Browsing by Department "Division of Neonatology"

Now showing 1 - 15 of 15
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    Antibiotic use in a level three NICU in South Africa
    (2018) Wireko, Brobby Naana; Tooke, Lloyd
    Background: Antibiotics are the most commonly used medications in the neonatal intensive care unit, and when used appropriately, can be lifesaving in the NICU. However, their inappropriate use has been found to be associated with certain adverse effects like Late Onset Sepsis, Necrotizing Enterocolitis, Chronic lung disease, Candidiasis, antibiotic resistance and death. Objective: This study seeks to describe the current antibiotic practices and management of neonatal sepsis including antibiotic use in a level III Neonatal unit in South Africa Method: The study was conducted at the Groote Schuur Hospital Neonatal Unit in South Africa which provides both emergency and continuous care for neonates in the Western Cape Province. All positive cultures as well as the duration of antibiotics within the period of 1st January 2016 to 31st December 2016 at the GSH Neonatal Unit were entered into a database. Data on infection and antibiotic use in Very Low Birth weight infants was extracted from the Vermont Oxford Network (VON) database. The GSH Neonatal Unit is one of the contributing units to the VON database. This was in addition to 2 Quality audits on antibiotic use in the unit done on 2 separate days in the months of February and November in 2016. The 10 month interval between the 2 audits was to allow for any policy changes to be implemented based on a series of educational webinars for staff that were organized during that period. Another audit was done in a randomly selected month collecting data of all infants on antibiotics for the entire month. Results: The overall incidence rates of Early and Late onset sepsis among the VLBW infants were 1.0% and 5.2% respectively with the 24 – 26 week Gestational age category having the highest rates. GBS and Klebsiella pneumonia were the leading pathogens for EOS and LOS respectively. The incidence of sepsis among babies bigger than 1500g was 0.52%.The commonly used antibiotics were Ampicillin, Gentamycin and Meropenem, which were consistent with the Unit‟s protocols. The major reasons for continued use of antibiotics beyond 48 hours were clinical signs concerning for risk of sepsis, pending culture results and laboratory results concerning for risk of sepsis. Regarding infants who received antibiotics for more than 48 hours, vii a comparison of both audits showed GSH plotting below the lower quartile at 30% in the 1st audit, and at 67% between the median and the lower quartile in the 2nd audit. Discussion: Gestational age has always been a universal risk factor for neonatal sepsis, and this was confirmed in this study. Inappropriate use of antibiotics in neonates arises on account of the difficulty clinicians face because of the nonspecific and vague nature of the signs of neonatal sepsis, especially in the VLBW category. Additional biomarkers for sepsis are increasingly being used to aid in the decision of whether or not to discontinue antibiotics after 36 - 48 hours. Conclusion: There is the need for stricter antibiotic stewardship to reduce the inappropriate use of antibiotics among neonates. Antibiotics being used at GSH are appropriate for the prevailing organisms although there are some resistant organisms.
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    Apnoea of prematurity - discontinuation of methylxanthines in a resource-limited setting
    (Health and Medical Publishing Group, 2013) Tooke, L J; Browde, K; Harrison, M C
    Background: Methylxanthines such as caffeine have been proven to reduce apnoea of prematurity and are often discontinued at 35 weeks’ corrected gestational age (GA). Objective. To ascertain whether a caffeine protocol based on international guidelines is applicable in our setting, where GA is often uncertain. Methods: A prospective folder review was undertaken of all premature infants discharged home over a 2-month period. Results: Fifty-five babies were included. All babies born at less than 35 weeks’ GA were correctly started on caffeine as per protocol. GA was assigned in 85.5% of cases by Ballard scoring and in 14.5% from antenatal ultrasound findings. Caffeine was discontinued before 35 weeks in 54.5%. Discussion: The main reason for discontinuing caffeine early was the baby’s ability to feed satisfactorily, a demonstration of physiological maturity. As feeding behaviours mature significantly between 33 and 36 weeks, the ability to feed may be a good indication that caffeine therapy can be stopped.
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    Congenital rubella: Is it nearly time to take action?
    (Health and Medical Publishing Group, 2012) Boshoff, L; Tooke, L
    Congenital rubella syndrome (CRS) is a rare but potentially debilitating disease with lifelong consequences. Although there is no cure, it is almost completely preventable by an effective immunisation programme. We present two confirmed cases of CRS diagnosed in the neonatal unit at Groote Schuur Hospital in 2011 and discuss aspects of the disease and its prevention.
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    Correlation between transcutaneous bilirubin and total serum bilirubin levels among preterm neonates at Groote Schuur Hospital
    (2012) Yaser, Abdallah; Rhoda, Natasha; Tooke, Lloyd
    Includes abstract. Includes bibliographical references.
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    Donor milk intake and infant growth in a South African neonatal unit: a cohort study
    (BioMed Central, 2018-09-04) Sparks, Hayley; Linley, Lucy; Beaumont, Jennifer L; Robinson, Daniel T
    Background Implications of donor milk feedings on infant growth in resource limited settings remain uncertain. This knowledge gap includes the impact of donor milk availability on infant intake of mother’s own milk. Therefore, this investigation aimed to measure intake and growth in infants receiving donor milk when born to women from resource limited backgrounds with high rates of human immunodeficiency virus (HIV). Methods A retrospective cohort study enrolled eligible infants admitted to a South African combined neonatal intensive and secondary high care unit, within a one year admission period during 2015, with signed consent for donor milk feedings. A certified milk bank provided donor milk. Daily nutritional intake during the first month was recorded. Details included proportional intake of donor milk, mother’s own milk and infant formula. The primary outcome of infant growth velocity from day back to birth weight to discharge was calculated when length of stay was ≥14 days. Analyses primarily used T-tests; mixed effects models compared weekly calorie intake. Results One hundred five infants with donor milk consent were born at 30.9 ± 3.6 weeks of gestation, weighing 1389 ± 708 g. Forty percent of mothers had HIV. Infant growth velocity did not differ based on percent of feedings as donor milk (≥ 50%: 11.8 ± 4.9 g/kg/d; < 50%: 13.5 ± 5.3 g/kg/d; p = 0.3). Percent of feedings from donor milk was similar based on maternal HIV status (positive: 31 ± 25%; negative: 36 ± 29%; p = 0.4), as was percent of feedings as mother’s milk (positive: 53 ± 35%; negative: 58 ± 30%; p = 0.4). Calorie intake increased markedly during the first two weeks and then plateaued (p < 0.0001). Conclusions Donor milk feedings in higher proportions did not further impair growth of infants managed in a South African combined neonatal intensive and secondary high care unit with growth rates already below reference ranges. The provision of donor milk contributed to feedings being composed of primarily human milk during the first month. Increasing early calorie intake may improve infant growth in this center.
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    Enteral feeding practices in preterm infants in South Africa
    (Health and Medical Publishing Group, 2013) Raban, M S; Joolay, Y; Horn, A R; Harrison, M C
    Background: Optimal feeding regimens in babies weighing <1 000 g have not been established, and wide variations occur. In South Africa (SA) this situation is complicated by varied resource constraints. Objective: To determine the preterm enteral feeding practices of paediatricians in SA. Methods: We invited 288 paediatricians to participate in a cross-sectional web-based survey. Results. We received responses from 31.2% of the paediatricians; 43.6% were from the state sector and 56.4% from the private sector. Most participants worked in medium-sized neonatal units with 6 - 10 beds. The proportions commencing feeds within the first 24 hours were 24% in infants of <25 weeks’ gestational age, 36% in infants 25 - 27 weeks, and 65% in infants 28 - 31 weeks. Feed volumes were routinely advanced daily in 47% of infants <25 weeks, 68% of infants 25 - 27 weeks, and 90% of infants 28 - 31 weeks. Forty-five per cent of infants <25 weeks received continuous intragastric feeds, while 50% of those in the 28 - 31 weeks group were on 3-hourly bolus feeds. The majority of the participants targeted full enteral feeds of 161 - 180 ml/kg/d, 66.7% had access to donor milk, and 77% used breastmilk fortifier. Conclusion: This is the first study to survey feeding practices in SA. The survey did not highlight differences in feeding practices among paediatricians. These data could be valuable in the design of local collaborative trials to determine optimal feeding strategies.
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    Factors associated with provision of mothers' own breast milk for Very Low Birth Weight (VLBW) infants on a South African tertiary care neonatal unit
    (2017) Mutesu-Kapembwa, Kunda; Raban, Moegammad Shukri; Joolay, Yaseen
    Background: The maternal struggle to provide adequate breast milk for the infants' nutritional needs disadvantage preterm infants as the outcomes of those exclusively breast milk fed are superior to those fed infant formula. Objectives: To determine the proportion of Mothers' Own breast Milk (MOM) consumed by very low birth weight (VLBW) infants at Groote Schuur Hospital and explore potential maternal difficulties to provide MOM. Methods: In a prospective cross sectional study of 104 VLBW infant-mother dyads admitted between January and May 2015, an interviewer administered a structured questionnaire to the participating mothers before day 3 and on day 14. Infant folders were reviewed for gestational age, weight, and mode of delivery and the proportion of MOM received on days 1, 7 and 14 of life. Results: Ninety-one (88%) infants received <25% of enteral feeds as MOM on day 1. MOM made up >75% of enteral feeds in 60 infants (62%) on day 14 of life and 56(57.7%) received 100% as MOM. Infants with 2 or less siblings (22.2% vs 33.7% p=0.010) received a greater proportion MOM on day 14 as compared to those with larger families. 85.7% of the interviewed mothers would have preferred to stay in the hospital with their infants post discharge. Infant's weight, mode of delivery, maternal age, HIV status, hypertension, breastfeeding counselling, income, transport mode or distance from the hospital had no impact on MOM provision. Conclusion: Domestic responsibilities may affect mothers' breast milk provision to the newborn preterm. Breast-feeding counselling did not improve breast milk provision in this study. The effectiveness of current counselling methods may need to be examined and improved. Facilitating accommodation and rooming in of mother infant pairs from delivery to discharge may be useful in improving MOM provision to VLBW infants.
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    Growth velocity of extremely low birth weight preterms at Groote Schuur Hospital nursery
    (2011) Lango, M O
    To describe the growth velocity of extremely low birth weight babies seen at Groote Schuur Hospital nursery and to compare this to growth velocities of similar babies in published literature.
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    Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia:Neonatal academic hospitals' consensus guidelines for South African hospitals and primary health care facilities
    (2006) Horn, A R; Kirsten, G F; Kroon, S M; Henning, P A; Möller, G; Pieper, C; Adhikari, M; Cooper, P; Hoek, B; Delport, S; Nazo, M; Mawela, B
    The purpose of this document is to address the current lack of consensus regarding the management of hyperbilirubinaemia in neonates in South Africa. If left untreated, severe neonatal hyperbilirubinaemia may cause kernicterus and ultimately death and the severity of neonatal jaundice is often underestimated clinically. However, if phototherapy is instituted timeously and at the correct intensity an exchange transfusion can usually be avoided. The literature describing intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants is therefore reviewed and specific intervention thresholds that can be used throughout South Africa are proposed and presented graphically. A simplified version for use in a primary care setting is also presented. All academic heads of neonatology departments throughout South Africa were consulted in the process of drawing up this document and consensus was achieved.
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    Quality of neonatal cranial ultrasound Interpretation among doctors in the Western Cape Metro: a clinical survey
    (2023) Belay, Fitsum; Pillay, Shakti; Horn Alan
    Background: Cranial ultrasound (cUS) is a recommended skill for paediatric and neonatal trainees in South Africa. Surveys in other countries showed inadequate knowledge and subsequently a global trend towards standards and training recommendations. There are no guidelines for training of clinicians performing cUS in South Africa. Objectives: To survey the following aspects of cUS among paediatric and neonatal trainees in the University of Cape Town (UCT): duration of paediatric training, experience and supervision; knowledge of reporting content, procedural and technical aspects; interpretation of common neonatal cUS pathologies and confidence in scan interpretation and counselling. Methods: An online survey was sent to all trainees, who had worked at least one month at a neonatal unit on the UCT training platform. The survey included seven questions on cUS interpretation. Procedural and image knowledge was compared between groups with ≥ 24 months' experience versus shorter duration. Results: Thirty-one paediatric registrars and five neonatal subspecialty senior registrars were sent the survey. Twenty-six surveys were returned (72%). None of the trainees had attended a formal cUS course, 18 (69%) had attended a formal lecture from a neonatologist, and 8 (30%) had attended a formal tutorial from a consultant. Ten (38%) trainees received initial training from other registrars, medical officers, or self-study. The components of a cUS report were stated as description of anatomy and haemorrhage by 24 (92%) and 21 (81%) respectively; only 17 (65%) mentioned ventricular size and other aspects of reporting were less frequently mentioned. Only 7 (27%) trainees knew the correct number of images to be taken in the coronal and sagittal planes. Correct identification of the major features of images ranged from 12% to 92% but was below 40% in five questions. Duration of training only affected answers in two questions; trainees with ≥ 24 months experience were more likely to correctly identify a normal scan (58% vs. 14%; p=0.038) and less likely to assign abnormal prognosis in a term infant with increased white matter echogenicity (0% vs. 43%; p=0.017). Conclusions: Our survey shows inadequate and variable cUS training and competency in paediatric and neonatal trainees in our institution. The findings indicate the need for a structured training program and standardised diagnostic and training criteria to accredit clinicians who perform and report on neonatal cUS.
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    Retinopathy of Prematurity in a cohort of neonates at Groote Schuur Hospital
    (2016) Keraan, Qaunitah; Joolay, Yaseen; Horn, Alan
    Background: Screening for Retinopathy of Prematurity (ROP) is recommended to prevent possible blindness. Prior to 2016, resource limitations precluded routine ROP screening at Groote Schuur Hospital (GSH). Previous pilot studies at GSH did not detect ROP requiring treatment. However, improved survival of very low birth weight infants may affect the prevalence of ROP. Objectives: The study objectives were to: i) Determine the prevalence and severity of ROP in a prospective cohort of premature infants; ii) Describe the association with pre-specified potential risk factors; iii) Assess the feasibility of screening for ROP in our resource-limited setting. Methods Infants with a birth weight of < 1251 g or gestational age < 31 weeks admitted to the GSH neonatal unit from November 2012 to May 2013 were screened. A paediatric ophthalmologist examined the infants at 4 weeks chronological age or 32 weeks corrected gestational age, with follow-up examinations as indicated. Results: Screening was performed in 135 of 191 eligible infants. A total of 313 ROP examinations were performed; 38.5% of infants required a single examination and 16.3% required more than four. The mean gestational age and weight at birth were 30.1 ± 1.9 weeks and 1056 ± 172 g respectively. Seventy-four infants were female (54.8%). Only black (57.0%) and coloured (42.9%) infants were represented. ROP was diagnosed in 40 (29.6%) infants: Eight (5.9%) infants had clinically significant ROP. No infants had stage 4 or 5 ROP. No infants weighing more than 1250 g required treatment. Two infants received laser treatment. Infants with ROP had a lower mean gestational age and lower mean birth weight than those without ROP: 29.2 ± 1.6 vs. 30.5 ± 1.9 weeks (P < 0.002) and 988 ± 181 g vs. 1085 ± 160 g (P = 0.001) respectively. Infants with ROP were more likely to have received a blood transfusion (P < 0.002); to have late onset sepsis (P = 0.024); and to have receive d exclusive breast milk feeds (P = 0.005). There were no significant differences in the level of respiratory support, the need for oxygen therapy, the occurrence of apnoea, early sepsis or severe intraventricular haemorrhage in infants with ROP compared to no ROP. On multivariate analysis, only gestational age was independently associated with ROP was gestational age (RR 0.85; 95% CI 95% 0.740 - 0.988; p=0.03). When gestational age was excluded in post-hoc analysis, birth weight (RR 0.99; 95% CI 0.997 - 0.999; P=0.03) and blood transfusions (RR 1.71; 95% CI 1.0 27 - 2.859; P=0.03) were independently associated with ROP. Infants <1000 g had a 2.5 times higher risk of having ROP than their larger counterparts (95% CI 1.05 - 5.90, P=0.03). ROP screening was completed in 91.1% (123/135) of infants. Conclusion Clinically significant ROP was found in this study. In contrast to previous studies conducted in this setting, two patients received laser treatment. Extensive resources were required for successful screening. The strong association with birth weight and gestational age suggests that infants with lower birth weights and gestational ages should be prioritized for screening in our resource-limited setting.
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    The short-term outcomes of HIV-exposed versus HIV-unexposed very low birth weight infants
    (2017) Riemer, Linda Jane; Tooke, Lloyd
    Introduction: HIV exposed but uninfected infants have been shown to have a higher morbidity and mortality than unexposed infants. There is almost no literature comparing the short-term outcomes of HIV exposed versus unexposed VLBW neonates who are born prematurely. Methods: A retrospective review of all VLBW neonates who were admitted at Groote Schuur Hospital nursery from 2012-2014. Data were obtained from the Vermont Oxford Database and the Prevention of Mother to Child register. Results: A total of 1593 VLBW neonates were admitted during the 3 years of which it was possible to obtain maternal HIV status in 1579 babies. Of these 1579 babies, 316 (20%)were HIV exposed. Eleven of the 230 (4.8%)infant HIV tests were positive. There was no difference in mortality, birth weight, gestational age, length of stay, sepsis and delivery room outcomes for the HIV-exposed (HIVE), maternal ARV-exposed (mARVE) and HIV-positive neonates. Differences between HIV exposed and HIV unexposed neonates were noted in an increased risk of NEC [OR 1.83 (1.2-2.8)] and an increased need for ventilation [OR 1.35 (1.01-1.8)]. Maternal antiretroviral exposed neonates developed less NEC compared with maternal antiretroviral under-exposed neonates with a birth weight under 1000grams appearing to contribute in the development and outcome of NEC. Differences in HIV-positive neonates included more chronic lung disease [OR 5.49 (1.31-23)] and more necrotising enterocolitis [OR 4.12 (1.02-17.18)]. Conclusion: This study is the first to compare the short-term outcomes of HIV exposed and HIV unexposed very low birth weight infants and consider maternal ARV exposure. It demonstrated no difference in birth weight, gestational age, mortality or sepsis. Necrotising enterocolitis is increased in the HIV exposed neonates especially if they are under-exposed to maternal antiretrovirals. Adequate maternal antiretrovirals may have a protective effect on incidence of necrotising enterocolitis and respiratory outcomes.
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    Short-term outcomes of inborn vs out-born very low birth weight neonates (< 1500 g) in the Groote Schuur neonatal nursery
    (2018) Gibbs, Lyndal; Harrison, Michael
    Background and aim: The Groote Schuur Hospital (GSH) Neonatal Nursery provides Level 3 care for the Metro West Health District in the Western Cape. Worldwide, VLBW neonates have improved outcomes when delivered in Level 3 neonatal units, compared with those who are transported from other facilities. This study aims to identify the characteristics and clinical outcomes of our VLBW patients, with emphasis on differences between inborns and outborns. Methodology: A retrospective cohort study. VLBW neonates admitted to the GSH Neonatal Nursery between 1 January 2012 and 31 December 2013 were enrolled on the Vermont Oxford Network database and reviewed. Maternal and infant characteristics, and outcomes at the time of discharge from hospital were analysed. Results: A total of 1032 VLBW neonates were enrolled. 906 (87.8%) were delivered at GSH, and 126 (12.2%) were outborn. Access to antenatal care, antenatal steroids and inborn status were statistically significant predictors for mortality and survival without morbidity. The mothers of inborn patients were more likely to have received antenatal care (89.1% vs 57.9%, p <0.0001) and antenatal steroids (64.2% vs 15.2%, p <0.0001). Inborns required less ventilatory support (16.2% vs 57.9%, p <0.0001) and surfactant administration (25.3% vs 65.1%, p <0.0001). Inborns had a lower incidence of late infection (8.8% vs 23.4%, p <0.0001), severe intraventricular haemorrhage (3.7% vs 13.9%, p <0.0001) and chronic lung disease (5.3% vs 13.4%, p =0.003). The incidence of necrotising enterocolitis was similar between the two groups (5.9% vs 8.7%, p =0.227). 18.4% of inborns and 33.3% of outborns demised (p <0.0001), mostly on the first 2 days of admission. Mortality declined as birth weight increased. Of the survivors, 83.5% of inborns and 70.2% of outborns did not develop serious morbidity (p =0.003). Significant morbidity and mortality was noted in the outborn group weighing 800g and less, with only one outborn patient in the cohort surviving to discharge without major morbidity. Conclusion: VLBW neonates delivered at Groote Schuur Hospital had better outcomes than their outborn counterparts. Perinatal regionalisation is beneficial to our patients, with antenatal care, timeous in-utero transfer and antenatal steroids contributing to excellent outcomes.
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    Symptomatic congenital syphilis in a tertiary neonatal unit: a retrospective descriptive study
    (2016) Pillay, Shakti; Tooke, Lloyd
    Background: Syphilis is a disease that was first described in the 1300s and now 700 years later, despite preventive measures and effective treatment, continues to impact on a global scale, with the burden falling largely on the developing world. We could find no recent published literature looking at predictors of outcomes in neonates born with symptomatic congenital syphilis, especially in the context of a tertiary neonatal setting. Methodology: The study design was a retrospective descriptive folder review of neonates born with symptomatic congenital syphilis at Groote Schuur Hospital (GSH) from January 2011 to December 2013. One of the primary objectives was to address outcome as well as look at modifiable preventable factors. All neonates treated at GSH (inborn and outborn) who tested serologically positive for syphilis together with clinical signs of syphilis were included. Data was obtained from the National Health Laboratory System (NHLS) database, as well as the notification and death registers at GSH nursery. All data was collected in a Microsoft excel spread sheet and analysed using Microsoft StatPlus. Results: Fifty of eighty neonates (62.5%) with positive syphilis serology as well as clinical signs of congenital syphilis were included together with their fifty mothers. The majority (98%) of mothers were inadequately untreated. Nineteen neonates demised. There were no statistically significant differences between the deaths and survivors in terms of gestational age (p = 0.15), birth weight (p = 0.08) or maternal age (p = 0.51). Two significant predictors of mortality were one minute and five minute Apgar scores of less than five ([RR], 3.5; 95% CI 1.6-7.7 and [RR], 2.9; 95% CI 1.5-5.3 respectively). Hydropic neonates, tended to be sicker at birth, requiring intubation and inotropes, which was associated with a poorer outcome (increased risk of mortality). Conclusion: Despite the introduction of a National Syphilis Screening programme more than twenty years ago together with a large proportion of pregnant women having access to antenatal care, congenital syphilis is still prevalent in South Africa. Failure to access antenatal care, poor partner tracing and a number of modifiable health worker related failures contribute to poor maternal diagnosis and treatment. Many neonates with congenital syphilis require aggressive interventions and there is a high mortality rate. This dissertation adds to the existing body of research particularly with regard to predictors of outcome in tertiary neonatal settings. Certain categories of neonates have a lower survival rate and guidelines about limitation of care may need to be considered in order to optimise resource allocation particularly in resource-constrained settings. Further research is required to elaborate how best to develop protocols in these neonates.
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    The use of inhaled nitric oxide to treat persistent pulmonary hypertension of the newborn in a tertiary public hospital in South Africa from 2010-2014: morbidity, mortality and cost
    (2018) McAlpine, Alastair; Horn, Alan R; Tooke, Lloyd
    Background and rationale: Inhaled nitric oxide (iNO) is recommended for the treatment of severe persistent pulmonary hypertension of the newborn (PPHN) because it reduces the need for extracorporeal membrane oxygenation (ECMO). There is insufficient evidence that iNO reduces mortality in the absence of ECMO. Although neonates in some South African public hospitals have access to iNO, ECMO is not available. Oral sildenafil can be effective in settings where iNO is not available, but its effect on outcome and cost of treatment in this setting have not been described. The literature review in the first part of this thesis describes five studies reporting short-term outcomes of PPHN in the absence of ECMO. No studies from South Africa were identified. Only two studies described outcomes after iNO – the coadministration of Sildenafil with iNO was only reported in one small study. There were insufficient published data to guide management in settings where ECMO is not available. Aim: To describe a cohort of term and near term neonates with PPHN who were treated with iNO, with or without sildenafil, in a tertiary neonatal unit in South Africa Objectives: (i) to describe the characteristics at birth, the clinical course, and shortterm outcomes; (ii) to determine if any variables were associated with mortality; (iii) to describe the relationship between the use of sildenafil and cost of care, represented by the duration of intubation and iNO use; and (iv) to describe the frequency of sildenafil prescription. Methods. A retrospective review was carried out on folders of neonates with PPHN who were treated with iNO in Groote Schuur Hospital, Cape Town, South Africa, between January 2010 and December 2014. Results. Forty neonates were included – most were full term (85%). Meconium aspiration syndrome (MAS) was the commonest cause of PPHN (50%), followed by intrapartum hypoxia (20%), sepsis (17.5%), pulmonary hypoplasia (7.5%) and idiopathic (5%). Fourteen neonates (35%) died. Pulmonary hypoplasia and pneumothorax were associated with mortality (p=0.037 and p=0.004 respectively). An FiO2 of 1.0 and an iNO dose of ≥ 20 ppm at 24 and 48 hours respectively, both predicted death (specificity 89% vs. 100%, sensitivity 67% vs. 43% and p=0.003 vs. p=0.007 respectively). Sildenafil was prescribed more often after 2011 (83% vs. 65%) and was associated with increased survival (p=0.018) – early administration was associated with a shorter time to extubation (p=0.012) and a shorter course of iNO (p=0.044). Conclusion. The treatment of PPHN with iNO in the absence of ECMO was associated with high mortality, particularly in neonates with congenital lung abnormalities. The FiO2 and iNO requirements at 24 and 48 hours respectively could be used to identify neonates who are unlikely to benefit from continued treatment. Sildenafil was prescribed with increasing frequency during the study. The combination of iNO with sildenafil was associated with more cost-effective care and improved short term outcomes. These findings provide a potential basis for costsaving measures and resource allocation.