Association of Hyperbilirubinemia Requiring Phototherapy or Exchange Transfusion with Hearing Impairment among Admitted Term and Late Preterm Newborn in a NICU.

Hearing impairment is one of the deleterious ramifications of neonatal hyperbilirubinemia, but its impact during the newborn period has not been well studied in Bangladesh. This prospective observational study was conducted during January 2016 to December 2017 in the Department of Neonatology and Otolaryngology-Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh to identify the relationship between hyperbilirubinemia requiring phototherapy or exchange transfusion with hearing impairment in term and late preterm neonates. Admitted term and late preterm neonates with hyperbilirubinemia requiring either phototherapy or exchange transfusion were taken as hyperbilirubinemia group. Neonates without hyperbilirubinemia from postnatal ward were taken as control. All newborn were screened with Distortion Product Otoacoustic Emissions (DPOAE) prior to discharge from hospital. A second screen was done in referred newborn after one month of first screen. A diagnostic Auditory Brainstem Response (ABR) was performed in both the ears prior to 3 months of postnatal age if referred in both 1st and 2nd screen. Total 264 neonates included in this study; 132 in the hyperbilirubinemia and 132 in the control group. In the hyperbilirubinemia group 74(56.06%) were male and 58(43.94) were female. Mean gestational ages in the hyperbilirubinemia group and control group were 36.95±1.60 weeks and 37.01±1.67 weeks respectively. Newborn in the hyperbilirubinemia group, 4(3.03%) had hearing impairment and none had hearing impairment in the control group. Peak Total Serum Bilirubin (TSB) 23mg/dl was found as best cut off value with a sensitivity of 100% and specificity of 93% for the development hearing impairment. Hearing impairment was significantly more frequent among newborn with TSB level >23mg/dl when compared to those having TSB level ≤23mg/dl (20% vs. 0.9%, p=0.009; OR=29, 95% CI 2.79, 301). Hearing impairment was associated with newborns with hyperbilirubinemia requiring phototherapy or exchange transfusion. Peak TSB level >23mg/dl can be predictive for the development of hearing impairment.

Neonatal Transport - Experience of a Tertiary Care Hospital of Bangladesh.

Safe transportation is mostly an unnoticed neonatal health issue in Bangladesh and no documentation is available regarding the existing practices. So this study was intended to document transport status of the referred newborn to a tertiary care hospital. This observational study included 150 out born neonates over 12 months period transported from various places to NICU, Bangabandhu Sheikh Mujib Medical University (BSMMU) from May 2015 to April 2016. A structured data collection form was used to record information categorized into pre-transport, during transport and at admission. At admission detailed clinical assessment of the baby was done and recorded. Outcome was determined as discharge or death. Of 150 transported neonates, two-third were preterm 115(77%) & LBW 113(75%). Common indications for referral were prematurity and sepsis. Most of the patients were referred from private hospital 107(71%). Majority of newborns (86%) were referred from hospitals of Dhaka city while only 14% were referred from outside Dhaka. Referral notes were supplied in most of the cases 134(89%) but comprehensive information was obtainable only in 3 cases. Although main transport vehicle was ambulance 130(87%), medical personnel accompanied the sick baby only in 6(4%) of cases. The distance traveled was less than 10 kilometers (kms) in 95(63%) and more than 100 km in 10(7%) of enrolled neonates. Transport time was less than 1 hour in 72(48%), 1-6 hours in 66(44%) and more than 6 hours in 12(8%) of cases. Nearly two third of newborn were transported after office period, 107(72%). At admission 21(14%) babies had hypothermia, 8(7.62%) hypoglycemia, 16(11%), poor perfusion 28(19%), low saturation 27(18%). Hyperthermia & hyperglycemia were observed in 8(5%) & 7(5%) cases respectively. Of the total 150 babies referred, 17(11%) died. While comparing with discharged newborn, died newborn were more frequent sufferer of hypothermia (p value 0.007) and low saturation (p value 0.049) at admission. Premature, low birth weight and sick newborns are being transported despite lack of safe transport system.

Clinical risk factors, bacterial aetiology, and outcome of urinary tract infection in children hospitalized with diarrhoea in Bangladesh.

Urinary tract infection (UTI) is common in children aged <5 years with diarrhoea, but little is known about risk factors, aetiology and outcome of such children. We aimed to evaluate these knowledge gaps of UTI in children aged <5 years with diarrhoea. We enrolled all children aged <5 years with diarrhoea admitted to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, between May 2011 and April 2013, who had history of fever (⩾38 °C) and obtained a urine sample for culture. Diarrhoea with UTI (confirmed by culture) constituted cases (n = 26) and those without UTI constituted controls (n = 78). Threefold controls were randomly selected. The case-fatality rate was comparable in cases and controls (4% vs. 1%, P = 0·439). Escherichia coli (69%) and Klebsiella (15%) were the most commonly isolated pathogens. Persistent diarrhoea, pneumonia and prior antibiotics use were identified as risk factors for UTI in logistic regression analysis (P < 0·05 for all). Thus, children with diarrhoea presenting with persistent diarrhoea, pneumonia, and prior antibiotic use should be investigated for UTI for their prompt management that may reduce morbidity.

Childhood malnutrition in households with contemporary siblings: a scenario from urban Bangladesh.

This study aimed to determine the effect of the presence of under-5 siblings (⩾ 1) in a household on childhood malnutrition in urban Bangladesh. During 2000 and 2013, a total of 16,948 under-5 children were enrolled in the Diarrhoeal Disease Surveillance of icddr,b. Under-5 siblings were categorised as ⩾ 1 and none except the child himself. In univariate analysis, the presence of siblings was associated with 1.13 (risk ratios=1.13; 95% CI:1.06-1.20) times higher risk of being stunted, 1.17 (1.09-1.25) times for wasted and 1.19 (1.13-1.26) times underweight compared with their peers who did not have siblings. In multivariate analysis, such associations remained significant for stunting (1.08; 1.01-1.15), wasting (1.12; 1.04-1.21) and underweight (1.13, 1.06-1.19) after controlling for possible confounders such as age of child, sex, parental education, maternal employment, family size, wealth quintile and time (year). The presence of under-5 siblings increases the risk of malnutrition in children in urban Bangladesh.

Determinants of percent expenditure of household income due to childhood diarrhoea in rural Bangladesh.

There is limited information on percent expenditure of household income due to childhood diarrhoea especially in rural Bangladesh. A total of 4205 children aged <5 years with acute diarrhoea were studied. Percent expenditure was calculated as total expenditure for the diarrhoeal episode divided by monthly family income, multiplied by 100. Overall median percent expenditure was 3·04 (range 0·01-94·35). For Vibrio cholerae it was 6·42 (range 0·52-82·85), for enterotoxigenic Escherichia coli 3·10 (range 0·22-91·87), for Shigella 3·17 (range 0·06-77·80), and for rotavirus 3·08 (range 0·06-48·00). In a multinomial logistic regression model, for the upper tertile of percent expenditure, significant higher odds were found for male sex, travelling a longer distance to reach hospital (⩾median of 4 miles), seeking care elsewhere before attending hospital, vomiting, higher frequency of purging (⩾10 times/day), some or severe dehydration and stunting. V. cholerae was the highest and rotavirus was the least responsible pathogen for percent expenditure of household income due to childhood diarrhoea.

Lack of BCG vaccination and other risk factors for bacteraemia in severely malnourished children with pneumonia.

We sought to examine the factors associated with bacteraemia and their outcome in children with pneumonia and severe acute malnutrition (SAM). All SAM children of either sex, aged 0-59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh with radiologically confirmed pneumonia from April 2011 to July 2012 were enrolled (n = 405). Comparison was made between pneumonic SAM children with (cases = 18), and without (controls = 387) bacteraemia. The death rate was significantly higher in cases than controls (28% vs. 8%, P < 0·01). In logistic regression analysis, after adjusting for potential confounders, the SAM children with pneumonia and bacteraemia more often had a history of lack of bacillus Calmette-Guérin (BCG) vaccination (odds ratio 7·39, 95% confidence interval 1·67-32·73, P < 0·01). The results indicate the importance of continuation of BCG vaccination which may provide benefit beyond its primary purpose.

Geographical diversity in seasonality of major diarrhoeal pathogens in Bangladesh observed between 2010 and 2012.

The study aimed to determine the geographical diversity in seasonality of major diarrhoeal pathogens among 21 138 patients enrolled between 2010 and 2012 in two urban and two rural sites in Bangladesh under the surveillance system of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Distinct patterns in seasonality were found for rotavirus diarrhoea which peaked in winter across the sites (December and January) and dipped during the rainy season (May) in urban Dhaka, August in Mirpur and July in Matlab, equated by time-series analysis using quasi-Poisson regression model. Significant seasonality for shigellosis was observed in Dhaka and rural Mirzapur. Cholera had robust seasonality in Dhaka and Matlab in the hot and rainy seasons. For enterotoxogenic Escherichia coli (ETEC) diarrhoea, clearly defined seasonality was observed in Dhaka (summer). Understanding the seasonality of such pathogens can improve case management with appropriate therapy, allowing policy-makers to identify periods of high disease burden.

Aetiology and clinical features of dysentery in children aged <5 years in rural Bangladesh.

The study identified the common aetiological agents and prominent clinical features of dysentery cases in children aged <5 years and compared this to non-dysentery diarrhoeal cases from the same population. From January 2010 to December 2011, 2324 children aged <5 years received treatment at Kumudini Hospital, of which 682 (29%) presented with dysentery. Of the dysenteric children, aetiology could not be determined for over half (61%). Shigella spp. accounted for 32% of dysentery cases. Significant associations were found between presence of blood in stool and: child age (24-59 months) [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.49-3.27], no treatment of drinking water at home (OR 2.00, 95% CI 1.09-3.67), vomiting (OR 0.19, 95% CI 0.14-0.25), abdominal pain (OR 4.68, 95% CI 3.24-6.77), straining (OR 16.45, 95% CI 11.92-22.69), wasting (OR 1.66, 95% CI 1.15-2.41), and presence of Shigella in stool (OR 6.25, 95% CI 4.20-9.29) after controlling for confounders. This study makes it clear that appropriate public health strategies are needed to reduce the burden of dysentery in Bangladesh.

Changing patient population in Dhaka Hospital and Matlab Hospital of icddr,b.

The Diarrhoeal Disease Surveillance System of icddr,b noted increasing number of patients ≥60 years at urban Dhaka and rural Matlab from 2001 to 2012. Shigella and Vibrio cholerae were more frequently isolated from elderly people than children under 5 years and adults aged 5-59 in both areas. The resistance observed to various drugs of Shigella in Dhaka and Matlab was trimethoprim-sulphamethoxazole (72-63%), ampicillin (43-55%), nalidixic acid (58-61%), mecillinam (12-9%), azithromycin (13-0%), ciprofloxacin (11-13%) and ceftriaxone (11-0%). Vibrio cholerae isolated in Dhaka and Matlab was resistant to trimethoprim-sulphamethoxazole (98-94%), furazolidone (100%), erythromycin (71-53%), tetracycline (46-44%), ciprofloxacin (3-10%) and azithromycin (3-0%).

Co-morbidity: exploring the clinical overlap between pneumonia and diarrhoea in a hospital in Dhaka, Bangladesh.

BACKGROUND: There is limited information on risk factors for pneumonia and pneumonia-related deaths in children who also have diarrhoea. AIM: To identify risk factors for the above in order to improve strategies for case management and to develop appropriate public health messages. METHODS: All children under 5 years of age admitted to the Special Care Ward, Dhaka Hospital of the International Centre for Diarrhoeal Disease Research (ICDDR,B) from 1 September to 31 December 2007 were considered for enrollment if they also had diarrhoea. Of the 258 children with diarrhoea enrolled, those with (n=198) or without (n=60) WHO-defined pneumonia constituted the pneumonia and comparison groups, respectively. Among the 198 children with pneumonia, children who survived (n=174) were compared with those who died in hospital (n=24). RESULTS: After adjusting for socio-demographic factors, including low levels of literacy of either parent, low household income, not having a window or exhaust fan in the kitchen, household smoking and over-crowding, children with pneumonia were more likely to sleep on a bare wooden-slatted or bamboo bed (OR 2·7, 95% CI 1·40-5·21, p = 0·003) than on other bedding, and were also more likely to have a parent/care-giver with poor knowledge of pneumonia (OR 1·94, 95% CI 1·02-3·70, p=0·043). Independent risk factors for death include severe underweight (OR 5·2, 95% CI 1·2-22·0, p=0·03), hypoxaemia (OR 17·5, 95% CI I 1·9-160·0, p=0·01), severe sepsis (OR 8·7, 95% CI I 1·8-41·5, p=0·007) and lobar consolidation (OR 11·9, 95% CI 2·3-61·6, p=0·003). CONCLUSIONS: Increased public awareness of signs of pneumonia and severe sepsis in children under 5 is important to mitigate the risks of pneumonia and pneumonia-related deaths, and the importance of appropriate bedding for young children in reducing the risk of pneumonia needs to be addressed.

Influences of dehydration on clinical features of radiological pneumonia in children attending an urban diarrhoea treatment centre in Bangladesh.

BACKGROUND: As the signs of dehydration often overlap with those of pneumonia, it may be difficult for health workers in resource-poor settings to make a clinical diagnosis of pneumonia in children with dehydration. This issue has received very little attention. AIM: To compare the clinical features of pneumonia in children with and without dehydration caused by diarrhoea. METHODS: All children aged 2-59 months with diarrhoea and radiologically confirmed pneumonia admitted to the Special Care Ward (SCW) of Dhaka Hospital, ICDDR,B between September and December 2007 were enrolled for the study. Children with dehydration (67 cases) and those without (101 controls) were compared. RESULTS: Cases presented less frequently with fast breathing (60% vs 88%, p<0.001) and lower chest-wall indrawing (67% vs 82%, p=0.035) than did controls. In logistic regression analysis, cases more often had severe malnutrition (OR 2.31, CI 1.06-5.02, p=0.035) and cyanosis (OR 19.05, CI 1.94-186.68, p=0.011) and were abnormally sleepy (OR 372, CI 1.71-8.08, p=0.001). CONCLUSIONS: Fast breathing and lower chest-wall indrawing may be less reliable for the diagnosis of pneumonia in children with dehydration, especially when there is severe malnutrition.

Predictors of mortality in infants with sclerema presenting to the Centre for Diarrhoeal Disease, Dhaka.

BACKGROUND: Sclerema is an uncommon, life-threatening condition, usually of newborns, with a case-fatality rate ranging from 50 to 100%. Very little is known about factors influencing outcome. AIM: To identify clinical and biochemical predictors associated with fatal outcome of sclerema in infants with diarrhoea. METHODS: Thirty infants with sclerema admitted to the Special Care Unit of the Dhaka Hospital of ICDDR,B with diarrhoea from May 2005 to end April 2006 were studied prospectively. Nine infants who died (30%) were considered to be cases while the 21 who survived constituted the comparison group. Hypothermia, severe malnutrition, septic shock, serum ammonia and CRP levels were considered to be predictors of death. Differences in proportions were compared by the chi(2) test and mean differences were compared using Student's t-test or the Mann-Whitney test, as appropriate. RESULTS: The mean age of the 30 infants was 2.1 months (range 12 d to 8 m). Fatal cases were more likely than survivors to be associated with severe underweight, a positive blood culture and higher serum ammonia and serum CRP levels. After adjusting for possible confounders in logistic regression analysis, the likelihood of death was higher in infants admitted with septic shock or who developed it soon after admission (OR 17.96, 95% CI 1.5-0220.4, p=0.024). CONCLUSIONS: Sclerema is associated with a high fatality rate and scleremic infants with diarrhoea who present with septic shock are at a greater risk of death.

Bacterial enteropathogens of neonates admitted to an urban diarrhoeal hospital in Bangladesh.

Data on the aetiology of diarrhoea in neonates are scarce, especially from developing countries including Bangladesh. A retrospective review of the electronic database of the Microbiology Laboratory of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), was carried out to examine enteropathogens associated with diarrhoea in neonates. Stool specimens of the neonates on admission to the Dhaka Hospital of ICDDR,B were collected and sent to the laboratory for direct plating onto taurocholate tellurite gelatin agar, Salmonella-Shigella agar and MacConkey's agar. Stool specimens of 2511 neonates of either sex were examined. Bacterial pathogens were recovered from the stools of 699 (27.8%) of these neonates--a single bacterial pathogen from 670 neonates and more than one pathogen from 29 neonates. Vibrio cholerae, Shigella, Salmonella, Aeromonas spp. and Plesiomonas shigelloides were isolated from 294, 108, 52, 222 and 19, respectively, of the neonates. The year-wise isolation of these pathogens varied between 4.9-23.4%, 2.7-5.4%, 0-4.7%, 0-19.4% and 0-1.6%, respectively, of the neonates. The results of the study indicate that infection by V. cholerae, Shigella spp., Salmonella spp., Aeromonas and P. shigelloides is common in neonatal diarrhoea in Bangladesh.