Nigerian Journal of Paediatrics 2011;38(2):82-89
ORIGINAL
A .A Okechukwu,
Congenital Malaria Among Newborns
E.K. Olateju,
Admitted for Suspected Neonatal Sepsis In
E.O. Olutunde.
Abuja.
Received:10 February 2011
Summary
parasites in their blood film, 97
Accepted: 22 May 2011
Background: Signs and symptoms
(36.5%) were blood culture
of congenital malaria do not differ
positive, and 12 (4.5%) had both
much from those of neonatal
positive blood culture and malaria
A .A Okechukwu ( )
sepsis: both can co-exist, and most
parasite. Among the recruited
Department of Paediatrics,
times very difficult to differentiate
babies, 82.4% were noticed to have
University of Abuja Teaching
clinically.
low parasite density, 13.2% had
Hospital , Gwagwalada.
Objective: To document the
moderate density, while 2.6% had
Email: nebokest@yahoo.com
prevalence, risk factors for
high density. Peripartum pyrexia,
Tel: +2348036719906
congenital
malaria
among
prematurity and intrauterine HIV
neonates admitted for suspected
exposure, were found to have
neonatal sepsis, and determine
significant association with
sensitivity,
specificity
and
congenital malaria, (OR = 7.9, 7.2,
predictive values of some common
4.4) for peripatum pyrexia,
signs and symptoms.
prematurity and HIV exposure, p
Method: Blood for culture, thin
values <0.05. None of the clinical
and thick blood film for malaria
feature had good sensitivity,
parasite were taken for all cases of
specificity or predictive value for
suspected neonatal sepsis at the
congenital malaria, and only 1.6%
special care baby unit of the
death was recorded in a baby with
hospital, from August 2007 to
high parasite density.
December 2009 .
Conclusion: Congenital malaria is
Results: A total of 266 newborns
common
in
newborns
with
(150 males and 116 females) with
suspected neonatal sepsis. History
suspected neonatal sepsis were
of peripartum pyrexia, prematurity
recruited. Their mean admission
and intrauterine HIV exposure was
weight
was
2.5±0.87
kg,
associated with increased risk of the
gestational age was 36.1±3.5
disease.
weeks, and age of 5.1±2.3 days.
While 76 (28.6%) had malaria
Introduction
cause of infant morbidity and mortality in African
4
but neonatal malaria (NM) was taught to be rare.
5,6
Neonatal sepsis (NS) has remained one of the
This was believed to be partly due to the protective
commonest reason for admission into most special
effect of fetal haemoglobin F present in the blood of
care baby unit (SCBU) in Nigeria. It is responsible
1
the neonates, as well as the transplacental transferred
7
for over 25% of all neonatal mortality,
2,3
and a major
maternal antibodies. Congenital malaria (CM) is
6
problem in many developing countries partly
defined as the presence of malaria parasite (MP) in
because of non-availability of standard neonatal
the peripheral blood smear of a new born baby within
the first seven days of life,
8-10
care. Malaria has also been recognized as a leading
Recently, there are many
83
reported cases of CM in most endemic malaria areas,
maternity homes, nearby primary health centers in
ranging from 1.5% in Maputo Mozambique,
11
to
addition to self referrals from home. SCBU is a 32-
28.2% in Jos, Nigeria 35% in Calabar
12
13
and as high
14
bed capacity key service ward in our health
as 46.7% in Ile-Ife. The reported increase has been
institution. It is an area where newborns are promptly
attributed to increased resistance of plasmodium
managed on 24 hour basis, and represents a high
falciparium (PF) to anti-malaria drugs resulting in
volume, high stress service area of the hospital.
increase in maternal parasitaemia,
15
mothers on
UATH is a 350-bed capacity tertiary health institution
regular malaria chemoprophylaxis having low
located in the Federal Capital Territory (FCT), Abuja
malaria antibody titers and hence transfer little
in the north central zone of the country. It is sub-
protective antibody to their newborns,
16
and most
serving many neighbouring states including
importantly increased reporting of cases.
17
CM is
Nassarawa, Niger, Kogi, Benue, parts of Kaduna
thought to have resulted from MP crossing the
state and FCT,Abuja
placenta from maternal blood to the fetal circulation.
The exact mechanism of this crossing is not know,
Blood for culture, total white blood cell count/
but damage to the syncytiotrophoblast occurring
differentials, and malaria parasite (MP) were
during active placental infection has been
collected from the study patients. Blood for culture
suggested.
14,18
This type of malaria has been shown to
was collected in 2 bottles, one containing glucose
occur in babies of clinically healthy mothers who are
broth and the other thio-glycolate medium, and both
delivered in malaria endemic areas. In babies of
19
were incubated at 37°C for 48 hours. Growth in either
these women with high level of immunity, CM is
of the media was sub-cultured on Mc-Conkey, blood
generally asymptomatic, majority of parasites being
or chocolate agar and further tested for antibiotic
rapidly cleared from the infant's circulation as a
sensitivity. However, if no growth was observed,
result of passive protection of the baby by maternal
further incubation was done for another 48 hours.
antibody crossing the placenta, active immunity
Other investigations like urine, stool or cerebrospinal
developing from exposure to soluble malaria
fluid culture were determined by clinical
antigens in utero, and high proportion of fetal
presentations of the neonate. Thin and thick blood
haemoglobin present in the babies which retards the
films were prepared immediately upon collection of
growth of the parasite.
7,18
blood on separate slide. For thick films, 12 µl of blood
Clinical signs of CM may be indistinguishable from
was spread over a diameter of about 15 mm, while 2
that of NS.
13,20
This has lead to many researchers
µl of blood was used for thin films. The thick film
suggested screening for MP to be included as part of
smear was allowed to air dry before being
routine investigation in newborn infants with fever.
20
dehaemoglobinized with buffered distilled water at
The increasing reported cases of CM in
PH of 7.2. The thin film was fixed in absolute
hyperendemic areas, and the difficulty in
differentiating NS from this disease condition
methanol for 1-2 minute before air drying. Both thick
necessitated the need to determine the prevalence of
and thin blood films were stained after 24-48 hr with
CM in babies admitted for NS, assess the risk factors
3% Giemsa stain solution at pH 7.2. For the thick film
associated with it and determine sensitivity,
the dilution was in the ratio of 1 volume of Giemsa to
specificity, and positive predictive values of some
9 volume of buffered distilled water, while that of thin
common clinical signs and symptoms. It is
film the dilution was at 1 : 29 of Giemsa and distilled
envisaged that the result(s) of this findings will assist
water. The stained slides were read by a Laboratory
health care providers in identifying newborns at risk
Technologist. The method adopted by Greenwood
andArmstrong and described by Cheesbrough was
21
22
of this disease for early investigation and
management.
used to determine MPdensity. The average number of
parasites counted per high power field (100 x
objectives) was multiplied by 500.
21,22
Between 10
Subjects and Methods
and 15 fields were counted for each slide, and results
given per μ l of blood. A definitive diagnosis of
An 18month prospective study was carried out at
malaria was made when a reddi sh chromatin dot with
University of Abuja Teaching Hospital (UATH),
a purple or blue cytoplasm of the malaria parasites are
Gwagwalada between the months of August 2007 to
seen together. A slide was pronounced negative when
December 2009. Neonates with features of NS and
100 high power fields have been examined using
admitted into the special care baby unit (SCBU) of
×100 oil immersion objective lens. Malaria parasite
the hospital were recruited into the study. For the
density was considered significant when MP count
purpose this study, analysis was on newborns with
was greater than 1,000 parasit es per μ l of blood. Low
congenital malaria (ie those babies with positive MP
parasite count was when count of 500 parasite/µ/ of
in their blood stream in their first seven days of life).
blood and below was ob tained, moderate count was a
Majority of the babies admitted into the unit were
count of >500-<1,500 parasite/µl of blood, while
referrals from the neighbouring general, private, and
high parasite count was a count of >1,500->3,000
mission hospitals. Referrals were also received from
parasite/µl.
84
Other information collected from the patients
Congenital Malaria Only
includes: age at onset of symptoms (days),
Table: 3 shows maternal and neonatal factors and
presenting problem and duration of such problem,
malaria parasite density among 64 newborns with
gender, admission weight (AW), mother's parity,
CM. Congenital malaria was identified in 71.9% of
history of maternal peri-partum pyrexia (PPP),
neonates from low socio-economic class (LSEC), in
history of rupture of membrane (ROM), whether the
67.2% of mothers on anti malaria prophylaxis
mother attended/ received antenatal care, gestational
(daraprim) during pregnancy, in 65.6% of preterm
age (GA), treatment given/ outcome of the illness,
deliveries, in 59.4% of para1 and 2 mothers, and in
HIV status of the mother, and socio-economic status
39.1% of mothers with peri-partum pyrexia (PPP).
(SES) of the parents using Olusanya's two factor
Low birth weight (LBW), maternal PPP, and intra
index: husband's occupation and mother's level of
uterine HIV exposure, were the maternal and
education. All newborns admitted into SCBU for
23
neonatal factors found to have significant association
CM and found to have moderate and high MPdensity
with CM (OR of 7.2 with CI of 1.20 18.47, p value
in their blood film were treated for malaria with oral
0.002 for LBW, OR of 7.6 with CI of 1.32 18.37, p
quinine.
value 0.002 for PPP, OR of 4.4, 95% CI of 0.98 -9.82
Ethical approval was obtained from the Ethics
and p value 0.35 for HIV exposure. No association
committee of the hospital. Signed or thumb-printed
was seen in mothers with rupture of membrane (OR
informed consent was also obtained from the
of 0.66, 95% CI of 0.19 - 2.14, p value 0.55), and
mothers of the subjects after adequate explanation of
those on anti malaria prophylaxis (OR of 0.33, 95%
the purpose of the research in the language they
CI 0.12 - 2.01, p value 0.65). Moderate and high
understood best. The research data was coded,
parasitaemia were seen more in newborns of mothers
privacy protected and confidentiality maintained.
with PPP, preterm deliveries, HIV exposed babies of
Data analysis was conducted using SPSS version
mothers from low socio-economic class (LSEC).
13.5. Tests for associations and differences were
Sensitivity, Specificity and Positive Predictive
done by chi-square analysis. Statistical significance
Values of Common Presenting Signs and Symptoms
was set at p value < 0.05.
Sensitivity, specificity and positive predictive values
(PPV) of common clinical signs and symptoms of
CM in newborns was shown in table 4. While
Results
hepatomegaly, fever, jaundice, fast breathing, poor
feeding, pallor, and irritability were the common
The characteristics of recruited newborns are shown
symptoms and signs seen in newborns with CM,
in table 1.Atotal of 266 newborns with suspected NS
jaundice, pallor, fever, and hepatomegaly were the
and accounting for 25.8% of the total admissions
only three clinical features that had fairly good
were recruited for the study. There were 150 males
sensitivity, specificity with PPV, 81.3%, 34.2% and
and 116 females with male to female ratio of 1.3:1.
28.1% for hepatomegaly, 50.0%, 43.5%, and 21.9%
The mean admission weight( AW) was 2.5±0.87 kg,
for fever, 39.0%, 67.8% and 38.5% for jaundice, and
with mean GAof 36.1±3.5 weeks, and age of 5.1±2.3
23.4%, 83.7% and 31.3% for pallor.
days.
Babies with Malaria Parasitaemia
A total of 76 neonates (35 males and 41 females: 0.9
Table 1
to 1) were positive for malaria parasitaemia (MP)
Profile of Recruited Newborns with Presumed
while 109 had culture-proven sepsis accounting for
Sepsis.
26.8% and 41.0% of the screened population
respectively. Of these, 64 had MP alone, 97 had
Male
Female
Total
bacterial sepsis alone and 12 had MP in association
with culture proven sepsis. The meanAW for babies
with CM was 2.4±0.24 kg, GAof 35±4.3 weeks and
Total no
150
116
266
recruited
*4.7±3.1
*5.5±4.3
*5.1±3.7
Age of 3±0.7 days. Further analysis of babies with
Age (days)
*2.6±0.84
*2.4±0.89
*2.5±0.87
CM showed that 52 (81.3%) of them had low PD
Weight (kg)
*36.9±2.8
*35.3±4.2
*36.1±3.5
(parasite count of 500 parasite/µ/ of blood), 10
Gestational age
*2.0±1.9
*3.0±1.1
*2.5±1.5
(15.6%) had moderate PD (parasite count of >500-
(weeks)
82
77
159
<1,500 parasite/µl of blood), while 2 (3.1%) had
Mother’s parity
33
28
61
high PD (parasite count of > 1,500-> 3,000
SVD
parasite/µl) fig 1. There was no significant
C/S
difference in malaria PD between male and female
*Values are mean ±SD
newborns, p >0.05 (table: 2).
SVD = Spontaneous vertex delivery.
Maternal/ Neonatal Factors and 64 Babies with
C/S = Caesarian section
3
85
Table 2
Malaria Parasite Density in Babies Admitted For
Neonatal Sepsis according to sex.
Male (%)
Female
Total %)
(%)
No of recruited patients
150(56.4)
116(43.6)
266(100)
Total no with CM
36(47.4)
40(52.6)
76(28.6)
No with only CM
30(46.9)
34(53.1)
64(24.1)
Only CM with low PD
23(44.2)
29(55.8)
52(81.3)
Only CM with moderate PD
3(30.0)
7(70.0)
10(15.6)
Only CM with high PD
2(100.0)
0(0.0)
2(3.1)
No of BCP patients
61(62.9)
36(37.1)
97(36.5)
No of BCP with CM
8(66.6)
4(33.3)
12(12.4)
CM with Low PD and BCP
7(77.7)
2(22.2)
9(75.0)
Figure 1 : Malaria parasite densiy distribution among
CM with moderate PD and BCP
1(33.3)
2(66.6)
3(25.0)
76 neonates with congenital malaria
CM with high PD and BCP
0(0.0)
0(0.0)
0(0.0)
MP= Malaria Parasite, CM= Congenital Malaria,
PD= Parasite Density, BCP= Blood culture positive.
Low= 500 parasite/µ/ of blood.
Moderate=>500- <1,500 parasite/µl of blood.
High=> 1,500-> 3,000 parasite/µl.
Table: 3 Maternal/Neonatal factors and Malaria Parasite Density in 64 Newborns with Congenital
Malaria only .
Maternal/Neonatal factors
Low
Moderate
High (%)
Total (%)
(%)
(%)
Peripartum pyrexia
14(56.0)
10(40.0)
1(4.0)
25(30.1)
Rupture of membrane
6(66.7)
33(33.3)
0(0.0)
9(14.1)
Para1
17(77.3)
5(22.7)
0(0.0)
22(34.4)
Para 2
13(1.3)
3(18.8)
0(0.0)
16(25.0)
Para 3
12(80.0)
1(6.7)
2(13.3)
15(23.4)
Para >3
10(0.9)
1(9.1)
0(0.0)
11(17.2)
Birth weight <2,500gms
31(73.8)
9(21.4)
2(4.8)
42(65.6)
Birth weight > 2,500gms
21(95.5)
1(4.5)
0(0.0)
22(34.4)
HIV exposed babies
6(50.0)
4(33.3)
2(16.7)
12(18.8)
Mothers on AM prophylaxis during pregnancy
41(95.3)
2(4.7)
0)0.0)
43(67.2)
SES 1
3(75.0)
1(25.0)
0(0.0)
4(6.3)
SES 11
5(100.0)
0(0.0)
0(0.0)
5(7.8)
SES 111
8(88.9)
1(11.1)
0(0.0)
9(14.1)
SES 1V
16(76.2)
4(19.1)
1(4.8)
21(32.8)
SES V
20(80.0)
4(16.0)
1(4.0)
25(39.1)
Low= 500 parasite/µ/ of blood
Moderate=>500- <1,500 parasite/µl of blood
High=> 1,500-> 3,000 parasite/µl
4
86
Table: 4
Frequency of selected maternal and neonatal factors among 64
neonates who had congenital malaria only.
Maternal/Neonatal factors
Low
Moderate
High
Total (%)
Peripartum pyrexia
14
10
1
25(39.1)
Rupture of membrane
6
33
0
9(14.1)
Para1
17
5
0
22(34.4)
Para 2
13
3
0
16(25.0)
Para 3
12
1
2
15(23.4)
Para >3
10
1
0
11(17.2)
Birth weight <2,500gms
31
9
2
42(65.6)
Birth weight > 2,500gms
21
1
0
22(34.4)
HIV exposed babies
6
4
2
12(18.8)
Mothers on AM prophylaxis during pregnancy
41
2
0
43(67.2)
SES 1
3
1
0
4(6.3)
SES 11
5
0
0
5(7.8)
SES 111
8
1
0
9(14.1)
SES 1V
16
4
1
21(32.8)
SES V
20
4
1
25(39.1)
Low= 500 parasite/µ/ of blood
Moderate=>500- <1,500 parasite/µl of blood
High=> 1,500-> 3,000 parasite/µl
SES- Socio-economic class.
Table 5: Clinical Signs and Symptoms and Malaria Parasite Density in 64 Neonates
with Only Congenital Malaria.
Symptoms
Malaria Parasite Density
And signs
Low
Moderate
High
Total
Sensitivity
Specificity
PPV
(%)
(%)
(%)
(%)
%
%
%
Fever
20(62.5)
10(31.3)
2(6.3)
32(50.0)
50.0
43.5
21.9
Diarrhoea
3(75.0)
1(25.0)
0(0.0)
4(6.2)
6.3
89.6
16.0
Jaundice
19(76.0)
4(16.0)
2(8.0)
25(39.0)
39.0
67.8
38.5
Irritability
2(15.4)
9(69.2)
2(15.4)
13(20.3)
20.3
57.4
13.3
Pallor
6(40.0)
7(46.7)
2(13.3)
15(24.3)
23.4
83.7
31.3
Fast breathing
10(50.0)
8(40.0)
2(10.0)
20(31.3)
39.0
32.2
15.4
Poor feeding
12(70.6)
5(29.4)
2(11.8)
17(26.6)
26.6
24.8
10.1
Hepatomegaly
20(62.5)
10(31.3)
2(6.3)
32(50.0)
81.3
34.2
28.1
Low=500 parasite/µ/ of blood and below
Moderate= >500- <1,500 parasite/µl of blood
High= >1,500- >3,000 parasite/µl
reported prevalence rates of CM in different parts of
the country and even in the same geographical zones
may be attributed to the skill and experience of the
Discussion
laboratory personnel involved in blood film
preparation, staining, and reading of the slides, as
The data generated from the study shows that CM is
results of training programmes on malaria
common in newborns with suspected NS (28.6%).
microscopy have shown low levels of sensitivity and
This was similar to 35.0% from a similar study in
specificity of those involved in malaria diagnosis
Calabar
13
and 28.2% from another study in
routinely and for research, or it could be as a result
24
hyperendemic area of Jos
12
in the same geographical
of increased resistance of plasmodium falciparium
zone. The finding was however higher than 5.1%
(PF) to anti-malaria drugs in some parts of the
reported in a multi-center study in the country,
24
country resulting in increase in maternal
8.25% from Northern part of the country,
20
parasitaemia. However, all these reports support the
15
and
16.7% from Tanzania, but much lower than 46.7%
25
growing number of cases of CM in hyperendemic
reported from Ile-Ife. The differences in the
14
areas.
87
Early workers found primary attack of CM to be mild,
between malaria parasite and low birth weight, as
and in most instances confined to a transient
placental parasitaemia has been reported as a major
asymptomatic parasitaemia.
25,26
In the majority of
cause of LBW in malaria endemic areas. Maternal
asymptomatic cases, the parasites
were rapidly
HIV infection has also been found to increases the
cleared from the infant's blood from the
prevalence and intensity of malaria infections in
transplacentally transferred maternal antibodies.
25,26
pregnancy. Both HIV infection and malaria in the
33
In support of above statement was the findings that
mother are well known independent risk factors for
62.1% of smear positive newborns had remained
both the mother and her baby, and when both co-
asymptomatic after three days of delivery in a multi-
exist, the
risk of damage to the placental
centered study in the country. In the present study,
27
syncytiotrophoblast will be increased so also will be
81.3% of newborns with CM had low parasite count
there be more chances of entry of MP into the feotal
of 500 parasite/µ/l of blood or less, thus this may
circulation, and hence CM.
represent the transient asymptomatic parasitaemia
Clinical signs of CM may be indistinguishable from
phase that may be cleared off with time. Only 18.7%
those of NS whose main presentation is fever, this has
presented with moderate and high malaria PD of
led to the suggestion that screening for MP should be
>500 parasite/µ/l of blood which could be the
included as part of routine investigation in newborn
s y m p t o m a t i c
f o r m
o f
C M .
infants with fever, as Nyirjesy et al
34
has reported
Many risk factors have been identified to increase the
increased risk of perinatal deaths (RR=7.2), and low
risk of CM in newborns, notably among them
birth weight from CM. In the present study, most
includes primigravidae, LBW and PPP. Similar risk
27
blood culture positive neonates and those with
factors including intrauterine HIV exposure were
moderate and high density parasitaemia in their
also found to have increased association with CM
blood smear presented with fever, thus justifying the
(OR = 4.4) in the present study. Peripartum pyrexia
recommendation that all newborns with fever should
which results from maternal infective conditions
be screened for malaria. There is wide documented
notably malaria may damage the syncytiotrophoblast
similarity in the clinical presentation of these two
during active placental infection. This damage as
disease entities and because of the difficulties
previously documented will facilitate the entry of MP
encountered clinically in differentiating the two
from the placenta into the fetal circulation, thus
especially in hyperendemic malaria areas, the
increasing the chances of CM in her offspring.
28,29
sensitivity, specificity as well as the PPV of common
Primigravidas have also been reported to be at a
f
clinical signs and symptoms tested. Though none of
Greatest risk of malaria in pregnancy because they
the clinical signs and symptoms showed good
lack the specific immunity to placental malaria which
sensitivity/ specificity and PPV for CM, however,
is acquired from exposure to malaria parasites during
fever, hepatomegaly, jaundice and pallor had fairly
pregnancy.
30,31
This immunity accumulates with
varying sensitivity, specificity and PPV for CM. The
successive pregnancies, provided there is exposure to
present study therefore justifies the recommendation
malaria infection.
32
that screening for MP be part of septic work up in
Literature exist between maternal/placental malaria
newborns who presented with fever, especially when
parasitaemia during pregnancy and LBW.
28,29
It is
there is an associated history of maternal PPP,
therefore not surprising to find a strong association
prematurity or intrauterine HIV exposure.
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