Adebola Emmanuel Orimadegun

Neonatal Mortality in an Urban Population in Ibadan, Nigeria

BACKGROUND Neonatal mortality remains a major contributor to death among children younger than 5 years in developing countries. This study was undertaken to determine the neonatal mortality rate (NMR), causes of death, and associated risk factors among hospital live births in a suburban population in Nigeria. PATIENTS AND METHODS A total of 1058 consecutive live newborns at Adeoyo Maternity Hospital, Ibadan, were enrolled at birth and followed up in their homes for 28 days. The causes of death were extracted from hospital records, and verbal autopsy was used to determine the causes of death outside the hospital. RESULTS The NMR was 32.1 per 1000 live births. The leading causes of death were severe perinatal asphyxia (79.4%), low birth weight (LBW: 55.9%), and infections (41.2%). The associated risk factors were lack of antenatal care [relative risk (RR)=45.18; 95% confidence interval (CI)=7.80, 261.60]; prolonged rupture of membranes (RR=4.47; 95% CI=1.95, 10.25); maternal peripartal fever (RR=5.42; 95% CI=2.35, 12.52); prematurity (RR=7.53; 95% CI=4.91, 11.55); and LBW (RR=5.50; 95% CI=3.88, 7.80). CONCLUSION NMR is high among hospital live births in Ibadan. There is a need for programs encouraging the use of antenatal care, improving skills on neonatal resuscitation and care of LBW infants; as well as implementation of community-based newborn survival strategies.

Esophageal, Tympanic, Rectal, and Skin Temperatures in Children Undergoing Surgery With General Anesthesia

The purpose of this study was to determine the degrees of agreement between various sites of temperature measurement and examine the trend of body temperature in children during surgery under general anaesthesia. Thirty-six consecutive children who underwent surgery with general anaesthesia, had temperatures measured at the oesophagus, skin, ear canal and rectum at baseline, every 15 minutes for the first hour and every 30 minutes thereafter. Spearman correlation and Bland-Altman analyses were used to compare data and trends of mean differences assessed by line graphs. The median age of the sample was 48 months. There were 575 temperature measurements taken. The inter-method correlation coefficients was highest for the oesophageal vs rectal (r = 0.96) temperature and lowest for rectal vs skin (r = -0.11) temperature. The lowest mean difference (95% CI) in temperature at commencement of surgery was between the oesophageal and rectal sites, -0.03°C (-0.08, -0.01) while the highest mean difference (95% CI) temperature was between oesophageal and skin sites, 3.24°C (2.65, 3.85). The trend in differential temperatures between sites remained throughout the duration of surgery. Bland-Altman plots showed that the least difference (bias) at baseline (0.3°C) was between the oesophageal and tympanic temperatures while at 1 hour (0.13°C ) was between the oesophageal and rectal temperatures. The oesophageal site was the closest to rectal for monitoring core temperature while the skin was the least reliable site in the study population. In the situation where oesophageal probe is not routine or functioning, rectal or tympanic temperatures may be used.

Early home treatment of childhood fevers with ineffective antimalarials is deleterious in the outcome of severe malaria

BackgroundEarly diagnosis and prompt treatment including appropriate home-based treatment of malaria is a major strategy for malaria control. A major determinant of clinical outcome in case management is compliance and adherence to effective antimalarial regimen. Home-based malaria treatment with inappropriate medicines is ineffective and there is insufficient evidence on how this contributes to the outcome of severe malaria. This study evaluated the effects of pre-hospital antimalarial drugs use on the presentation and outcome of severe malaria in children in Ibadan, Nigeria.MethodsTwo hundred and sixty-eight children with a median age of 30 months comprising 114 children with cerebral malaria and 154 with severe malarial anaemia (as defined by WHO) were prospectively enrolled. Data on socio-demographic data, treatments given at home, clinical course and outcome of admission were collected and analysed.ResultsA total of 168 children had treatment with an antimalarial treatment at home before presenting at the hospital when there was no improvement. There were no significant differences in the haematocrit levels, parasite counts and nutritional status of the pre-hospital treated and untreated groups. The most commonly used antimalarial medicine was chloroquine. Treatment policy was revised to Artemesinin-based Combination Therapy (ACT) in 2005 as a response to unacceptable levels of therapeutic failures with chloroquine, however chloroquine use remains high. The risk of presenting as cerebral malaria was 1.63 times higher with pre-hospital use of chloroquine for treatment of malaria, with a four-fold increase in the risk of mortality. Controlling for other confounding factors including age and clinical severity, pre-hospital treatment with chloroquine was an independent predictor of mortality.ConclusionThis study showed that, home treatment with chloroquine significantly impacts on the outcome of severe malaria. This finding underscores the need for wide-scale monitoring to withdraw chloroquine from circulation in Nigeria and efforts intensified at promoting prompt treatment with effective medicines in the community.

A comparison of tympanic and rectal temperatures in term Nigerian neonates

BackgroundTympanic thermometry has come as a suitable alternative to traditional thermometry because of its safety and ease of use. However, it is still yet to gain wide acceptance in African settings due to conflicting results on its accuracy, thus rectal thermometry remains the gold standard in the newborn. The aim of this study was to compare tympanic and rectal temperatures in term Nigerian neonates.MethodsRectal and tympanic temperatures were measured simultaneously in 300 consecutive term neonates between the ages of 37 and 42 weeks gestation using mercury-in-glass and the Infrared tympanic thermometers respectively. Paired t test, Pearson correlation coefficient and the Bland-Altman plot were used to compute data. Using rectal thermometry as gold standard, the sensitivity, specificity and predictive values of tympanic thermometry at various rectal temperature cut-offs were determined. Receiver Operating Curves (ROC) were constructed and the Areas Under the Curves (AUC) were compared.ResultsThe mean rectal temperature (37.34 ± 0.55°C) was significantly higher than the mean tympanic temperature (37.25 ± 0.56°C) (p < 0.001) with a mean difference of 0.09 °C ± 0.24 °C (95% CI: 0.06, 0.12). There was a strong positive correlation between the two measurements (r = 0.9; p < 0.001). Tympanic thermometry showed sensitivities ranging from 65% to 86% and specificities of 95% to 99% at rectal temperature cut-offs of 37.5°C to 38°C. The positive and negative predictive values of the tympanic temperatures at the various temperature cut-offs ranged from 82% to 93% and 80% to 98% respectively. Accuracy was noted to increase with higher temperatures as shown by the Receiver Operating Curves with the highest accuracy at the temperature cut-off of 38°C and AUC of 0.91.ConclusionsThe sensitivity of tympanic thermometry was relatively low in detecting rectal temperatures despite the good correlation and agreement between them. The specificities and predictive values of tympanic temperatures in detecting rectal temperatures were high and accuracy increased with higher temperatures. Though using the tympanic route for measuring temperature in the newborn is relatively safe and non-invasive, its low sensitivity limits its use. Further studies would be required to further assess the accuracy of tympanic temperature measurements in the newborn.

Metabolic derangements identified through untargeted metabolomics in a cross-sectional study of Nigerian children with severe acute malnutrition

IntroductionSevere acute malnutrition (SAM) is a major cause of child mortality worldwide, however the pathogenesis of SAM remains poorly understood. Recent studies have uncovered an altered gut microbiota composition in children with SAM, suggesting a role for microbes in the pathogenesis of malnutrition.ObjectivesTo elucidate the metabolic consequences of SAM and whether these changes are associated with changes in gut microbiota composition.MethodsWe applied an untargeted multi-platform metabolomics approach [gas chromatography–mass spectrometry (GC-MS) and liquid chromatography–mass spectrometry (LC-MS)] to stool and plasma samples from 47 Nigerian children with SAM and 11 control children. The composition of the stool microbiota was assessed by 16S rRNA gene sequencing.ResultsThe plasma metabolome discriminated children with SAM from controls, while no significant differences were observed in the microbial or small molecule composition of stool. The abundance of 585 features in plasma were significantly altered in malnourished children (Wilcoxon test, FDR corrected P < 0.1), representing approximately 15% of the metabolome. Consistent with previous studies, children with SAM exhibited a marked reduction in amino acids/dipeptides and phospholipids, and an increase in acylcarnitines. We also identified numerous metabolic perturbations which have not been reported previously, including increased disaccharides, truncated fibrinopeptides, angiotensin I, dihydroxybutyrate, lactate, and heme, and decreased bioactive lipids belonging to the eicosanoid and docosanoid family.ConclusionOur findings provide a deeper understanding of the metabolic consequences of malnutrition. Further research is required to determine if specific metabolites may guide improved management, and/or act as novel biomarkers for assessing response to treatment.

Hypoxemia predicts death from severe falciparum malaria among children under 5 years of age in Nigeria: The need for pulse oximetry in case management

BACKGROUND Oxygen saturation is a good marker for disease severity in emergency care. However, studies have not considered its use in identifying individuals infected with Plasmodium falciparum at risk of deaths. OBJECTIVE To investigate the prevalence and predictive value of hypoxaemia for deaths in under-5s with severe falciparum malaria infection. METHODS Oxygen saturation was prospectively measured alongside other indicators of disease severity in 369 under-5s admitted to a tertiary hospital in Nigeria. Participants were children in whom falciparum malaria parasitaemia was confirmed with blood film microscopy in the presence of any of the World Health Organization-defined life-threatening features for malaria. RESULTS Overall mortality rate was 8.1%. Of the 16 indicators of the disease severity assessed, hypoxaemia (OR=7.54; 95% CI=2.80, 20.29), co-morbidity with pneumonia (OR=19.27; 95% CI=2.87, 29.59), metabolic acidosis (OR=6.21; 95% CI=2.21, 17.47) and hypoglycaemia (OR=19.71; 95% CI=2.61, 25.47) were independent predictors of death. Cerebral malaria, male gender, wasting, hypokalaemia, hyponatriaemia, azotaemia and renal impairment were significantly associated with death in univariate analysis but not logistic regression model. CONCLUSIONS Hypoxaemia predicts deaths in Nigerian children with severe malaria, irrespective of other features. Efforts should always be made to measure oxygen saturation as part of the treatments for severe malaria in children.

Immunity Against Tetanus Infection, Risk Factors for Non-Protection, and Validation of a Rapid Immunotest Kit among Hospitalized Children in Nigeria

Seroepidemiological studies of tetanus in Africans have focused mainly on adults especially pregnant women and data on children are scarcely reported. We investigated the seroprevalence of protective immunity level, determined risk factors for non-protection against tetanus, and evaluated the performance of Tetanos Quick Stick® (TQS) among hospitalized children aged 1–9 years in Nigeria. Blood IgG antibody levels to tetanus was determined using enzyme-linked immunosorbent assay (ELISA) in the laboratory and TQS (an immunochromatographic test) at the bedside for 304 children admitted into emergency unit of a tertiary hospital in Ibadan, Nigeria. Demographic information and vaccination history were also collected. TQS results were compared with anti-tetanus antibody measured by ELISA using seroprotection cut-off of 0.1 IU/ml. Seroprevalence of protective level of immunity against tetanus using ELISA and TQS methods was 44.7 and 45.4% respectively. Protective level of immunity increased as age increases. Of the seven potential factors assessed, male gender and being second or more position among mother’s children were independent predictors of non-protective level of immunity. Absence of history of recent tetanus toxoid injection was significantly associated with non-protective level of immunity in univariate analysis but not logistic regression model. The agreement between the ELISA and the TQS results was good with a k coefficient of 0.931. TQS sensitivity was 95.7%, specificity 97.6%, positive predictive value 98.0%, and negative predictive values 96.0%. This study showed that lack of protective immunity against tetanus is common; few demographic characteristics correctly predict non-protection and IgG antibody levels to tetanus was accurately detected by TQS.

Prevalence and predictors of hypoxaemia in respiratory and non-respiratory primary diagnoses among emergently ill children at a tertiary hospital in south western Nigeria.

BACKGROUND Hypoxaemia is a potentially harmful complication of both acute lower respiratory tract infections (ALRI) and non-ALRI in children but its contribution to burden and outcomes of hospital admissions in Africa is unclear. We investigated prevalence and predictors of hypoxaemia in ALRI and non-ALRI according to age and primary diagnoses in emergently ill children in south western Nigeria. METHODS In 1726 emergently ill children admitted to a tertiary hospital in Ibadan, south western Nigeria, oxygen saturation was measured shortly after admission. Hypoxaemia was defined as oxygen saturation <90%. Clinical features and the primary admission diagnoses were recorded. Prevalence of hypoxaemia according to age and diagnoses was calculated. Symptoms and signs associated with hypoxaemia were compared between children with ALRI and those with non-ALRI. RESULTS Hypoxaemia was detected in 28.6% (494/1726) of admissions. Prevalence of hypoxaemia varied in different conditions: it was 49.2% (154/313) in ALRI, 41.1% (188/454) in neonates, 27.2% (6/22) in post-neonatal tetanus, 23.3% (14/60) in sickle cell anaemia, 22.6% (38/168) in septicaemia and 14.4% (76/527) of malaria cases. Nasal flaring (OR 3.86; 95% CI 1.70 to 8.74) and chest retraction (OR 4.77; 95% CI 1.91 to 11.92) predicted hypoxaemia in ALRI but not in non-ALRI. CONCLUSIONS Hypoxaemia is common among Nigerian children admitted to an emergency unit and is associated with a poor outcome irrespective of primary admission diagnosis. Provision of equipment to measure oxygen saturation and facilities for effective oxygen delivery might substantially reduce mortality.

Serum Apolipoprotein-A1 and Cholesterol Levels in Nigerian Children with Plasmodium falciparum Infection

Objective: This study was carried out to determine whether or not Plasmodium falciparum malaria infection significantly affected apolipoprotein-A1 and cholesterol levels and if apolipoprotein-A1 correlated with the malaria severity in children younger than 5 years old. Subjects and Methods: Two hundred and fifty-five children, 170 of whom had microscopically confirmed P. falciparum infection, i.e. 85 cases of uncomplicated malaria (UM) and 85 of complicated malaria (CM), and 85 healthy controls were enrolled in this study. Serum levels of apolipoprotein-A1, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL) and triglycerides were determined. These levels were compared among the malaria and control groups, using ANOVA and post hoc analyses at p = 0.05. Results: There were significant differences in the mean serum levels of apolipoprotein-A1 (UM: 104.5 ± 38.1 mg/dl, CM: 90.9 ± 33.3 mg/dl and controls: 129.7 ± 48.3 mg/dl; p < 0.001), total cholesterol (UM: 138.8 ± 62.9 mg/dl, CM: 121.2 ± 55.2 mg/dl and controls: 155.1 ± 69.8 mg/dl; p = 0.002) and LDL (UM: 98.2 ± 55.5 mg/dl, CM: 84.3 ± 47.4 mg/dl and controls: 122.7 ± 69.4 mg/dl; p < 0.001). Post hoc analyses revealed that children with UM and CM had significantly lower levels of apolipoprotein-A1, cholesterol, HDL and LDL than controls but that there was no difference between the 2 malaria groups. Reductions in levels of lipids and apolipoprotein-A1 were worse in CM than in UM. Conclusion: Altered levels of serum lipids with CM were associated with a reduction in apolipoprotein-A1. These findings have potential diagnostic utility for the management of malaria.

Mothers' understanding of childhood malaria and practices in rural communities of Ise-Orun, Nigeria: implications for malaria control

Introduction: Regular evaluations of communities’ understanding of malaria-related practices are essential for control of the disease in endemic areas. This study was aimed at investigating the perceptions, prevention and treatments practices for childhood malaria by mothers in rural communities. Materials and Methods: We conducted a community-based cross-sectional study at rural communities of Ise-Orun local Government area, Nigeria. We randomly sampled 422 mothers of children less than 5 years and administered a validated questionnaire to assess their perceptions and practices relating to childhood malaria. We used a 10-point scale to assess perception and classified it as good (≥5) or poor (<5). Predictive factors for poor perceptions were identified using logistic regression. Results: Approximately 51% of the mothers had poor perception and 14.2% ascribed malaria illness to mosquito bite only. Majority (85.8%) of the mothers practiced malaria preventive measures, including: Insecticide treated nets (70.0%), chemoprophylaxis (20.1%) and environmental sanitation (44.8%). Of the 200 mothers whose children had malaria fever within the 3 months prior to the study visits, home treatment was adopted by 87.5%. Local herbal remedies were combined with orthodox medicine in the treatments of malaria for 91.5% of the children. The main reasons for not seeking medical treatment at existing formal health facilities were “high cost”, “challenges of access to facilities” and “mothers’ preference for herbal remedies”. Lack of formal education was the only independent predictor of poor malaria perceptions among mothers (OR = 1.91, 95% CI = 1.18, 3.12). Conclusions: Considerable misconceptions about malaria exist among mothers in the rural communities. The implications for malaria control in holoendemic areas are highlighted.