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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 26-30

Common Neonatal Emergencies in Zaria


Department of Paediatrics, Ahmadu Bello University Teaching Hospital Shika-Zaria, Kaduna State, Nigeria

Date of Web Publication6-Mar-2018

Correspondence Address:
Isa Abdulkadir
Neonatal Unit Department of Paediatrics, Ahmadu Bello University Teaching Hospital Shika-Zaria, Kaduna State
Nigeria
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DOI: 10.4103/ssajm.ssajm_14_17

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  Abstract 

Background: Neonatal mortality remains high and currently accounts for about 54 and 29% of infant and under-five mortality rates, respectively, in Nigeria. Newborn deaths usually result from varying causes, some of which are neonatal emergencies. The study was conducted to document neonatal emergencies and their relative contributions to newborn death.
Patients: and Methods A retrospective review of emergency cases admitted into the Special Care Baby Unit (SCBU) of Ahmadu Bello University Teaching Hospital, Zaria in Northwestern Nigeria over an 18-month period (January 2013–June 2014) detailing information on age, sex, place of delivery, birth weight and outcome.
Results: About 70% (700/997) of the admissions were the emergency cases of which severe neonatal jaundice, sepsis and perinatal asphyxia accounted for 96%. A mortality of 9.8% was recorded with the case fatality rates of 5, 11, 18.8 and 25% for severe neonatal jaundice, neonatal sepsis, perinatal asphyxia and neonatal tetanus, respectively. Overall, neonatal emergencies accounted for 68% of neonatal mortality in the SCBU. Outborns were 1.4 times more likely to die from these emergencies compared to inborns.
Conclusion: Neonatal emergencies constitute a major proportion of admissions and deaths in Zaria. Efforts should be directed at the prevention of the three major emergencies (neonatal jaundice, sepsis, perinatal asphyxia) identified and provision of available, accessible and affordable neonatal healthcare services.

Keywords: Neonatal emergencies, neonatal mortality, perinatal asphyxia, THE MISFITS


How to cite this article:
Abdulkadir I, Hassan L, Abdullahi FL, Purdue S, Adebiyi NM, Abubakar Y, Adeoye G, Ogala WN. Common Neonatal Emergencies in Zaria. Sub-Saharan Afr J Med 2017;4:26-30

How to cite this URL:
Abdulkadir I, Hassan L, Abdullahi FL, Purdue S, Adebiyi NM, Abubakar Y, Adeoye G, Ogala WN. Common Neonatal Emergencies in Zaria. Sub-Saharan Afr J Med [serial online] 2017 [cited 2019 Oct 17];4:26-30. Available from: http://www.ssajm.org/text.asp?2017/4/1/26/226657


  Introduction Top


Globally, about three million neonates die annually and as many as over 90% of these occur in low-income and middle-income countries, with the highest rates in sub-Saharan Africa.[1],[2],[3],[4],[5],[6] The under-five (U-5) and infant mortality rates in Nigeria remain comparatively high at 128 and 67 deaths per 1000 live births, respectively despite the intensified effort to improve child survival.[1],[2] In 2014, recordable improvement in under-five child health with reduction in mortality was largely reported; however, the under-five mortality rate did not reflect this improvement owing to a large extent the non-reduction in the high neonatal mortality (37/1000 live births) constituting 54 and 29% of infant and under-five mortalities, respectively.[1],[2],[4],[7] Neonatal mortality results mainly from several neonatal morbidities including emergencies.[8],[9],[10],[11],[12],[13],[14],[15],[16],[17] These emergencies are life-threatening conditions occurring within the first 28 days of life and which in the absence of appropriate and optimal intervention result in fatal or grave complications with indelible sequelae in the surviving newborn. The mnemonic ‘THE MISFITS’ has been used to categorize neonatal emergency conditions where T − represents trauma, H − heart and lung disease, E − endocrine, M − metabolic, I − inborn errors of metabolism, S − sepsis, F − formula mishaps, I − intestinal catastrophes, T − toxins and poisons and S − seizures.[10] Efficient recognition and prompt management of these illnesses can be lifesaving.

The study was conducted to document the common emergencies encountered and their outcome in Zaria to bring into light the areas of focus where strategic emphases should be placed to enable realization of the much desired reduction in hospital neonatal mortality as part of the overall child mortality.


  Patients and methods Top


This was a retrospective review of cases admitted into the Special Care Baby Unit of the Ahmadu Bello University Teaching Hospital (ABUTH) Shika − Zaria over an 18-month period between January 2013 and June 2014. The hospital is a tertiary health facility in northwestern Nigeria with a 25-bed capacity neonatal unit that serves a population of 7,102,877 in Kaduna state which has an annual birth of 262,000. The facility also receives referrals from surrounding local government areas (LGAs) from Katsina and Kano states. The unit is operated by a team of doctors including consultants and residents and other specialized nurses and supporting staff. Information on age, sex, place of delivery, birth weight (BW), diagnosis and outcome was retrieved from the records of all neonates admitted into the unit. Emergencies were defined as life-threatening conditions that required specific interventions to save the life of and stabilize the neonates and included sepsis, severe neonatal jaundice, perinatal asphyxia, aspiration syndrome, neonatal tetanus, birth injury and poisoning. Infants who had severe jaundice requiring treatment irrespective of the aetiology were categorized as severe neonatal jaundice once the neonate met the unit’s criteria to commence intensive phototherapy or required exchange blood transfusion and phototherapy. Data were entered into and analysed using the Statistical Package for the Social Sciences version 20.0 software (IBM Corporation, Armonk, NY) and results summarized and presented using simple statistical tables and figures. Where required, data were analysed for relationship using appropriate statistical analysis including odds ratio. A P value <0.05 was considered statistically significant.


  Results Top


A total of 700 (70.2%) of the 997 neonates admitted over the study period were the cases of neonatal emergencies. Male neonates accounted for 57.7% (404/700) of the cases, whereas the remaining 296 (42.3%) were females with a M:F ratio of 1.4:1. The majority [552 neonates (79%)] of the cases presented within the first 7 days of life with 37.9% (265) presenting within the first 24 hours of life, whereas the remaining 287 (41%) presented between the age of 1 and 7 days [Table 1].
Table 1: Age at presentation of newborns with neonatal emergencies

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The BWs of neonates ranged from 1000 to 5000 g with a mean BW of 2839 ± 790 g for the 356 (50.8%) who had their BW recorded. About two-third (62.4%) of the neonates were outborns, whereas 37.6% were inborns. Severe neonatal jaundice accounted for almost half (45.4%) of the cases of emergency in the newborn [Table 2]. The other two more common emergencies were neonatal sepsis (27.3%) and perinatal asphyxia (23.6%) in descending order [Table 2]. Overall, 9.8% (69 deaths) mortality was recorded among the emergencies. Neonatal emergencies accounted for 68% (69/102) of the neonatal deaths recorded within the study period. Among inborns, of the 21 deaths recorded, 17 and two deaths occurred among neonates in the age categories <1 and 1–7 days, respectively, whereas a death each occurred in the age categories 8–14 and 15–21 days. No death was recorded in those aged 22–28 days [Figure 1]. Overall, 51% (35/69) of the deaths occurred in neonates who developed and presented with emergencies at less than a day old, whereas 93% (64/69) of the neonatal emergency deaths occurred in neonates aged 7 days and below at presentation.
Table 2: Frequency distribution of neonatal emergencies in Zaria

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Figure 1: Outcome of neonatal admissions by age and place of birth

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Case fatality rates were 5% (16/318), 11% (21/191), 18.8% (31/165) and 25% (1/4) for severe neonatal jaundice, neonatal sepsis, perinatal asphyxia and neonatal tetanus, respectively [Table 3]. There were no deaths recorded among the cases of anaemia, birth injury, aspiration syndrome and poisoning (totalling 22 cases). The odds of dying from neonatal emergencies was 1.8 times higher in neonates aged <24 h compared to those aged 24 h and above [odds ratio (OR) = 1.77, P = 0.0216]. Outborns were 3 times more likely to die from perinatal asphyxia compared to inborns (OR = 3.05, P = 0.00825 Fisher exact) [Table 3]. The odds of outborns dying from neonatal jaundice was 0.064, whereas it was 0.0351 in inborns (OR = 1.819; Fisher exact P = 0.4772). Inborns were 1.3 times more likely to die from sepsis compared to outborns (OR = 1.3; Fisher exact P = 0.588). Overall, outborns were 1.4 times likely to die compared to inborns (OR = 1.4; Fisher exact P = 0.1957).
Table 3: Case fatality rates among inborn and outborn neonates in Zaria

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  Discussion Top


The common causes of neonatal emergencies in Zaria consist of neonatal jaundice, perinatal asphyxia, sepsis (neonatal sepsis and neonatal tetanus), heart and lungs diseases (aspiration syndromes and anaemia), trauma (birth injury) and toxins (accidental kerosene poisoning). Sepsis and jaundice are more common in Zaria. The leading causes of neonatal morbidity and mortality across the country have consistently been documented to include perinatal asphyxia, prematurity and sepsis.[11],[12],[13],[14],[15] No literature, to the best of our knowledge, has attempted to disaggregate neonatal emergency morbidities and mortalities from other causes such as prematurity. This, we believe, is quite essential to highlight these cases and direct attention towards preparation to address them particularly because specific immediate actions could halt the emergency condition’s process, reverse ill health, prevent complications and improve outcome. The three major emergencies can also be prevented through the implementation of optimal antenatal care, essential newborn care and availability of skilled birth attendant at every delivery.

Deaths from neonatal emergencies in Zaria constitute 68% of all neonatal deaths. This suggests that seven in every 10 newborn deaths are attributable to emergencies and underscores the significance of these cases. Though the study did not evaluate the challenges in managing these cases, several reasons including delayed presentation, unaffordability and inaccessibility of standard optimal care could be postulated to have acted individually or jointly to contribute to the mortalities. This is particularly more so, bearing in mind that standard optimum care protocols for these emergencies are available in ABUTH. Further prospective studies to evaluate and document the challenges to the management of these emergencies are therefore desirable.

A high proportion of deaths from these emergencies (51 and 93%) were recorded among neonates who developed the emergency condition within the first 24 h and 7 days of life and the odds of dying from neonatal emergencies was 1.8 times significantly higher in neonates who presented with emergencies at age <24 h compared to those aged 24 h and above despite surviving 87 and 90% of neonates of these age categories respectively. Reports[1],[2],[3] have shown that up to 50 and 75% of neonatal deaths occur within the first day and week of life respectively. Cases who died could have presented with more severe or complicated forms of the emergencies, thus succumbing to illness. The above finding suggests that this period (the first week of life) is critical and will imply that it is a key period when all possible preventive measures to keep the neonate healthy should be implemented, because this may be the most vulnerable and riskiest period in the neonate’s life.

Severe neonatal jaundice was the most common neonatal emergency in Zaria, accounting for 45.4% of all admitted emergencies. This is in contrast to findings from Enugu, South East Nigeria in which neonatal jaundice constituted only 0.06% of all newborn admissions.[13] ABUTH Zaria remains a major referral and one of the very few centres in Kaduna state where optimal management for neonatal jaundice (NNJ) is available and affordable, a situation which may be different in Enugu where possibly numerous such centres are available for patronage. On the other hand, it may unlikely reflect a true lower incidence of NNJ. Our finding is, however, consistent with findings by Owa and Osinaike[14] in Ilesha, South West Nigeria who documented jaundice as the major reason for admission of newborns, accounting for 45.6%. Severe neonatal jaundice case fatality rate was the least of all the emergencies. Ekanem[15] noted neonatal jaundice as the leading cause of death in his study. Our contrasting finding may suggest an efficient management of NNJ particularly with the popularized use of intensive phototherapy. The odds of outborns dying from severe neonatal jaundice, however, was almost twice that of inborns (OR = 1.8). This is possibly due to late presentation with very high serum bilirubin or even kernicterus at the time of presentation among outborns putting them at more risk of dying.

The highest case fatality was recorded among those with perinatal asphyxia (18.8%) though lower than the 38.2 and 52.9%, respectively documented by Eke et al.[11] and Ekwochi et al.,[13] it is consistent with the finding of perinatal asphyxia being the leading cause of neonatal fatality in their respective studies. Asphyxiated outborns were 3 times more likely to die from asphyxia than inborns, even though more asphyxiated inborns were admitted in our study similar to findings documented by other researchers.[14],[17] This suggests that delivery in a tertiary facility significantly improves the chances of a newborn surviving asphyxia. This may be a reflection of the high alert threshold for asphyxia in the tertiary hospital and the availability of expertise and appropriate care to survive this category of babies. On the other hand, though we did not document the severity of asphyxia, it is more likely that the asphyxiated outborns were of the severer category with late presentation resulting from the failure to detect and lack or inadequacy of skills to resuscitate babies that require help to breath at birth among those receiving the deliveries outside the tertiary hospital.

Neonatal sepsis (11.3%) including neonatal tetanus was the second most common neonatal emergency. Reports of the 2011 saving newborn lives at birth[16] among other studies categorize neonatal sepsis as a leading cause of neonatal death. Neonates generally have unprimed and developing immunity and are, therefore, more likely to succumb to infection to which they are highly exposed particularly when delivery takes place outside health facilities. Inborns were 1.5 times more likely to die from sepsis compared to outborns. This may be a reflection of the causative organisms possibly resistant and virulent, associated with nosocomial infection to which inborns are at increased risk.

Overall, outborns were 1.5 times more likely to die compared to inborns similar to findings from other studies.[11],[12],[14],[17] This may suggest the availability of better care and services to newborns in tertiary health facilities where better manpower with the necessary skills and equipment abound to prevent perinatal and neonatal mortalities.


  Conclusion Top


Neonatal emergencies constitute a major proportion of admissions and deaths in Zaria. The emergencies are mainly severe neonatal jaundice, perinatal asphyxia, sepsis (neonatal sepsis and neonatal tetanus), heart and lungs conditions (aspiration syndromes and anaemia), trauma (birth injury) and toxins (accidental kerosene poisoning). Efforts should be directed at prevention of the three major emergencies (neonatal jaundice, sepsis and perinatal asphyxia) identified and the provision of available, accessible and affordable neonatal healthcare services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
National Population Commission (NPC) [Nigeria] and ICF International. Infant and Child Mortality in Nigeria. Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International; 2014. p. 117–25.  Back to cited text no. 1
    
2.
National Population Commission [Nigeria] and ICF International. Nigeria Demographic and Health Survey 2013-Key Findings. Rockville, Maryland, USA: National Population Commission and ICF International; 2014. p. 7.  Back to cited text no. 2
    
3.
UN Inter-Agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality: Report 2013. New York: UNICEF; 2013.  Back to cited text no. 3
    
4.
Shiffman J. Network advocacy and the emergence of global attention to newborn survival. Health Policy Plan 2016;31:i60-i73.  Back to cited text no. 4
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Lawn JE, Kerber K, Enweronu-Laryea C, Cousens S. 3.6 million neonatal deaths—What is progressing and what is not? Semin Perinatol 2010;34:371-86.  Back to cited text no. 5
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Lawn JE, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet 2005;365:891-900.  Back to cited text no. 6
    
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Cooper PA. The challenge of reducing neonatal mortality in low- and middle-income countries. Pediatrics 2014;133:4-6.  Back to cited text no. 7
    
8.
Lawn JE, Kinney MV, Black RE, Pitt C, Cousens S, Kerber K et al. Newborn survival: A multi-country analysis of a decade of change. Health Policy Plan 2012;27:6-28.  Back to cited text no. 8
    
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Lawn J, Kerber K, Enweronu-Laryea C, Bateman OM. Newborn survival in low resource settings—Are we delivering? BJOG 2009;116:49-59.  Back to cited text no. 9
    
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Brousseau T, Sharieff GQ. Newborn emergencies: The first 30 days of life. Pediatr Clin North Am 2006;53:69-84.  Back to cited text no. 10
    
11.
Eke CB, Ezomike UO, Chukwu B, Chinawa JM, Korie FC, Chukwudi N et al. Pattern of neonatal mortality in a tertiary health facility in Umuahia, South East, Nigeria. Int J Trop Dis Health 2014;4.  Back to cited text no. 11
    
12.
Ezechukwu CC, Uguchukwu EF, Egbuonu I, Chukwuka JO. Risk factors for neonatal mortality in a regional tertiary hospital in Nigeria. Niger J Clin Pract 2004;50-2.  Back to cited text no. 12
    
13.
Ekwochi U, Ndu IK, Nwokoye IC, Ezenwosu OU, Amadi OF, Osuorah DI. Pattern of morbidity and mortality of newborns admitted into the sick and special care baby unit of Enugu State University Teaching Hospital, Enugu state. Niger J Clin Pract 2014;17:346-51.  Back to cited text no. 13
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Owa JA, Osinaike AI. Neonatal morbidity and mortality in Nigeria. Indian J Pediatr 1998;65:441-9.  Back to cited text no. 14
    
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Ekanem EE. Causes of neonatal and postneonatal mortality in Nigerian children. Early Child Dev Care 1990;57:9-13.  Back to cited text no. 15
    
16.
Federal Ministry of Health, Nigeria. Saving Newborn Lives in Nigeria. Newborn Health in the Context of the Integrated Maternal, Newborn and Child Health Strategy. Revised 2nd ed; 2011. p. 25-32.  Back to cited text no. 16
    
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Mukhtar-Yola M, Iliyasu Z. A review of neonatal morbidity and mortality in Aminu Kano Teaching Hospital, northern Nigeria. Trop Doct 2007;37:130-2.  Back to cited text no. 17
    


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    Tables

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