Cardiac troponin T as a marker of myocardial injury in a group of asphyxiated African neonates.

BACKGROUND: In caucasian newborns, troponin T (cTnT) is a specific marker for myocardial injury in perinatal asphyxia. This is the first such study in negroid neonates. AIMS: To evaluate myocardial injury in a group of asphyxiated African newborns and determine the influence of mode of delivery on cTnT levels. METHODS: Serum cTnT and clinical parameters in 40 asphyxiated and 40 healthy negroid neonatal controls were measured within the first 72 hours of life by chemiluminescence immune-assay. Perinatal asphyxia was assessed by APGAR score. The infants were followed up until discharge or death. RESULTS: Mean (SD) cTnT values were significantly higher in asphyxiated infants [0.03 (0.04) ng/ml] than in healthy controls [0.01 (0.006) ng/ml, P = 0.002]. Asphyxiated infants delivered by forceps and vacuum extraction had significantly higher levels of cTnT [0.04 (0.018) ng/ml] than those born by caesarian section [0.02 (0.008) ng/ml] and by normal delivery [0.03 (0.01) ng/ml, P = 0.003]. cTnT levels were higher in infants who died (P = 0.037). CONCLUSION: In the asphyxiated infants, mean cTnT levels were significantly higher than in controls. They were also significantly higher in those born by vacuum and forceps delivery and asphyxiated infants who died.

Exclusive breastfeeding and infant growth studies: reference standards for head circumference, length and mid-arm circumference/head circumference ratio for the first 6 months of life.

This paper presents the development of reference standards for head circumference (HC), length and mid-arm circumference/head circumference (MAC/HC) ratio for the evaluation of exclusively breastfed infants. A total of 219 exclusively breastfed term appropriate-for-gestational age (AGA) infants were studied and analysed from 1 June 1995 to 31 May 1997 at the Neonatal Follow-up Clinic, University Teaching Hospital, Benin City, Nigeria. Head circumference and length measurements were recorded for the infants at each postnatal completed month. MAC/HC ratios were also computed for each infant at each completed postnatal month. There was a progressive increase in the mean measurements at the completed months with increasing postnatal age and the differences between the mean measurements of length and head circumference at the 4th and 6th completed months were significant (p < 0.001). The head circumference, length and MAC/HC ratio had significant correlations with postnatal age. The standards represent the regression lines of the anthropometric measurements and MAC/HC ratio on postnatal age with the corresponding 95 per cent confidence limits. The standards identified 95 per cent (for head circumference), 93 per cent (for length) and 94 per cent (for MAC/HC ratio) of exclusively breastfed healthy infants as having normal infant growth for age.

Observations on water supplementation in breastfed infants.

A total of 378 infants, under six completed months, were evaluated at the University of Benin Teaching Hospital, Benin City, Nigeria, to investigate some aspects of water supplementation in breastfed infants. Data were recorded concerning water supplementation and age at introduction of supplementary water among others. Water supplementation accounted for 91.7% of partial breastfeeding up to one completed month compared with 70-76% from up to 2 completed months to up to 5 completed months or earlier. The postnatal period of up to one month completed month may possibly be considered as the critical period for water supplementation since after this period, water was introduced only in a small proportion of infants during the first six months. It is suggested that strategies which prevent water supplementation at this critical period may ultimately reduce the prevalence of water supplementation during the first six months and, therefore, increase the rates and duration of exclusive breastfeeding in the studied population.

A new method for maturity determination in newborn infants.

A two-part study was conducted in several centres in Nigeria to develop and evaluate a simple method for maturity determination in newborn infants. The first part involved the development of a six-feature model which included head circumference, mid-arm circumference, skin texture, ear form, breast size and genitalia. These were features which had highly significant correlation with gestational age in the studied population. The model consisted of a chart showing the regression line of gestational age on total maturity score based on the six selected features. It had comparable accuracy with the Dubowitz method. Different subgroups of term and low-birth weight infants were also reliably identified by the model. In the evaluation of sick newborn infants, the model was more accurate than a previously reported abbreviated method from the same population. The model is suggested as an appropriate clinical tool for rapid and reliable maturity determination in healthy and sick newborn infants.

Normative growth standard for upper arm measurements for exclusively breastfed infants.

OBJECTIVE: To develop a normogram for upper arm measurements for the evaluation of exclusively breastfed infants and to evaluate the clinical usefulness of the normogram. DESIGN: A prospective study involving the evaluation of infants discharged from the Newborn Unit and follow-up for the first six months of life while being exclusively breastfed. SETTING: Neonatal follow up Clinic, University Teaching Hospital, Benin City, Nigeria from 1st June, 1995 to 31st May, 1997. SUBJECTS: A total of 219 exclusively breastfed infants were recruited and analysed for the development of the normogram. A second group of 100 normal exclusively breastfed infants were evaluated to determine the clinical usefulness of the normogram. INTERVENTIONS: Determination of the upper arm measurement of the infants and development of the normogram using the statistics of the regression analysis of these measurements on postnatal age. MAIN OUTCOME MEASURES: Upper arm measurements, mean measurements at each completed month, regression statistics (MAC on postnatal age). RESULTS: Mean MAC measurements increased progressively from the first to the sixth completed months. There was a significant difference between the mean measurements at the 4th and 6th completed months. Upper arm measurements showed a highly significant correlation with postnatal age and the regression line and the 95% confidence limits were used to develop the normogram. Of the 100 infants in the second group, 92% had normal infant growth using the normogram. CONCLUSION: The developed normogram of upper arm measurements was evaluated to be clinically useful in exclusively breastfed infants.

Evaluation of two standards of arm/head ratios in neonatal nutritional assessment.

OBJECTIVE: To evaluate the percentage agreement between two standards of arm/head ratios in neonatal nutritional assessment. DESIGN: The nutritional status of newborn infants was determined using a standard of arm/head ratio on gestational age and another standard of arm/head ratio on birthweight. The two assessments were then compared for percentage agreement in the study sample and in sub-groups of birthweight categories. SETTING: Newborn Unit, Specialist Hospital, Yola, Nigeria. SUBJECTS: Two hundred and seventy two neonates including 74 low birthweight infants and 198 infants with birthweight > or = 2.5 kg. INTERVENTIONS: The nutritional status of each infant was determined, using the two standards of arm/head ratios. The percentage agreement between the two methods was investigated. MAIN OUTCOME MEASURES: Neonatal nutritional status (malnourished and well-nourished) and percentage agreement between methods. RESULTS: In the study sample of 272 infants, the percentage agreement was 94.1%. In the sub-group of low birthweight infants, the percentage agreement was 83.8% while in the larger infants, it was 89.9%. CONCLUSION: This report is a further confirmation of the clinical usefulness of the newer standard of arm/head ratio on birthweight in neonatal nutritional assessment. It is particularly recommended for its independence of precise maturity determination.

Studies on exclusive breastfeeding: a report on associated factors in an African population.

This study was conducted at the Infant Welfare Clinic of the University Teaching Hospital, Benin City, Nigeria, in April 1996, to investigate factors associated with exclusive breastfeeding in this African population. Birth weight showed significant association with exclusive breastfeeding. Maternal age and maternal educational level did not. It is suggested that the association between maternal educational level and exclusive breastfeeding needs further investigation in different cultures.

Neonatal nutritional assessment by a method independent of precise maturity determination.

Data from a previous study were analysed to develop a new model for neonatal nutritional evaluation which is independent of precise maturity determination. Birth weights and arm/head ratios were recorded for each infant recruited for the study. Both indices were correlated by simple regression analysis with gestational age as the independent variable. Birth weight showed highly significant correlation with gestational age (r = 0.77; P < 0.001). Arm/head ratio was also correlated with birth weight with highly significant correlation coefficient (r = 0.81; P < 0.001). The regression line of arm/head ratio on birth weight, with the demarcated 95 per cent confidence spread, formed the new model for neonatal nutritional assessment. The model had a sensitivity of 80.54 per cent and specificity of 90.22 per cent using nutritional status determined by clinical features as reference. Since the model is independent of precise maturity determination, which limits the potential usefulness of several methods of neonatal nutritional assessment, it is recommended as a rapid, simple, and reliable appropriate health technology for developing communities.

Observations on urinary frequency in exclusively breastfed neonates.

This study was conducted at the University Teaching Hospital, Benin City, Nigeria to investigate urinary frequency in exclusively breastfed neonates. Amongst exclusively breastfed neonates, 59.0% passed urine eight times or more per day while 14.5% passed urine less than five times a day. The comparative figures in partially breastfed neonates were 55.8% and 12.8% respectively. There was no significant association between the type of breastfeeding and urinary frequency. Sex was also not significantly associated with urinary frequency amongst exclusively breastfed infants. However, birthweight showed significant association with urinary frequency in the analysed sample. It is suggested that birthweight, which correlates with gestational maturity may influence urinary frequency because of its effect on renal functional maturation and possibly differential threshold for intravesical pressures required for initiating the micturition reflex. The observed association is, however, not an indication for supplementary water in low-birthweight infants since all the infants had normal hydration status. It is, therefore, recommended that all neonates should not receive supplementary water irrespective of their birthweights.

Ulceration of a previously healed BCG scar in suspected disseminated BCG infection.

A 2.5-year-old boy with disseminated tuberculosis, highly suspected to be disseminated BCG infection which occurred against a background of secondary immunodeficiency due to measles and malnutrition, is presented. The initial diagnosis was post-measles bronchopneumonia, meningitis and marasmus. The final diagnosis was arrived at only because of a high clinical index of suspicion of tuberculosis which is needed in all communities with a high prevalence of tuberculosis. The absence of AIDS and the extreme rarity of ulceration of a previously healed BCG scar are noted.

Non-puerperal lactation in nutritional rehabilitation: case report.

An experience in non-puerperal lactation, specifically induced for nutritional rehabilitation of a malnourished motherless male infant, is presented from a Fulani culture in northern Nigeria where the usual cultural practice is to feed such infants with raw cow's milk. The value of non-puerperal lactation in nutritional rehabilitation of motherless infants is highlighted and the role of adequate psychological preparation and support in successful relactation is emphasised.

A case report of rapidly progressive fibrodysplasia (myositis) ossificans progressiva.

We present the case of a 4-year-old boy who was the first in his family to be diagnosed as having fibrodysplasia ossificans progressiva, which was radiologically confirmed. The initial recurrence of the swellings, which were completely painless, is highlighted. The bilateral clinodactyly is also noted. It is suggested that when onset and confirmed diagnosis are in early childhood the disease is rapidly progressive.

Factors associated with neonatal tetanus mortality in northern Nigeria.

Over a 12-month period, a cluster survey on Neonatal tetanus (NNT) mortality was conducted in Northern Nigeria. The relative contributions of knowledge, attitude and practice (KAP) to certain epidemiological factors associated with NNT deaths were evaluated. NNT mortality was 20.6/1000 live-births (i.e. over 65% of neonatal mortality). Poor cord management showed the strongest association with NNT mortality with comparable contributions from KAP. Less than 40% of 2,623 live-births recorded during the survey followed two or more ante natal visits. This was significantly associated with NNT mortality with virtually equal contributions from KAP. Over 60% of the births had traditional surgeries performed with highly significant association with NNT mortality. Knowledge deficit was the most important contributor to performance of traditional procedures. Tetanus toxic coverage (32.0%) was also associated with NNT mortality with knowledge and attitudinal deficits accounting for over 75% of poor coverage. Most deliveries were outside hospitals and related facilities with highly significant association with NNT deaths. Attitude and practice contributed over 80% to this observation. In view of the associated epidemiological factors, and the relative roles of KAP, community--specific prevention strategies are suggested. Training and involvement of traditional birth attendants is emphasized. Domicilliary service are also suggested in view of the widely practised purdah system.

Clinical determination of maturity of newborn infants: comparison of some simplified methods.

A total of 508 infants were examined at three hospitals in Nigeria to evaluate the relative accuracy of maturity determination using 6 abbreviated and simplified methods in an African population. For each infant, total maturity scores were computed for each of the 6 methods and correlated with gestational age by simple regression analysis to construct regression lines of gestational age on total maturity score. The regression line for the 6 methods were used to determine the maturity of a prospective cohort of 262 infants and to evaluate accuracy of maturity determination with the Dubowitz methods as gold standard. Three simplified methods had comparable accuracy with the Dubowitz scoring system. This probably implies that simplified methods, developed from local populations, may not be universally applicable and reliable. Indeed, the method with the highest accuracy in this study was developed originally from an African population.

Uvulectomy as an epidemiological factor in neonatal tetanus mortality:- observations from a cluster survey.

A total of 2,623 live-births were recorded over a 12-month period during a cluster survey on Neonatal tetanus (NNT) mortality in Kano metropolis, Northern Nigeria. There were 79 neonatal deaths including 54 NNT deaths. NNT mortality was 20.6/1000 live-births. Although there was a male preponderance (55.6%) amongst NNT deaths, the association between sex and NNT death was not significant. Traditional Surgery was performed in over 80% of NNT deaths. The association between NNT death and traditional surgery was highly significant. Uvulectomy was the most frequently performed traditional surgery while circumcision was the least performed. There was also a highly significant association between uvulectomy and NNT death. Indeed, uvulectomy alone had a much stronger association with NNT death than traditional surgeries combined. There was no association between sex and performance of uvulectomy. It is reported that circumcision is not an important epidemiological factor in NNT mortality in this region. Health education is suggested to improve utilization of health facilities and discourage uvulectomy and other traditional surgeries.

Cluster survey on neonatal tetanus mortality in Nigeria: observation on some clinical aspects.

A total of 2623 live births were recorded over a 12-month period during a cluster survey on neonatal tetanus (NNT) mortality in Kano Metropolis, Northern Nigeria. The survey involved a two-stage cluster sampling technique. Some aspects of the clinical features of NNT were evaluated. There were 79 neonatal deaths and 54 NNT deaths with NNT mortality rate of 20.6/1000 live births. The mean incubation period for NNT was 7.3 days, while the mean age at death was 12.7 days. The peak age at death was 8 days. Interval between mean age at onset and mean age at death was 5.4 days. Mean delay in presentation at health facilities for treatment was 4.8 days. The possible significance of these features in prognosis is highlighted.

Epidemiological factors associated with neonatal tetanus mortality: observations from a cluster survey in Nigeria.

A cluster survey on neonatal tetanus (NNT) mortality was conducted in Kano Metropolis, Northern Nigeria, to investigate epidemiological factors associated with NNT mortality. The survey was a two-stage cluster sampling technique and lasted for two weeks. A total of 2,623 live-births were recorded over a 12-month period. Less than 40% of the births followed two or more antenatal visits and tetanus toxoid coverage was 32.0%. Over 60% of births were outside hospitals and related facilities. Of the epidemiological factors investigated, only antenatal care, tetanus toxoid coverage, hospital delivery, poor cord management and traditional surgery showed significant association with NNT death. It is suggested that an appropriate community-specific prevention strategy for the region should include health education to improve utilisation of antenatal and hospital-delivery facilities, discourage traditional surgery and improve tetanus toxoid coverage. A case is also made for training and involvement of traditional birth attendants (TBAs) since most deliveries occurred outside hospitals and related facilities.

PIP: Data obtained from a survey conducted in Kano Metropolis in northern Nigeria in July 1990 on a cluster sample of 2623 live births within the year were used to investigate epidemiological factors associated with neonatal tetanus (NNT) mortality. The sample included 1283 males and 1340 females, of which 79 died (54 from NNT). The NNT mortality rate is a high 20.6/1000. 51% of births in the sample were to mothers who received at least one prenatal visit. 37.9% of births involved mothers who received two or more prenatal visits, which is the typical pattern in developing countries. 32% were immunized with a tetanus toxoid vaccine, which is much higher than the typical 14% in developing countries. 40% were hospital or related health facility births. Low socioeconomic status was attributed to 60% of the infants. Over 80% of mothers practiced purdah, and 83% had a health facility within their cluster. Prenatal care, tetanus toxoid vaccine coverage, hospital delivery, poor cord management, and traditional surgery were related to NNT. Poor cord management and traditional surgery increased the risk of mortality, and the other factors reduced the risk. There were relative, but insignificant, risks associated with a male birth, low socioeconomic status, and the purdah system. One recommendation is for improvements in traditional birth attendant training. Affordability and use of health facilities are affected by the purdah system and the low socioeconomic status of most mothers. Prevention should stress good cord management, which Chinese studies show to be effective in reducing NNT mortality. Tetanus toxoid vaccine is recommended for all mothers who are attending any health facility for any reason. Mass immunization campaigns are an additional means of supplementing coverage. Traditional surgery such as circumcision, vulvectomy, ear piercing, and facial marking should be discouraged. Health education is recommended as a means of increasing use of health care facilities, discouraging unhealthful practices, and increasing immunization.