was collected by the
research himself to limit the selection bias and CRIB score was obtained through a prospective
human errors. way from a total of two hundred and fifty four
(n=254) newborns with birth weight of 500 to
DATA ANALYSIS PROCEDURE: 1500 g and gestational age ≤ 35 weeks. Out of
total two hundred and fifty four (n=254)
All the collected data was entered into SPSS newborns, 54.3% (n=138) were males with
version 16 and analyzed. The qualitative data mean gestational age of 33.3 weeks ±1.03 and
like gender, mortality and CRIB score levels 45.7% (n=116) were females with mean
were analyzed as frequency and percentages. gestational age of 33.4 weeks ±1.05. Total
The quantitative data like age, gestational age mean gestational age was 33.3 weeks ± 1.04.
and CRIB score were analyzed as means and Mean birth weight among males was 1107.8
standard deviations. Independent sample t-test grams ±223.4 and mean birth weight among
was applied to see the significance of difference females was 1156.1 grams ±192.1. Total mean
between mean CRIB score among mortality and birth weight of study population was 1129.9
discharge group. Chi-square test was applied to grams ± 210.6 (table I).
see the significance of difference in percentage
mortality among different CRIB score levels. P-

Table-I:
Demographic Characteristics of Study Population.

GENDER Total
Male Female
Frequency (%) 138(54.3) 116(45.7) 254(100.0)
Mean ± Std (gestational age) 33.3±1.03 33.4±1.05 33.3±1.04
Mean ± Std (birth weight (grams)) 1107.8±223.4 1156.1±192.1 1129.9±210.6
Mean ± Std (crib score) 6.8±3.4 5.6±2.4 6.3±3.1

CRIB SCORE AND ITS RELATIONSHIP 45.3% (n=115) female newborns were
WITH MORTALITY AMONG THE STUDY discharged (table III). Mean CRIB score was
GROUP found to be 8.27± 2.1 SD among mortality
group and it was 3.87±3.4 SD among newborns
Mean CRIB score among males was 6.8 ± 3.4 who were discharged. Independent t-test was
SD and mean CRIB score among females was applied to see the significance of difference
5.6±2.4 SD. Total mean CRIB score among among both groups. P-value was
whole of the study population was 6.3 ± 3.1 SD found to be 0.000 (<0.05) implying significant
(table I). 36.2% (n=92) newborns had CRIB difference between two means with mean CRIB
score between 1-5, 58.3% (n=148) had CRIB score was significantly higher in mortality group
score between 6-10 and 5.5% (n=14) had CRIB (table IV).
score between 11-15 (table II). Percentage mortality was calculated among
Overall mortality was found to be 54.7% newborns with different CRIB score levels.
(n=139) male newborns during NICU stay Among newborns who had CRIB score between

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 KHAN Z., ZULFIQAR N., et al. CLINICAL RISK INDEX FOR BABIES (CRIB SCORE)

1-5 mortality was present in 4.3% (n=4) of the significance of difference among the
neonates. Among newborns who had CRIB groups. P-value was found to be 0.000 (<0.05)
score between 6-10 mortality was present in implying significant difference with
87.1% (n=121) of neonates and among significantly higher percentage mortality was
newborns who had CRIB score between 11-15 noted among neonates with higher CRIB scores
mortality was present in 100% (n=14) of (table V).
neonates. Chi-square-test was applied to see

Table-II:
CRIB-score levels study in population.

CRIB LEVELS FREQUENCY PERCENT
1-5 92 36.2
6-10 148 58.3
11-15 14 5.5
TOTAL 254 100.0

Table-III:
Mortality in study population.

GENDER FREQUENCY PERCENT
MALES 139 54.7
FEMALES 115 45.3
TOTAL 254 100.0

Table-IV:
Mean CRIB score among mortality and discharge group.

CRIB SCORE STD. P-Value
MORTALITY N
(MEAN) DEVIATION (t-test)
PRESENT 139 8.27 2.1
<0.001
ABSENT 115 3.87 2.1

Table-V:
Percentage mortality in different levels of CRIB score.

CRIB SCORE MORTALITY Total P-value
Chi-square
LEVELS PRESENT ABSENT
4 88 92
1-5
4.3%* 95.7% 36.22%
121 27 148
6-10
87.1% 18.2% 58.26% <0.001
14 0 14
11-15
100% 0% 5.51%
139 115 254
TOTAL
54.7% 45.3% 100%

DISCUSSION: neonatal units is a blessing for the children with

low weight as they are being treated more
The low birth weight babies are considered to professionally by the qualified pediatricians.
be at high risk of mortality in early days of their There is lot of improvement in the prenatal
life between 7 to 28 days. Now a days there is care [ 1 5 ] . Intensive care units have been
lot of technological improvement in assessing specially designed to meet the needs of the
the weight of the babies before they are going neonatal care and are given the name of
to be delivered in the labor room by the neonatal intensive care units which are
gynecologist. The presence of intensive care available in the secondary and tertiary care

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hospitals[16]. Very low birth weight babies were clinical settings. We also intend to compare
considered to be at risk in their early life CRIB and SNAPE scoring systems in future
between 7-28 days particularly in the lower studies at our setup.
and middle income countries due to non-
availability of prenatal medicines, general CONCLUSION:
facilities and the intensive care facilities [17].
World Health Organization and United Nations Mean CRIB score was significantly higher in
General Assembly have taken key steps to mortality group and significantly higher
lower down the morbidity and the mortality in percentage mortality was noted among
very low birth weight babies. They are neonates with higher CRIB scores.
providing guidelines to the member countries,
UNAP, UNDP, UNICEF and WHO to take care of CONFLICT OF INTEREST:
very low birth weight babies. Due to the
reason, all the stakeholders were taken on There is no declared conflict of interest.
board to reduce the morbidity and mortality of
very low birth weight babies. ETHICAL REVIEW COMMITTEE:
Rationale of this study was to gather data
about the strength of CRIB score in predicting Ethical review committee of the said institute
the outcome as if the outcome is predicted has reviewed and approved this article.
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