Abstract
Introduction: Data on cost, short term complications and outcome of Sri Lankan extremely low birth weight (ELBW) babies is largely unavailable.
Introduction
Extremely low birth weight (ELBW) infants are those that weigh less than 1000g. Very low birth weight (VLBW) infants (less than 1500g) account for over 50% of neonatal deaths and 50% of handicapped infants; their survival is directly related to birth weight with approximately 20% of those between 500 and 600g and over 90% of those between 1200 and 1500g surviving in the United States 1 . Although the rate of low birth weight is available, we do not have a national figure for VLBW or ELBW. Castle Street Hospital for Women (CSHW) in Colombo caters for more than 18,000 births annually and in 2008, 3,344 babies were admitted to the neonatal unit of the hospital out of which 326 (9.74%) babies were VLBW. In this hospital VLBW infants accounted for 47% of neonatal deaths 2, 3 .
Introduction
The care of ELBW neonates may impose an enormous burden on professional resources and finances of caregivers. The cost varies greatly between developed countries and developing countries and between different centres within a country or a region as it largely depends on the cost of sophisticated and advanced neonatal care and the cost of the health care system in general [4] [5] [6] [7] [8] . Consequently, it is difficult to compare the cost among different centres. In a few studies costs were calculated by dividing the total number of hospital days or ventilator days before death or discharge home by the number of survivors in order to calculate the resource use and costs incurred per survivor 7, 9 . This type of data on Sri Lankan babies is largely unavailable. However, it is essential to have this information to guide forward planning, therapeutic intervention, budgeting and staffing with the aim of improving outcome.
Introduction
Surfactant replacement therapy for hyaline membrane disease (HMD) in premature infants has been shown to be safe and efficacious in many studies including a study done in Sri Lanka 10 . However, surfactant therapy is extremely expensive and we may not be able to afford it as prophylaxis for HMD in the government sector.
Objectives
• To determine the outcome of ELBW babies born in CSHW during the study period
Objectives
• To determine the incidence of selected short term complications
Objectives
• To determine the average direct cost of managing such babies and All live births with birth weights less than 1000g born in CSHW during the study period were recruited after obtaining informed written consent. Infants with birth weights less than 500g, gestational age at birth less than 23 completed weeks, and infants who were transferred out for reasons other than surgical management of necrotising enterocolitis (NEC) or patent ductus arteriosus (PDA), were excluded from the study.
Objectives
The data was collected by the investigators using a pretested standard questionnaire. Clinical notes from the babies and mothers were used to collect the relevant data. The birth weight was plotted on Fenton 11 growth charts to determine whether the baby was appropriate for gestational age (AGA), small for gestational age (SGA) or large for gestational age (LGA). All the survivors of the test population were examined by a consultant ophthalmologist for retinopathy of prematurity (ROP). These children were followed up until discharge from the ophthalmology clinic and findings of this referral were entered into the questionnaire. In the neonatology unit at CSHW a cranial ultrasound scan (USS) is done in all ELBW infants at the age of 7-14 days routinely or whenever intraventricular haemorrhage (IVH) is suspected. It is performed by the consultant radiologist on duty. Repeat USS is done on discharge or at 36-40 weeks postmenstrual age. In this study we collected data related to IVH, germinal matrix haemorrhage (GMH), periventricular leukomalacia (PVL) and ventriculomegaly (mild 0.5-1cm, moderate 1.0-1.5cm, severe >1.5cm). The diagnosis of NEC was made if the baby had modified Bell's stage 2 or 3 12 .
Objectives
The survival rate (percentage of babies who were live at discharge or by 40 week corrected gestational age), incidence and severity (stages 1-5) of ROP, incidence and severity of IVH, feeding method on discharge, weight gain/loss on discharge and supplemental oxygen on discharge were considered as short-term outcomes of infants.
Objectives
In this study we used "average direct cost" which could be used easily to compare the costs taking into account the cost incurred on drugs as well. The incidence of IVH, NEC, pulmonary air leak (PAL), pulmonary haemorrhage and clinical PDA were the selected short term complications looked for in this study.
Results
During the study period 39 ELBW babies (17 boys, 22 girls) were born in CSHW. Birth weights were between 540g to 980g (mean 853g) and the maturity was from 25 weeks to 34 weeks and 3days. Majority (55.5%) were between 27 and 30 weeks of gestation and 700g to 900g (44.4%) kevingillespie@example.org. 48.7% of birth weights were appropriate for gestational age (AGA) while 51.3% were small for gestational age (SGA). None were large for gestational age (LGA). Distribution of the sample according to the birth weight, maturity and percentage of AGA babies is shown in table 1. Hospital stay, intensive care unit (ICU) stay and non-ICU stay were calculated by dividing total number of hours for each category (including those spent by non-survivors) by number of survivors. (Table 3) Median maturity at discharge home was 35 weeks and 1 day. Corrected gestational age at discharge was between 33 weeks and 5 days to 50 weeks and 5 days. Investigations including blood gas, excluding ultrasound scans 6,160
Results
Linen, cloths, swabs 1,600
Results
Total 82,207
Results
In calculating direct cost, cost for ROP screening, laser therapy, costs of transportation were not included. Cost of enteral nutrition was not included as the data were not completed. None received TPN.
Results
The average direct cost in Sri Lankan rupees (SLR) is shown in The incidence of selected complications was restricted to the 36 ELBW babies who survived for more than 6 hours after birth. One of the 7 babies with IVH had bilateral grade 4 IVH from which he succumbed.
Results
Eye examination, done in the 36 ELBW babies who survived for more than 6 hours after birth, revealed the presence of ROP in 25 (83.3%) babies on first eye examination. Incidence of stages 1, 2, and 3 ROP was 60%, 16.7% and 6.7% respectively. Only 5 (16.7%) had completely normal retina on first ophthalmologic examination. None of the babies developed stages 4 or 5 ROP.
Results
Average weight gain per survivor at discharge was 5.2g/kg/day. None of the babies were oxygen dependent or tube kevingillespie@example.org.
Discussion
Itabashi et al, in a study of 3,065 ELBW infants born in 2005 in Japan, showed that neonatal mortality rate and the mortality rate during NICU stay among ELBW infants were 13% and 17%, respectively 13 . As all the deaths in our study occurred within first 7 days of life and during ICU stay, neonatal mortality rate and the mortality rate during NICU stay can be calculated as 23% and 25.7% respectively (4 babies did not get admitted to NICU). In another study done in South Africa, overall survival rate of VLBW was 70.5% and survival rate of ELBW infants was 34.9% 14 . In our study the overall survival rate of ELBW infants was 77%.
Discussion
The cost of managing ELBW infants varies between developed and developing countries and different regions within a country 4, 6, 15, 16 17 . In the South African study 14 , mean duration of mechanical ventilation was 8.08 days and the mean duration of supplemental oxygen was 8.2 days in VLBW babies. In our study mean duration of mechanical ventilation and supplemental oxygen was 3.5 days and 8.9 days respectively. Approximately 30% of VLBW premature infants have IVH and 11.4% of ELBW infants have grades 3 or 4 (severe) IVH 18 . In our study 19.4% ELBW infants had IVH and 2.7% had severe IVH. However this may be an under estimate as not all the babies who died early had cranial ultrasound scans. Only one out of the 7 babies who developed IVH had received surfactant replacement therapy compared to 6 who had not received surfactant (P<0.001). Otherwise the complications were similar in those receiving and not receiving surfactant therapy.
Discussion
UK ROP screening guidelines recommend that first ROP screening should be undertaken at 30 to 31 weeks postmenstrual age for the babies born before 27 weeks and between 4 to 5 weeks postnatal age for babies born between 27 and 32 weeks. For babies >32 weeks gestational age but with birth weight <1501g first ROP screen should be undertaken between 4 to 5 weeks 19 . In general, more than 50% of premature infants weighing less than 1250 g at birth show evidence of ROP, and about 10% of the infants develop stage 3 ROP 19 . In our cohort 25 (83.3%) showed evidence of ROP and 2 (6.7%) had stage 3 ROP.
Conclusions
• ELBW babies in this study had an overall survival rate of 77%.
Conclusions
• Mean duration of mechanical ventilation was 3.5 days and the mean duration of supplemental oxygen was 8.9 days.
Conclusions
• IVH, NEC, PAL, pulmonary haemorrhage and clinical PDA occurred in 19.4%, 8.3%, 22.2%, 11,1% and 2.7% respectively.
Conclusions
• IVH was significantly less in babies treated with surfactant.
Limitation of the study
Small sample size is the biggest limitation of this study.

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