|Year : 2022 | Volume
| Issue : 4 | Page : 176-179
Autopsy trends in paediatric mortalities in a Nigerian tertiary hospital
Sebastian Anebuokhae Omenai1, Uchenna Simon Ezenkwa2, Harrison Ojevwe Egbo1, Gabriel Olabiyi Ogun2
1 Department of Anatomical Pathology, Edo University, Iyamho, Edo State, Nigeria
2 Department of Pathology, University College Hospital, Ibadan, Nigeria
|Date of Submission||05-Apr-2022|
|Date of Decision||20-May-2022|
|Date of Acceptance||22-Jul-2022|
|Date of Web Publication||22-Dec-2022|
Sebastian Anebuokhae Omenai
Department of Anatomical Pathology, Edo State University, Uzairue, Edo State
Source of Support: None, Conflict of Interest: None
Background: Sub-Saharan Africa has the highest childhood mortality worldwide. In this study, we reviewed post-mortem records retrospectively noting both the causes of death and autopsy trend in childhood documented at our hospital. Aim: This study was done to ascertain the mortality patterns in childhood as seen in post mortem examinations. Materials and Methods: Autopsy records of deceased who were 16 years or less performed from 2008 to 2017 in our hospital were accessed and reviewed. Written consents were duly obtained before all post-mortem examinations. The causes of death were defined using the International Classification of Diseases-11. Results: There were 89 cases representing 8.2% of 1092 autopsies performed within the review period. Most of the childhood mortalities were in the 1st year of life. The majority of cases in the 1st year of life were cases of early neonatal death (40%), followed by deaths from 29 days to 1 year (34.3%) and late neonatal death constituting 25.7% of cases. Infections resulted in deaths in 34.8% of cases, followed by malignancies at 12.4%, developmental anomalies at 10.1%, accidents at 6.7%, sickle cell disorder at 4.5%, and nephrotic syndrome at 4.5%. Pneumonia represented 48.4% of all infectious death, followed by bacteria sepsis of newborn at a distant 9.7%. Malignancies are the main cause of mortality in children above 10 years of age. It constitutes 36% of the cases in that age group. Mortalities from developmental anomalies were relatively more common in infants (17.1% of deaths). Conclusion: This study has shown varying causes of death in different age demographics among children in the population studied. Infection control and adequate treatment in addition to early diagnosis of malignancies are advocated.
Keywords: Childhood mortality, developmental anomalies, neonatal mortality, paediatric autopsy
|How to cite this article:|
Omenai SA, Ezenkwa US, Egbo HO, Ogun GO. Autopsy trends in paediatric mortalities in a Nigerian tertiary hospital. Hamdan Med J 2022;15:176-9
| Introduction|| |
In 2019, the WHO estimated that treatable or preventable diseases resulted in deaths in approximately 5.2 million children under the age of 5 years. Despite the global decline in reported childhood mortality, even among developing countries, Nigeria has continued to witness high childhood mortality rates with an under-five mortality rate of 117.2/1000 live-births in 2019. Poverty, low socio-economic status and poor health-care infrastructure in developing countries like Nigeria contribute to this high mortality rate.
In a review of paediatric deaths by Forae et al., mortality was reported in 17.5% of childhood hospital admissions with neonatal deaths accounting for 48.4% of deaths. Most peadiatric deaths tend to occur before the age of five years accounting for as much as 80% of cases., More than half of these deaths (57%) occur within 24 hours of admission. Causes of death vary, among the most commonly reported were malaria, protein-energy malnutrition and birth asphyxia.,,
Autopsies are important as a quality assurance instrument in medical practice. Some African and Indian studies have documented relatively high paediatric autopsy rates ranging from 10.6% to 30.5%., With a significant proportion of children dying within 24 h of admission, post-mortem examination would provide different causes of death in up to 12% of cases and could reveal unexpected findings in about 72% of the instance.,, This underscores the need for paediatric autopsies, especially in populations where diseases are often not fully investigated before death.
There are some studies showing childhood mortality patterns in Nigeria but limited literature on paediatric autopsies., This study aims to provide autopsy data on paediatric mortality in a Nigerian tertiary hospital.
| Materials and Methods|| |
This study retrospectively reviewed 10-year postmortem records of deceased children aged 16 years and below over the study period (January 2008–December 2017). The cases were deceased children whose relatives consented to autopsy with a duly signed consent form. All post-mortem examinations were performed according to standard techniques. Cases without full post-mortem examination were excluded from the study. This review was in compliance with the Helsinki declaration of maintaining the confidentiality and dignity of patients. Names of deceased or any unique patient identifiers were not used for this study.
Details such as the cause of death, age and sex were obtained from the autopsy records and the clinical information was taken only from the clinical summary in the archived post-mortem reports. The cause of death was classified using the International Classification of Diseases-11 coding of mortality and morbidity statistics. The categories were developmental anomalies, infectious diseases, accidents, assaults, malignant neoplasms, intracranial haemorrhages, urogenital diseases, respiratory, blood disorders and cardiovascular disorders.
Our hospital is located in Ibadan an urban city in south-western Nigeria and serves as the referral centre for nearby rural communities and other peripheral health facilities within and outside the city.
The data was analysed using IBM SPSS Statistics (version 23 IBM Corporation, Armonk, New York) and results were presented in statistics using frequencies, median, means and mode. The Chi-square test for statistical significance was used for categorical variables. P ≤ 0.05 was considered statistically significant.
| Results|| |
There were 89 paediatric autopsies out of 1,092 autopsies performed during the study period, representing 8.2% of all postmortem examinations. The majority of deaths are attributable to infections (34.8%), and malignancies (12.4%) [Table 1]. The majority (41.5%) of under 5-year mortality was due to infections. The most fatal infectious disease was pneumonia which resulted in death in 48.4% of all infections and bacteria sepsis in the newborn was responsible for 9.7% [Table 2]. In older children above 10 years old, malignancies were the dominant cause of death as 9/25 deaths within this age group were cancer related with the majority being lymphoid neoplasms [Table 3]. Mortality within the 1st year of life accounted for 43.8% of deaths and early neonatal deaths constituted 40% of these mortalities. Late neonatal deaths constituted 25.7% and the infancy period (day 29 to 1st year) accounted for 34.3%. There is a total of 33.8% decline in autopsy requests in the later 5 years when compared to the first 5 years of the study period with the worse period being 2014 and 2015 when only one autopsy was done each [Figure 1].
|Figure 1: The prevalence of paediatric autopsy over the 5-year periods of the study|
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| Discussion|| |
There is a general decline in adult postmortem examinations worldwide which is attributable to modern diagnostic modalities. This decline is also seen in paediatric cases and can be compounded in societies with cultural aversion to post-mortem examination. This study shows a significant decline in post-mortem examinations from 76.4% in the initial 5 years of the study to 23.6% in the preceding 5 years of the study period. The number of paediatric autopsies, overall, is rare in countries like Nigeria where bereaved parents prefer to finalise burials and do not want to go through the experience of an autopsy. A lot of reviews of childhood mortality done in our environment are based on the clinical cause of death. The UNICEF estimates that one Nigerian child dies of every thirteen born before reaching 1 year and one in eight does not survive till their 5th-year birthday. Adedini et al. demonstrated regional variations in childhood mortality in Nigeria with south-western Nigeria where our hospital is located having the lowest infant mortality rate at 5.2% and child mortality rate of 1.4%. Despite a study by Adeboye et al. showing that 57% of paediatric deaths occur within 24 h of admission, most of these deaths never get to be autopsied. In this autopsy review of paediatric deaths, our findings show that infectious diseases were the main cause of mortality amongst children accounting for 34.8% of all mortalities. This finding is similar to a study by Craver et al. which demonstrated that despite advances in the use of antimicrobials, the majority (44%) of deaths resulted from infections.
The most common fatal infective disease in this study is bacterial pneumonia, followed by bacterial sepsis in the newborn. This is similar to the findings by Craver which reported bronchopneumonia, sepsis and meningitis as the most common infectious causes of death. Forae et al., in their review, documented that malaria was the main infective cause of death in those under 5 years old. The probable reason accounting for the high incidence of fatal infections in children could be their poorly developed immune system juxtaposed with some environmental conditions such as the low socio-economic status of parents, poor sanitary conditions and poor maternal education.,
Malignancies were relatively more common in late childhood accounting for more than a third of mortalities in children older than 10 years. A review of childhood mortality in a tertiary hospital in Benin City, Nigeria, showed that malignancy was the most common cause of death between the ages of 5–17 years. George et al. who studied mortalities from paediatric malignancies reported that Non-Hodgkin's lymphoma was responsible for more than half of the deaths and this is similar to the finding in our study. Neuroblastoma and nephroblastoma are also common causes of death in children >5 years although none were seen in this autopsy review.
Under-five mortality is still a cause for concern in developing countries, especially in Africa with weak health infrastructure. This study is highlighting the gravity of the problem knowing fully well that this is an autopsy study and only some cases of under 5 deaths end up having post-mortem examination. Similar to other studies, under-five mortality contributed to more than half of the mortalities in the present study with most of the deaths occurring within the 1st year of life., Yaya et al. found that under-five mortality rates per 1000 live birth are still relatively high in Africa reporting 133/1000, 104/1000, 95/1000, 127/1000 and 69/1000 for Chad, DRC, Mali, Niger and Zimbabwe, respectively. Onyiriuka observed that 84% of paediatric admissions in a Nigerian tertiary hospital were under-five years and that 92% of paediatric mortalities were under 5 years of age.
Infant (inclusive of neonatal) mortality is the most common death category in childhood in this study with most of the deaths being neonatal. This is similar to a study in India by Dalal et al. who reported neonatal mortality of 70.3% and infant mortality of 8.6%. Infections, congenital anomalies and birth asphyxia were the main cause of death in this group. In this study, 80% (8 cases) of all congenital anomaly-related deaths occurred within the 1st year of life. The conditions were multiple congenital anomalies, acyanotic heart disease and a case of biliary atresia.
The absence of obstetric, prenatal, natal and postnatal history was a major limitation of this study. Such information would be helpful to determine predisposing factors to some of the conditions that lead to these deaths and shed light on how to possibly avoid them in other yet unborn children. However, these data were not present in the summarised clinical notes of these decedents. Despite this, this study has highlighted important data on the proportion of paediatric deaths seen at autopsy and their associated causes.
| Conclusion|| |
Paediatric autopsy is waning in our population, despite its huge benefit in helping to determine the actual cause of deaths in these children. As shown, preventable causes of death rank highest and this can be diminished by instituting policy on healthy personal and public hygiene for mothers and newborns. Recognising the presence of infections in neonates early enough is also a key target to addressing this challenge.
The study institution offer waiver for ethical approval for some category of laboratory study using anonymized archival data. This study was waived as data obtained did not infringe on the rights of subjects and did not violate the principles of confidentiality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]