Statistical Study of Preterm Infants Admitted to NICU in Fawzy Moaz

Hospital For Children

Mohamed Fakher,1 Waleed Shaaban,2 Ahmed Abdel Monein,3 Zohdy Hassan,4
and Mohga Moustafa Fikry5
Assistant Professor of Pediatrics,1 Consultant of Pediatrics,2 Consultant of Pediatrics, Ministry of Health and
Population,3 Lecturer of Pediatrics,4 Public Health (Maternal and Child Health), Alexandria Health Directorate5

Abstract:
Prematurity is a major health problem and a leading cause of neonatal mortality. Prematurity is defined as
gestational age less than 37 weeks of gestation measured from the first day of the last normal menstrual
period. The aim of the present work is to detect premature problems, incidence of premature and
incidence of neonatal deaths in neonatal intensive care unit (NICU) in Fawzy Moaz pediatric hospital in
Alexandria (Egypt) through one year (October 1999-October 2000). Data were collected retrospectively
from Healthy Mother/Healthy Child files in the NICU. Sample size included 480 neonates (106 <37 weeks).
Results revealed that 22.1% of cases admitted in the NICU were prematures. Among those 51.9% were
females, 75.5% were ≥32 weeks and 62.3% weighed ≥ 1500 gm. Deaths constituted 48% of admitted
preterms. Premature death was significantly higher among those less than 32 weeks (80.8%) and less
than 1500 gm (60%). Hyperbilirubinemia was the first cause of admission (28.4%).
Conclusion: Premature admission and death rate were high. Better antenatal care coverage for
pregnant women and continuous training of neonatologists is needed for more accurate assessment and
management of premature cases.

Introduction: study, prematurity depending on data collected from

Prematurity is a major health problem because it is a
leading cause of infant mortality.1-4 Prematurity is
defined as gestational age less than 37 completed
weeks of gestation measured from the first day of the
last normal menstrual period.4 The etiology of
prematurity is not clearly known in most situations.5
Personal factors including maternal age, ethnical
variations, low socioeconomic class, over activity and
maternal malnutrition are risk factors.6-8 Many
obstetric factors may share in this problem including
grand multiparity, multiple pregnancy, polyhydra-
mnios, uterine malformation, placenta previa,
incompetent cervix, premature rupture of membrane
and amnionitis.5-10
Maternal illness, either acute or chronic renal,
pulmonary, hepatic diseases, diabetes and
hypertension may decrease placental perfusion below
the exceeding needs of the fetus.9 Also behavioral
factors as smoking, alcoholism, excessive coffee,
caffeine and lack of ante-natal care, all may affect the
length of gestational duration leading to prema-
turity.5-9
The incidence of prematurity varies from one country
to another and from one locality to the other in the
same country. It is difficult to obtain accurate data
about incidence especially in the developing countries
due to lack of recording systems. According to a WHO
birth certificates ranged from 2.2% to 19.4%.11
The percentage of preterm in six countries namely
Cuba, Hungary, New Zealand, Sweden, Australia and
Japan rated 10.5%, 19.5%, 4%, 4.5%, 10.5% and
2.5% respectively. In the United states, preterms
among blacks and whites were 17.8% and 8%
respectively.12
In Egypt, data regarding the incidence of preterm is
lacking due to poor recording system. Premature
babies are liable to many problems either on the short
term or on the long term. The survival of VLBW
prematures has improved with due to Hi technology
facilities caring for those vulnerable infants.13,14
The aim of the present study is to detect premature
problems in NICU in Fawzy Moaz hospital in
Alexandria through one year (October 1999-October
2000).
Subjects and Methods:
Study design:
This is a cross-sectional retrospective record study.
Study Setting:
The study included all neonates admitted though one
year (October 1999-October 2000) in the NICU in
Fawzy Moaz hospital (a MOHP pediatric hospital) in
Alexandria governorate (Egypt). The NICU is a tertiary
care level and is considered to be one of the most

Alexandria Journal of Pediatrics, Volume 19, Number 1, January 2005

155
important referral centers for prematures in October 1999 11 10.4
November 1999 5 4.7
Alexandria. December 1999 7 6.6
Sample size: January 2000 4 3.8
The study sample included 480 neonates (106 less February 2000 0 0.0
than 37 weeks and 374 equal or more than 37 weeks) March 2000 11 10.4
April 2000 3 2.8
admitted during the period October 1999-October May 2000 4 3.8
2000. June 2000 12 11.3
Data collection technique: July 2000 13 12.3
August 2000 9 8.5
Neonatal data was collected from healthy September 2000 8 7.5
mother/healthy child files in NICU. Data included October 2000 19 17.9
incidence of preterm babies admitted /month, birth Total 106 100.0
weight, gestational age, cause of admission, fate and N.B: The unit was closed during February 2000 for renovation
number of ventilated preterms cases.
Table III: Distribution of deaths of preterms by selected variables
Results: Deaths of No deaths Deaths Total Test of
preterm n % n % n % significance
Table I: Distribution of neonates included in the sample by Gestational age
selected variables <32 weeks 5 19.2 21 80.8 26 100.0 X2= 14.34
Variable Number % >32 weeks 49 62.0 30 38.0 79 100.0 P= 0.00015*
1-All neonates (n=480) Weight
<37 weeks 106 22.1 < 1500 gm 16 40.0 24 60.0 40 100.0 X2= 3.38
>37 weeks 374 77.9 ≥1500 gm 38 58.5 27 41.5 65 100.0 P= 0.06604
2-Preterms (n= 106) * Significant Chi square testing (95% confidence limit)
- Sex
Males 51 48.1 Table III shows the distribution of deaths of preterm by
Females 55 51.9
- Gestational age selected variables. The percentage of deaths among
<32 weeks 26 24.5 preterms less than 32 weeks was 80.8% compared to
≥32 weeks 80 75.5
- Weight
38% among those more than 32 weeks of gestational
< 1500 gm 40 37.7 age. This difference was statistically significant (X2=
≥1500 gm 66 62.3 14.34, P= 0.00015). The table also reveals that the
- Fate of preterm
Survived 54 51.0
percentage of death was higher among preterms less
Deaths 51 48.0 than 1500 gm (60%) compared to 41.5% among
Referral 1 1.0 preterms more than 1500 gm. This difference was
- Ventilation ( n=9) 9 8.5
Deaths 6 66.7 statistically insignificant (X2= 3.38, P= 0.066049).
No death 3 33.3
Table IV: Distribution of preterms included in the sample by
cause of admission
Table I shows the distribution of neonates included in Cause of admission Number %
the sample by selected variables. Nearly one-quarter ƒ Hyperbilirubinemia 61 28.4
of neonates admitted in the NICU were preterms ƒ Septicemia & meningitis 56 26.0
ƒ Respiratory problems 55 25.6
(22.1%). Regarding preterms, more than one-half ƒ Neurological problems 12 5.6
(51.9%) of admissions were females, three-quarters ƒ Others (IDM, CHD ..etc) 31 14.4
(75.5%) were ≥32 weeks and 62.3% weighed ≥1500 Total 215 100.0
N.B. Preterms had more than one cause during admission
gm. Survival rate among preterms included in the
sample was 51% and deaths constituted 48% of
Table IV shows the distribution of preterm included in
admitted preterms. Among those who were ventilated
the sample by cause of admission. Hyperbilirubinemia
only one-third survived (33.3%).
was found to be the first cause of admission (28.4%)
Table II shows the distribution of the preterms
followed by septicemia and meningitis (26%),
included in the sample by month of admission. The
respiratory problems (25.6%) and neurological
percentage of admission was 17.9% in October 2000,
causes (5.6%).
followed by 12.3% in July 2000, 11.3% in June 2000
and 10.4% in March 2000. Again, October 1999 had
the highest percentage (10.4%) followed by December
1999 (6.6%). The least admissions were during April Discussion:
2000 (2.8%). No cases were admitted during February
Prematurity is a major health problem that may lead to
as the unit was under reconstruction and renovation.
infant mortality and contributes to substantial neuro-
Table II: Distribution of the preterms by month of admission cognitive, pulmonary and ophthalmologic morbidity.1-
3,13 The incidence of premature infants is highly
Month of admission Number of preterms %

Alex J Pediatr, 19(1), Jan 2005 156

variable in different countries and even within the
same country.11,12,15
Preterm survival depends mainly on antenatal care,
level of medical service and social as well as cultural
factors. In Egypt, there are several obstacles facing
the accuracy of collection of accurate data about
preterms including: the high incidence of home
deliveries with no precise data from birth certificates,
lack of antenatal care, lack of good filing system, lack
of communication between obstetricians and
neonatologists and communication between hospitals
and centers of statistical surveillance.
The present study revealed several problems of
prematurity. The NICU in Fawzy Moaz hospital (a
MOHP pediatric hospital) is a tertiary care level
referral center for preterms in Alexandria. It does not
reflect a national trend but this study tells us about
referred diseased preterms.
The present study revealed that the total number of
admitted cases of neonates during the year of study
was 480 cases, and 22% were preterms. Among
these 24.3% were less than 32weeks, and 37.7%
were less than 1500gms (LBWs).
In developed countries, the majority of admitted cases
were preterm infants.16,17 This might be due to an
actual reduction in the incidence of prematurity in
Egypt or might be due to the fact that these preterm
babies die before referral. Reduced incidence of
prematurity may be a cause as the incidence of LBW
infants estimated in Egypt was 10% (4.18) which is
lower than the incidence of other countries of east
Mediterranean area which was 18%.4,18,19 Data about
the incidence of preterm infants in Egypt are limited.
Seasonal variation had no effect on admitted preterm
cases (table II). The present study revealed that
climate was not an effective factor leading to
prematurity. Also no statistical significance was found
between males (48.1%) and females (51.9%). This
was different to what had been reported about VLBWs
in a study conducted during a period 1995 to 1997 in
Egypt where males constituted 0.6% and females
were 1.1% of the total number of births. This means
that either males may be more susceptible to diseases
of prematurity and VLBWs and need more
hospitalization or may mean that females may sustain
more of these stresses.
In the current study, hyperbilirubinemia was the first
cause for hospital admission (57.5%) (table IV). The
main cause of hyperbilirubinemia was physiological
jaundice, which may be augmented by dehydration
secondary to poor feeding and cultural taboos of
keeping babies indoors. Also, septicemia may be
another cause of both direct and indirect
hyperbilirubinemia. Only one case was due to
exchange blood transfusion.
157
Septicemia and meningitis were the 2nd cause of
admission of preterms in the NICU in the present
study. They constituted 26% of total admissions (table
IV). This might be due to many reasons including
home deliveries which usually occur under incomplete
aseptic techniques with exposure to sources of
infections, bad personal hygiene and lack of
knowledge about the poor immune system of preterm
babies. Many of these cases were not referred
immediately to the hospital but spend a period of time
in the community under these unsuitable conditions
that favor the occurrence of sepsis.
Respiratory problems constituted only 51.8% which is
different from the developed countries where the main
cause of admission in the units is Respiratory distress
syndrome (RDS). Only 8.5% of these cases required
ventilation which augments our belief that the majority
of respiratory problems were not RDS.20,21
Neurological problems (HIE & ICH) represented
11.3% of admitted preterm infants. This small number
may be due to the fact that the admitted ages were
not too young to produce severe neurological
problems which are different to what is happening
abroad.22 The reduced rate of ventilated cases with all
of its complications may also reduce neurological
problems.
The total survival of preterm infants was 50.9% while
the survival of those less than 32 weeks was 19.2%.
These results were far away from the results of
neonatal units in USA with a survival rates for VLBWs
in 1990 that was 98-99%.9 Also, it is lower than the
recorded case fatality for LBWs admitted to NICUs in
Egypt between 1995-1997 which was (34.3%).23
Many factors were responsible for high mortality;
firstly, the delayed referral of preterm infants after
spending a period of time under unsuitable conditions
together with bad communications and delay of
means of transportation which may worsen the
outcome. Secondly, lack of suitable diagnostic and
therapeutic tools in the studied unit as portable
Echocardiogram and ultrasound and lack of surfactant
as well as IV immunoglobulins. Lastly, personnel in
the unit need more training and instructions
particularly about infection control to decrease
nosocomial infections. The area of prematurity in
Egypt still needs more researches for better
evaluation.
Conclusion & Recommendations:
1. More efforts should be exerted to evaluate the
magnitude of the problem of prematurity in Egypt
through better coverage of antenatal care in the
primary health care centers and through better
statistical systems in both primary care and
hospitals.
Alex J Pediatr, 19(1), Jan 2005
2. Continuous training to the medical staff for better
assessment, diagnosis and management of
premature cases.
3. Providing neonatal care units with modern
technical instruments and medications. Surfactant
and IV alimentation are not available.
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