Time to full enteral feeds in hospitalised preterm and very low birth weight infants in Nigeria and Kenya.

BACKGROUND: Preterm (born < 37 weeks' gestation) and very low birthweight (VLBW; <1.5kg) infants are at the greatest risk of morbidity and mortality within the first 28 days of life. Establishing full enteral feeds is a vital aspect of their clinical care. Evidence predominantly from high income countries shows that early and rapid advancement of feeds is safe and reduces length of hospital stay and adverse health outcomes. However, there are limited data on feeding practices and factors that influence the attainment of full enteral feeds among these vulnerable infants in sub-Saharan Africa. AIM: To identify factors that influence the time to full enteral feeds, defined as tolerance of 120ml/kg/day, in hospitalised preterm and VLBW infants in neonatal units in two sub-Saharan African countries. METHODS: Demographic and clinical variables were collected for newborns admitted to 7 neonatal units in Nigeria and Kenya over 6-months. Multiple linear regression analysis was conducted to identify factors independently associated with time to full enteral feeds. RESULTS: Of the 2280 newborn infants admitted, 484 were preterm and VLBW. Overall, 222/484 (45.8%) infants died with over half of the deaths (136/222; 61.7%) occurring before the first feed. The median (inter-quartile range) time to first feed was 46 (27, 72) hours of life and time to full enteral feeds (tFEF) was 8 (4.5,12) days with marked variation between neonatal units. Independent predictors of tFEF were time to first feed (unstandardised coefficient B 1.69; 95% CI 1.11 to 2.26; p value <0.001), gestational age (1.77; 0.72 to 2.81; <0.001), the occurrence of respiratory distress (-1.89; -3.50 to -0.79; <0.002) and necrotising enterocolitis (4.31; 1.00 to 7.62; <0.011). CONCLUSION: The use of standardised feeding guidelines may decrease variations in clinical practice, shorten tFEF and thereby improve preterm and VLBW outcomes.

Marked variability in institutional deliveries and neonatal outcomes during the COVID-19 lockdown in Nigeria.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the interventions to mitigate its spread impacted access to healthcare, including hospital births and newborn care. This study evaluated the impact of COVID-19 lockdown measures on newborn service utilization in Nigeria. METHODS: The records of women who delivered in hospitals and babies admitted to neonatal wards were retrospectively reviewed before (March 2019-February 2020) and during (March 2020-February 2021) the COVID-19 pandemic lockdown in selected facilities in Nigeria. RESULTS: There was a nationwide reduction in institutional deliveries during the COVID-19 lockdown period in Nigeria, with 14 444 before and 11 723 during the lockdown-a decrease of 18.8%. The number of preterm admissions decreased during the lockdown period (30.6% during lockdown vs 32.6% pre-lockdown), but the percentage of outborn preterm admissions remained unchanged. Newborn admissions varied between zones with no consistent pattern. Although neonatal jaundice and prematurity remained the most common reasons for admission, severe perinatal asphyxia increased by nearly 50%. Neonatal mortality was significantly higher during the COVID-19 lockdown compared with pre-lockdown (110.6/1000 [11.1%] vs 91.4/1000 [9.1%], respectively; p=0.01). The odds of a newborn dying were about four times higher if delivered outside the facility during the lockdown (p<0.001). CONCLUSIONS: The COVID-19 lockdown had markedly deleterious effects on healthcare seeking for deliveries and neonatal care that varied between zones with no consistent pattern.

Enterobacter agglomerans, an uncommon cause of community-acquired bacterial infection in neonates.

Enterobacter agglomerans formerly termed Erwina herbicola but now called Pantonea agglomerans is a ubiquitous gram-negative bacterium that rarely causes mild and opportunistic infection in humans. Sources of infection are myriad causing both local and systemic disease across all systems of the body. Infection is often fulminant and fatal in neonates. We aim to report another facet of the infection as seen in our centre. Of the 248 neonates recruited into the study, 94 had bacteria isolated from their blood, eight (8.5%) of whom had E. agglomerans sepsis. Infection was acquired from the community though its source could not be determined. The clinical features were non-specific running a mild course. Toxic granulation, elevated immature polymorph count and procalcitonin level was found in 50% and 75% of the neonates. Isolate was sensitive to most tested antibiotics, showing 100% sensitivity to gentamicin and ciprofloxacin and the survival rate was excellent (87.5%).

Enterobacter agglomerans formerly Erwina herbicola but now called Pantonea agglomerans is a gram-negative organism that is found everywhere in our environment. It rarely causes a mild infection in humans, which is either local or generalized. Severe disease has been reported in babies and the elderly because of their low immunity and/or comorbid condition. The study aimed to report this rare condition in our neonatal unit. The study was conducted in the baby unit of Ahmadu Bello University Teaching Hospital in Zaria over 10 months. Any baby with symptoms/signs of infection was enrolled in the study and had their blood samples taken to look for the presence of infection. Of the 248 babies who were recruited, 94 had bacteria isolated from their blood out of whom 8 were due to E. agglomerans. All our babies came from the community as such source of infection could not be determined. Most had non-specific presentation fever, poor suck and jaundice and none had comorbidity or complicated procedures. The organism is generally sensitive to most antibiotics tested. All but one of the babies survived. Our study found E. agglomerans infection to be mild with a good prognosis.

Enteral Feeding Practices for Very Preterm and Very Low Birth Weight Infants in Nigeria and Kenya.

Background: Optimizing nutrition in very preterm (28-32 weeks gestation) and very low birth weight (VLBW; 1,000 g to <1,500 g) infants has potential to improve their survival, growth, and long-term health outcomes. Aim: To assess feeding practices in Nigeria and Kenya for very preterm and VLBW newborn infants. Methods: This was a cross-sectional study where convenience sampling was used. A standard questionnaire was sent to doctors working in neonatal units in Nigeria and Kenya. Results: Of 50 respondents, 37 (74.0%) were from Nigeria and 13 (26.0%) from Kenya. All initiated enteral feeds with breastmilk, with 24 (48.0%) initiating within 24 h. Only 28 (56.0%) used written feeding guidelines. Starting volumes ranged between 10 and 80 ml/kg/day. Median volume advancement of feeds was 20 ml/kg/day (IQR 10-20) with infants reaching full feeds in 8 days (IQR 6-12). 26 (52.0%) of the units fed the infants 2 hourly. Breastmilk fortification was practiced in 7 (14.0%) units, while folate, iron, calcium, and phosphorus were prescribed in 42 (84.0%), 36 (72.0%), 22 (44.0%), 5 (10.0%) of these units, respectively. No unit had access to donor breastmilk, and only 18 (36.0%) had storage facilities for expressed breastmilk. Twelve (24.0%) used wet nurses whilst 30 (60.0%) used formula feeds. Conclusion: Feeding practices for very preterm and VLBW infants vary widely within Nigeria and Kenya, likely because of lack of locally generated evidence. High quality research that informs the feeding of these infants in the context of limited human resources, technology, and consumables, is urgently needed.

Prospective observational study of the challenges in diagnosing common neonatal conditions in Nigeria and Kenya.

OBJECTIVES: Accurate and timely diagnosis of common neonatal conditions is crucial for reducing neonatal deaths. In low/middle-income countries with limited resources, there is sparse information on how neonatal diagnoses are made. The aim of this study was to describe the diagnostic criteria used for common conditions in neonatal units (NNUs) in Nigeria and Kenya. DESIGN: Prospective observational study. Standard case report forms for suspected sepsis, respiratory disorders, birth asphyxia and abdominal conditions were co-developed by the Neonatal Nutrition Network (https://www.lstmed.ac.uk/nnu) collaborators. Clinicians completed forms for all admissions to their NNUs. Key data were displayed using heatmaps. SETTING: Five NNUs in Nigeria and two in Kenya comprising the Neonatal Nutrition Network. PARTICIPANTS: 2851 neonates, which included all neonates admitted to the seven NNUs over a 6-month period. RESULTS: 1230 (43.1%) neonates had suspected sepsis, 874 (30.6%) respiratory conditions, 587 (20.6%) birth asphyxia and 71 (2.5%) abdominal conditions. For all conditions and across all NNUs, clinical criteria were used consistently with sparse use of laboratory and radiological criteria. CONCLUSION: Our findings highlight the reliance on clinical criteria and extremely limited use of diagnostic technologies for common conditions in NNUs in sub-Saharan Africa. This has implications for the management of neonatal conditions which often have overlapping clinical features. Strategies for implementation of diagnostic pathways and investment in affordable and sustainable diagnostics are needed to improve care for these vulnerable infants.

Neonatal Eye Shielding during Phototherapy: What Protects the Eye Better?

BACKGROUND: Phototherapy remains an important component of the management of unconjugated neonatal jaundice, a major cause of newborn morbidity. During phototherapy the toxic unconjugated form of bilirubin is converted to nontoxic form through action of light delivered by phototherapy. An important possible complication of phototherapy is retinal damage and therefore eye protective measures are taken during therapy to prevent this from occurring. Devices currently in use for phototherapy are capable of providing intensive phototherapy with the attendant increased risk of eye injury. The materials used in providing eye protection are varied among care providers. A dearth of information exists on shielding provided by the commonly used eye protectors during phototherapy, more so during intensive phototherapy. OBJECTIVE: To evaluate the shielding provided by the different eye protectors commonly used in our setting under intensive phototherapy. MATERIALS AND METHOD: Five materials in use for eye shielding were obtained. Using an institutional built light emitting diode phototherapy device, intensive phototherapy was provided and the irradiance at varying distances of 35 cm, 25 cm, 15 cm and 10 cm was measured using an Olympic bili meterTM Natus. At the distance of each measured irradiance the different eye protective materials were then placed one after the other over the surface of the measuring sensor of the meter and the irradiance measurement was recorded. Two measurements were taken for each material at each distance and the average irradiance measurement was then recorded for each of the materials tested at that distance. RESULTS: Five eye shielding materials in use were identified: black cotton fabric, white cotton fabric, black cotton fabric with foam, white cotton fabric with foam and gauze. The black cotton fabric with or without foam at the phototherapy device irradiances of 30, 46.3, 58.7 and 75.4 µw/m2/nm recorded 0 irradiance. CONCLUSION: Black cotton fabric with or without foam pad provided the most shielding under intensive phototherapy.

Strengthening retinopathy of prematurity screening and treatment services in Nigeria: a case study of activities, challenges and outcomes 2017-2020.

OBJECTIVES: Retinopathy of prematurity (ROP) will become a major cause of blindness in Nigerian children unless screening and treatment services expand. This article aims to describe the collaborative activities undertaken to improve services for ROP between 2017 and 2020 as well as the outcome of these activities in Nigeria. DESIGN: Descriptive case study. SETTING: Neonatal intensive care units in Nigeria. PARTICIPANTS: Staff providing services for ROP, and 723 preterm infants screened for ROP who fulfilled screening criteria (gestational age <34 weeks or birth weight ≤2000 g, or sickness criteria). METHODS AND ANALYSIS: A WhatsApp group was initiated for Nigerian ophthalmologists and neonatologists in 2018. Members participated in a range of capacity-building, national and international collaborative activities between 2017 and 2018. A national protocol for ROP was developed for Nigeria and adopted in 2018; 1 year screening outcome data were collected and analysed. In 2019, an esurvey was used to collect service data from WhatsApp group members for 2017-2018 and to assess challenges in service provision. RESULTS: In 2017 only six of the 84 public neonatal units in Nigeria provided ROP services; this number had increased to 20 by 2018. Of the 723 babies screened in 10 units over a year, 127 (17.6%) developed any ROP; and 29 (22.8%) developed type 1 ROP. Only 13 (44.8%) babies were treated, most by intravitreal bevacizumab. The screening criteria were revised in 2020. Challenges included lack of equipment to regulate oxygen and to document and treat ROP, and lack of data systems. CONCLUSION: ROP screening coverage and quality improved after national and international collaborative efforts. To scale up and improve services, equipment for neonatal care and ROP treatment is urgently needed, as well as systems to monitor data. Ongoing advocacy is also essential.

Burden of disease and risk factors for mortality amongst hospitalized newborns in Nigeria and Kenya.

OBJECTIVE: To describe the patient population, priority diseases and outcomes in newborns admitted <48 hours old to neonatal units in both Kenya and Nigeria. STUDY DESIGN: In a network of seven secondary and tertiary level neonatal units in Nigeria and Kenya, we captured anonymised data on all admissions <48 hours of age over a 6-month period. RESULTS: 2280 newborns were admitted. Mean birthweight was 2.3 kg (SD 0.9); 57.0% (1214/2128) infants were low birthweight (LBW; <2.5kg) and 22.6% (480/2128) were very LBW (VLBW; <1.5 kg). Median gestation was 36 weeks (interquartile range 32, 39) and 21.6% (483/2236) infants were very preterm (gestation <32 weeks). The most common morbidities were jaundice (987/2262, 43.6%), suspected sepsis (955/2280, 41.9%), respiratory conditions (817/2280, 35.8%) and birth asphyxia (547/2280, 24.0%). 18.7% (423/2262) newborns died; mortality was very high amongst VLBW (222/472, 47%) and very preterm infants (197/483, 40.8%). Factors independently associated with mortality were gestation <28 weeks (adjusted odds ratio 11.58; 95% confidence interval 4.73-28.39), VLBW (6.92; 4.06-11.79), congenital anomaly (4.93; 2.42-10.05), abdominal condition (2.86; 1.40-5.83), birth asphyxia (2.44; 1.52-3.92), respiratory condition (1.46; 1.08-2.28) and maternal antibiotics within 24 hours before or after birth (1.91; 1.28-2.85). Mortality was reduced if mothers received a partial (0.51; 0.28-0.93) or full treatment course (0.44; 0.21-0.92) of dexamethasone before preterm delivery. CONCLUSION: Greater efforts are needed to address the very high burden of illnesses and mortality in hospitalized newborns in sub-Saharan Africa. Interventions need to address priority issues during pregnancy and delivery as well as in the newborn.

The Vulnerable Newborn of a Mentally Ill Mother in a Resource-Limited Setting.

Mental illness is not uncommon in women of childbearing age. Pregnancy, delivery and the postpartum state could precipitate mental illness in predisposed women or worsen psychiatric symptoms in those known to have mental ill-health. Maternal mental illness exposes the infant to neglect, abuse or outright harm. We aimed to report a case of a neonate born to a mentally ill mother and to highlight the challenges of management of the mother-infant dyad in a resource-constrained- setting. The hospital records of the mother and that of her baby were summarized and the literature was reviewed to contextualize the report. The index newborn suffered neglect, late presentation, under nutrition, neonatal jaundice, anaemia, and late-onset neonatal sepsis with meningitis. Postpartum maternal mental illness poses a significant challenge to the management of the mother-infant dyad. This calls for the deployment of more human and material resources that will ensure integrated and comprehensive care for a better mother-infant dyad in resource-limited settings.

Congenital absence of the nasal septum in a Nigerian newborn with multiple congenital anomalies.

Congenital absence of the nasal septum (hyporhynia) is infrequently reported in the literature. We report a rare case in a newborn with multiple congenital anomalies with the aim to highlight its rarity and compatibility with life in a resource-limited setting. The case notes of the child were summarised and the relevant literature reviewed to give the report a context. A 2-hour-old term baby boy presented with a history of abnormal facie characterised by a single nostril and noisy breathing. On examination, he had stridulous breathing, bilateral proptosis, sloping of the forehead, depressed nasal bridge absent nasal septum, absence of columella and hypoplastic mid-face, among other dysmorphic features. A diagnosis of hyporhynia in a baby with multiple congenital anomalies was made and managed accordingly. The baby was discharged to continue follow-up. Congenital absence of the nasal septum is rare and could present without respiratory distress and may be compatible with life.

Parents' perceptions of core outcomes in neonatal research in two Nigerian neonatal units.

BACKGROUND: There is a scarcity of information regarding the most important outcomes for research in neonatal units in low-resource settings. Identification of important outcomes by different stakeholder groups would inform the development of a core outcome set (COS) for use in neonatal research. OBJECTIVE: To determine the perceptions and opinions of parents of newborn babies regarding what outcomes were most important to them in order to contribute towards development of a COS for neonatal research in sub-Saharan Africa. METHODS: Semistructured interviews were undertaken with parents, mostly mothers, of babies admitted to one neonatal unit in North central and one in Southwest Nigeria. Participants were purposively sampled to include parents of babies with common neonatal problems such as prematurity. RESULTS: We conducted 31 interviews. The most frequently raised outcomes were breast feeding, good health outcomes for their baby, education, growth and financial cost. Parents placed more emphasis on quality of life and functional status than health complications. CONCLUSIONS: The opinions of parents need to be considered in developing a COS for neonatal research in low-resource settings. Further research should assess the opinions of families in other low-resource settings and also engage a broader range of stakeholders.

Maternal Instruction About Jaundice and the Incidence of Acute Bilirubin Encephalopathy in Nigeria.

OBJECTIVE: To evaluate whether teaching mothers about neonatal jaundice will decrease the incidence of acute bilirubin encephalopathy among infants admitted for jaundice. STUDY DESIGN: This was a multicenter, before-after and cross-sectional study. Baseline incidences of encephalopathy were obtained at 4 collaborating medical centers between January 2014 and May 2015 (Phase 1). Structured jaundice instruction was then offered (May to November 2015; Phase 2) in antenatal clinics and postpartum. Descriptive statistics and logistic regression models compared 3 groups: 843 Phase 1 controls, 338 Phase 2 infants whose mothers received both antenatal and postnatal instruction (group A), and 215 Phase 2 infants whose mothers received no instruction (group B) either because the program was not offered to them or by choice. RESULTS: Acute bilirubin encephalopathy occurred in 147 of 843 (17%) Phase 1 and 85 of 659 (13%) Phase 2 admissions, which included 63 of 215 (29%) group B and 5 of 338 (1.5%) group A infants. OR for having acute bilirubin encephalopathy, comparing group A and group B infants adjusted for confounding risk factors, was 0.12 (95% CI 0.03-0.60). Delayed care-seeking (defined as an admission total bilirubin ≥18 mg/dL at age ≥48 hours) was the strongest single predictor of acute bilirubin encephalopathy (OR 11.4; 6.6-19.5). Instruction decreased delay from 49% to 17%. Other major risk factors were home births (OR 2.67; 1.69-4.22) and hemolytic disease (hematocrit ≤35% plus bilirubin ≥20 mg/dL) (OR 3.03; 1.77-5.18). The greater rate of acute bilirubin encephalopathy with home vs hospital birth disappeared if mothers received jaundice instruction. CONCLUSIONS: Providing information about jaundice to mothers was associated with a reduction in the incidence of bilirubin encephalopathy per hospital admission.

The burden of extended-spectrum ß-lactamase-producing Enterobacteriaceae in Nigeria: a systematic review and meta-analysis.

Antibiotic resistance on account of extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL-PE) has become a major public health concern in developing countries. The presence of ESBL-PE is associated with increased morbidity, mortality and healthcare costs. There is no active antimicrobial surveillance mechanism in Nigeria. The aim of this study is to determine a precise estimate of the burden of ESBL-PE in Nigeria. We employed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched electronic databases for suitable studies. We derived pooled prevalence estimates using random effects models and assessed trends with meta-regression. We found 208 studies, with 38 satisfying our inclusion criteria. The overall pooled prevalence of ESBL-PE in Nigeria was 34.6% (95% CI 26.8 to 42.3%) and increased at a rate of 0.22% per year (p for trend=0.837). In summary, we found the prevalence of ESBL-PE in Nigeria to be high and recommend a robust national survey to provide a more detailed picture of the epidemiology of ESBL-PE in Nigeria.

Making Locally Fabricated Phototherapy Devices Work Better.

BACKGROUND: The efficiency of a phototherapy (PT) device is a function of the irradiance delivered by the device at the surface of the skin. Because cost limits the ability of health care facilities in low- and middle-income countries to procure commercial PT devices, efforts have gone into local fabrication of devices for use in health care facilities in Nigeria. Evaluation of such fabricated devices is yet to be conducted. OBJECTIVE: To identify and document essential features of locally fabricated phototherapy (FPT) devices in use in Nigeria. MATERIALS AND METHODS: A cross sectional survey of locally FPT devices available in health facilities providing newborn health care services was conducted as part of evaluating neonatal jaundice management services in Kaduna State. Each FPT was characterized with respect to mobility/portability, adjustability, lamp type, number and color of lamps used. The irradiance of each device was measured using Model 22 Olympic BiliMeter™ at the facility's traditional PT distance and also at a distance at which optimum irradiance is delivered by the device. RESULTS: A total of 54 PT devices were in use. Thirty-two (59.3%) of these devices were locally fabricated while others were obtained from commercial sources. Of the fabricated devices 22/32 (68.8%) were non-adjustable while the remaining 10 devices were adjustable but with limited adjustability. Only 5/32 (15.6%) of the FPT devices used special blue fluorescent lamps. The majority, 68.8% (22/32) of the FPT devices used ordinary low-intensity blue lamps while the remaining 5/32 (15.6%) devices used white light fluorescent lamps. None of the devices used light emitting diodes as a PT light source. Only three fabricated devices offered irradiance (9.4, 13.6 and 33 µW/cm2/nm) at the facilities' traditional distances for PT. CONCLUSIONS: FPT devices in use in Kaduna, functioned sub-optimally because of technically inadequate designs. The devices will need to be designed to especially enable adjustability to vary distance between device and patient's skin and the use of lamps which offer high irradiance.

Patterns of acute bilirubin encephalopathy in Nigeria: a multicenter pre-intervention study.

BACKGROUND: Acute bilirubin encephalopathy (ABE) is an important cause of neonatal morbidity in Nigeria, accounting for 5-14% of neonatal deaths. Most newborns with severe ABE have irreversible damage before receiving treatment emphasizing the need for timely pre-admission monitoring and referral. There is limited evidence that educational interventions targeting mothers and health care providers will reduce delayed care. OBJECTIVE: To provide baseline data on the incidence of ABE and associated pre-admission risk factors in five centers of Nigeria in order to evaluate the effect of subsequent educational interventions on outcome. STUDY DESIGN: The incidence of ABE among newborns treated for hyperbilirubinemia was documented prospectively. Bivariate analysis and multivariate logistic regression were used to evaluate risk factors for acute bilirubin encephalopathy and reasons for regional differences in its occurrence. RESULTS: Of 1040 infants, 159 treated for hyperbilirubinemia (15.3%) had mild to severe bilirubin encephalopathy (including 35 deaths), but the incidence ranged from 7 to 22% between centers. Logistic regression identified four common predictors: total serum bilirubin (odds ratio 1.007 per mg/dl rise), out-of-hospital births (OR 2.6), non-alloimmune hemolytic anemia (OR 2.8), and delayed care seeking (OR 4.3). CONCLUSION: The high occurrence of bilirubin encephalopathy in Nigeria is due in large part to a delay in seeking care. A planned intervention strategy will target conditions leading to severe hyperbilirubinemia and delay.

Malaria rapid diagnostic test in children: The Zamfara, Nigeria experience.

BACKGROUND: Malaria remains a major cause of under-five morbidity and mortality in Nigeria, and prompt diagnosis occupies a strategic position in its management. Malaria rapid diagnostic test (RDT), a nontechnical, easy to perform test promises to meet this need. It is important to locally document the usefulness of the use of RDT in making prompt malaria diagnosis in children. OBJECTIVE: To determine the prevalence of malaria and evaluate the diagnostic performance of malaria RDT kit in febrile under-five children presenting to a Tertiary Health Facility in Gusau, North-Western Nigeria. MATERIALS AND METHODS: A cross-sectional study of children aged 6-59 months, evaluated for malaria in a tertiary health facility from August 2012 to January 2013. Information was obtained from care providers of all subjects with fever and a presumptive diagnosis of malaria. All subjects were investigated using Giemsa stain microscopy and Carestart™ malaria RDT. RESULTS: The prevalence of malaria in 250 febrile under-five children was 54%. Three-quarter (79%) of the children received inappropriate nonrecommended antimalaria prior to their presentation, including 20% who received chloroquine. The overall sensitivity of RDT was 40.3%. The specificity, positive and negative predictive values were 89.6%, 81.8%, and 56.5%, respectively. CONCLUSION: Use of RDT should be encouraged for screening and diagnosis using a protocol such that febrile children with positive RDT results are confirmed as having malaria while those with negative results are further evaluated using microscopy.