Neurodevelopmental outcome of high-risk newborns discharged from NICU in a tertiary-care hospital of western India.
Progresses in neonatal medicine have eventuated in heightened survival of infants at very low birth weight (LBW). While these medical success stories bring to light the strength of medical technology to rescue numerous tiniest infants at birth, serious questions prevail about how these infants will grow and whether they will lead normal, productive lives. LBW children can be born at term or before term and show varying degree of other medical and social risk factors. LBW children exhibit varied outcome, generally show higher rates of subnormal growth, illnesses, and developmental problems. These problems increase as birth weight decreases. Impaired neurodevelopmental outcome is a major long-term complication of surviving premature infants, especially extremely premature infants who are born at or below 32 weeks gestation. [1,2] Premature infants are at risk of major and minor deficits, such as cerebral palsy, cognitive and speech delays, motor and visual deficits, psychosocial and behavioral disorders, and dysfunction at school. [3-7] With the exception of a small minority of LBW children with mental retardation and/or cerebral palsy, the developmental sequel for most LBW infants includes mild problem in cognition, attention, and neuromotor functioning such as depression and ADHD. Long-term follow-up studies conducted on children born in the year 1960 indicated that the adverse consequences of being born with LBW were still apparent in adolescence.
Very often, their problems are identified quite late, may be at school age, when only some rehabilitation measures can be taken and which do not bring out the best in the child. Such issues are of paramount importance to the average Indian parent. Timely and appropriate intervention can prevent or modify many of these disabilities. The neonates at increased risk of neurodevelopment disability can be identified by assessing certain perinatal risk factors and the course of their illness postnatally: a structured plan of follow-up can then be designed for them in order to assess their developmental status and identify delay at the earliest, using simplified developmental assessment tools such as the Trivandrum Developmental Screening Chart (TDSC) or the Denver Developmental Screening Test (DDST) even by general pediatrician. Now, in modern days, focus of care is shifting from merely survival to intact survival of the infants. Early identification of developmental delay and early stimulation and intervention to give better neurological outcome and, hence, a better quality of life has become the need of the hour.
In India, unfortunately, there is not enough awareness about the abovementioned facts and that neurodevelopment assessment has long been considered the domain of pediatric neurologist, and general pediatricians often fail to recognize the delay that had begun to set in the neonatal intensive care unit (NICU) graduate that had come to him for various medical problems. This opportunity is big one to miss because, it was at this point, if early intervention done to modify social and psychosocial environment of the infant would have made a large difference to his eventual neurodevelopment outcome.
This study was carried out with objective to assess the level of neurodevelopment delay (NDD) using standard scale and establish an association between the risk factors and level of developmental delay.
Materials and Methods
This prospective, observational study was conducted in a tertiary-care hospital at Ahmedabad city, Gujarat, India. Neonates admitted in NICU in this institute during the year 2011 were followed up for the next 1 year. Neonates with life threatening, gross congenital anomalies were excluded from the study. Prenatal and postnatal risk factors were assessed among study participants. Each neonate was inquired for antenatal risk factors, and postnatal risk factors were assessed during their NICU admission. For each neonate, total number of risk factors was enlisted, and total risk score for each neonate was calculated. Those with total risk score of [is less than or equal to] 5 were considered to be at low risk, scores 6-9 were considered moderate risk, and those with >9 were considered to be at high risk of NDD. The enrolled babies were called for follow-up at 3, 6, 9, and 12 months. At each visit, infant's weight, length, and head circumference were measured. Developmental screening was performed using TDSC: this is a simple screening tool with 17 items covering the motor, cognitive, and language domains of development, based on Bayley developmental screening tool, developed and validated in India.
Data were entered in Microsoft Excel and analyzed using Epi info 7.1. Frequency was used to show the distribution of participants and risk factors distribution among them. Appropriate tests were used to analyze qualitative and quantitative data accordingly.
A total of 150 babies were enrolled in the study initially, of which 50 babies were followed up completely for a duration of 1 year. There were 52% boys and 48% girls in the study. Of these participants, 70% were delivered vaginally. Eight neonates revealed birth weight more than 2.5 kg, and three (6%) neonates showed very LBW. Among study participants, 30% neonates were term neonates, and six (12%) neonates were born before 30 weeks of gestation [Table 1].
About 10% babies showed none of the antenatal risk factors that were included in this study. Consanguinity among parents was seen in about half of the study participants. Pregnancy-induced hypertension (50%) and severe preeclampsia/ eclampsia formed the major chunk among antenatal risk factors. Thirty percentage of mothers experienced a previous abortion, and most of them were in the first trimester of pregnancy. In this study, when total score was calculated for each baby depending upon the antenatal and postnatal risk factors, 12% babies fell in mild risk category for NDD. About 48% neonates fell in moderate risk category, while 40% fell in to severe-risk category [Table 2].
The mean time required for assessment of babies using TDSC was 2.79 [+ or -] 1.3 min. When babies were assessed for neurodevelopment by TDSC, 50% babies showed delay in development. In Table 3, we can see that, of those classified as being at mild risk of NDD, none showed NDD when assessed by TDSC method. Of twenty-five babies who showed developmental delay, most of them fell in severe risk category. This higher-risk category assigned by antenatal and postnatal risk factors show significant association with chances of development of NDD.
Fourteen of seventeen babies (82.3%) with birth weight of < 1.5 kg. showed some degree of NDD, while only 33.3% of babies whose weight was more than 1.5 kg revealed NDD. This difference is statistically significant. Eighty percentage of the babies who were born at gestational age <32 weeks of gestation age revealed NDD. Gestational age showed statistically significant association with neurological development. In this study, eight of nine babies (88.9%) who showed perinatal asphyxia and subsequent hypoxic ischemic encephalopathy (HIE) as judged clinically using Leven's criteria were found to show NDD, while in others, 17 of 41 babies (41.5%) developed NDD. Thus, the association between the HIE and NDD were found to be statistically significant [Table 4].
In our study population, we have noticed a sex predilection with a male preponderance, which is also reflected in the children identified with developmental delay. The difference in care seeking for male and female newborns and children probably shows the gender bias prevalent among the families who are more concerned about the survival and well-being of male offsprings than the females, rather than an actual difference in neurodevelopmental outcome among male and female babies.
In our study, most of the neonates fell into moderate and severe risk categories, while in the study by Chaudhari,  it was found that 70% of their babies were in the low-risk category. In our study, consanguinity was high among parents of participants than general population. This high level of consanguinity is explained by major patients in our hospital being from Muslim community. This is probably because the sample population was collected from a tertiary-level NICU, where more number of high-risk babies is likely to be admitted.
The prevalence of developmental delay among NICU graduates is found to be quite high (50%), which is higher to the 29% incidence reported by Calame et al.  A systematic review of 153 studies across the globe, documenting 22,161 survivors of intrauterine or neonatal insults showed an overall median risk of at least one sequela in any domain as 39.4%. 
In this study, LBW and prematurity were found to be the major contributory factors for NDD. Maximum incidence of developmental delay was noted in babies with birth weight between 1.5 and 2.0 kg, with a sharp decline in incidence in babies weighing >2.5 kg at birth. Incidence of developmental delay is also significantly higher in preterm babies, than in term babies, which is supported by similar results noted in other studies. [11-14] This is because developing brain of premature infant is extremely vulnerable to injury, and if they are exposed to any adverse condition, they are more prone to developmental delay. In our study, the association between the HIE and NDD was found to be statistically significant. These results were comparable with the observation made by Carli et. al.,  where 72% babies presenting HIE showed severe NDD. Improvement of gestational age at birth and birth weight will help in curbing the incidence of developmental delay.
This study had involved a faculty from pediatric department for assessment of neurological development; so, there is proper assessment and less chance of error. The study was done on limited number of participants; so, study will be replicated with more number of participants so that it will strengthen the results of study.
Incidence of NDD among high-risk newborns is significantly high, with LBW, prematurity, and birth asphyxia being major contributors. Most NDDs go undetected in the early years of life. Improved perinatal care, early detection, and early intervention at the grass-root level will bring down incidence of developmental challenges in this vulnerable group.
[1.] Arzani A, Kermanshahi SM, Zahed Pasha YA, Mohammadzadeh I. The role of predischarge mothers' education on follow-up examination of visual, hearing and brain problems in preterm neonates. Hormozgan Med J 1388;13(2):115-22.
[2.] Bennett FC, Scott DT. Long-term perspective on premature infant outcome and contemporary intervention issues. Semin Perinatol 1997;21(3):190-201.
[3.] Russell RB, Green NS, Steiner CA, Meikle S, Howse JL, Poschman K, et al. Cost of hospitalization for preterm and low birth weight infants in the United States. Pediatrics 2007;120(1):e1-9.
[4.] Cuevas KD, Silver DR, Brooten D, Youngblut JM, Bobo CM. The cost of prematurity: hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight. Am J Nurs 2005;105(7):56-64.
[5.] Ballot DE, Potterton J, Chirwa T, Hilburn N, Cooper PA. Developmental outcome of very low birth weight infants in a developing country. BMC Pediatr 2012;12:11.
[6.] van Baar AL, van Wassenaer AG, Briet JM, Dekker FW, Kok JH. Very preterm birth is associated with disabilities in multiple developmental domains. J Pediatr Psychol 2005;30(3):247-55.
[7.] de Kieviet JF, Piek JP, Aarnoudse-Moens CS, Oosterlaan J. Motor development in very preterm and very low-birth-weight children from birth to adolescence: a meta-analysis. JAMA 2009;302(20):2235-42.
[8.] Chaudhari S. Learning problems in children who were "high risk" at birth. Indian Pediatr 1994;31(12):1461-4.
[9.] Calame A, Reymond-Goni I, Maherzi M, Roulet M, Marchand C, Prod'hom LS. Psychological and neurodevelopmental outcome of high risk newborn infants. Helv Paediatr Acta 1976;31(4-5): 287-97.
[10.] UNICEF. The state of the World's Children. Children with Disabilities 2013. New York: UNICEF, 2013. Available at: http://www. unicef.org/gambia/SOWC_Report_2013.pdf
[11.] Gutbrod T, Wolke D, Soehne B, Ohrt B, Riegel K. Effects of gestation and birth weight on the growth and development of very low birthweight small for gestational age infants: a matched group comparison. Arch Dis Child Fetal Neonatal Ed 2000;82:208-14.
[12.] Carli G, Reiger I, Evans N. One-year neurodevelopmental outcome after moderate newborn hypoxic ischaemic encephalopathy. J Paediatr Child Health 2004;40(4):217-20.
[13.] Hack M, Fanaroff AA. Outcomes of children of extremely low birth weight and gestational age in 1990s. Semin Neonatal 2000;5(2):89-106.
[14.] Wilson-Costello D, Friedman H, Minich N, Fanaroff AA, Hack M. Improved survival rates with increased neurodevelopmental disability for extremely low birth weight infants in the 1990s. Pediatrics 2005;115(4):997-1003.
Rohit Modi (1), Jaiminkumar Patel (2), Apupa Mishra (3)
(1) Department of Pediatrics, GMERS Medical College, Gandhinagar, Gujarat, India.
(2) Department of Community Medicine, GMERS Medical College, Dharpur - Patan, Gujarat, India.
(3) HCG Hospital, Ahmedabad, Gujarat, India.
Correspondence to: Rohit Modi, E-mail: firstname.lastname@example.org
Received October 6, 2015. Accepted October 8, 2015
Table 1: Baseline variables of the study population Variable Number Percentage Sex Male 26 52 Female 24 48 Birth weight (kg) [greater than or equal to] 2.5 8 16 1.5-2.499 28 56 1-1.499 11 22 [less than or equal to] 1 3 6 Gestation period (weeks) [greater than or equal to] 37 15 70 <37 35 30 Type of delivery Vaginal 35 70 Cesarean section 15 30 Neurodevelopment assessment by TDSC NDD present at 1 year 25 50 NDD absent at 1 year 25 50 Table 2: Distribution of risk factors among study participants Frequency Percentage Antenatal risk factor Deaf parent 1 2 Consanguinity 13 26 Mental retardation in parent 1 2 Previous abortion/miscarriage 15 30 Neonatal death in family 4 8 Infertility treatment taken 8 16 Developmental delay in sibling 1 2 Hypertensive mother on drugs 25 50 Severe preeclamptic toxemia to mother 16 32 Diabetic mother on insulin 0 0 Postnatal risk factor Sepsis 42 84 Jaundice 45 90 Respiratory distress 25 50 H/o mechanical ventilation 18 36 Hypoglycemia 15 30 Hypocalcemia 4 8 Hypoxic ischemic encephalopathy 9 18 Early circulatory failure 3 6 Abnormal neurological examination at 8 16 discharge Nonlife-threatening GCA/CHD 11 22 Risk category (risk score) Mild ([less than or equal to] 5) 6 12 Moderate (6-9) 24 48 Severe (>9) 20 40 Table 3: Assessment of neurodevelopmental delay by different risk category Risk No Neurodevelopmental P category neurodevelopmental delay by TDSC, n (%) delay by TDSC, n (%) Mild 6 (24) 0 (0) <0.001 Moderate 16 (64) 8 (32) Severe 3 (12) 17 (68) Table 4: Effect of variable on neurodevelopmental delay No Neurodevelopmental P neurodevelopment delay, n (%) delay, n (%) Perinatal hypoxia Present 1 (11.1) 8 (88.9) <0.05 Absent 24 (58.5) 17 (41.5) Gestational age (weeks) <32 4 (20) 16 (80) <0.05 [greater than or 20 (66.7) 10 (33.3) equal to] 32 Birth weight (kg) <1.5 3 (87.7) 14 (82.3) <0.05 [greater than or 22 (66.7) 11 (33.3) equal to] 1.5
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research Article; neonatal intensive care unit|
|Author:||Modi, Rohit; Patel, Jaiminkumar; Mishra, Apupa|
|Publication:||International Journal of Medical Science and Public Health|
|Article Type:||Clinical report|
|Date:||Jul 1, 2016|
|Previous Article:||A cross-sectional study of impact of lifestyle determinants on middle-aged male diabetic patients.|
|Next Article:||Assessment of growth monitoring activities under Integrated Child Development Services (ICDS) in western Rajasthan.|