Role of score for neonatal acute physiology (SNAP) in predicting neonatal mortality

SNAPPE II Score as a Predictor of Neonatal Mortality in NICU at a Tertiary Care Hospital in Pakistan

Introduction

The concept of illness severity scoring has been around for long and is currently being utilized in many neonatal intensive care unit (NICU). Scoring systems that help to quantify mortality risks on the basis of clinical conditions not only help in estimating prognosis, but also help clinicians in making decisions particularly in situations presenting with dilemmas. This study aims to determine SNAPPE-II (Score for Neonatal Acute Physiology-Perinatal Extension) score as a predictor of neonatal mortality in NICU at a tertiary care hospital in Pakistan.

Methodology

It was a longitudinal cohort study. The study was conducted at a neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH) Karachi, Pakistan. All neonates were included who were born in AKUH and who needed respiratory support in NICU.

Results

A total of 333 newborns were enrolled for this study. Out of those 30 (9.1%) neonates expired while 298 (90.9%) survived. Area Under the Receiver operative curve was calculated to obtain the SNAPPE-II score’s diagnostic discrimination ability. Area under the curve (AUC) was 80.2±4.6% which corresponds to a moderate diagnostic accuracy for the prediction of neonatal mortality. The 95% CI for this was between 71.1-89.2%. SNAPPE-II category III (>40) was found to be the strongest predictor of mortality, with a sensitivity of 40% and a specificity of 98.7%.

Conclusion

The SNAPPE-II scoring system, we conclude, might be a valuable technique for predicting newborn death in resource-constrained NICUs.

Neonatal mortality risk assessment using SNAPPE- II score in a neonatal intensive care unit

Background

There are many scoring systems to predict neonatal mortality and morbidity in neonatal intensive care units (NICU). One of the scoring systems is SNAPPE-II (Score for Neonatal Acute Physiology with Perinatal extension-II). This study was carried out to assess the validity of SNAPPE-II score (Score for Neonatal Acute Physiology with Perinatal Extension-II) as a predictor of neonatal mortality and duration of stay in a neonatal intensive care unit (NICU).

Methods

This prospective, observational study was carried out over a period of 12 months from June 2015 to May 2016. Two hundred fifty five neonates, who met the inclusion criteria admitted to NICU in tertiary care hospital, BPKIHS Hospital, Nepal were enrolled in the study and SNAPPE-II score was calculated. Receiver Operating Characteristic (ROC) curve was constructed to derive the best SNAPPE-II cut-off score for mortality.

Results

A total of 305 neonates were admitted to NICU over a period of one year. Among them, 255 neonates fulfilled the inclusion criteria. Out of 255 neonates, 45 neonates (17.6%) died and 210 were discharged. SNAPPE-II score was significantly higher among neonates who died compared to those who survived [median (IQR) 57 (42–64) vs. 22 (14–32), P < 0.001]. SNAPPE II score had discrimination to predict mortality with area under ROC Curve (AUC): 0.917 (95% CI, 0.854–0.980). The best cut - off score for predicting mortality was 38 with sensitivity 84.4%, specificity 91%, positive predictive value 66.7% and negative predictive value 96.5%. SNAPPE II score could not predict the duration of NICU stay (P = 0.477).

Conclusion

SNAPPE- II is a useful tool to predict neonatal mortality in NICU. The score of 38 may be associated with higher mortality.

Preterm Stress Behaviors, Autonomic Indices, and Maternal Perceptions of Infant Colic

BACKGROUND

While biological and behavioral stress response systems are intact in early gestation, preterm infants' behaviors are often more subtle and difficult to interpret compared with full-term infants. They are also more vulnerable for regulatory issues (ie, colic) that are known to impact caregiver-infant interactions. Biobehavioral measures such as behavioral responsivity and heart rate variability (HRV), particularly cardiac vagal tone, may help elucidate preterm infants' stress/regulatory systems.

PURPOSE

To test the hypotheses that preterm infants' consoling behaviors and high-frequency (HF) HRV in the first week of life are significantly associated and they are inverse correlates of future colic risk.

METHODS/SEARCH STRATEGY

Thirty preterm (mean ± SE = 32.7 ± 0.3 weeks postmenstrual age [PMA]) infants underwent direct NIDCAP (Newborn Individualized Development and Assessment Program) observation during routine care and had HRV measurements during their first week postbirth. Sixty-three percent of mothers completed the Infant Colic Scale at 6 to 8 weeks adjusted postnatal age. Nonparametric tests were used to determine associations among behaviors, HRV, and maternal perceptions of infant colic.

FINDINGS/RESULTS

Self-consoling behaviors were positively associated with HF-HRV (vagal tone). In addition, stress behaviors were positively associated with low-frequency/high-frequency HRV (sympathetic dominance). Infants who displayed more stress behaviors also demonstrated more self-consoling behaviors. No significant associations were found with colic.

IMPLICATIONS FOR PRACTICE

HF-HRV provides information on the infant's capacity to modulate stress and is a useful, noninvasive measure when behaviors are more difficult to discern.

IMPLICATIONS FOR RESEARCH

Further study in a larger sample is needed to determine whether behavioral stress measures and HF-HRV may be useful to determine colic risk.

Assessment of sickness severity of illness in neonates: review of various neonatal illness scoring systems

Sickness severity scores are widely used for neonates admitted to neonatal intensive care units to predict severity of illness and risk of mortality and long-term outcome. These scores are also used frequently for quality assessment among various neonatal intensive care unit and hospital. Accurate and reliable measures of severity of illness are required for unbiased and reliable comparisons especially for benchmarking or comparative quality improvement care studies. These scores also serve to control for population differences when performing studies such as clinical trials, outcome evaluations, and evaluation of resource utilisation. Although presently there are multiple scores designed for neonates' sickness assessment but none of the score is ideal. Each score has its own advantages and disadvantages. We did literature search for identifying all neonatal sickness severity score and in this review article, we discuss these scores along with their merits and demerits.

Blood zinc, iron, and copper levels in critically ill neonates

The aim of this study is to explore the prognostic value of blood zinc, iron, and copper levels in critically ill neonates by comparing blood metal levels with the score for neonatal acute physiology (SNAP). Forty-six neonates (26 boys, 20 girls; ages ranging from 10 min to 23 days) who had been admitted to the neonatal intensive care unit of hospital and who were critically ill according to SNAP were included. Another 15 neonates (12 boys, 8 girls; ages ranging from 30 min to 24 days) who were brought to the hospital for a health checkup were included as controls. Clinical data, time in the intensive care unit, prognosis, and SNAP for critically ill neonates were recorded. Blood Cu, Zn, and Fe values were measured by inductively coupled plasma atomic emission spectrophotometry. Ill neonates were divided into extremely critical (SNAP ≥ 10) and critical groups (1 ≤ SNAP < 9). Zn levels were lower in patients than in controls (p <0.05). Cu levels did not differ between patients and controls (p >0.05). Fe levels were not significantly between the critical and control groups (p >0.05). In ill neonates, blood Zn and Fe concentrations in the extremely critical group were lower than in the critical group (p <0.05). Serious illness in neonates may lead to decreased Zn and Fe blood concentrations. Zn and Fe supplements may be beneficial for critically ill children.

Volumetric MRI and MRS and early motor development of infants born preterm

PURPOSE

To investigate the relationship between volumetric magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) in infants born less than 30 weeks gestation and early motor development at 6 months adjusted age.

METHODS

Twenty infants born preterm and 4 born at term (control) underwent MRI with volumetric analysis and MRS prior to neonatal intensive care unit discharge. Infants were assessed using the Bayley Scale of Infant Development at 6 months adjusted age.

RESULTS

At 6 months, infants born preterm with low motor scores had a reduction in their subcortical gray matter. No differences were detected in other brain structures. N-acetylaspartate/choline correlated with white matter (R = 0.45, P = .03), gray matter (R = 0.43, P = .04), and cerebellar volume (R = 0.6, P = .002) but not with 6-month motor performance.

CONCLUSION

There is an association between diminished subcortical gray matter volume and low motor scores. Our data suggest that volumetric MRI performed prior to hospital discharge may have some role in counseling parents about potential motor delays.

Effect of severe neonatal morbidities on long term outcome in extremely low birthweight infants

PURPOSE

To assess the validity of individual and combined prognostic effects of severe bronchopulmonary dysplasia (BPD), brain injury, retinopathy of prematurity (ROP), and parenteral nutrition associated cholestasis (PNAC).

METHODS

We retrospectively analyzed the medical records of 80 extremely low birthweight (ELBW) infants admitted to the neonatal intensive care unit (NICU) of the Severance Children's Hospital, and who survived to a postmenstrual age of 36 weeks. We analyzed the relationship between 4 neonatal morbidities (severe BPD, severe brain injury, severe ROP, and severe PNAC) and poor outcome. Poor outcome indicated death after a postmenstrual age of 36 weeks or survival with neurosensory impairment (cerebral palsy, delayed development, hearing loss, or blindness) between 18 and 24 months of corrected age.

RESULTS

Each neonatal morbidity correlated with poor outcome on univariate analysis. Multiple logistic regression analysis revealed that the odds ratios (OR) were 4.9 (95% confidence interval [CI], 1.0-22.6; P=0.044) for severe BPD, 13.2 (3.0-57.3; P<.001) for severe brain injury, 5.3 (1.6-18.1; P=0.007) for severe ROP, and 3.4 (0.5-22.7; P=0.215) for severe PNAC. Severe BPD, brain injury, and ROP were significantly correlated with poor outcome, but not severe PNAC. By increasing the morbidity count, the rate of poor outcome was significantly increased (OR 5.2; 95% CI, 2.2-11.9; P<.001). In infants free of the above-mentioned morbidities, the rate of poor outcome was 9%, while the corresponding rates in infants with 1, 2, and more than 3 neonatal morbidities were 46%, 69%, and 100%, respectively.

CONCLUSION

In ELBW infants 3 common neonatal mornidifies, severe BPD, brain injury and ROP, strongly predicts the risk of poor outcome.

Role of TOPS (a simplified assessment of neonatal acute physiology) in predicting mortality in transported neonates

AIM

To evaluate role of TOPS (a simplified assessment of neonatal acute physiology) in predicting mortality in transported neonates and to compare it with SNAP II.

DESIGN

Prospective study.

SETTING

Referral Neonatal Unit of a teaching hospital.

SUBJECTS

175 neonates > 1000 g admitted to referral nursery.

METHODS

Temperature, oxygenation, capillary refill time (proxy for perfusion) and blood sugar (given the acronym of TOPS) were recorded at admission. SNAP II was also recorded for first 12 hours following admission.

RESULTS

All the TOPS variables had significant correlation with fatality on univariate analysis. Fatality was 100% when all the four TOPS variables were deranged. The sensitivity, specificity, positive and negative predictive values of derangements of two or more TOPS parameters in predicting mortality were 81.6%, 77.39%, 65.3% and 89%, respectively All the variables of SNAP II significantly correlated with mortality. A cut-off score of 24 was derived from the ROC curve. The sensitivity, specificity, positive and negative predictive values of SNAP II score > 24 in predicting mortality were 78.3%, 86.1%, 74.6% and 88.4%, respectively. The area under ROC curve for derangements of 2 or more TOPS parameters was 0.89 while that for SNAP II was 0.88. Both models were well calibrated (p value for Hosmer Lemeshow goodness of fit for TOPS was 0.75 while that for SNAP II was 0.80). The total correct classification rate for TOPS was 81.7%, while that for SNAP II was 83.4%.

CONCLUSION

TOPS has an equally good prediction for mortality as SNAP II and can be used as a simple and useful method of assessment of risk of fatality that can be assessed immediately, at admission.