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Changing mortality and causes of death in infants 23-27 weeks' gestational age
L W Doyle1, E Gultom, S L Chuang
1Division of Paediatrics, Royal Women's Hospital, Carlton, Victoria, Australia. I.doyle@obgyn-rwh.unimelb.edu.au
Insights
The introduction of exogenous surfactant significantly reduced mortality in very preterm infants. While respiratory deaths decreased, there was a concerning rise in septic deaths, highlighting the need for infection control strategies.
Area of Science:
- Neonatalogy
- Perinatal Medicine
- Pediatric Critical Care
Background:
- Very preterm infants (23-27 weeks gestation) face high mortality risks.
- Exogenous surfactant therapy was introduced in 1991 to improve respiratory outcomes.
- Understanding changes in mortality and causes of death is crucial for improving neonatal care.
Purpose of the Study:
- To compare mortality rates in very preterm infants before and after exogenous surfactant introduction.
- To analyze shifts in causes of death among these infants.
- To identify remaining preventable causes of death in the 1990s.
Main Methods:
- A cohort study of liveborn infants (23-27 weeks gestation) without lethal anomalies.
- Data collected from two distinct periods: 1983-1990 and 1992-1996.
- Primary outcomes included mortality and causes of death during initial hospitalization.
Main Results:
- Overall mortality significantly decreased from 51.4% (1983-90) to 28.4% (1992-96).
- Respiratory causes of death decreased proportionally (82.5% to 60.0%), while septic causes increased significantly (14.3% to 43.8%).
- Lower mortality rates were observed at each gestational week in the later period.
Conclusions:
- Exogenous surfactant use has reduced mortality and respiratory-related deaths in very preterm infants.
- There has been a significant increase in deaths attributed to sepsis.
- Enhanced strategies for preventing nosocomial infections are essential for further reducing mortality.
Objective:
To contrast the mortality rates and changes in the causes of death of very preterm infants (23-27 weeks), before and after the introduction of exogenous surfactant in 1991, and to identify any preventable causes of death remaining in the 1990s.
Methodology:
This was a cohort study on consecutive preterm infants of 23-27 weeks' gestational age born in the Royal Women's Hospital, Melbourne, a level III perinatal centre. The infants were livebirths free of lethal anomalies from two distinct eras, 1983-90, and 1992-96, inclusive. The main outcome measures were mortality during the primary hospitalization and the causes of death before and after the introduction of exogenous surfactant in 1991.
Results:
In 1983-90, 261 of 508 livebirths (51.4%) of 23-27 weeks' gestational age died, a significantly higher proportion than the 109 of 384 (28.4%) livebirths who died in the period 1992-96. The mortality rate fell significantly with increasing gestational age and was lower at each week of gestational age in 1992-96. More infants who died in 1992-96 were treated intensively in the neonatal intensive care unit (NICU). Of the group of infants who died or who were treated intensively in NICU, respiratory causes of death predominated. However, the causes of death changed over time. In 1992-96 proportionally fewer infants died from respiratory causes (1983-90, 82.5%; 1992-96, 60.0%; odds ratio (OR) 0.31, 95%; confidence interval (CI) 0.16-0.57), but more from septic causes (1983-90, 14.3%; 1992-96, 43.8%; OR 4.9, 95%; CI 2.6-9.2).
Conclusions:
As the mortality rate has fallen over time, respiratory causes of death have diminished, but septic causes of death have increased. Further advances in the use of exogenous surfactant and respiratory support may reduce respiratory deaths. Effective strategies to reduce nosocomial infections are urgently required.