Neonatal mortality: effects of selective pediatric interventions.

A previous prospective study of neonatal mortality in babies receiving special care at the University College Hospital, Ibadan, revealed that respiratory failure associated with prematurity, perinatal asphyxia, sepsis, and congenital malformations were the major causes of high neonatal mortality. To improve survival, selective measures were taken to improve care of low-birth-weight infants and prevent or treat intrapartum and postnatal hypoxia, metabolic acidosis, hypoglycemia, and hypothermia. A change in the initial antibiotic management of suspected septicemia to the use of cloxacillin and an aminoglycoside was also introduced, based on the current knowledge of etiologic agents and their antimicrobial sensitivities. In the 5-year period (1976 to 1980), the neonatal mortality in babies weighing 2,500 g and more at birth dropped significantly from 1.2% to 0.7% (P less than .02). The case fatality rates from birth asphyxia and neonatal sepsis dropped by 48% and 32%, respectively. Despite therapeutic interventions, however, the neonatal mortality in babies with birth weight of 1,000 g or less, 1,001 to 1,500 g, 1,501 to 2,000 g, and 2,001 to 2,499 g remained unchanged at about 82%, 25%, 9%, and 3%, respectively. These results suggest that early identification of infants at risk of developing birth asphyxia or neonatal septicemia and institution of prompt and appropriate management could produce a significant reduction in mortality in infants of normal birth weight. Survival of low-birth-weight infants requires additional high technical, financial, and manpower resources, which most centers in developing countries cannot afford at the present time. Therefore, efforts are probably better concentrated on decreasing the incidence of low birth weight.

Severe facial clefting, limbic dermoid, hypoplasia of the corpus callosum, and multiple skin appendages: severe frontofacionasal "dysplasia" or newly recognised syndrome?

We report on a child with severe midline facial cleft, bilateral cleft lip and palate, telecanthus, S-shaped palpebral fissures, limbic dermoid, midface hypoplasia, hypoplastic corpus callosum, and multiple skin appendages. This case may be an example of severe frontofacionasal "dysplasia" or a newly recognised syndrome.

Tecto-cerebellar dysraphia with occipital encephalocele.

We report four cases with the rare syndrome of tecto-cerebellar dysraphia with occipital encephalocele. The clinical features seen in these patients included episodic tachypnea and irregular breathing, opsoclonus, ataxia, marked hypotonia of the limbs, coloboma, and polydactyly. All four patients had midline occipital encephalocele. The cranial computed tomography scan showed partial to total agenesis of the vermis with a large communication between cisterna magna and the fourth ventricle. The computed tomography scan also showed partial deficiency of the midbrain tectum. We discuss the clinical and radiological findings and review the literature.

A cluster of choanal atresia.

During a 5-month period in 1991 four infants with choanal atresia or stenosis were born at one hospital. We therefore reviewed our experience of this condition during the past 6 years and compared the patients who presented before with the four clustered cases. No definite explanation has been ascertained for this cluster of cases of choanal obstruction but a viral or other environmental teratogen could not be excluded.

Hepatic injury and disturbed amino acid metabolism in mice following prolonged exposure to organophosphorus pesticides.

Chronic occupational exposure to organophosphorus and carbamate-type pesticides significantly inhibits acetylcholinesterase activity and causes morbidity. This study on mice was designed to evaluate their amino profile and to identify signs of hepatic dysfunction following their chronic exposure to mixtures of organophosphorus pesticides. Laboratory mice were exposed to a formulated mixture of the six organophosphorus pesticides (Dimethoate, Chlorpyrifos, Profenofos, Pirimiphos methyl, Triazophos and Dimethoate) most commonly used in agriculture in this region of the Middle East. Doses (10% of LD50 of the mixture) were given once a week by gavage in corn oil for 7 weeks; the control group was given only corn oil. At the end of the exposure period, mice were culled and blood samples were collected to determine erythrocyte acetylcholinesterase activity, biochemical markers of liver function and concentrations of serum amino acids. Erythrocyte acetylcholinesterase activity and total serum proteins decreased significantly in the exposed group. Serum concentrations of alanine aminotransferase and aspartate aminotransferase, alanine, glutamic acid, glycine, isoleucine, leucine, methionine, ornithine, proline, serine, threonine and valine were significantly increased in the exposed mice, while serum levels of cystine were decreased significantly. There were also non-significant increases in serum alkaline phosphatase, gama-glutamyl transpeptidase and some of the other amino acids. Chronic exposure to mixtures of organophosphorus pesticides is associated with decreased acetylcholinesterase activity, hepatic dysfunction and disturbance of amino acids profile. Biochemical indices of hepatocellular injury and disturbed amino acid metabolism may be of value as markers of chronic exposure to such pesticides.

Nutrient composition of milk produced by mothers of preterm infants in Nigeria.

Nutrient composition was determined in breast milk obtained by manual expression from 12 mothers who delivered prematurely (mean 32 weeks) and 15 mothers who delivered at term (mean 39.4 weeks), on days 3, 7, 14, 21 and 28 postpartum. Complete 24-hour milk expressed by five term mothers and seven preterm mothers on days 7, 14, 21 and 28 lactational ages was also recorded. In both preterm and term mothers' milk, lactose and fact concentrations increased with lactational age, while protein and mineral concentrations decreased. The preterm mothers' milk contained higher concentrations of protein, fat and minerals and lower concentrations of lactose than term mothers's milk. The fat and caloric density of milk of the mothers in this study, who were mostly of low social class, was lower than that reported from Western countries. The implication of this finding for feeding premature infants in developing countries is discussed.

Socio-psychological factors affecting emergency obstetric deliveries at the University College Hospital, Ibadan, Nigeria.

PIP: This study was designed to determine the influence of socio- psychological characteristics on reproductive outcomes among emergency cases admitted into the Labor Ward of the University College Hospital in Ibadan City, Nigeria. The study took place between May 1, 1984 and February 28, 1985 and included all emergency cases admitted (EA) into the hospital. 144 matched pairs of patients (emergency and booked cases) were admitted into the study making a total of 228 patients. Results of the study showed no observed differences in the educational or occupational status of the spouses of booked patients compared with EA. However, there were more uneducated women among the EA than the booked. IN both groups younger patients (15-34) had format education compared with the older patients (35+), strengthening the hypothesis that education is the most influential factor in patient's acceptance of modern maternity care. Polygamy and Islam were more prevalent among the EA than the booked. It is believed that the economic affects of polygamy exercise more direct adverse effects on reproduction than religion. The purdah system, practiced by Moslems confines women to their homes, interfering with their ability to get pre-natal care. Fewer number of EA lived with their spouses compared with booked patients. Lower social class is associated with larger numbers of adverse factors in reproductive outcomes such as increased rates of low birth weight babies, multiple pregnancies and fetal abnormalities. (Author's modified).^ieng

Neonatal jaundice among Nigerian preterm infants.

Jaundice among Nigerian preterm infants under special care was studied to determine the incidence of clinical jaundice, the predisposing factors and outcome among those with significant hyperbilirubinaemia (SBR greater than or equal to 10mg/dl). The incidence of jaundice among 292 preterm infants over an 18-month period was 71.2%. The male: female ratio was 1:1.04. Of the 74 infants with serum bilirubin 10mg/dl or more, prematurity alone was the identified cause in 44 (59.5%), Glucose-6-phosphate dehydrogenase (G-6-PD) deficiency and septicaemia were the only additional factors in 13 (17.6%) and 7 (9.5%) respectively, while multiple aetiological factors (prematurity, septicaemia and G-6-PD deficiency) were identified in six (8.1%) of the babies. Septicaemia was associated with higher mean bilirubin levels and the highest mortality. The two kernicteric infants in the study had septicaemia. Thus, the single most important cause of jaundice was prematurity. G-6-PD deficiency alone did not appear to increase the incidence and severity of hyperbilirubinaemia in this study. Septicaemia should be suspected and promptly treated in order to reduce mortality and risk of kernicterus among preterm infants with hyperbilirubinaemia.

Neonatal septicaemia in the tropics.

This review has shown a high incidence of neonatal septicaemia in a tropical environment. The predisposing factors leading to increased incidence of primary septicaemia include low maternal socioeconomic status, lack of adequate prenatal care, unsterile delivery practices in those born at home and increased incidence of susceptible hosts. Apart from gram-negative organisms, Staphylococcus aureus was the next common agent responsible for neonatal septicaemia. A combination of penicillinase-resistant penicillin and an eminoglycoside in particular gentamycin, should be the initial antibiotic of choice in suspected cases of neonatal septicaemia. Suggestions for reduction in the incidence of neonatal septicaemia were discussed.

Reproductive performance following active management of diabetic pregnancies at the University College Hospital, Ibadan, Nigeria.

This article presents a report of the first 5 years of an active approach to the management of diabetic pregnancies at the University College Hospital, Ibadan. During this period the incidence rate of diabetic pregnancy was 0.64 per 1000 deliveries per year. The mean birthweight (3.40 +/- 1.68 kg) of babies whose mothers had good diabetic control was lower than the mean birthweight (4.19 +/- 1.05 kg) of babies born to mothers with poorly-controlled diabetes. The difference was however not statistically significant (P less than 0.5). Whilst the overall perinatal mortality rate was 10.8%, there was a statistically significant difference in the perinatal mortality associated with poor control of diabetes (42.9%) when compared with good control (0.0%): P less than 0.02. The authors conclude that earlier booking in pregnancy, stricter control of diabetes by multiple insulin injections and improved cooperation of the patients will in future help to lower the perinatal mortality rate associated with diabetic pregnancy.

Congenital diaphragmatic hernia: Update on regional experience.

A consecutive series of 34 patients with congenital diaphragmatic hernia are reported from a tertiary neonatal care unit in the Eastern Province. All the patients presented within the first 24 hours of life with left-sided defect. The overall mortality (56%) and postoperatiVE mortality (44%) are comparable with reports from other centers. The outcome of treatment correlated well with the age on presentation, the size of the defect, and preoperative blood gas results. Our approach to management has been modified lately, in the light of recent experience from other centers. The surgery is delayed until the neonate is stabilized with biochemical values of PaCO2 = 45 torr or less; pH = 7.2 or higher; and PaO2 = 50 torr or more. This management policy did not adversely affect overall survival. The problem encountered with patient transfer and the need for continued improvement in the organization of regionalized care are highlighted.

Hearing screening of infants at King Fahd Hospital of the University.

The detection of hearing impairment in neonatal life and prompt intervention prevents the hazards of physical and developmental delay in speech. During a 12-month period between April 1987 and March 1988, the hearing of 151 well babies and 30 high-risk babied aged 6 to 12 months attending the pediatric clinics of King Fahd Hospital of the University (KFHU), Al-Khobar, were screened. The modified Ewing-Stykar test was performed on all babies. Tympanometry, stapedial reflex, and brainstem evoked response (BERA) were carried out in the well babies who failed the screening test and in all high-risk babies. The failure rate was found to be 4.6% and 43.3% and the validity index 71.4% and 92.3% for the well and high-risk babies, respectively. The results of this limited study encourages us to recommend the implementation of this screening test in all the well baby and the high-risk baby clinics in the Kingdom of Saudi Arabia.

Tuberculin conversion following BCG vaccination in preterm infants.

Tuberculin conversion following BCG vaccination was evaluated in 3 groups of infants. Group I consisted of 12 preterm appropriate-for-gestational-age (AGA) infants given BCG vaccination at birth; Group II was made up of 15 term AGA infants similarly immunized while 8 preterm AGA infants (Group III) received BCG about the time estimated to be their normal birth-date. The tuberculin conversion rates of 83%, 93% and 88% in groups I, II and III respectively were not significantly different (p greater than 0.5). The results suggest that the preterm AGA infants born at 32-36 weeks of gestation can be effectively immunized with BCG at birth.

Low birthweight in an urban community in Nigeria.

Six thousand, one hundred and thirty-five consecutive live births in six major health centres in the city of Ibadan were studied between September 1982 and March 1983 in order to assess the incidence, distribution and causes of low birthweight (LBW) in an urban community in Nigeria. Of the 6135 live births, 504 (8.2%) were of LBW. Two hundred and thirty-six (62%) of the LBW were small-for-gestational-age (SGA), while 146 (38%) were appropriate-for-gestational-age (AGA). Two hundred and five (87%) of the SGA were term while 115 (79%) of the AGA infants were preterm. Multiple pregnancy was an important cause of LBW, occurring in 4.4% of pregnancies. One hundred and forty-six (2.6%) of the 5631 infants who weighed 2500 g or over and 122 (24.2%) of the LBW infants were products of multiple pregnancy (P less than 0.001). The young (less than 20 years), short statured (less than 155 cm) and primigravid mothers were more likely than the others to give birth to LBW infants (P less than 0.001). Of the obstetric and medical factors examined, pre-eclamptic toxaemia (PET) (P less than 0.01), ante-partum haemorrhage (APH) (P less than 0.01) and anaemia (P less than 0.02) significantly increased the risk of LBW. Pre-eclamptic toxaemia, eclampsia, hypertension and renal diseases tended to be associated with SGA while APH and anaemia were found more often with prematurity. Multiple pregnancy contributed equally to the delivery of preterm and growth-retarded infants. Although no obvious cause could be identified in about two-thirds of the cases, pre-conceptional maternal malnutrition and poor diet in pregnancy might play an important role.