Neurological distress in Togolese newborn: Prevalence, causes and clinical features.

BACKGROUND: The transition from fetal to neonatal life during birth is difficult for all babies. We aim to analyze the demography, clinical presentation, causes, and outcome of neurologically distressed newborns.
MATERIALS AND METHODS: We reviewed a total of 615 newborns files admitted with life threatening condition. Amongst them, 453 had presented neurological distress syndrome. Only cases with severe neurological impairment (Apgar Score System [ASS] ≤6) with no other associated injury were included in the study group. The study covered a period from January to December 2011 and located in pediatric intensive care unit. The information regarding clinical presentation, condition of birth, causes of distress, and outcome were analyzed. Neonate examination had been conducted by neonatologist and pediatric neurologist.
RESULTS: The sample included 272/453 (60.04%) males and 181/453 (39.96%) females. Newborns were aged from 1 to 14 days. The incidence of neurological distress amongst all admissions was 453/615 (73.65%). Clinical signs were weakness of primary reflexes (86.70%), non reactivity (78.19%), flaccid muscle tone (59.49%) and impaired consciousness (32.29%). On Apgar score, 73 (20.68%) had a score from 0 to 3; 234 (66.29%) had a score 4-6 in the first minute of life. A total of 307 (86.97%) newborns had been resuscitated at birth during the first five minutes. Death rate was 35.69%. Asphyxia (51.27%) and neonatal infection (43.34%) were the most common causes of death.
CONCLUSION: These results show that much effort remains to be done in obstetric care, resuscitation management and improvement in neonatal infection care.

Introduction

The transition from fetal to neonatal life during birth is marked by rapid physiological changes to survival for all babies. Each year about 5–10% of all neonates need some degree of resuscitation.[1-4] The need for neonatal resuscitation is most urgent in low-resource settings. In these countries, access to intrapartum obstetric care is poor and the burden of long-term impairment from intrapartum-related events is high.[5] About 15–20% of non reactive newborn will die during the postnatal period and 25% will sustain permanent functional and cognitive deficits.[6-9]

Materials and Methods

The present study was conducted in the pediatric service of the Tokoin University Teaching hospital of Lomé. This level 3 hospital has a capacity of 1264 beds distributed in sixteen services. The pediatric department has one hundred beds and it is divided into ten units. It received out-patient about 9,000 and hospitalized 3,000 per year. It is the national referral service for children health in Togo.

P8, the Neonatal Intensive Care Unit (NICU) with ten baby′s beds has located the current study. It deals with newborns in life threatening conditions (respiratory distress syndrome, circulation failure syndrome, and neurological distress). There is minimum equipment for neonatal resuscitation and few trained personnel for this purpose.

We retrospectively reviewed medical records of neurological distressed newborns, admitted in the NICU from January to December 2011. They were referred for resuscitation by obstetricians from birth room. Baseline information concerns perinatal distress risk factors (maternal, delivery, fetal, and neonatal condition), anthropometric and vital [Apgar Score System (ASS) ≤6] features, and the outcome. Newborns who deceased being transferred and those received only for consultation or with other distress condition have not been included. Neonate physical and neurological examination had been conducted by neonatologist, neurologist and intensive care specialist.

Results

The incidence rate of neurological distress was 453/615 (%). Our results were presented in three tables. These findings concern the demography, perinatal risk factor, clinical presentation, causes and management of neurological distress in newborns. We can find the characteristics of newborn′s mother in Tables 1 and 2 shows the neonates′ afterbirth clinical examination and finally, newborn anthropometric, and vital parameters were presented in Table 3.

Table 1

Characteristics of newborn′s mothers (total=453)

Table 2

Neonates clinical examination in delivery room

Table 3

Newborn anthropometric and hemodynamic parameters

Discussion

Medical files of neurological and vital distressed newborns were reviewed. For low-income countries, more widespread access to NICU could be an important component of efforts to achieve Millennium Development Goal-4. It is now widely acknowledged that effective efforts aimed to improving child health in resource-poor countries must be preceded and underpinned by improvement in maternal health within a continuum of care from pregnancy to adolescence.[10-13]

This retrospective study had some limitations. The baseline information concerning inpatients are not always well filled, so that limits the included cases. Some babies died while being transferred from birthplace to resuscitation room. Another weakness was the lack of resuscitation tools and intensive caregivers in the birthplace. Resuscitation could not be performed until newborns were transferred to NICU. We also were unable to collect patients who could not afford this care unit or were more likely to attend basic clinic-type Level 1 hospitals or traditional healers. These findings may not reflect the real incidence of cerebral distress in the whole Togo country. These have been the bias in the recruitment of patients. However, the consistency of our results with other studies provides some validity to the data. Several previous studies regarding distressed newborn after delivery focused on resuscitation, risk factors, mortality and outcome of that critical condition.[14-16] Large prospective studies with early resuscitation beginning in birthplace are needed in our setting to confirm these findings.

In the present study, the frequency of neonates with neurological distress was 66.60%; 334 (94.62%) were aged of 1–7 days of which 207 (58.64%) had only 24 h with more males than females. Nearly 60% of infants with brain injury were admitted in NICU within the first 24 h of life. The incidence of brain injury varies according to many parameters ranging from pregnancy monitoring to neonates care at birth, and it remains high in many African countries as reported by several other researchers.[35613]

With regard to neurological distress syndrome, its principal manifestations were expressed by weakness of primitive reflex, none motor reactivity, flaccid muscle tone, impaired consciousness, weak crying, and seizures. The risk factors of neurological distressed newborn included maternal primiparous, eclampsia, prolonged premature rupture of membranes, meconium stained amniotic fluid, birth asphyxia and infections, pre-term and post-term delivery and Apgar score under seven after five minutes of resuscitation, similar to previous studies.[1261617]

In Europe and the United States, the survival of extremely pre-term and severe distressed infants has continued to improve because of good practices establish to manage intrapartum and antenatal risk factors and the pregnancy monitoring,[891418] most are term new-born with normal weight. In our country the cause is maternal, delivery and neonatal poor management condition. This underline the worst condition of work in obstetric unit and neonate′s resuscitation room daily met in developing countries. Countries from sub Saharan African must make effort to improve the quality of first aids giving. We Need changes in thinking, health strategies plan and daily practice among care givers. This remains the main challenge to overcome before achieve the millennium goal-4.

To more understand about causes of neonatal distress, variety of methods are used to identify perinatal asphyxia in different observational studies, including Apgar score, umbilical cord gases, fetal heart recording, and presence of meconium.[171920] Recent evidence from prospective cohorts using magnetic resonance imaging shows that most brain injury happens at or near the time of birth.[21] The presence of an abnormal neurological examination right after birth is the most useful indicator that a brain insult has occurred and allows to classify newborns into groups of low, moderate and high-risk for abnormal neurodevelopmental outcomes.[7922] The relation between greater fetal motor activity and more reflex performance reveals good maturation of newborn central nervous system and conservation in motor functioning from prenatal to postnatal period.

A criterion of vitality of the newborn and effectiveness of resuscitation, the Apgar score was improved after 5 min of resuscitation in 84.93% of newborns with 0–3 score at the first minute of life. This represents 40% of resuscitation response of the neonates, and far less than studies from middle-high income countries. The lack of NICUs coupled to maternity hospitals in our health facility, is responsible for these poor results, and the highest rate of morbidity and mortality related to life threatening. The overall death rate was 35.69%, involving that, over one-third neonate who enters the NICU died. Our death rate is still high compare to other countries.[3417]

The fight must again regard the improvement of risk factors, obstetric monitoring of pregnancy, and neonates resuscitation. The cognitive and neurodevelopmental impairment results in a rise in health expenditure to parents and society and slows down the developing country.[2324]

Ethical approval

Newborns relatives or near-misses had provided informed consent. The study was approved by the Ethics Committee of Lomé University.