Survival and Short-Term Morbidities Among Extremely Preterm Infants: A Prospective Cohort Study

Background: Outcomes of extremely preterm (EPT) infants in low- and middle-income countries (LMIC) remain heterogeneous, with limited gestational age (GA)-defined data from India. Objective: To evaluate survival, short-term morbidities, and predictors of mortality among infants born ≤28 weeks' gestation in a North Indian tertiary neonatal intensive care unit (NICU). Methods: This prospective observational cohort included all inborn infants ≤28 weeks admitted between November 2020 and October 2021, excluding those with major anomalies. Maternal, perinatal, and neonatal data were collected prospectively. The primary outcome was survival to discharge; secondary outcomes included major morbidities. Predictors of mortality were assessed using multivariable logistic regression. Results: Eighty-three infants were enrolled (median GA 27.0 weeks (IQR 26.3-27.9); median birth weight 892 g (IQR 731-1021)). Overall survival to discharge was 61.4%, with survival increasing with gestational age. Sepsis (37.5%) and extreme prematurity (40%) were leading causes of death. Major morbidities included sepsis (61.4%), bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA) (41.5% any grade, 15.1% moderate-severe), necrotizing enterocolitis (NEC) ≥ stage II (13.3%), severe intraventricular hemorrhage (IVH) (12.0%), and treatment-requiring retinopathy of prematurity (ROP) (7.8%). In adjusted analysis, higher birth weight (adjusted odds ratio (AOR) 0.59 per 100 g increase; 95% CI 0.37-0.94) and higher five-minute Apgar score (aOR 0.25 per point; 95% CI 0.13-0.48) independently predicted survival. The final model demonstrated excellent discrimination (area under the curve (AUC) 0.89, 95% CI 0.83-0.96). Conclusions: Survival of EPT infants in this Indian cohort was higher than pooled LMIC estimates but remained lower than high-income benchmarks. Birth weight and five-minute Apgar score were the strongest predictors of outcome. Strengthening perinatal care, infection prevention, and standardized neonatal practices may further improve outcomes.