Nigerian Journal of Paediatrics

5Spectrum of neonatal diseases requiring respiratory support in UBTH Benin City Edo State Nigeria

Niger J Paediatr 2016; 43 (4): 258 – 263

ORIGINAL

Okolo AA

Spectrum of neonatal diseases

Okonkwo RI

Ideh RC

requiring respiratory support in

UBTH, Benin City, Edo State,

Nigeria

DOI:http://dx.doi.org/10.4314/njp.v43i4.5

Accepted: 8th August 2016

Abstract : Introduction: In Nige-

cephalopathy (ABE) 8.2%, tran-

ria, eighty two percent of the three

sient tachypnoea of the new-born

Okolo AA

(

)

leading causes of neonatal mortal-

(TTNB) 2% and neonatal tetanus

Okonkwo RI, Ideh RC

ity may require respiratory sup-

(NT) 2%.

Neonatal Unit,

University of Benin Teaching Hospital

port for their management, yet

They were non- invasive support

PMB 1111

this is unavailable.

(NIVRS) 33(67.3%) for respira-

Benin City, Edo State, Nigeria.

Objective: To review the spec-

tory distress; invasive support

Email: angelneneo@yahoo.com

trum of respiratory disorders that

(IVRS) 16(32.7%) for respiratory

were ventilated, their outcomes

failure. NIVRS was mostly for

and the contribution of such sup-

RDS (88.9%); ABE (100%) re-

port to survival

ceived invasive support.

Mortal-

Methods: A data base of cases

ity

was:

NIVRS7/33(21.2%);

managed in the unit is maintained

IVRS 11/16(68.75 %). Respiratory

and reviewed regularly for en-

dysfunction contributed 25.4% of

hancement of quality of care.

the total neonatal mortality of 123

Such prospectively documented

per thousand. Survival was 63.3%.

information on babies who re-

Conclusion: The morbidities were:

ceived respiratory support over

asphyxia, prematurity, sepsis,

the period 1 January to 31 June

ABE, and tetanus. Ventilator sup-

2014 were analysed.

port was non-invasive with bubble

Results: Five hundred and seventy

CPAP and invasive with mechani-

six babies were admitted. Forty-

cal ventilation through endotra-

nine (8, 5%) received ventilator

cheal intubation. Survival was

support. These comprised preterm

improved. There is the urgent need

(77.6%) and term (22.4%) babies

to commence and sustain basic non

with mean gestational age of 33.2

-invasive respiratory support in all

weeks (range 28-41). The spec-

neonatal units in Nigeria.

trum of disorders supported were:

respiratory

distress

syndrome

Key Words: Spectrum; Neonatal

(RDS) 55.1%, asphyxia 20.4%,

diseases; Respiratory support

sepsis12.3%, acute bilirubin en-

Introduction

function is inadequate. Such support could be invasive

(via endotracheal tube) or non-invasive (NIV), for short

or long periods.

Close monitoring of a mother in labour with prompt

intra partum care and provision of delivery room resus-

citation have all been shown to reduce asphyxia

Respiratory dysfunction is a major component of the

rates. The changing pattern of admissions with increase

causes of neonatal mortality. Presently in Nigeria, neo-

in preterm births over the more recent times indicate the

natal mortality rates are unacceptably high. Eighty two

need to search for newer approaches to address prob-

percent of the causes of these deaths are largely prevent-

lems associated with prematurity and LBW. It is well

able. The major causes of neonatal deaths are asphyxia,

prematurity, infection and tetanus. Globally, three of

known fact that prematurity is often complicated by res-

piratory problems.

these are also responsible for 75% of the causes of new-

born deaths. Developed countries have made significant

We realise that establishing and maintaining an ICU/

advances and reduced neonatal mortality because they

ventilator facilities is expensive even in the developed

focused on management modalities that target these

countries. However, their use in such developed econo-

causes in their approach towards reduction. Progress is

mies contributed significantly to neonatal survival.

1, 2

particularly slow in Africa. Nigeria ranks second and

contributes 9% of the global mortality figures.

Respiratory support though not curative is essential for

management of neonatal respiratory problems when

Artificial ventilation for new-borns was introduced in

259

1959. Despite the fact that its use at the time was contro-

In the developed countries, the refinement of mechanical

versial for RDS because the ventilators were not de-

ventilation dramatically improved the survival of many

high-risk neonates. Respiratory distress accompanies a

signed specifically for new-borns and in particular for

preterm newborns. Its use contributed to decreased

myriad of problems in the newborn and thus constitutes

rates of mortality in larger infants who died of inade-

a major clinical sign for hospital admissions into neona-

tal units. Respiratory support is therefore urgently

quate respiratory effort.

needed when respiratory function is inadequate to avoid

The neonatal mortality rate (NMR) in the United States

further deterioration and death.

has decreased markedly over the past 60 years. In 1935,

Prematurity contributes significantly to cases of respira-

before the field of neonatology existed, the NMR was 35

tory distress and emphasises the need for availability of

per 1000 live births. Since the 1950s, medical advances

respiratory support. It is therefore not surprising that

have decreased the NMR in a linear fashion to its cur-

premature births account for 35% of neonatal deaths

rent rate of 4 per 1000 live births.

9,10

Despite the im-

globally.

5,18

provements in neonatal care in high-income settings,

neonatal mortality contributes 40% to the mortality rate

Respiratory support had been in place for the care of

for children younger than 5 years globally. This empha-

sick new-born in our establishment in the 1980s but the

sises the need to refocus neonatal care in resource lim-

technology was not sustained through the 1990s and

ited settings where the gap in standards and quality

beyond for various reasons common to resource poor

exist.

settings. It has only been recently reintroduced in late

2013. Because of differences in epidemiology of dis-

Mechanical ventilation was not widespread outside of

eases, the spectrum of disorders needing respiratory sup-

Europe and USA until the 1980s.

It came into use in

port in our local environment may differ from that of

India in the late 1980s and showed some improvements

developed communities. Therefore, we conducted a re-

to mortality indicators.

By 1995 it was increasingly

view of our recently introduced strategy to better under-

utilised and infants with RDS accounted for 36% of its

stand the spectrum of disorders requiring respiratory

use across the neonatal units in India. Nevertheless in

support, the type of interventions provided, whether

that setting, another study revealed that 17.8% of new-

these have decreased mortality attributable to respiratory

borns who required ventilator care could not be referred

dysfunction in our low resource setting. Results of this

because of financial constraints. Limited financial ac-

finding may be useful for policy setting for improved

cess is still a major constraint to neonatal care for most

quality and standard of new-born care services nation-

of the resource limited economy countries. Thus, the

ally.

level of technology available to treat a new-born with

respiratory distress varies significantly according to

This survey aimed at the documentation of evidence for

where the infant is born, the distance the sick infant has

the contribution of ventilator support in the management

to travel to reach a health centre with the appropriate

of respiratory dysfunction to survival and thus the urgent

level of care, and financial resources of the family. De-

need for its introduction in neonatal care in Nigeria.

spite the increased use of more sophisticated technology,

morbidity and mortality rates related to RDS remain

high in India largely because of disparities in standards

and limited access to quality care. Similar challenges are

Subjects and Methods

experienced in Neonatal care in low resource settings

Study site

like in Nigeria where the use of ventilator support is yet

to become widespread. To experience remarkable im-

This study was conducted at the special care baby unit

provements in neonatal survival these technological ad-

of our teaching hospital (SCBU). This Neonatal unit

vancements are required. In the introduction of these

(separated into IN Born and Out Born) has a cot capac-

advanced technological skills, it is to be realised that

ity of 50. The University of Benin Teaching Hospital

ventilator care cannot be used as a standalone support.

neonatal unit (SCBU) is functionally divided into neona-

Its use requires other ancillary support. This was noted

tal intensive care, high dependency unit, special care

in the work of Bhutta et al in a study of risk factors for

baby unit and transitional care bays. The neonatal unit is

mortality in infants with RDS at Aga Khan University

equipped with five (5) Neonatal mechanical ventilators,

Hospital in Pakistan. Bhutta and Yusuf noted that de-

three (3) patented standalone Nasal Continuous Positive

spite access to high technology, the medical staff re-

Airway Pressure (nCPAP) machines and capacity to

quired requisite training for the appropriate care of

offer improvised CPAP using our local devices.

sick new-borns. Basic neonatal care support like provi-

sion of warmth, gavage feeding or more sophisticated

Methods and Procedure

parenteral alimentation and monitoring of functions

The study was conducted from 1 January to 31 June

should be available in the context of neonatal intensive

care to support the technological efforts like ventilator

2014. It was a prospective descriptive study of all cases

support. This is not yet so in Nigeria where the popula-

with respiratory dysfunction identified from the unit’s

tion has limited access to acceptable standard of care.

data base. Data obtained included: Babies’ gestational

There are wide gaps and variation in the level of care

age, gender, mode of delivery, birth weight category,

available to the new-borns in Nigeria.

respiratory features, diagnosis, indication, mode and

260

duration of respiratory support and outcome. The

Table 2: Diagnosis and indication for support with the mode

subjects consisted of all babies who received respiratory

of support

support.

Diag-

N (%)

Indication n (%)

Mode of Support n (%)

nosis

The Silverman-Anderson score was used to grade the

Distress

Failure

NIV

Invasive

severity of respiratory distress and to indicate respiratory

RDS

27 (55.1)

25 (92.6

2 (7.4)

24(88. 9)

3 (11.1)

failure. The higher score is indicative of more severe

As-

10 (20.4)

6 (60)

4 (40)

5 (50)

degree of respiratory distress. A score greater than 7

phyxia

indicates that the baby is in respiratory failure. The indi-

Sepsis

6 (12.3)

4 (66.7)

2 (33.3)

3 (50)

cation for commencement of respiratory support was

ABE

4 (8.7)

4 (100)

according to the Neonatal unit protocol. (Babies with

TTNB

1 (2)

1 (100)

NNT

1 (2)

1 (100)

respiratory distress or evidence of increased work done

Total

49(100)

36 (73.5)

13(26.5)

33 (67.3)

16 (32.7)

for breathing were commenced on nCPAP). Babies were

on non – invasive (NIVRS) when on nCPAP or invasive

(IVRS) when on Mechanical ventilation with endotra-

Respiratory distress syndrome (RDS) (72.7%) is signifi-

cheal intubation.

cantly associated with the use of non-invasive support

while Acute Bilirubin Encephalopathy (ABE) (31.3%) is

Data analysis

significantly associated with invasive support (p=0.001).

Respiratory distress syndrome is the commonest indica-

The IBM/SPSS 19 was utilized. The means, ranges, fre-

tion for non-invasive support and non-invasive support

quencies and percentage were calculated. The indication

was the most frequently used mode.

and mode of support were cross-tabulated with the gen-

Whilst respiratory distress 36 (73.5%) and respiratory

eral characteristics. Chi-square was used to test associa-

failure 13 (26.5%) were the commonest cause for respi-

tions between indication and mode of support with ges-

ratory support. The support received were invasive in16

tational maturity. The level of significance was set at

(32.7%) and non – invasive in33 (67.3%) (Table 2).

p<0.05 and confidence level at 95%.

nCPAP devices were utilised to provide non-invasive

support. 24 (72.7%) of the 33 babies and 9 (27.3%) of

the 33 cases had the patented and the locally improvised

CPAP devices.

Results

Table 3 presents, Duration and indication for support

with the mode of support 14/49 babies (28.6%) received

Forty nine (8.5%) out of 576 babies admitted during the

support for less than 24 hours.

study period received respiratory support. Table 1 shows

Table 3: Duration and indication for support with the mode of

the general characteristics of these babies. Gestational

support

age (GA) ranged from 28-41weeks; with a mean of 33.2

± 3.69.

Duration / Indication

N (%)

Mode of Support

NIV

Invasive

Table 1: General characteristics of the study population

Length of time

Features

Characteristic n (%)

Duration

<24hrs

14 (28.6)

10 (71.4)

4 (28.6)

Gender

Male

25 (51)

M: F= 1:0.96

1-7days

34 (69.4)

23 (67.7)

11 (32.4)

female

24 (49)

>7days

1 (2)

1 (100.0)

Booking status

Booked

31 (63.3)

Indication

Total

Unbooked

18 (36.7)

Distress

36 (73.5)

33 (91.7)

3 (8.3)

Mode of delivery

SVD

22 (44.9)

Failure

13 (26.5)

13 (100)

ELCS

4 (8.2)

Total

33 (67.5)

16 (32.7 )

EMCS

23 (46.9)

Maturity

Term

11 (22.4)

Table 4 presents Gestational maturity with indication

Preterm

38 (77.6)

and Mode of support received. 13/16 of the mechani-

Weight Category

NBW

15 (30.6)

cally ventilated had endo- tracheal intubation.

LBW

12 (24.5)

33/49(67.4%) of the supported babies survived

VLBW

18 (36.7)

Overall mortality in the supported babies was18/49

ELBW

4 (8.2)

(36.7%). Mortality was significantly higher in babies

The spectrum of disorders that received respiratory sup-

who received IVRS (11/16 (68.75%) compared to those

port were: respiratory distress syndrome (RDS),

that received NIVRS 7/33 (21.2%); (X = 10.478; p =

asphyxia, sepsis, neonatal tetanus and acute bilirubin

0.001). Their diagnosis ranged from Neonatal Tetanus,

encephalopathy (Table 2)

ABE, HIE, to Sepsis and RDS. The commonest indica-

tion for this mode of support was respiratory failure. Of

the 33 babies who received NIVRS: 9 improvised

nCPAP and 24 patented nCPAP, a total of 7 died. 4/9

(44.4%) had the improvised CPAP. 3/24 (12.5 %) had

the patented nCPAP. (X² =3.997; p= 0.068 fishers exact

test) There was no significant difference in outcome

between the two groups. Among the dead babies who

261

had IVRS; 3 term babies had ABE, 2 term babies had

survival of these babies as there was no significant dif-

HIE and 1 ELBW had severe BA, 5 other preterm babies

ference in outcomes compared with the use of the pat-

who also had IVRS died.

ented device. The use of such local innovations as previ-

The neonatal mortality during the study period was

ously reported by Audu et al contributed to improved

status of babies with respiratory distress.

123.3 per thousand live births and respiratory related

mortality contributed 25.4% to this rate.

The introduction of NICU as well as ventilator care in

The overall mortality for the supported babies was

the developed countries yielded a sharp decline in neo-

natal mortality rates. This emphasises the point that

36.7%: survival for the supported respiratory disorders

was 33/49(67.4%) %. Survival for the modes are: IVRS

urgent attention needs to be given to improving quality

is (21.1%); NIVRS (78.8%). Survival for the patented

and standards of neonatal care in developing economy

nCPAP is 21/24(87.5%) while for improvised 5/9

as would be commensurate to available means. This

(55.5%) (Very small numbers)

would support the need for innovative approaches to

meet these demands. Such would include the widespread

Table 4: Gestational maturity with indication and Mode of

use of the bubble nCPAP in most parts of Nigeria so as

support

to reduce neonatal mortality accruing from respiratory

Gesta-

N (%)

Indication

Mode of Support

related causes.

tional

Distress

Failure

NIV

Invasive

maturity

As has been shown by this survey, 67.3% of cases of

Term

11 (22.4)

5(45.5)

6 (54.6)

5 (45.5)

6(54.6)

supported babies needed non-invasive support and this

Preterm

38 (77.6)

31(81.6)

7 (18.5)

28 (73.7)

10(26.3)

Total

49 (100)

36(73.5)

13 (26.5)

33 (67.3)

16(32.7)

was associated with a lower mortality relative to the

group who received invasive support. Non-invasive sup-

X =5.711, p=0.017 X =3.091, p= 0.079

port requires less sophistication and can be provided in

the context of a special care Baby unit in developing

countries.

15,26, 27

Discussion

Eight percent of the 576 babies assessed required respi-

ratory support; nearly 10% of the total, this actually

A low respiratory support rate of 8.5% has been ob-

makes the case for the availability of devices even at the

served in this survey. This is much lower than 43% ob-

lowest level of sophistication in resource limited set-

served by the Canadian neonatal network. This low

tings. Given that these were predominantly preterm ba-

support rate can be accounted for by the relatively new

bies who had RDS, it makes the case for other additional

introduction of respiratory support service in our centre

measures like the use of antenatal corticosteroids and the

compared to what obtains in a developed country’s neo-

use of surfactant in these group of babies to optimise the

natal health care system. Neonatal respiratory support is

non-invasive support that can be utilised in its simplest

available only in a few centres in our sub-region.

form in most of our communities in Nigeria.

Seventy seven per cent of the supported babies were

preterm and this emphasises the fact that preterm births

Sixty eight percent of babies who received invasive sup-

account for a sizeable proportion of our neonatal mor-

port died. This high mortality rate might have been due

bidities and mortalities. Evidence from literature con-

to the severity of the primary disease, it might also have

firms that high mortality rates are associated with pre-

been due to the low capacity of the health work force to

term birth rates as these are often associated with com-

cope with the high level technical support needed for

plications the most important of which include RDS.

mechanically ventilated babies in resource poor settings.

Despite this, the industrialised economies have suc-

The babies who were supported with the IVRS had

ceeded in driving down their neonatal mortality rates

ABE, HIE III and NT, all of which are causes that are

with the introduction of various forms of care for these

largely preventable. These direct causes of the morbid-

high risk new-borns. Such forms of care are embodied in

ities can be tackled by implementation of widespread

the context of Neonatal intensive care and regionalisa-

preventive strategies on a large scale. These may influ-

tion of care.

22-24

ence a decline in neonatal mortality as these causes are

also related to the major causes of neonatal mortality in

In this study, majority of these preterm babies required

Nigeria.

only non- invasive support which mode appeared to

have favoured their outcome as fewer of the babies with

The spectrum of disorders requiring respiratory support

non- invasive support died. It is possible that the early

in our setting are largely similar to the National causes

provision of the support which was more proactive had

of neonatal mortality and to a large extent similar to the

allowed for the early relief of work done for breathing in

global causes of Neonatal mortality. This implies that

3,4

such babies before worsening of their situation. This is

the causes can be positively influenced by improved

in tandem with current recommendations.

standard and quality of New-born care in Nigeria. This

Among the babies who received non-invasive support, a

requires not only measures to introduce less sophisti-

few were supported with the local bubble nCPAP inno-

cated technology devices but also measures must be

vation. Given the high demands for support we had to

taken to enhance the capacity and skills of the neonatal

utilise our locally improvised CPAP device to meet the

care health work force as this is highly relevant to intro-

needs. This local innovation may appear crude in their

duction of high level technology. This can be attested to

present form, however, its use also contributed to

262

by the fact that invasive respiratory support carried a

Conclusion

high mortality rate which might not be only related to

their morbidities of such babies but also to the skills of

We examined the spectrum of conditions requiring res-

the carers. Such high level skills and care is best pro-

piratory support they are disorders that lead to respira-

vided in the context of a neonatal Intensive care.

tory distress and respiratory failure. These predomi-

We recognise the role of various interventions in the

nantly required management with non-invasive tech-

drastic reduction of neonatal mortalities. Such include:

niques of the nCPAP. Respiratory support contributed to

Clean and safe delivery in the prevention of neonatal

survival in these babies. There is thus urgent need to

sepsis; prompt identification and treatment of infection

make available in Nigeria institutions that provide neo-

further efforts should identify other interventions that

natal care, basic non-invasive respiratory support as a

could contribute significantly to mortality reduction par-

possible cost effective intervention for neonatal mortal-

ticularly in a setting where health seeking behaviour is

ity reduction.

suboptimal. Such reductions could be achieved if atten-

tion is given to prompt management of respiratory prob-

Conflict of interest: None

lems.

Funding: None

The study is limited by the short duration of the report

and it only evaluated for outcome in relation to mortal-

ity. Such works would be better measure of quality of

Acknowledgements

care if it examined long term survival, as intact survival

and quality of life beyond survival are far more impor-

The Authors gratefully acknowledge the superlative care

tant particularly in such low resource setting as ours.

provided by the nurses on the Neonatal Unit and the

Such works in the future should actually evaluate intro-

contribution of the Resident doctors in the care of these

duced strategies for how readily replicable and sustain-

Babies

able they may be. The influence of capacity develop-

ment of providers of Neonatal care to outcomes should

also be evaluated.

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