title: Risk factors for mortality among human immunodeficiency virus-exposed and unexposed infants admitted to a neonatal intensive care unit in Botswana.
abstract: OBJECTIVE
  Newborns admitted to neonatal units (NNUs) in resource-limited settings face a high risk of mortality, but the epidemiology of these deaths is poorly understood. We describe risk factors for NNU mortality in an area with high prevalence of human immunodeficiency virus (HIV).
  
  
  METHODS
  We performed a prospective cohort study of infants admitted to the NNU at a public referral hospital in Gaborone, Botswana. The primary outcome was neonatal death, defined as death within 28 days of a live delivery. Cox proportional hazard models were used to evaluate risk factors for mortality.
  
  
  RESULTS
  From October 2008 to April 2009, 449 neonates were admitted to the NNU. Cumulative mortality was 24.5% (110/449). Factors associated with increased risk of death included lack of enteral feeding (hazard ratio (HR) 18.8, 95% confidence interval (CI) 10.3, 34.2), gestational age <28 weeks (HR 2.0, 95% CI 1.1, 3.8) and Apgar score <7 at 10 min (HR 2.5, 95% CI 1.5, 4.2). Among 348 (78%) infants who were fed, there was no difference in mortality between infants who were breastfed compared with those who were formula fed or had mixed feeding (P = 0.76). There was no significant mortality difference by HIV exposure status; 35 (28%) of 128 HIV-exposed infants died compared with 55 (21%) of 272 HIV-unexposed infants (P = 0.19).
  
  
  CONCLUSIONS
  This study identified low Apgar scores, extreme prematurity and lack of enteral feeding as the most important risk factors for mortality in this NNU setting. HIV exposure and formula feeding were not significantly associated with death in neonates who were very ill.
authors.affiliation: Division of Infectious Disease, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States; Botswana-Harvard AIDS Institute Partnership for HIV Research and Education, Gaborone, Botswana.
authors.forename: Rebecca M
authors.initials: RM
authors.lastname: Zash
authors.forename: Olubunmi
authors.initials: O
authors.lastname: Ajose-Popoola
authors.forename: Ketil
authors.initials: K
authors.lastname: Stordal
authors.forename: Sajini
authors.initials: S
authors.lastname: Souda
authors.forename: Anthony
authors.initials: A
authors.lastname: Ogwu
authors.forename: Scott
authors.initials: S
authors.lastname: Dryden-Peterson
authors.forename: Kathleen
authors.initials: K
authors.lastname: Powis
authors.forename: Shahin
authors.initials: S
authors.lastname: Lockman
authors.forename: Joe
authors.initials: J
authors.lastname: Makhema
authors.forename: Max
authors.initials: M
authors.lastname: Essex
authors.forename: Roger L
authors.initials: RL
authors.lastname: Shapiro
mesh_terms: D001902:Botswana / Q000453:epidemiology; D002423:Cause of Death; D016001:Confidence Intervals; D005260:Female; D006679:HIV Seropositivity / Q000401:mortality*; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical; D007363:Intensive Care Units, Neonatal; D008297:Male; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors
keywords: Botswana; HIV; feeding method; neonatal intensive care unit; neonatal mortality