Pediatric Infectious Diseases: Open Access

Keywords

Neonate, Neonatal sepsis, Birth asphyxia

Introduction

Over the past decade, there has been a decline in neonatal mortality rate. It was reported that 4 million neonatal died in 2005 [1]. Neonatal mortality rate reduced to 3.1 million and 2.9 million respectively in 2010 and 2014 [2,3]. Despite some improvement, the decline in neonatal mortality is not satisfactory particularly in African countries as we still have over nine million babies dying every year during the perinatal and neonatal periods and nearly all (98%) of these deaths occur in developing countries [1,4]. Neonatal mortality contributes between 40-70% of infant mortality [1,4] and about 60% of all under 5 mortality [5]. Therefore, improving supervised delivery, obstetric practices and effective management of neonatal morbidities are important to neonatal survival and long term improvement in the neonatal mortality [6] especially in developing countries.

Prematurity is a significant cause of neonatal morbidity and mortality. Ali et al. [7] found out that prematurity was the commonest cause of admission to a second care hospital in Paskistan. In Nigeria, Toma et al. [8] found the commonest cause of admission among neonates in a tertiary hospital was neonatal infections followed by prematurity. In India, neonatal sepsis and birth asphyxia were the commonest cause of neonatal morbidity [9]. In Kenya, bacterial infections and prematurity were found to be the important causes of neonatal morbidity both at the district and rural hospitals [10,11]. Neonatal sepsis was found to be the most important cause of neonatal morbidity and mortality in Northern part of Ghana [12].

Neonatal jaundice can be a worrisome cause of neonatal admissions to hospitals [5,7,9,11]. Congenital anomalies are causes of neonatal morbidity [13] in many parts of the world. One in 40 infants is born with congenital malformation [14]. More than 4,000 syndromes have been defined and many of them are associated with severe morbidity [14,15]. It is therefore important that they are diagnosed immediately at birth so that appropriate management and follow up plan can be instituted [16]. To this effect many countries have new born screening programs for early diagnosis, management and follow up plan [14].

There has not been any previous study describing the causes of neonatal morbidity at the Mother Baby Unit (MBU), neonatal unit, of Komfo Anokye Teaching Hospital (KATH) and hence the motivation to do this study.

Methods

The study was a prospective cross-sectional descriptive, conducted on neonates admitted to MBU for a period of four month between 1^st October, 2014 to 31^st January, 2015. MBU is the neonatal Unit of KATH, Kumasi, Ghana. It is the main referral neonatal Unit of the Northern Sector and middle belt of Ghana. Sick babies less than three months old are usually admitted to the Unit. An average of four hundred babies is admitted to the unit every month.

Sick babies are usually admitted to the unit through KATH labour wards, pediatric outpatient department at the polyclinic and specialist consulting room and directly from other hospitals and facilities. Patients admitted to MBU are managed till they are stable and well enough to be discharged. All babies admitted to the unit were eligible to participate in this study.

Data were collected daily between 8 h and 20 h GMT. Information was obtained from both the clinical team and the mothers of the neonates. Data were collected on Case Report Form (CRF) which was designed to capture demographic (sex, age at admission) and clinical diagnoses. Data were entered onto a predesigned electronic CRF using Epi-Info version 3.5.1 and transferred to Stata version 12 (Stata Corp, TX, USA), for analysis. Continuous variables were summarized and presented as mean with standard deviation as well as median with corresponding ranges. Single categorical variables were tabulated and expressed as percentages. The relationships between causes of morbidity on MBU and the various categorical variables were determined using analysis of variance.

Informed consent form (ICF) detailing the study purpose, benefit, and possible risks to the babies was provided. Authorization to conduct the study was obtained from the Head of Department of Child Health and the Medical Director of KATH. Ethical clearance was obtained from the Committee on Human Research Publication and Ethics of the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Written informed consent was obtained from the mothers of the neonates before recruitment.

Results

Within the study period 1661 babies were admitted to the neonatal ward, out of which 1580 (95.12%) were recruited. Seventy eight (4.70%) babies were observed and discharged same day because they were well while three mothers (0.18%) refused informed consent and so the babies were not recruited. With regard to sex of the neonates, 57.03% were normal males, 42.22% were normal females while 0.75% had ambiguous genitalia. Majority of the babies, 64.87% were delivered at KATH labour ward, 23.96% were delivered at hospitals and clinics within Kumasi but outside KATH and 11.27% from outside Kumasi.

The reasons for admission were neonatal sepsis (38.10%), birth asphyxia (27.91%), neonatal jaundice (18.86%), congenital malformations (7.09%), syndromes (1.77%) and genital anomalies (1.47%). Prematurity was the cause of admission for 31.27% of babies Tabel 1.

Table 1: Reasons for Admission.

Musculoskeletal defects included omphalocele, gastroschisis, talipes equinovarus, extra digits, cleft lip/palate and bladder exostrophy. Nervous system defect included neural tube defects and anencephaly.

Gastrointestinal defect included duodenal atresia, pyloric stenosis and Hirschsprung disease Table 2.

Table 2: Congenital Anomalies.

23 babies had genital abnormalities Table 3.

Table 3: Abnormal Genitalia.

Commonest syndrome was Down syndrome Table 4.

Table 4: Syndromes.

Discussion

This study demonstrated the huge admissions to the MBU. Similar pattern of heavy neonatal admission was documented by Toma et al. [8] at Jos University Teaching Hospital situated in North Central Nigeria. In our study, we recruited a total of 1580 babies and 64.87% were inborn and 57.02% were males, 42.22% were females and 0.76% had ambiguous genitalia denoting DSD. This trend of having more males being admitted to neonatal units has been found in other studies [7,8,11,17] and this is partly because the male baby is more susceptible to diseases, both communicable and non-communicable, than the female baby [18,19].

The commonest cause of morbidity found on MBU was neonatal sepsis (38.10%), followed by prematurity (31.27%), birth asphyxia (27.91%) and neonatal jaundice (18.86%). Similar pattern was observed in Kenya [11], Pakistan [7] and Indian [9]. However, some studies in Nigeria [8,20] and in India [17] rather found prematurity and low birth weight as the commonest cause of admission to neonatal wards. In our study, however, most of the premature babies were also treated for neonatal sepsis.

Congenital anomalies were the cause of morbidity for 7.22% of neonates admitted to MBU for the period of study. The most common congenital anomaly was musculoskeletal defect (33.33%). The other congenital anomalies included nervous system defects (22.80%), anorectal malformation (12.28%), ambiguous genitalia (10.53%), congenital heart diseases (10.53%), and gastrointestinal anomalies (8.77%). Similar pattern has been found in Kenya [21], Uganda [22] and Egypt [23]. However, in Tanzania, Mashuda et al. [24] found central nervous system anomalies to be the commonest. The sample size in the Tanzanian study was 445 and most of the mothers did not take folic acid in pregnancy while our sample size was 1580 and 97.35% took folic acid and other recommended medications during pregnancy. Genital abnormalities were found in 1.47% of the babies admitted to MBU. The most common genital abnormalities was ambiguous genitalia (disorder of sexual development), followed by isolated micropenis. It is quite surprising that the other studies on morbidity and congenital anomalies in babies did not consider genital anomalies. Genital anomalies are not uncommon among neonates [25] and important source of psychological stress to families and can be a cause of medical emergency in case of congenital adrenal hyperplasia [26,27] and they should always be looked for at the labour and neonatal wards. Even in our study we did not diagnose any male baby with congenital adrenal hyperplasia (CAH). Males with CAH have normal genitalia but could have slightly bigger penis with hyperpigmented scrotum, features that may be very subjective in the African population and therefore evade diagnosis. A male neonate with salt losing CAH could present with recurrent vomiting and shock. Such a neonate would likely be treated for neonatal sepsis and may die unnoticed [28] and such death would be wrongly recorded as due to neonatal sepsis and not due to CAH.

Syndromes were found in 1.77% of the neonates studied. Down syndrome was the commonest syndrome identified. Other syndromes included Patau, Turner, Beckwith Wiederman, Perre Robin, Moebius, Noonan, Edward, velocardiofacial syndromes, Oesteogenesis imperfect and Arthrogryposis multiplex congenita. Four of the syndromes could not be diagnosed and so we simply tagged them “syndromic babies”. We believe that congenital malformation and syndromes among babies are under reported as in some communities in Ghana these babies are not brought to hospital for medical intervention but rather end up in infanticide according to remote traditional believe that they are rather ‘spirits’ and so they cannot live among human beings [29].

There is no organized clinic for patients with syndromes at KATH. The long term outcomes of these patients are not know and may be disastrous as we do not know where they end up.

Conclusion

Majority of admissions to MBU is from KATH labour ward with high neonatal sepsis, prematurity and birth asphyxia. Therefore this study calls for an improved labour practices to prevent neonatal infections and asphyxia. Congenital anomalies including syndromes are not uncommon among neonates admitted to MBU and therefore supervised care and long term follow up plan are needed for such neonates.

Recommendation

Regular grand rounds between the departments of obstetrics and child health are important to improve neonatal outcome. Males neonates who are diagnosed as neonatal sepsis without laboratory evidence and support should be further evaluated for congenital adrenal hyperplasia. It would be clinically helpful if the Child Health Department, KATH, could have a follow up clinic for babies with congenital anomalies and syndromes.

Source of Funding

Global Pediatric Endocrinology and Diabetes (GPED) supported this study.

References

1. Lawn JE, Cousens S, Zupan J (2005) 4 million neonatal deaths: When? Where? Why? Lancet 365: 891-900.
2. Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, et al. (2010) Neonatal, post neonatal, childhood and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards millennium development goal 4. Lancet 375: 1988-2008.
3. Lawn JE, Blencowe H, Oza S, You D, Lee AC, et al. (2014) Every Newborn Study Group. Every newborn: progress, priorities, and potential beyond survival. Lancet 384: 189-205.
4. WHO (2016) One Million Babies Die Within 24 Hrs Of Birth.
5. Rutstein SO (2000) Factors associated with trends in infant and child mortality in developing countries during the 1990s. Bull of the W Heal Org 78: 1256-1270.
6. Becher JC, Stenson B, Lyon A (2007) Is intrapartum asphyxia preventable? BJOG Int J Obstet Gynaecol 114: 1442-1444.
7. Ali SR, Ahmed S, Lohana H (2013) Disease Patterns and Outcomes of Neonatal Admissions at a Secondary Care Hospital in Pakistan. Sultan Qaboos Univ Med J 13: 424-428.
8. Toma BO, Ige OO, Abok II, Onwuanaku C, Abah RO, et al. (2014) Pattern of neonatal admissions and outcome in a tertiary institution in north central Nigeria. J Med Trop 15: 121-125.
9. Sridhar PV, Thammanna PS, Sandeep M (2015) Morbidity Pattern and Hospital Outcome of Neonates Admitted in a Tertiary Care Teaching Hospital, Mandya. Intl J Sci St 3: 126-129.
10. Talbert AWA, Mwaniki M, Mwarumba S, Newton CRJC, Berkley JA (2010) Invasive Bacterial Infections in Neonates and Young Infants Born Outside Hospital Admitted to a Rural Hospital in Kenya. Pediatr Infect Dis J 29: 945-949.
11. English M, Ngama M, Musumba C, Wamola B, Bwika J, et al. (2003) Causes and outcome of young infant admissions to a Kenyan district hospital. Arch Dis Child 88: 438-443.
12. Welaga P, Moyer CA, Aborigo R, Adongo P, Williams J, et al. (2013) Why Are Babies Dying in the First Month after Birth? A 7-Year Study of Neonatal Mortality in Northern Ghana. PLOS ONE 8: e58924.
13. Linhart Y, Bashiri A, Maymon E, Shoham-Vardi I, Furman B, et al. (2000) Congenital anomalies are an independent risk factor for neonatal morbidity and perinatal mortality in preterm birth. Eur J Obstet Gynecol Reprod Biol 90: 43-49.
14. Clayton SJ (2008) Assessment of the dysmorphic infant. Infant 4: 206-210.
15. Leão LL, Aguiar MJB (2008) Newborn screening: what pediatricians should know. J Pediatr 84: S80-90.
16. Reardon W, Donnai D (2007) Dysmorphology demystified. Arch Child Fetal Neonatal Ed 92: F225-F229.
17. Vinod KP (2004) Morbidity and mortality among outborn neonates at 10 tertiary care institutions in India during the year 2000. J Trop Pediatr 50: 170-174.
18. Kraemer S (2000) The fragile male. BMJ 321: 1609-1612.
19. Pongou R (2013) Why is infant mortality higher in boys than in girls? A new hypothesis based on preconception environment and evidence from a large sample of twins. Demography 50: 421-444.
20. Okechukwu AA, Achonwa A (2009) Morbidity and mortality patterns of admissions into the Special Care Baby Unit of University of Abuja Teaching Hospital, Gwagwalada, Nigeria. Niger J Clin Pract 12: 389-394.
21. Muga R, Mumah SCJ, Juma PA (2009) Congenital malformations among newborns in Kenya. Afr J Food Agric Nutr Dev 9.
22. Ndibazza J, Lule S, Nampijja M, Mpairwe H, Oduru G, et al. (2011) A Description of Congenital Anomalies Among Infants in Entebbe, Uganda. Birt Defects Res A Clin Mol Teratol 91: 857-861.
23. El Koumi MA, Al Banna EA, Lebda I (2013) Pattern of congenital anomalies in newborn: a hospital-based study. Pediatr Rep 5: 5.
24. Mashuda F, Zuechner A, Chalya PL (2014) Pattern and factors associated with congenital anomalies among young infants admitted at Bugando medical centre, Mwanza, Tanzania. BMC Res Notes 7: 195.
25. Ahmed SF, Dobbie R, Finlayson AR, Gilbert J, Youngson G, et al. (2004) Prevalence of hypospadias and other genital anomalies among singleton births, 1988–1997, in Scotland. Arch Dis Child - Fetal Neonatal 89: F149-151.
26. Trakakis E, Basios G, Trompoukis P, Labos G, Grammatikakis I, et al. (2010) An update to 21-hydroxylase deficient congenital adrenal hyperplasia. J Int Soc Gynecol Endocrinol 26: 63-71.
27. Maciejewska JM, Czyzyk A, Katulski K, Podfigurna Stopa, Meczekalski B (2014) Congenital adrenal hyperplasia – contemporary diagnostics and management during pregnancy. Arch Med 20: 99-102.
28. Shah BA, Padbury JF (2014) Neonatal sepsis: an old problem with new insights. Virulence 5: 170-178.
29. Allotey P, Reidpath D (2001) Establishing the causes of childhood mortality in Ghana: the “spirit child.” Soc Sci Med 52: 1007-1012.