Low birth weight newborn: epidemiological, therapeutic and evolutive aspects in the commune of Kara (TOGO) from 2014 to 2015

Introduction: Low birth weight (LBW) is the third leading cause of neonatal death after neonatal infections and asphyxia. Objective: Describe the epidemiological, therapeutic and evolutionary effects of LBW neonates. Methods: This was an analytical retrospective study from January 1, 2014 to December 31, 2015, in three neonatal units in Kara commune concerning the LBW newborn. The main parameters studied were clinical, therapeutic and evolutionary. Results: Of 1712 newborns hospitalized, 527 were LBW (30.8%) of which 451 were included with 222 males (sex ratio 0.97). The average birth weight was 1775.72 g. Delivery was carried out through caesarean section in 16.9% mainly did about eclampsia (29.5%) and prævia hemorrhagic placenta (12.6%). The main co-morbidities were neonatal infections (55.4%) and perinatal asphyxia (12.9%). The treatment consisted of an antibiotic therapy (73.8%), an exclusive breastfeeding (43.7%) and Kangaroo Maternal Care (30.2%). Immediate results were marked by deaths in 18.8% after an average of 6 days hospital admission. The main factors significantly related to neonatal mortality were the early neonatal period, low sucking, hypotonia, high preterm birth, very LBW, inadequate pregnancy monitoring, referrals, perinatal asphyxia, artificial breastfeeding. Conclusion: The incidence of LBW remains high with significant mortality due to preventable factors, requiring actions to be coordinated from conception through the end of the period to improve the survival of these newborns.


Introduction
Neonatal infections, low birth weight (LBW) and perinatal asphyxia are the three leading causes of neonatal deaths [1,2] in developing countries. In Africa between 1998 and 2008, the prevalence of LBW varied from 7 to 17% depending on the areas and periods of study [3]. LBW is a multifactorial health problem for which the prevention is possible through targeted interventions on modifiable factors  [4,5]. In Togo, in 2013, neonatal mortality was 2.7%. Newborns accounted for 32.3% deaths among of children under five and 11.6% of these deaths were premature births and LBW neonates [6]. Most of the LBW studies in Togo were conducted in Lomé [7,8]. We have carried out this study in order to assess the situation of the LBW in Kara, a region in the northern Togo. Our objective was to describe the epidemiological, therapeutic and evolutionary aspects of LBW in the pediatric ward in Kara commune.
Type and period of study: It was a retrospective analytical review of LBWs' records in these units from January 1, 2014 to December 31, 2015 (24 months).

Inclusion criteria:
We had included all hospitalized newborns in one of the three centres with a birth weight lesser than 2500g. Newborns weighing ≥ 2500g and stillbirths were excluded.
Parameters studied: The main parameters studied concerned the monitoring of pregnancy and childbirth, the birth status of newborns, clinical and therapeutic data and the immediate prognosis.

Statisticalmethods:
The processing and analysis of data was done using the Excel software, EPI Info version (TM) 3.5.1. We used chi-square testto compare some variables with a significance thres hold of 0.05.

Results
Out of the 1712 newborns identified in the three centres surveyed, 527 had LBW(30.8%) of which 451 met our inclusion criteria. They were divided into 222 boys and 229 girls (sex ratio of 0.97). Hypotrophic newborns accounted for 34.9% of the lbws and premature babies, 65.1%.
Perinatal data-The average parity (n = 208 cases) of LBW mothers was 2.80 children per woman (extreme from one to ten), 98 mothers were primipara (31.9%) and 39 were large multipara (14.44%). In the mothers' histories, we counted 30 cases of abortions, 10 high blood pressure cases (HPB), three cases of uterine scarring, two cases of LBW and two cases of multiple pregnancies.
The number of prenatal consults(n=205 cases) in LBW pregnancy follow-up ranged from one to nine with an average of three prenatal consults. The weeks of pregnancy (n = 212 cases) ranged from 24 to 42 weeks.
The very premature babies (gestational age under 33 weeks) accounted for 52.8% of LBW, the preterm infants of 34 at 36 weeks of gestational age represented 12.3%. Of the 451 LBW newborns surveyed, 104 were from multiple pregnancies (23.1%) of which 98.1% are twins.
With regard to the place of birth (n = 386), childbirth occurred at the maternity of the three studied centres in 288 cases (63.9%), in other health facilities in 80 cases (17.7%) and at home in 18 cases (4%). The delivery was performed through vaginal in 375 cases (83.1%) and by caesarean section in 76 cases (16.9%).
Clinical data-The Apgar score at birth was reported in 245 cases. It was less than 7 in 58 cases (23.7%) at the first minute (of which 10 in apparent state of death), in 28 cases at the 5 th minute and in 12 cases at the10 th minute.
The neonatal resuscitation has been reported in 33 cases. Birth weight (n = 445 cases) ranged from 750 g to 2475 g with an average of 1775.72 ± 408,75g.
Data relating to care and support-The time frame for transferring LBW between maternity and neonatal services at the same centre varied from 5 minutes to 48 hours. This delay was on average 12 hours in the case of referral from a maternity ward to that of neonatology of another centre; 55.65% of LBWs (251 cases) were transferred within the first 24 hours.
The care received by these newborns was essentially a metabolic contribution by glucosate serum (78.0%), a heating with plate or incubator (76.7%), antibiotic therapy (73.8%), exclusive breastfeeding (43.7%), and Kangaroo Mother Care or KMC (30.2%). The antibiotic treatment consisted mainly of a double antibiotic therapy (63.4%) combining gentamycin for three to five days and ceftriaxone or cefotaxime ( Table-I).
Outcome data-The discharge weight ranged from 700 to 2920 g with an average hospitalization time of 6.07 ± 4.7 days (one to 30 days).
The evolution was favorable in 302 cases (67%), 85 LBW had died (18.8%) and therest being escapes or exits against medical advice (14.2%). A variety of pregnancy-obstetrical factors have been associated with LBW's mortality.
Inadequate pregnancy monitoring, referrals of LBW from another centre, high prematurity, veryLBWand perinatal asphyxia were the main factors significantly related to death (Table-II).  Therapeutically, mortality was significantly related to artificial breastfeeding, insufficient intake of calories (glucosate serum), first week of hospitalization, and LBW less than 7 days old (Table III).

Original Research Article
Pediatric Review: International Journal of Pediatric Research Aailable online at: www.pediatricreview.in 750|P a g e

Discussion
The retrospective nature of this study did not allow the collection of certain data related to incomplete files filling and the imprecision of certain diagnoses. Beyond these, this study provides an overview of LBWs' support in Kara that can serve as a starting point for future studies on the subject.
Epidemiological aspects-LBWs new borns accounted for 30.8% of hospitalized newborns, as reported in a previous study (29.71%) in the same ward [9]. In 2002, premature infants accounted for 11.1% in Lomé (Togo) out of 1672 live births [8]. This frequency varied in Africa from 8.5% in Nigeria [10] to 15.1% in Madagascar in 2010 [11] for premature births. This high frequency of LBWs at Kara is explained by its report only to hospitalized newborns and highlights the weight and the problems associated with the support of these LBW newborns.  [8]. The importance of pathologies associated with LBW seems to depend on geographical regions, socioeconomic level and diagnostic means.

Diagnostic aspects-
The averageof antenatal visits during pregnancy was 2.79: this deficiency in pregnancy follow-up is accentuated in developing countries, where unfavorable socio-economic conditions influence pregnancy follow-up and would favor LBW [13][14].
Multiple pregnancies, one of the LBWs'causes (23.1%), was also reported in a less proportion (17.7%) in Lomé [8]. Compared to delivery, caesarean section was reported in 16.9% in this study with the main indication of pregnancy toxemia (29.5%). Vaginal delivery could have been the preferred mode of delivery of LBW because of the smallness of the fetal motive. The caesarean section is the sanction in relation to specific or general causes that may endanger the life of the mother and the already fragile newborn.
Clinically, 29.9% (135 cases) of hypothermia were found as in the case of the 29.0% found on admission in Ghana [15]. It may be linked to a failure of its prevention or to a neonatal infection and should be sought for better care. Neonatal infections (55.4%) and perinatal asphyxia (12.9%) were the two main associated comorbidities in the LBWs. The importance of perinatal asphyxiain neonatal deaths has for some years now justified the resuscitation trainings "Help Baby Breath" [16].

Support and evolution of LBW infants-
The average time taken to transfer LBW newborns was 12 hours for referral from another centre. This delay seems relatively long due to insufficient medical means of transportation and the financial resources of the parents who provide the care themselves. All actors must work to act on the different types of delays (decision-making, consultation, diagnosis and support) in order to improve the care and lbw prognosis.
Three-quarters of the LBWs have received antibiotic therapy, with neonatal infection being one of the most common causes of LBW [1,4] but paraclinical confirmation is sometimes difficult to achieve in ourregions. It is necessary for services to have a neonatal infection care protocol to which staff is trained to avoid complications and death.
Parenteral nutrition with lipid and protein substances is limited in this context while the risk of dehydration and hypoglycemia remains high: 78.05% of the LBW newborns were hydrated with glucose and ionic salts without a defined protocol. As a result of this limitation, LBW feeding has become more dependent on breastfeeding when conditions permit or artificial milk for premature infants if breastfeeding is not feasible. It is essential that a fairly precise way of feeding the LBW newborn be set up to enable the paramedicalteam to carry it out.
For the warming-up of the LBW newborn, the KMCs were mentioned in 30.2% contrary to the use of incubators or warming plates (76.7%). Several studies have demonstrated the clinical, therapeutic, evolutionary, psycho-affective and socio-economic benefits of KMC [17]. KMCs make it possible to compensate for the lack of material, financial and human resources: their extension in our neonatology services would significantly reduce LBW newborns mortality.
Per the progress, LBW newborns were discharged on the recommendation of a medical doctor in 67% for an average hospitalization period of 6.07 dayswith longer stays depending on very and extreme LBW [8]. The relatively short period of stay of our LBW newborns could be explained by an improvement in the care provided, related to the introduction of KMC, but above all by a limitation in the availability of places, outings due to parents' financial restrictions. The trend was deadly in 18.8%, far less than 30.1% in preterm infants during the year 2002 in Lomé, where the risk of death is twice as high (60.9%) in premature infants under 31weeks of pregnancy and three times higher (93.7%) in LBW newborns of less than 1000g [8].
The death rate in this study, however, shows all the potential of KMC method.  [7][8]. LBW infants are poorly tolerant of labor and vaginal delivery; they have a higher incidence of asphyxia, more pronounced in the premature than the hypotrophic infant, resulting in early and effective treatment [18].

Predictive evolutionary factors of low birth weight mortality-
Extramural transfers of newborns, especially LBW newborns, area significant risk of neonatal mortality: in Cameroon in 2006, newborns in contact with the outside environment had 26.4% mortality rate compared to 16.1% in the group that had not been exposed [18]. Often non-medicalized non-aseptic birth and transfer conditions expose newborns to infections and other complications such as hypothermia and hypoglycemia.
The first week of admission and artificial breastfeeding were significantly related to death causing an effective intensive care management and feeding of the LBW newborn problem at the beginning of hospitalization. This justifies an improvement in the care of newborns at birth as well as the availability of qualified personnel in the various structures to improve the prognosis of the LBW.

Conclusion
Various avoidable factors have been linked to LBW occurrence such as poor pregnancy monitoring, previous abortion, eclampsia and HBP. The main comorbidities were neonatal infection and perinatal asphyxia.LBW newborn's management has been limited by the insufficiency of the technical and therapeutic facilities. In the absence of a remarkable improvement in the socio-economic status of populations, linked to the global economic situation, an integrated development program for perinatal medicine taking local realities into account could help to improve the prognosis of LBWneonates in developing countries.The survival of the LBWdepends on the availability of neonatal care unit in the centre. Pregnancy women must be educated to avoid LBW and complicationsrelated to these fragile babies.