Determinants and outcomes of preterm births in Nigerian tertiary facilities.

OBJECTIVE: To describe the incidence, and sociodemographic and clinical factors associated with preterm birth and perinatal mortality in Nigeria. DESIGN: Secondary analysis of data collected through the Maternal Perinatal Database for Quality, Equity and Dignity (MPD-4-QED) Programme. SETTING: Data from births in 54 referral-level hospitals across Nigeria between 1 September 2019 and 31 August 2020. POPULATION: A total of 69 698 births. METHODS: Multilevel modelling was used to determine the factors associated with preterm birth and perinatal mortality. OUTCOME MEASURES: Preterm birth and preterm perinatal mortality. RESULTS: Of 62 383 live births, 9547 were preterm (153 per 1000 live births). Maternal age (<20 years - adjusted odds ratio [aOR] 1.52, 95% CI 1.36-1.71; >35 years - aOR 1.23, 95% CI 1.16-1.30), no formal education (aOR 1.68, 95% CI 1.54-1.84), partner not gainfully employed (aOR 1.94, 95% CI 1.61-2.34) and no antenatal care (aOR 2.62, 95% CI 2.42-2.84) were associated with preterm births. Early neonatal mortality for preterm neonates was 47.2 per 1000 preterm live births (451/9547). Father's occupation (manual labour aOR 1.52, 95% CI 1.20-1.93), hypertensive disorders of pregnancy (aOR 1.37, 95% CI 1.02-1.83), no antenatal care (aOR 2.74, 95% CI 2.04-3.67), earlier gestation (28 to <32 weeks - aOR 2.94, 95% CI 2.15-4.10; 32 to <34 weeks - aOR 1.80, 95% CI 1.3-2.44) and birthweight <1000 g (aOR 21.35, 95% CI 12.54-36.33) were associated with preterm perinatal mortality. CONCLUSIONS: Preterm birth and perinatal mortality in Nigeria are high. Efforts should be made to enhance access to quality health care during pregnancy, delivery and the neonatal period, and improve the parental socio-economic status.

Burden and outcomes of postpartum haemorrhage in Nigerian referral-level hospitals.

OBJECTIVE: To determine the prevalence of primary postpartum haemorrhage (PPH), risk factors, and maternal and neonatal outcomes in a multicentre study across Nigeria. DESIGN: A secondary data analysis using a cross-sectional design. SETTING: Referral-level hospitals (48 public and six private facilities). POPULATION: Women admitted for birth between 1 September 2019 and 31 August 2020. METHODS: Data collected over a 1-year period from the Maternal and Perinatal Database for Quality, Equity and Dignity programme in Nigeria were analysed, stratified by mode of delivery (vaginal or caesarean), using a mixed-effects logistic regression model. MAIN OUTCOME MEASURES: Prevalence of PPH and maternal and neonatal outcomes. RESULTS: Of 68 754 women, 2169 (3.2%, 95% CI 3.07%-3.30%) had PPH, with a prevalence of 2.7% (95% CI 2.55%-2.85%) and 4.0% (95% CI 3.75%-4.25%) for vaginal and caesarean deliveries, respectively. Factors associated with PPH following vaginal delivery were: no formal education (aOR 2.2, 95% CI 1.8-2.6, P < 0.001); multiple pregnancy (aOR 2.7, 95% CI 2.1-3.5, P < 0.001); and antepartum haemorrhage (aOR 11.7, 95% CI 9.4-14.7, P < 0.001). Factors associated with PPH in a caesarean delivery were: maternal age of >35 years (aOR 1.7, 95% CI 1.5-2.0, P < 0.001); referral from informal setting (aOR 2.4, 95% CI 1.4-4.0, P = 0.002); and antepartum haemorrhage (aOR 3.7, 95% CI 2.8-4.7, P < 0.001). Maternal mortality occurred in 4.8% (104/2169) of deliveries overall, and in 8.5% (101/1182) of intensive care unit admissions. One-quarter of all infants were stillborn (570/2307), representing 23.9% (429/1796) of neonatal intensive care unit admissions. CONCLUSIONS: A PPH prevalence of 3.2% can be reduced with improved access to skilled birth attendants.

Point prevalence surveys of antibiotic prescribing in children at a tertiary hospital in a resource constraint, low-income sub-Saharan African country-the impact of an antimicrobial stewardship program.

BACKGROUND: Resistance to multiple antibiotics by several pathogens has been widely described in children and has become a global health emergency. This is due to increased use by parents, caregivers, and healthcare providers. This study aims to describe the prevalence rates of antibiotic prescribing, ascertain the impact of antimicrobial stewardship programs, and target improving the quality of antibiotic prescribing in the paediatric population over time in a hospital. METHOD: A point prevalence survey of antibiotic use was performed yearly for 4 years to monitor trends in antibiotic prescribing. Data from all patients admitted before 8 a.m. on the day of the PPS were included. A web-based application designed by the University of Antwerp was used for data entry, validation, and analysis ( http://www.global-pps.com ). RESULTS: A total of 260 children, including 90 (34.6%) neonates and 170 (65.4%) older children, were admitted during the four surveys. Overall, 179 (68.8%) patients received at least one antibiotic. In neonates, the prevalence of antibiotic use increased from 78.9 to 89.5% but decreased from 100 to 58.8% in older children. There was a reduction in the use of antibiotics for prophylaxis from 45.7 to 24.6%. The most frequently prescribed antibiotic groups were third generation cephalosporins and aminoglycosides. The most common indications for antibiotic prescription were sepsis in neonates and central nervous system infection in older children. The documentation of reason in notes increased from 33 to 100%, while the stop-review date also increased from 19.4 to 70%. CONCLUSION: The indicators for appropriate antibiotic prescription improved over time with the introduction of antibiotic stewardship program in the department.

Rates and predictors of mortality of very low birthweight infants in three Nigerian tertiary hospitals.

AIM: We aimed to describe in-hospital mortality, and its predictors, in very low birthweight (VLBW) infants managed in tertiary centres in a low- to middle-income country. METHODS: This was a retrospective cohort study of VLBW infants (birthweight 500 to 1500 grams) admitted within 72 h of life to the neonatal intensive care units (NICUs) of three tertiary centres in Nigeria from July 2017 to March 2021. We describe in-hospital mortality rates, causes and when they died. The independent predictors of in-hospital mortality were determined using multivariate logistic analysis. RESULTS: Of the 6187 NICU admissions, 1161 met the inclusion criteria: 545 (47%) VLBW infants died, including 309 (57%) from respiratory distress syndrome, and 55% occurred within 72 h of life. The adjusted odds (aOR) for mortality increased with each extra Downes respiratory distress score (aOR 1.27) with a 95% confidence interval (CI) of 1.14-1.41. Study site 3 had a higher aOR for mortality than site 1 (aOR 2.78, 95% CI 1.72-4.48) and site 2 (aOR 2.29, 95% CI 1.45-3.61). CONCLUSION: Nearly half (47%) of all VLBW infants admitted to three tertiary referral hospitals in Nigeria died during hospitalisation. Mortality varied significantly by site and both the centre and respiratory distress independently predicted mortality.

'Prospective audit with intervention and feedback' as a core antimicrobial stewardship strategy in the paediatrics department of a Nigerian tertiary hospital.

Introduction: Inappropriate use of antibiotics for childhood illnesses, especially for non-bacterial infections, contributes to the development of antimicrobial resistance (AMR). Globally, implementation of antimicrobial stewardship programme (ASP) in all healthcare institutions is a strategic intervention to improve the appropriate use of antibiotics, reduce antimicrobial consumption and tackle AMR. The aim of this study was to evaluate the effect of prospective audit with intervention and feedback as an antimicrobial stewardship strategy on antimicrobial use, evaluate prescribers' response to recommendations and determine the rate of AMR in the Paediatrics Department of the Lagos University Teaching Hospital, Nigeria. Materials and Methods: This was an implementation study of the paediatrics Antimicrobial Stewardship Programme (ASP) over a period of 6 months. It was initiated with a point prevalence survey (PPS) to describe the antimicrobial prescribing patterns and followed by prospective audit with interventions and feedback using an antimicrobial checklist and the existing antimicrobial guidelines in the Paediatrics Department. Results: The antibiotic prescribing prevalence was high (79.9%) at baseline PPS with 139 patients on admission, of which 111 (79.9%) were treated with 202 antibiotic therapies. Over the 6 months of study, 582 patients on 1146 antimicrobial therapies were audited. Compliance with departmental guidelines was 58.1% of the total 1146 prescriptions audited (n = 666), making the antimicrobial prescription inappropriate in 41.9% (n = 480) of therapies. The most recommended intervention for inappropriateness was 'change antibiotics' 48.8% (n = 234), followed by 'stop antibiotics' 26% (n = 125), 'reduce the number of antibiotics' 19.6% (n = 194) and 'de-escalate' 2.4% (n = 11). Agreement with ASP interventions occurred in 193 (40.2%) cases, and the least agreed intervention was 'stop antibiotics' (n = 40, 32%). However, there was a steady increase in compliance rates with ASP interventions over the 6 months of period study, which was statically significant (χ2: 30.005; P = 0.001). Conclusion: ASP prospective audit with intervention and feedback was of significant benefit in improving compliance with antimicrobial guidelines, thereby improving antimicrobial therapy in the Paediatrics Department of LUTH, Nigeria.

Impact of Erythropoietin in the management of Hypoxic Ischaemic Encephalopathy in resource-constrained settings: protocol for a randomized control trial.

BACKGROUND: Perinatal asphyxia, more appropriately known as hypoxic-ischemic encephalopathy (HIE), is a condition characterized by clinical and laboratory evidence of acute or sub-acute brain injury resulting from systemic hypoxemia and/or reduced cerebral blood flow. HIE is a common and devastating clinical condition in resource-poor countries with poor treatment outcome. This paper describes the protocol for an ongoing study that aims to evaluate the neuroprotective effects of Erythropoietin (EPO) as compared to routine care in the management of moderate to severe HIE among term infants. METHODS: This study is a double-blind randomized controlled trial that will be conducted in the neonatal wards of the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria, over a two-year period after ethical approvals and consents. One hundred and twenty-eight term newborns (≥ 37 weeks gestation) diagnosed with moderate/ severe HIE at admission will be allocated by randomization to receive either EPO or normal saline. All the participants will be offered standard care according to the unit protocol for HIE. Baseline investigations and close monitoring of the babies are done until discharge. Participants are followed up for 2 years to monitor their outcome (death or neurological development) using standard instruments. DISCUSSION: Previous trials had shown that EPO confers neuroprotective benefits and improve neurological and behavioral outcome in infants with HIE both singly or as an adjuvant to therapeutic hypothermia. This study hypothesized that administering EPO to newborns with moderate /severe HIE can positively influence their clinical and neurological outcomes and will provide evidence to either support or disprove the usefulness of Erythropoietin as a sole agent in the treatment of HIE, especially in resource-limited environment with the highest burden of the disease. TRIAL REGISTRATION: The study has been registered with the Pan African Clinical trials registry on the 2nd of December 2018, with registration number PACTR201812814507775.

Pediatric Bacterial Meningitis Surveillance in Nigeria From 2010 to 2016, Prior to and During the Phased Introduction of the 10-Valent Pneumococcal Conjugate Vaccine.

BACKGROUND: Historically, Nigeria has experienced large bacterial meningitis outbreaks with high mortality in children. Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcus), and Haemophilus influenzae are major causes of this invasive disease. In collaboration with the World Health Organization, we conducted longitudinal surveillance in sentinel hospitals within Nigeria to establish the burden of pediatric bacterial meningitis (PBM). METHODS: From 2010 to 2016, cerebrospinal fluid was collected from children <5 years of age, admitted to 5 sentinel hospitals in 5 Nigerian states. Microbiological and latex agglutination techniques were performed to detect the presence of pneumococcus, meningococcus, and H. influenzae. Species-specific polymerase chain reaction and serotyping/grouping were conducted to determine specific causative agents of PBM. RESULTS: A total of 5134 children with suspected meningitis were enrolled at the participating hospitals; of these 153 (2.9%) were confirmed PBM cases. The mortality rate for those infected was 15.0% (23/153). The dominant pathogen was pneumococcus (46.4%: 71/153) followed by meningococcus (34.6%: 53/153) and H. influenzae (19.0%: 29/153). Nearly half the pneumococcal meningitis cases successfully serotyped (46.4%: 13/28) were caused by serotypes that are included in the 10-valent pneumococcal conjugate vaccine. The most prevalent meningococcal and H. influenzae strains were serogroup W and serotype b, respectively. CONCLUSIONS: Vaccine-type bacterial meningitis continues to be common among children <5 years in Nigeria. Challenges with vaccine introduction and coverage may explain some of these finding. Continued surveillance is needed to determine the distribution of serotypes/groups of meningeal pathogens across Nigeria and help inform and sustain vaccination policies in the country.

Invasive candidiasis in a neonatal intensive care unit in Lagos, Nigeria.

BACKGROUND: Invasive candidiasis has been identified globally as a major cause of morbidity and mortality in neonatal intensive care units (NICU). Systemic candidiasis presents like bacterial sepsis and can involve multiple organs. OBJECTIVE: The objective of this study was to determine the prevalence of Candida infection in a NICU at a tertiary hospital in Nigeria and to identify its associated risk factors. MATERIALS AND METHODS: The study was a retrospective descriptive study of all cases of culture-proven invasive Candida infection (ICI) in neonates admitted to the NICU over a 4-year period. The study participants were identified from microbiology records of all neonates with a positive Candida culture. Medical records of identified neonates were also reviewed, and relevant information obtained. RESULTS: Over the 4 years, 2712 newborns were admitted to the NICU. From these, 1182 various clinical samples were collected from babies with features of sepsis and processed in the medical microbiology laboratory. Twenty-seven (2.3%) of the cultures yielded Candida organisms; fifteen of the Candida cultures were from male infants with a male:female ratio of 1.3:1. Bloodstream infection was the most frequent ICI seen in preterm babies (seven [58.3%] out of 12 babies with ICI). Nearly, all (91.7%) affected preterm infants with ICI were <1500 g in weight. All were exposed to invasive procedures and broad-spectrum antibiotics. The case fatality rate among those with ICI was 18.5%. CONCLUSION: There was a significant prevalence of invasive candidiasis in high-risk newborns and the incidence increases with increased practices in risk factors such as invasive procedures and antibiotic use and lower gestational age babies with very low birth weight.

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.

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

[This corrects the article DOI: 10.1371/journal.pone.0244109.].

Non-pharmacological pain relief interventions in preterm neonates undergoing screening for retinopathy of prematurity: a systematic review.

OBJECTIVE: The objective of this review was to determine the efficacy of non-pharmacological interventions for pain management during retinopathy of prematurity (ROP) screening. METHODS AND ANALYSIS: Electronic search of Ovid MEDLINE, PubMed, EMBASE, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature, Google Scholar and ClinicalTrials.gov (USA) was conducted. Search terms from the research question and inclusion criteria were used to select randomised control trials (RCT) published from January 2000 to May 2023. Relevant data were extracted, and risk of bias was assessed using the Cochrane Risk of Bias tool V.2. Critical appraisal and grading of the quality of evidence were done using the Critical Appraisal Skills Programme tool for RCTs and the Grading of Recommendations Assessment, Development and Evaluation, respectively. RESULTS: Twenty-one RCTs were included; 14 used sweet taste, while 7 used modified developmental care, touch or positioning, multisensory stimulation, non-nutritive sucking or music. Six studies on sweet taste and all seven latter studies showed a difference in the pain scores in favour of the interventions. The quality of evidence was however judged low and moderate due to some concerns in the randomisation process, measurement of outcome assessment and selection of reported results domains. CONCLUSION: The use of gentle touch, nesting, positioning, music, multisensory stimulation and developmental care in reducing pain during ROP screening is promising, however, larger studies designed to eliminate the identified concerns are needed. More evidence is also needed before sweet taste interventions can be recommended in routine practice.

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.

Diagnosing renal failure due to diethylene glycol in children in a resource-constrained setting.

BACKGROUND: In 2008, several Nigerian children developed acute kidney injury (AKI) after ingesting teething syrup contaminated with diethylene glycol (DEG). Because there are limited diagnostic facilities in resource-constrained countries, this study investigated whether AKI associated with DEG could be identified by other means. METHODS: This was a multicenter study. Information was obtained from hospital records. Clinicopathological features of all children with AKI over a 6-month period were reviewed. RESULTS: Sixty (50.4%) of 119 children ingested "My pikin" teething syrup. Compared to children who had not ingested it, they were significantly (p < 0.05) younger (11.95 vs. 31 months), more were anuric (98.3 vs. 74.6%), hypertensive (84 vs. 52%), had severe metabolic acidosis (46.7 vs. 20.5%), and died (96.6 vs. 71.2%). They developed increasing metabolic acidosis and multiorgan dysfunction despite peritoneal dialysis. Late presentation, financial difficulties, inadequate facilities for toxicology, and hemodialysis complicated management. CONCLUSIONS: Identifying AKI associated with DEG is difficult. Detailed drug history, increasing metabolic acidosis, and multiorgan deterioration despite peritoneal dialysis should arouse suspicion. Simple diagnostic tests need to be developed and facilities for hemodialysis of infants and financial support provided. Recurrences can be prevented by creating awareness, improving manufacturing practices, field-testing of drugs, and international monitoring of pharmaceuticals imported for manufacture.

Obesity and elevated blood pressure among adolescents in Lagos, Nigeria: a cross-sectional study.

BACKGROUND: Childhood obesity and associated hypertension are major public health concerns globally. This study aimed to determine the prevalence of obesity and the associated risk of high blood pressure among Nigerian adolescents. METHODS: A cross-sectional school-based study of 885 apparently healthy adolescents was performed. Weight, height and blood pressure (BP) were measured using standard methods. Body mass index (BMI) was calculated and categorized by age, sex and percentile. Obesity and overweight were defined as: ≥ 95th and 85th to < 95th percentiles, respectively, for age, sex and height. Subjects were sub-categorized into age 10-13 years (A) and 14-17 years (B). The odds ratio for pre-hypertensive and hypertensive range BP by age and BMI were generated. Significance was set at P < 0.05. RESULTS: The prevalence of overweight and obesity were 13.8% and 9.4%, respectively. The prevalence of hypertensive range systolic BP in obese versus normal BMI females was 16% versus 23% (p=0.00) and 12.1% versus 6.4% (p=0.27) in males. The prevalence of hypertensive range diastolic BP in obese versus normal BMI females was 12% versus 1.4% (p=0.00) and 15.2% versus 3.5% (p=0.01) in males. BMI in group B was significantly associated with pre-hypertensive and hypertensive range systolic BP in overweight (P = 0.01, P = 0.002) and obese subjects (P = 0.00, P = 0.00) and with hypertensive range diastolic BP (P = 0.00) only in obese subjects. The only significant association in group A was between obesity and pre-hypertensive range diastolic BP (P = 0.00). CONCLUSION: The prevalence of hypertensive range BP among obese Nigerian adolescents was high. Screening for childhood obesity and hypertension, and long-term follow-up of obese adolescents into adulthood are recommended.

Perspectives of medical students on simulation-based training: the Nigerian experience.

Introduction: simulation-based education (SBE) is becoming more prevalent in higher education. However, little is known of the perceptions of medical students towards this training approach. The objective of this study was to explore the perceptions of Nigerian medical students on manikin-based and virtual simulation training. Methods: in January 2019, a paper-based 25-item survey on simulation-based training was administered to a convenience sample of 120 medical students in the 4th year (400 level) and final year (600 level). Data were analysed using descriptive statistics, Pearson´s chi square, and the Fisher´s Exact test. Results: a total of 95 surveys were completed (RR 79%). Respondents were mostly 21-30 years 95 (81%) and about half were female 60 (51%). Under half of 600 level students 22 (38%) reported receiving simulation-based training in Basic Life Support. A lack of curriculum 27 (28%), instructors trained in simulation education 31 (33%) and funding 52 (55%) were perceived as challenges to manikin-based simulation. Lack of awareness was the greatest single challenge to online simulation 50 (53%). A majority of medical students 181 (96%) owned smartphones, but only 3% (n=3) of respondents had experienced a virtual reality (VR) simulation. If facilities were available, 99% of respondents would recommend the use of online simulation. Conclusion: there is an opportunity for increased exposure to simulation-based training during undergraduate medical education in Nigeria. Instruction in simulation methods for clinical lecturers in medical schools would increase awareness of the potential advantages of simulation-based training and access for medical students to simulation education.

Current Trends in Neonatal Morbidity and Mortality: Experiences from a Tertiary Center in Lagos, Nigeria.

Neonatal mortality is a major contributor to under-five mortality, and Nigeria has the second-highest number of neonatal deaths globally. The country has introduced evidence-based interventions to improve newborn care over the years. The aim of this study was to determine the current trends in neonatal morbidity and mortality at the Lagos University Teaching Hospital, monitor progress over time, and identify areas for improvement. The admission registers and case files of all the neonatal ward admissions were reviewed from January 2018 to April 2020; the age at admission, gestational age, sex, inborn or out-born status, diagnosis, and outcome were recorded and analyzed. Of the 2,959 admissions during the study period, 68.4% were out-born and 77.9% were term gestation infants. The most common diagnoses were neonatal jaundice (NNJ; 28.4%), infection (28.0%), prematurity with associated complications (22.1%), and hypoxic ischemic encephalopathy (HIE; 18.2%). The overall mortality rate was 17.6%. Prematurity with associated complications (39.2%), HIE (24.8%), congenital anomalies (CAs; 12.7%), and NNJ (11.5%) were the most common conditions associated with mortality. Of those who died, the most common diagnoses were term infants with HIE (40.7%), CAs (21.8%), NNJ (18.9%), and infection (15.5%); respiratory distress syndrome (52.4%), infection (31.8%), and CAs (7.8%) were the most common diagnoses in preterm infants. The high risk of mortality with HIE, jaundice, infections, and CAs in this cohort reflects the national figures and trends. Efforts to improve neonatal care, especially respiratory support and education of the populace on NNJ, should be intensified to reduce neonatal mortality in the country.

Antimicrobial susceptibility and neonatal sepsis in a tertiary care facility in Nigeria: a changing trend?

Background: Neonatal sepsis remains one of the leading causes of morbidity and mortality in neonates, especially in developing countries. Objectives: To determine the prevalence, common bacterial pathogens, and the antibiotic susceptibility pattern of neonatal sepsis at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. Methods: This was a cross-sectional study of neonates who presented at the facility with symptoms and signs of sepsis from January 2017 to October 2017. Demographic and clinical data were extracted using a structured questionnaire. Blood culture, urine and CSF were collected and cultured on blood and MacConkey agar. Bacterial isolates were identified using Microbact 24E system and biochemical tests. Antibacterial susceptibility testing was done using the modified Kirby-Bauer disc diffusion method. Results: Two hundred and ninety neonates were recruited during the study period. Seventy-three (25.2%) neonates had culture-proven sepsis. One (0.3%) neonate had meningitis and no neonates (0%) had confirmed urinary tract infection. Of the 73 neonates with positive blood cultures, 56 (76.7%) had early-onset sepsis and 17 (23.3%) had late-onset sepsis. Gram-negative bacilli accounted for 60.3% of all isolates. Predominantly isolated pathogens were Staphylococcus aureus (20.5%), CoNS (19.2%) and Klebsiella pneumoniae (13.7%). The isolates were most susceptible to levofloxacin and amikacin. Conclusions: Neonatal sepsis is still a huge burden in the newborn. S. aureus, CoNS and K. pneumoniae are the prevalent pathogens in the local facility, with good susceptibility to levofloxacin and amikacin. Maintaining regular antibiotic surveillance for appropriate empirical antibiotics is important as part of neonatal care.

Using Mobile Virtual Reality Simulation to Prepare for In-Person Helping Babies Breathe Training: Secondary Analysis of a Randomized Controlled Trial (the eHBB/mHBS Trial).

BACKGROUND: Neonatal mortality accounts for approximately 46% of global under-5 child mortality. The widespread access to mobile devices in low- and middle-income countries has enabled innovations, such as mobile virtual reality (VR), to be leveraged in simulation education for health care workers. OBJECTIVE: This study explores the feasibility and educational efficacy of using mobile VR for the precourse preparation of health care professionals in neonatal resuscitation training. METHODS: Health care professionals in obstetrics and newborn care units at 20 secondary and tertiary health care facilities in Lagos, Nigeria, and Busia, Western Kenya, who had not received training in Helping Babies Breathe (HBB) within the past 1 year were randomized to access the electronic HBB VR simulation and digitized HBB Provider's Guide (VR group) or the digitized HBB Provider's Guide only (control group). A sample size of 91 participants per group was calculated based on the main study protocol that was previously published. Participants were directed to use the electronic HBB VR simulation and digitized HBB Provider's Guide or the digitized HBB Provider's Guide alone for a minimum of 20 minutes. HBB knowledge and skills assessments were then conducted, which were immediately followed by a standard, in-person HBB training course that was led by study staff and used standard HBB evaluation tools and the Neonatalie Live manikin (Laerdal Medical). RESULTS: A total of 179 nurses and midwives participated (VR group: n=91; control group: n=88). The overall performance scores on the knowledge check (P=.29), bag and mask ventilation skills check (P=.34), and Objective Structured Clinical Examination A checklist (P=.43) were similar between groups, with low overall pass rates (6/178, 3.4% of participants). During the Objective Structured Clinical Examination A test, participants in the VR group performed better on the critical step of positioning the head and clearing the airway (VR group: 77/90, 86%; control group: 57/88, 65%; P=.002). The median percentage of ventilations that were performed via head tilt, as recorded by the Neonatalie Live manikin, was also numerically higher in the VR group (75%, IQR 9%-98%) than in the control group (62%, IQR 13%-97%), though not statistically significantly different (P=.35). Participants in the control group performed better on the identifying a helper and reviewing the emergency plan step (VR group: 7/90, 8%; control group: 16/88, 18%; P=.045) and the washing hands step (VR group: 20/90, 22%; control group: 32/88, 36%; P=.048). CONCLUSIONS: The use of digital interventions, such as mobile VR simulations, may be a viable approach to precourse preparation in neonatal resuscitation training for health care professionals in low- and middle-income countries.

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.