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The impact of Neonatal Resuscitation Program courses on mortality and morbidity of newborn infants with perinatal asphyxia
Brain & Development 30 (2008) 43–46 www.elsevier.com/locate/braindev
Original article
The impact of Neonatal Resuscitation Program courses on mortality and morbidity of newborn infants with perinatal asphyxia Rıdvan Duran
¨ lfet Vatansever a, Necdet Su¨t b, Betu¨l Acunasß , Nu¨khet Aladag˘ a, U
a,*
a
a b
Department of Pediatrics, Trakya University School of Medicine, Edirne, Turkey Department of Biostatistics, Trakya University School of Medicine, Edirne, Turkey
Received 26 January 2007; received in revised form 7 May 2007; accepted 11 May 2007
Abstract Objective. Neonatal care provided within the first few minutes of life plays a major role in the reduction of neonatal morbidity and mortality. Neonatal Resuscitation Program (NRP) courses had been held since 1996. The aim of this study was to evaluate the impact of the NRP on morbidity and mortality of newborn infants with perinatal asphyxia. Methods. This retrospective study comprised newborn infants who were born in hospitals at Trakya region of Turkey during the last 3 years and were diagnosed as perinatal asphyxia and were referred to our Neonatal Unit. Those patients who were referred before NRP course (pretraining period) were designated as Group 1, those who were referred after the first NRP course (transition period) as Group 2, and those who were referred after the second NRP course (post-training period) as Group 3. Chart review was performed with regard to gestational age, birth weight, Apgar scores, resuscitation type, stage of hypoxic ischemic encephalopathy (HIE), existence of meconium aspiration syndrome (MAS), progress of the disease, duration of hospitalization. Results. The study comprised 66 patients; 35 in Group 1, 18 in Group 2 and 13 in Group 3. The number of cases who had not been resuscitated was 10 in the pretraining period, 3 in the transition period and 1 in the post-training period which decreased significantly. The first minute Apgar scores in three groups were as follows; 2.08 ± 1.2, 2.2 ± 1.1 and 3.7 ± 1.4, and this increase was statistically significant. The fifth minute Apgar scores also increased from 5.43 ± 1.5 in the pretraining period to 6.5 ± 1.9 in the post-training period, but this increase was not statistically significant. The number of patients with Stage 1 and 2 HIE decreased more in Group 3 (n = 11 in Stage 1 HIE, n = 17 in Stage 2 HIE) compared to those in Group 1 (n = 7 in Stage 1 HIE, n = 5 in Stage 2 HIE) but the difference was not statistically significant. The duration of hospitalization decreased in post-training period (15.1 ± 10.3 days in pretraining period, 12.0 ± 8.9 days in transition period, 6.1 ± 1.2 days in post-training period). Conclusions. After NRP courses, the number of patients with perinatal asphyxia and with no resuscitation and also the duration of hospitalization decreased significantly, whereas the first minute Apgar scores increased significantly. Ó 2007 Elsevier B.V. All rights reserved. Keywords: Neonatal Resuscitation Program course; Perinatal asphyxia; Hypoxic ischemic encephalopathy; Apgar scores
1. Introduction It is estimated by World Health Organization that neonatal deaths account for 37% of global child mortality less than 5 years of age, and 23% of these deaths were * ¨ niversitesi Tıp Faku¨ltesi, Corresponding author. Address: Trakya U C ¸ ocuk Sag˘lıg˘ı, ve Hastalıkları Anabilim Dalı, 22030 Edirne, Turkiye. Tel.: +90 284 235 7641x4909; fax: +90 284 235 2338. E-mail address: [email protected] (R. Duran).
0387-7604/$ - see front matter Ó 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.braindev.2007.05.009
related to perinatal asphyxia. Neonatal care provided within the first few minutes of life plays a major role in the reduction of neonatal morbidity and mortality rates [1]. To assure that the health care staff in delivery room in all rural, suburban, and urban hospitals have the necessary knowledge and skills, and that they use these skills appropriately, to provide care to newborns immediately after birth; a training program, the Neonatal Resuscitation Program (NRP), contained in an education manual endorsed by the American Heart
44
R. Duran et al. / Brain & Development 30 (2008) 43–46
Association (AHA) and the American Academy of Pediatrics (AAP) was initiated throughout the United States in the late 1980s [2,3]. The NRP courses had been arranged by Health Ministry and Turkish Neonatology Association since 1996 in our country [4]. In spite of a few studies demonstrating an improved quality of care at birth after neonatal resuscitation program courses on Apgar scores [2,5], there are few number of studies searching for mortality and morbidity of cases with perinatal asphyxia [6,7]. The aim of this study was to evaluate the impact of the NRP in decreasing morbidity and mortality of newborn infants with perinatal asphyxia in Trakya region of Turkey.
2. Methods In Trakya region, NRP courses had been held for the hospital health staff two times till today in September 2003 and September 2004. Fifty percent of the staff working in this area was given NRP course in September 2003, and the remaining 45% of the staff in September 2004. Approximately 12,000 children are born in Trakya region each year and our hospital is the only Level 3 referral center in this area. The newborn infants who had to be followed up in neonatal intensive care unit (perinatal asphyxia, meconium aspiration syndrome (MAS), prematurity, respiratory distress syndrome type 1, and neonatal convulsion, etc.) are referred to this unit. This retrospective study compromised newborn infants who were born at Trakya region hospitals during the last 3 years and were diagnosed as perinatal asphyxia and were referred to our Neonatal Unit. Those patients who were referred before NRP course (pretraining period) were designated as Group 1, those who were referred after the first NRP course (transition period) as Group 2, and those who were referred after the second NRP course (post-training period) as Group 3. Chart review was performed in terms of gestational age, birth weight, Apgar scores, resuscitation type, stage of hypoxic ischemic encephalopathy (HIE), existence of MAS, progress of disease, duration of hospitalization, outcomes, and survival in the neonatal period. HIE was classified as mild (Stage 1), moderate (Stage 2) and severe (Stage 3) using Sarnat and Sarnat scoring system [8] and cranial computerized tomography (CT) was performed in all patients who were diagnosed as HIE. The time of cranial CT was determined according to level of consciousness. If patient was lethargic, in stupor or coma, cranial CT was performed within the first week of life and repeated at the end of the first month of postnatal period. Otherwise, cranial CT was performed at the end of the first month of postnatal period. The given results about cranial CT in this study involved the first month results. Infants were designated as having asphyxia if they fulfilled the following criteria [8].
(1) Intrapartum distress indicated by the cardiotocograph pattern (late decelerations, absence of variability, persistent bradycardia, etc.) and/or abnormal blood flow pattern (loss or reversal of end-diastolic velocity) and/or early passage of thick meconium, (2) Requirement for resuscitation with positive pressure ventilation and tracheal intubation, (3) Low Apgar score (1st min 6 3, 5th min < 6) or umbilical arterial/first postnatal (pH < 7.1). STATISTICA 7.0 package was used for statistical analysis. All numeric values were expressed as mean ± SD and n (%). Normal distribution of variables was tested using the Kolmogorov–Smirnov test. Repeated Measures ANOVA test with Bonferoni correction was performed for inter-groups comparisons of normal variables, Freidman ANOVA test with Bonferoni correction was used for inter-groups comparisons of non-normal variables. Categorical variables were compared by chi-square test. A p value of <0.05 was considered statistically significant.
3. Results Tables 1 and 2 outline the demographic and clinical features of all cases. The study comprised 66 patients. There were 35 patients in Group 1 (53%), 18 in Group 2 (27.3%) and 13 in Group 3 (19.7%). The number of patients decreased significantly in post-training period compared to the pretraining period. There were no significant differences among the 3 groups in terms of gestational ages, birth weight, gender, cesarean section rate, and type of resuscitation. The number of patients who did not have any resuscitation were 10 (31.2%) in the pretraining period, 3 (16.7%) in the transition period and 1 (7.8%) in the post-training period, and this decrease was statistically significant (p < 0.05). The first minute Apgar scores in three groups were as follows; 2.08 ± 1.2, 2.2 ± 1.1 and 3.7 ± 1.4, and especially the first minute Apgar scores increased significantly in the post-training period compared to the pretraining period (p = 0.01). The fifth minute Apgar scores also increased from 5.43 ± 1.5 in the pretraining period to 6.5 ± 1.9 in the post-training period, but this increase was not statistically significant. The number of infants who were diagnosed as HIE Stage 1 and 2 in Group 3 were lower than the ones in Group 1, but this difference was not statistically significant. In all 3 groups the number of patients ones diagnosed as HIE Stage 3 was similar. The number of patients diagnosed as MAS was 5 (14.3%) in the pretraining period and this number decreased to 1 in the post-training period but this was not significant. The number of patients who had ischemic regions in cranial CT was 32 (91.4%) in the pretraining period and this
R. Duran et al. / Brain & Development 30 (2008) 43–46
45
Table 1 Demographic characteristics of all cases (n = 66) Demographic features
Group 1 (n = 35) (Pretraining period)
Group 2 (n = 18) (Transition period)
Group 3 (n = 13) (Post-training period)
p Value
Gestation age (wk) Birth weight (g) Cesarean (%) Female gender (%)
38.4 ± 1.4 2978 ± 570 20 (57.1) 17 (48.5)
38.4 ± 2.2 2903 ± 600 10 (55.5) 9 (50)
39.4 ± 1.2 3176 ± 484 7 (53.8) 7 (53.8)
NS NS NS NS
Type of resuscitation (%) Bag-mask ventilation Intubation Cardiac massage Medications
7 (20) 11 (31.4) 5 (14.3) 2 (5.7)
5 6 2 2
3 5 2 2
NS NS NS NS
(27.8) (33.3) (11.1) (11.1)
(23.1) (38.5) (15.3) (15.3)
Abbreviations: NS, not significant.
Table 2 Clinical characteristics of all cases (n = 66) Clinical features
Group 1 (n = 35) (Pretraining period)
Group 2 (n = 18) (Transition period)
Group 3 (n = 13) (Post-training period)
p Value
No resuscitation Apgar 1 Apgar 5 HIE Stage 1 (%) HIE Stage 2 (%) HIE Stage 3 (%) MAS (%) Ischemic areas in CT (%) Date of cranial CT (day) Duration of hospitalization (day) Survival (%)
10 (31.2) 2.08 ± 1.2 5.43 ± 1.5 11 (31.4) 17 (48.6) 5 (14.3) 5 (14.3) 32 (91.4) 29.7 ± 2.3 15.1 ± 10.3 33 (94.3)
3 (16.7) 2.2 ± 1.1 5.65 ± 1.9 7 (38.9) 5 (27.8) 3 (16.7) 2 (11.1) 9 (50) 29.4 ± 1.4 12.0 ± 8.9 17 (94.4)
1 (7.8) 3.7 ± 1.4 6.5 ± 1.9 2 (15.4) 4 (30.8) 2 (15.4) 1 (7.7) 8 (61.5) 29.2 ± 1.8 6.1 ± 1.2 11 (84.6)
<0.05 0.01 NS NS NS NS NS 0.02 NS <0.05 NS
Abbreviations: NS, not significant; HIE, hypoxic ischemic encephalopathy; MAS, meconium aspiration syndrome; CT, computerized tomography.
number decreased to 9 (50%) in the transition period, and to 8 (61.5%) in the post-training period and this decrease was statistically significant (p = 0.02). The patients were hospitalized for 15.1 ± 10.3 days in Group 1, for 12.0 ± 8.9 days in Group 2, and for 6.1 ± 1.2 days in Group 3 and this decrease in duration of hospitalization was statistically significant (p < 0.05). The survival rate in Group 1 was 94.3%, 94.4% in Group 2, and 84.6% in Group 3 and the difference was not statistically significant.
4. Discussion There are several ways to evaluate the impact of the NRP courses on the quality of care at birth in a regional area. Our study has examined the effectiveness of the NRP courses in Trakya Region of Turkey on neonatal outcomes such as the number of cases with perinatal asphyxia, the severity and the outcome of the disease by comparing the pretraining period, transition period and post-training period. The need for resuscitation of the newborn cannot be predicted in most cases; therefore it is judicious to train all providers who may be involved in the delivery of
newborns to follow guidelines developed to improve outcome, especially in the presence of transitional asphyxia [9]. Simple measures such as protection from hypothermia, appropriate head positioning and suctioning and recognizing those who need respiratory support can make significant changes in neonatal mortality and morbidity rates [3]. The goal of the NRP courses is to assure that the health care personnel in the delivery room in all rural, suburban, and urban hospitals have the necessary knowledge and skills and that they use these skills appropriately to provide well care to newborns after birth. This program was intended to have the greatest impact on designated Level 1 and Level 2 nurseries in rural and urban hospitals. Level 1 and Level 2 hospitals did not routinely have trained staff and have less technologic support [2]. The results of the Neonatal Resuscitation Program established in China demonstrated an approximately 3 times decreased infant mortality, and the perinatal asphyxia rate was reduced within 2 years [6]. Vakrilova et al. [7] reported a slight decrease in mortality of neonates after NRP courses in Bulgaria. In our study even though there was no change in mortality that is regarding patients with perinatal asphyxia referred to our neonatal intensive care unit, the number of patients referred
46
R. Duran et al. / Brain & Development 30 (2008) 43–46
to us who had perinatal asphyxia decreased after the NRP courses compared to the number before the courses. The resuscitation types used in our patients (bag-mask ventilation, intubation, chest compression and medication) did not vary in groups significantly, and the number patients who did not have resuscitation decreased significantly in the post-training period compared to the pretraining period. At the same time, the duration of hospitalization decreased significantly. The reason of this decrease in the number of unresuscitated patients might be increased knowledge and skill of health care staff about newborn resuscitation after NRP courses. The impact of the appropriate and timely performed newborn resuscitation might have resulted in less severe perinatal asphyxia and shortened the length of hospital stay. Although previous studies have shown that the NRP courses improve knowledge and skill among health care personnel in the delivery room, there has been little evidence to demonstrate the impact of NRP on infant morbidity and mortality [10–12]. In spite of a few studies demonstrating an improved quality of care at birth after neonatal resuscitation program courses on Apgar scores [2,5], there are few studies about the morbidities and mortalities of the patients with birth asphyxia [6,7]. Patel et al. [2] demonstrated a significant improvement occurring among neonates in their Apgar score after the NRP course. In our study, the first minute Apgar scores of the patients with perinatal asphyxia increased significantly in the post-training period compared to the pretraining period. The fifth minute Apgar scores also increased and the number of patients who were diagnosed as HIE Stages 1 and 2 decreased but these were not statistically significant probably because of insufficient number of patients in the study. The morbidity and mortality rates in our study were only reported regarding the neonatal period. Cranial CT is much less sensitive compared to magnetic resonance imaging (MRI) regarding smaller ischemic changes [13]. In our study, MRI could not be performed because of technical and insurance problems, and thus it is still possible that these neonates have ischemic lesions that could only be detected by MRI. The timing of the cranial CT in patients with perinatal asphyxia is important [13]. Cranial CT is not sensitive for early ischemic changes [13], so in our study cranial CT was performed in the first week of life only in those who had abnormal level of consciousness. For these
patients cranial CT was repeated at the end of the first month of life. The patients who were referred at the post-training period had less ischemic regions on cranial CT at the end of first month of life compared to pretraining period. In conclusion, we determined a decrease in the cases who had not resuscitation and perinatal asphyxia, increase in the first Apgar score and decrease in the duration of hospitalization after NRP courses. These findings reveal the effectiveness of NRP courses and the importance of the education of the staff in the delivery room.
References [1] Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimated of the causes of death in children. Lancet 2005;365:1147–52. [2] Patel D, Piotrowski ZH, Nelson MR, Sabich R. Effect of a statewide neonatal resuscitation training program on apgar scores among high-risk neonates in Illinois. Pediatrics 2001;107:648–55. [3] Bloom RS, Cropley C. Textbook of neonatal resuscitation. American Academy of Pediatrics, American Heart Association; 2000. [4] Ergenekon E, Koc E, Atalay Y, Soysal S. Neonatal resuscitation course experience in Turkey. Resuscitation 2000;45:225–7. [5] Patel D, Piotrowski ZH. Positive changes among very low birth weight infant Apgar scores that are associated with the Neonatal Resuscitation Program in Illinois. J Perinatol 2002;22:386–90. [6] Zhu XY, Fang HQ, Zeng SP, Li YM, Lin HL, Shi SZ. The impact of the neonatal resuscitation program guidelines (NRPG) on the neonatal mortality in a hospital in Zhuhai, China. Singapore Med J 1997;38:485–7. [7] Vakrilova L, Elleau CH, Sluncheva B. French-Bulgarian program ‘‘Resuscitation of the newborn in a delivery room’’—results and perspectives. Akush Ginekol (Sofiia) 2005;44:35–40. [8] Sarnat HB, Sarnat MS. Neonatal encephalopathy following fetal distress. A clinical and electroencephalographic study. Arch Neurol 1976;33:696–705. [9] Malinowski C. Neonatal resuscitation program and pediatric advanced life support. Respir Care 1995;40:575–86. [10] Trevisanuto D, Ferrarese P, Cavicchioli P, Fasson A, Zanardo V, Zacchello F. Knowledge gained by pediatric residents after neonatal resuscitation program courses. Pediatr Anesth 2005;15:944–7. [11] Levitt C, Kaczorowski J, Outerbridge E, Jimenez V, Connolly B, Slapcoff B. Knowledge gained following neonatal resuscitation program courses. Fam Med 1996;28:403–6. [12] Dunn S, Niday P, Watters NE, McGrath P, Alcock D. The provision and evaluation of a neonatal resuscitation program. J Contin Educ Nurs 1992;23:118–26. [13] Barkovich AJ. MR and CT evaluation of profound neonatal and infantile asphyxia. Am J Neuroradiol 1992:13959–72.
Original article
The impact of Neonatal Resuscitation Program courses on mortality and morbidity of newborn infants with perinatal asphyxia Rıdvan Duran
¨ lfet Vatansever a, Necdet Su¨t b, Betu¨l Acunasß , Nu¨khet Aladag˘ a, U
a,*
a
a b
Department of Pediatrics, Trakya University School of Medicine, Edirne, Turkey Department of Biostatistics, Trakya University School of Medicine, Edirne, Turkey
Received 26 January 2007; received in revised form 7 May 2007; accepted 11 May 2007
Abstract Objective. Neonatal care provided within the first few minutes of life plays a major role in the reduction of neonatal morbidity and mortality. Neonatal Resuscitation Program (NRP) courses had been held since 1996. The aim of this study was to evaluate the impact of the NRP on morbidity and mortality of newborn infants with perinatal asphyxia. Methods. This retrospective study comprised newborn infants who were born in hospitals at Trakya region of Turkey during the last 3 years and were diagnosed as perinatal asphyxia and were referred to our Neonatal Unit. Those patients who were referred before NRP course (pretraining period) were designated as Group 1, those who were referred after the first NRP course (transition period) as Group 2, and those who were referred after the second NRP course (post-training period) as Group 3. Chart review was performed with regard to gestational age, birth weight, Apgar scores, resuscitation type, stage of hypoxic ischemic encephalopathy (HIE), existence of meconium aspiration syndrome (MAS), progress of the disease, duration of hospitalization. Results. The study comprised 66 patients; 35 in Group 1, 18 in Group 2 and 13 in Group 3. The number of cases who had not been resuscitated was 10 in the pretraining period, 3 in the transition period and 1 in the post-training period which decreased significantly. The first minute Apgar scores in three groups were as follows; 2.08 ± 1.2, 2.2 ± 1.1 and 3.7 ± 1.4, and this increase was statistically significant. The fifth minute Apgar scores also increased from 5.43 ± 1.5 in the pretraining period to 6.5 ± 1.9 in the post-training period, but this increase was not statistically significant. The number of patients with Stage 1 and 2 HIE decreased more in Group 3 (n = 11 in Stage 1 HIE, n = 17 in Stage 2 HIE) compared to those in Group 1 (n = 7 in Stage 1 HIE, n = 5 in Stage 2 HIE) but the difference was not statistically significant. The duration of hospitalization decreased in post-training period (15.1 ± 10.3 days in pretraining period, 12.0 ± 8.9 days in transition period, 6.1 ± 1.2 days in post-training period). Conclusions. After NRP courses, the number of patients with perinatal asphyxia and with no resuscitation and also the duration of hospitalization decreased significantly, whereas the first minute Apgar scores increased significantly. Ó 2007 Elsevier B.V. All rights reserved. Keywords: Neonatal Resuscitation Program course; Perinatal asphyxia; Hypoxic ischemic encephalopathy; Apgar scores
1. Introduction It is estimated by World Health Organization that neonatal deaths account for 37% of global child mortality less than 5 years of age, and 23% of these deaths were * ¨ niversitesi Tıp Faku¨ltesi, Corresponding author. Address: Trakya U C ¸ ocuk Sag˘lıg˘ı, ve Hastalıkları Anabilim Dalı, 22030 Edirne, Turkiye. Tel.: +90 284 235 7641x4909; fax: +90 284 235 2338. E-mail address: [email protected] (R. Duran).
0387-7604/$ - see front matter Ó 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.braindev.2007.05.009
related to perinatal asphyxia. Neonatal care provided within the first few minutes of life plays a major role in the reduction of neonatal morbidity and mortality rates [1]. To assure that the health care staff in delivery room in all rural, suburban, and urban hospitals have the necessary knowledge and skills, and that they use these skills appropriately, to provide care to newborns immediately after birth; a training program, the Neonatal Resuscitation Program (NRP), contained in an education manual endorsed by the American Heart
44
R. Duran et al. / Brain & Development 30 (2008) 43–46
Association (AHA) and the American Academy of Pediatrics (AAP) was initiated throughout the United States in the late 1980s [2,3]. The NRP courses had been arranged by Health Ministry and Turkish Neonatology Association since 1996 in our country [4]. In spite of a few studies demonstrating an improved quality of care at birth after neonatal resuscitation program courses on Apgar scores [2,5], there are few number of studies searching for mortality and morbidity of cases with perinatal asphyxia [6,7]. The aim of this study was to evaluate the impact of the NRP in decreasing morbidity and mortality of newborn infants with perinatal asphyxia in Trakya region of Turkey.
2. Methods In Trakya region, NRP courses had been held for the hospital health staff two times till today in September 2003 and September 2004. Fifty percent of the staff working in this area was given NRP course in September 2003, and the remaining 45% of the staff in September 2004. Approximately 12,000 children are born in Trakya region each year and our hospital is the only Level 3 referral center in this area. The newborn infants who had to be followed up in neonatal intensive care unit (perinatal asphyxia, meconium aspiration syndrome (MAS), prematurity, respiratory distress syndrome type 1, and neonatal convulsion, etc.) are referred to this unit. This retrospective study compromised newborn infants who were born at Trakya region hospitals during the last 3 years and were diagnosed as perinatal asphyxia and were referred to our Neonatal Unit. Those patients who were referred before NRP course (pretraining period) were designated as Group 1, those who were referred after the first NRP course (transition period) as Group 2, and those who were referred after the second NRP course (post-training period) as Group 3. Chart review was performed in terms of gestational age, birth weight, Apgar scores, resuscitation type, stage of hypoxic ischemic encephalopathy (HIE), existence of MAS, progress of disease, duration of hospitalization, outcomes, and survival in the neonatal period. HIE was classified as mild (Stage 1), moderate (Stage 2) and severe (Stage 3) using Sarnat and Sarnat scoring system [8] and cranial computerized tomography (CT) was performed in all patients who were diagnosed as HIE. The time of cranial CT was determined according to level of consciousness. If patient was lethargic, in stupor or coma, cranial CT was performed within the first week of life and repeated at the end of the first month of postnatal period. Otherwise, cranial CT was performed at the end of the first month of postnatal period. The given results about cranial CT in this study involved the first month results. Infants were designated as having asphyxia if they fulfilled the following criteria [8].
(1) Intrapartum distress indicated by the cardiotocograph pattern (late decelerations, absence of variability, persistent bradycardia, etc.) and/or abnormal blood flow pattern (loss or reversal of end-diastolic velocity) and/or early passage of thick meconium, (2) Requirement for resuscitation with positive pressure ventilation and tracheal intubation, (3) Low Apgar score (1st min 6 3, 5th min < 6) or umbilical arterial/first postnatal (pH < 7.1). STATISTICA 7.0 package was used for statistical analysis. All numeric values were expressed as mean ± SD and n (%). Normal distribution of variables was tested using the Kolmogorov–Smirnov test. Repeated Measures ANOVA test with Bonferoni correction was performed for inter-groups comparisons of normal variables, Freidman ANOVA test with Bonferoni correction was used for inter-groups comparisons of non-normal variables. Categorical variables were compared by chi-square test. A p value of <0.05 was considered statistically significant.
3. Results Tables 1 and 2 outline the demographic and clinical features of all cases. The study comprised 66 patients. There were 35 patients in Group 1 (53%), 18 in Group 2 (27.3%) and 13 in Group 3 (19.7%). The number of patients decreased significantly in post-training period compared to the pretraining period. There were no significant differences among the 3 groups in terms of gestational ages, birth weight, gender, cesarean section rate, and type of resuscitation. The number of patients who did not have any resuscitation were 10 (31.2%) in the pretraining period, 3 (16.7%) in the transition period and 1 (7.8%) in the post-training period, and this decrease was statistically significant (p < 0.05). The first minute Apgar scores in three groups were as follows; 2.08 ± 1.2, 2.2 ± 1.1 and 3.7 ± 1.4, and especially the first minute Apgar scores increased significantly in the post-training period compared to the pretraining period (p = 0.01). The fifth minute Apgar scores also increased from 5.43 ± 1.5 in the pretraining period to 6.5 ± 1.9 in the post-training period, but this increase was not statistically significant. The number of infants who were diagnosed as HIE Stage 1 and 2 in Group 3 were lower than the ones in Group 1, but this difference was not statistically significant. In all 3 groups the number of patients ones diagnosed as HIE Stage 3 was similar. The number of patients diagnosed as MAS was 5 (14.3%) in the pretraining period and this number decreased to 1 in the post-training period but this was not significant. The number of patients who had ischemic regions in cranial CT was 32 (91.4%) in the pretraining period and this
R. Duran et al. / Brain & Development 30 (2008) 43–46
45
Table 1 Demographic characteristics of all cases (n = 66) Demographic features
Group 1 (n = 35) (Pretraining period)
Group 2 (n = 18) (Transition period)
Group 3 (n = 13) (Post-training period)
p Value
Gestation age (wk) Birth weight (g) Cesarean (%) Female gender (%)
38.4 ± 1.4 2978 ± 570 20 (57.1) 17 (48.5)
38.4 ± 2.2 2903 ± 600 10 (55.5) 9 (50)
39.4 ± 1.2 3176 ± 484 7 (53.8) 7 (53.8)
NS NS NS NS
Type of resuscitation (%) Bag-mask ventilation Intubation Cardiac massage Medications
7 (20) 11 (31.4) 5 (14.3) 2 (5.7)
5 6 2 2
3 5 2 2
NS NS NS NS
(27.8) (33.3) (11.1) (11.1)
(23.1) (38.5) (15.3) (15.3)
Abbreviations: NS, not significant.
Table 2 Clinical characteristics of all cases (n = 66) Clinical features
Group 1 (n = 35) (Pretraining period)
Group 2 (n = 18) (Transition period)
Group 3 (n = 13) (Post-training period)
p Value
No resuscitation Apgar 1 Apgar 5 HIE Stage 1 (%) HIE Stage 2 (%) HIE Stage 3 (%) MAS (%) Ischemic areas in CT (%) Date of cranial CT (day) Duration of hospitalization (day) Survival (%)
10 (31.2) 2.08 ± 1.2 5.43 ± 1.5 11 (31.4) 17 (48.6) 5 (14.3) 5 (14.3) 32 (91.4) 29.7 ± 2.3 15.1 ± 10.3 33 (94.3)
3 (16.7) 2.2 ± 1.1 5.65 ± 1.9 7 (38.9) 5 (27.8) 3 (16.7) 2 (11.1) 9 (50) 29.4 ± 1.4 12.0 ± 8.9 17 (94.4)
1 (7.8) 3.7 ± 1.4 6.5 ± 1.9 2 (15.4) 4 (30.8) 2 (15.4) 1 (7.7) 8 (61.5) 29.2 ± 1.8 6.1 ± 1.2 11 (84.6)
<0.05 0.01 NS NS NS NS NS 0.02 NS <0.05 NS
Abbreviations: NS, not significant; HIE, hypoxic ischemic encephalopathy; MAS, meconium aspiration syndrome; CT, computerized tomography.
number decreased to 9 (50%) in the transition period, and to 8 (61.5%) in the post-training period and this decrease was statistically significant (p = 0.02). The patients were hospitalized for 15.1 ± 10.3 days in Group 1, for 12.0 ± 8.9 days in Group 2, and for 6.1 ± 1.2 days in Group 3 and this decrease in duration of hospitalization was statistically significant (p < 0.05). The survival rate in Group 1 was 94.3%, 94.4% in Group 2, and 84.6% in Group 3 and the difference was not statistically significant.
4. Discussion There are several ways to evaluate the impact of the NRP courses on the quality of care at birth in a regional area. Our study has examined the effectiveness of the NRP courses in Trakya Region of Turkey on neonatal outcomes such as the number of cases with perinatal asphyxia, the severity and the outcome of the disease by comparing the pretraining period, transition period and post-training period. The need for resuscitation of the newborn cannot be predicted in most cases; therefore it is judicious to train all providers who may be involved in the delivery of
newborns to follow guidelines developed to improve outcome, especially in the presence of transitional asphyxia [9]. Simple measures such as protection from hypothermia, appropriate head positioning and suctioning and recognizing those who need respiratory support can make significant changes in neonatal mortality and morbidity rates [3]. The goal of the NRP courses is to assure that the health care personnel in the delivery room in all rural, suburban, and urban hospitals have the necessary knowledge and skills and that they use these skills appropriately to provide well care to newborns after birth. This program was intended to have the greatest impact on designated Level 1 and Level 2 nurseries in rural and urban hospitals. Level 1 and Level 2 hospitals did not routinely have trained staff and have less technologic support [2]. The results of the Neonatal Resuscitation Program established in China demonstrated an approximately 3 times decreased infant mortality, and the perinatal asphyxia rate was reduced within 2 years [6]. Vakrilova et al. [7] reported a slight decrease in mortality of neonates after NRP courses in Bulgaria. In our study even though there was no change in mortality that is regarding patients with perinatal asphyxia referred to our neonatal intensive care unit, the number of patients referred
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R. Duran et al. / Brain & Development 30 (2008) 43–46
to us who had perinatal asphyxia decreased after the NRP courses compared to the number before the courses. The resuscitation types used in our patients (bag-mask ventilation, intubation, chest compression and medication) did not vary in groups significantly, and the number patients who did not have resuscitation decreased significantly in the post-training period compared to the pretraining period. At the same time, the duration of hospitalization decreased significantly. The reason of this decrease in the number of unresuscitated patients might be increased knowledge and skill of health care staff about newborn resuscitation after NRP courses. The impact of the appropriate and timely performed newborn resuscitation might have resulted in less severe perinatal asphyxia and shortened the length of hospital stay. Although previous studies have shown that the NRP courses improve knowledge and skill among health care personnel in the delivery room, there has been little evidence to demonstrate the impact of NRP on infant morbidity and mortality [10–12]. In spite of a few studies demonstrating an improved quality of care at birth after neonatal resuscitation program courses on Apgar scores [2,5], there are few studies about the morbidities and mortalities of the patients with birth asphyxia [6,7]. Patel et al. [2] demonstrated a significant improvement occurring among neonates in their Apgar score after the NRP course. In our study, the first minute Apgar scores of the patients with perinatal asphyxia increased significantly in the post-training period compared to the pretraining period. The fifth minute Apgar scores also increased and the number of patients who were diagnosed as HIE Stages 1 and 2 decreased but these were not statistically significant probably because of insufficient number of patients in the study. The morbidity and mortality rates in our study were only reported regarding the neonatal period. Cranial CT is much less sensitive compared to magnetic resonance imaging (MRI) regarding smaller ischemic changes [13]. In our study, MRI could not be performed because of technical and insurance problems, and thus it is still possible that these neonates have ischemic lesions that could only be detected by MRI. The timing of the cranial CT in patients with perinatal asphyxia is important [13]. Cranial CT is not sensitive for early ischemic changes [13], so in our study cranial CT was performed in the first week of life only in those who had abnormal level of consciousness. For these
patients cranial CT was repeated at the end of the first month of life. The patients who were referred at the post-training period had less ischemic regions on cranial CT at the end of first month of life compared to pretraining period. In conclusion, we determined a decrease in the cases who had not resuscitation and perinatal asphyxia, increase in the first Apgar score and decrease in the duration of hospitalization after NRP courses. These findings reveal the effectiveness of NRP courses and the importance of the education of the staff in the delivery room.
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