Neonatal herpes simplex virus encephalitis with intracranial bleeding in a newborn baby with concurrent rhesus incompatibility.

We report a baby with neonatal herpes simplex virus (HSV) encephalitis concurrent with Rrhesus (Rh) incompatibility. He was delivered by a Ggravida 2 mother with a history of miscarriage in her previous pregnancy at a gestation age of 4 months. She had Bblood group 0 and Rrhesus negative. The baby was noticed to have jaundice on day one1 of life accompanied by generalised petechiae on the face and upper chest. A full blood picture revealed severe anaemia and severe thrombocytopaenia and HSV 1/2 IgM was positive. MRI of the brain showed multiple extensive haemorrhagic lesions on the frontal-temporal regions.

Esophageal atresia with tracheoesophageal fistula: two case reports.

BACKGROUND: The incidence of esophageal atresia with tracheoesophageal fistula is 1 out of 3000-5000 live births. Its incidence in lower middle income countries is not known. The infants usually present with excessive secretions or choking while feeding and are at risk for aspiration. The outcome of these infants in lower middle income countries is not encouraging due to delays in referral, sepsis at presentation requiring preoperative stabilization, postoperative complications such as anastomosis leaks, pneumonia, and pneumothorax. CASE PRESENTATION: We present two African babies who were term infants at age 2 days (male) and 5 days (female) with diagnosis of esophageal atresia and tracheoesophageal fistula. The 5-day-old infant required preoperative stabilization due to sepsis and delayed surgery with a poor postoperative outcome. The 2-day-old infant was preoperatively stable and had a good postoperative outcome. The challenges faced in management of these two cases have been highlighted. CONCLUSION: Outcome of infants with esophageal atresia and tracheoesophageal fistula in lower middle income countries is not encouraging due to delays in referral and poor postoperative healing attributed to sepsis and recurrent pneumothorax. Timely referral, preoperative condition of the infant, and timely management has shown to be a contributory factor for an improved outcome.

Prevalence of anaemia and associated factors among preterm infants at six weeks chronological age at Muhimbili National Hospital, Dar es Salaam, Tanzania: a cross-sectional study.

Introduction: preterm infants are vulnerable to several medical complications including anaemia, a significant public health problem with consequences on neurodevelopment. This study looked at the magnitude of anaemia and its associated factors among preterm infants at 6 weeks chronological age in a paediatric clinic of Muhimbili National Hospital (MNH). Methods: this was a hospital based cross-sectional study conducted among preterm infants at 6 weeks chronological age attending follow-up clinic at MNH from October 2019 to March 2020. Parental interviews, medical records reviews and haemoglobin assessment was done during the clinic visits. Logistic regression was used to determine the association between studied factors and anaemia. Results: the proportion of preterm infants with anaemia at 6 weeks chronological age was 38.4% (142/370) with 74% of these infants having moderate anaemia. Morphological types of anaemia were normocytic (56.3%) and microcytic anaemia (4.9%). Two-thirds of preterm infants (62%) were on haematinics supplementation. Moderate preterm born at gestation age 32 to <34 weeks (OR=2.21, 95% CI 1.15-4.25, p=0.017), two or less phlebotomies (OR=2.3; 95% CI 1.23-4.30; P=0.010) and more than two phlebotomies (OR=7.2, 95% CI 3.62-14.16, p≤0.001) were significantly associated with anaemia. Conclusion: the proportion of preterm infants with anaemia at 6 weeks chronological age is high despite two-thirds being on haematinics supplementation. Moderate preterm and multiple phlebotomies significantly contributed to the occurrence of anaemia. Screening preterm infants for anaemia, appropriate management, and close follow-up are recommended to reduce its burden.

Late diagnosis of congenital diaphragmatic hernia: a case report.

BACKGROUND: Congenital diaphragmatic hernia beyond the neonatal period is not uncommon. Its diagnosis in infancy and early childhood poses a challenge owing to different clinical presentation ranging from gastrointestinal to respiratory symptoms. These neonates are usually misdiagnosed as having pneumonia until radiological imaging picks up the defect during routine scan for worsening respiratory symptoms. In high-income countries, the survival rate for these patients has been reported to be high, while in Sub-Saharan Africa the survival rate is still low due to delayed diagnosis, delayed referral, and hence delayed management. CASE REPORT: We present an African male baby from non-consanguineous parents, 6 weeks old, diagnosed with congenital diaphragmatic hernia at 6 weeks of age after failure to respond to antibiotics for suspected pneumonia. Despite attempts at management, he died at 5 weeks post surgery. CONCLUSION: Our case emphasizes the importance of early clinical suspicion and early detection for a differential diagnosis of congenital diaphragmatic hernia in infants who present with respiratory symptoms not responding to antibiotics or recurrent pneumonia, and improving the availability of imaging in primary care facilities to diagnose such defects early and manage them accordingly.

CPAP failure in the management of preterm neonates with respiratory distress syndrome where surfactant is scarce. A prospective observational study.

BACKGROUND: The mainstay in the management of preterm neonates with respiratory distress syndrome (RDS) include early Continuous Positive Airway Pressure (CPAP), timely surfactant replacement and mechanical ventilation. Preterm neonates with RDS who fail CPAP are at higher risk for chronic lung disease as well as death. Unfortunately, in low resource settings CPAP may be the only treatment available for these neonates. OBJECTIVE: To determine the prevalence of CPAP failure among premature newborns with RDS and associated factors. METHODS: We conducted a prospective observational study over the first 72 h of life on 174 preterm newborns with RDS receiving CPAP at Muhimbili National Hospital (MNH). At MNH newborns with Silverman Andersen Score (SAS) of ≥ 3 are commenced on CPAP; surfactant and mechanical ventilation are very scarce. Study newborns not maintaining oxygen saturation > 90% or with SAS score ≥ 6 despite being on 50% oxygen and PEEP of 6 cmH2O and those with > 2 episodes of apnoea needing stimulation or positive pressure ventilation in 24 h were considered as CPAP failure. The prevalence of CPAP failure was determined as a percentage and factors associated were determined by logistic regression. A p-value of < 0.05 was considered significant and 95% confidence interval was used. RESULTS: Of the enrolled newborns, 48% were male and 91.4% were in-born. The mean gestational age and weight were 29 weeks (range 24-34 weeks) and 1157.7 g (range 800-1500 g) respectively. Of the mothers 44 (25%) received antenatal corticosteroids. Overall CPAP failure was 37.4% and among those weighing ≤ 1200g, it was 44.1% . Most failure occurred within the first 24 h. No factor was identified to be independently associated with CPAP failure. Mortality among those who failed CPAP was 33.8% and 12.8% among those who did not. CONCLUSIONS: In resource limited settings like ours with low up take of antenatal corticosteroids and scarce surfactant replacement a significant portion of preterm neonates especially those weighing ≤ 1200 g with RDS fail CPAP therapy.

Caudal regression syndrome without maternal diabetes mellitus.

Caudal regression is a rare complex disorder impacting the formation of the caudal segment of the spine and spinal cord. We report a preterm newborn baby who was referred to us due to respiratory distress syndrome and bilateral knee contracture. A clinical examination and a radiographic skeletal survey revealed a short spinal cord with complete agenesis of the lumbar, sacrum and coccygeal spine, and hypoplastic iliac bones with bilateral knee contractures. The mother did not have diabetes. The long-term outcome is not well-known in our set-up.

Neurocristic cutaneous hamartoma of the scalp with disseminated melanocytic nevi.

We report a newborn with neurocristic cutaneous hamartoma of the scalp. He was delivered at term via caesarean section due to a previous scar and presented at the neonatal unit on the fifth day with giant congenital nevi on the scalp and disseminated melanocytic nevi throughout the body. The MRI scan of the brain showed a defect at the occipital region with herniation of the occipital lobes and ventricles through the defect, with infratentorial brain parenchyma exhibiting normal signal return and intact cerebellum. The initial diagnosis was a giant haemangioma, which has ruptured, and possible cytomegalovirus infection, causing 'blueberry muffin' syndrome. On follow-up, the hamartoma/haemangioma-like mass regressed, and a large well-demarcated melanotic patch on scalp and large encephalocele were seen. This infant is now being scheduled for neurosurgical intervention.

Feasibility of a novel ultra-low-cost bubble CPAP (bCPAP) System for neonatal respiratory support at Muhimbili National Hospital, Tanzania.

OBJECTIVE: Continuous Positive Airway Pressure (CPAP) is recommended in the treatment of respiratory distress syndrome of premature newborns, however there are significant barriers to its implementation in low-resource settings. The objective of this study was to evaluate the feasibility of use and integration of Vayu bCPAP Systems into the newborn unit at Muhimbili National Hospital in Tanzania. STUDY DESIGN: A prospective qualitative study was conducted from April 6 to October 6 2021. Demographic and clinical characteristics of patients treated with Vayu bCPAP Systems were collected and analyzed. Healthcare workers were interviewed until thematic saturation. Interviews were transcribed, coded, and analyzed using a framework analysis. RESULTS: 370 patients were treated with Vayu bCPAP Systems during the study period. Mean birth weight was 1522 g (500-3800), mean duration of bCPAP treatment was 7.2 days (<1-39 d), and survival to wean was 81.4%. Twenty-four healthcare workers were interviewed and perceived Vayu bCPAP Systems as having become essential for treating neonatal respiratory distress at MNH. Key reasons were that Vayu bCPAP Systems improve patient outcomes, are easy to use, and more patients are now able to receive quality care. Barriers to integration included durability of oxygen tubing material and training. CONCLUSIONS: It was feasible to implement and integrate Vayu bCPAP Systems into the care of neonates at Muhimbili National Hospital.

Neonatal resuscitation: EN-BIRTH multi-country validation study.

BACKGROUND: Annually, 14 million newborns require stimulation to initiate breathing at birth and 6 million require bag-mask-ventilation (BMV). Many countries have invested in facility-based neonatal resuscitation equipment and training. However, there is no consistent tracking for neonatal resuscitation coverage. METHODS: The EN-BIRTH study, in five hospitals in Bangladesh, Nepal, and Tanzania (2017-2018), collected time-stamped data for care around birth, including neonatal resuscitation. Researchers surveyed women and extracted data from routine labour ward registers. To assess accuracy, we compared gold standard observed coverage to survey-reported and register-recorded coverage, using absolute difference, validity ratios, and individual-level validation metrics (sensitivity, specificity, percent agreement). We analysed two resuscitation numerators (stimulation, BMV) and three denominators (live births and fresh stillbirths, non-crying, non-breathing). We also examined timeliness of BMV. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine recording of resuscitation. RESULTS: Among 22,752 observed births, 5330 (23.4%) babies did not cry and 3860 (17.0%) did not breathe in the first minute after birth. 16.2% (n = 3688) of babies were stimulated and 4.4% (n = 998) received BMV. Survey-report underestimated coverage of stimulation and BMV. Four of five labour ward registers captured resuscitation numerators. Stimulation had variable accuracy (sensitivity 7.5-40.8%, specificity 66.8-99.5%), BMV accuracy was higher (sensitivity 12.4-48.4%, specificity > 93%), with small absolute differences between observed and recorded BMV. Accuracy did not vary by denominator option. < 1% of BMV was initiated within 1 min of birth. Enablers to register recording included training and data use while barriers included register design, documentation burden, and time pressure. CONCLUSIONS: Population-based surveys are unlikely to be useful for measuring resuscitation coverage given low validity of exit-survey report. Routine labour ward registers have potential to accurately capture BMV as the numerator. Measuring the true denominator for clinical need is complex; newborns may require BMV if breathing ineffectively or experiencing apnoea after initial drying/stimulation or subsequently at any time. Further denominator research is required to evaluate non-crying as a potential alternative in the context of respectful care. Measuring quality gaps, notably timely provision of resuscitation, is crucial for programme improvement and impact, but unlikely to be feasible in routine systems, requiring audits and special studies.

Management of neonatal sepsis at Muhimbili National Hospital in Dar es Salaam: diagnostic accuracy of C-reactive protein and newborn scale of sepsis and antimicrobial resistance pattern of etiological bacteria.

BACKGROUND: We determined the accuracy of Rubarth's newborn scale of sepsis and C- reactive protein in diagnosing neonatal sepsis and assessed antimicrobial susceptibility pattern of etiological bacteria. METHODS: This cross sectional study was conducted at Muhimbili National Hospital in Dar es Salaam, Tanzania between July 2012 and March 2013. Neonates suspected to have sepsis underwent physical examination using Rubarth's newborn scale of sepsis (RNSOS). Blood was taken for culture and antimicrobial sensitivity testing, full blood picture and C - reactive protein (CRP) performed 12 hours apart. The efficacy of RNSOS and serial CRP was assessed by calculating sensitivity, specificity, negative and positive predictive values, receiver operating characteristics (ROC) analysis as well as likelihood ratios (LHR) with blood culture result used as a gold standard. RESULTS: Out of 208 blood samples, 19.2% had a positive blood culture. Single CRP had sensitivity and specificity of 87.5% and 70.9% respectively, while RNSOS had sensitivity of 65% and specificity of 79.7%. Serial CRP had sensitivity of 69.0% and specificity of 92.9%. Combination of CRP and RNSOS increased sensitivity to 95.6% and specificity of 56.4%. Combination of two CRP and RNSOS decreased sensitivity to 89.1% but increased specificity to 74%. ROC for CRP was 0.86; and for RNSOS was 0.81. For CRP the LHR for positive test was 3 while for negative test was 0.18, while for RNSOS the corresponding values were 3.24 and for negative test was 0.43. Isolated bacteria were Klebsiella spp 14 (35%), Escherichia coli 12 (22.5%), Coagulase negative staphlococci 9 (30%), Staphylococcus aureus 4 (10%), and Pseudomonas spp 1 (2.5%). The overall resistance to the WHO recommended first line antibiotics was 100%, 92% and 42% for cloxacillin, ampicillin and gentamicin, respectively. For the second line drugs resistance was 45%, 40%, and 7% for ceftriaxone, vancomycin and amikacin respectively. CONCLUSIONS: Single CRP in combination with RNSOS can be used for rapid identification of neonates with sepsis due to high sensitivity (95.6%) but cannot exclude those without sepsis due to low specificity (56.4%). Serial CRP done 12hrs apart can be used to exclude non-cases. This study demonstrated very high levels of resistance to the first-line antibiotics.