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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 176-179

Autopsy trends in paediatric mortalities in a Nigerian tertiary hospital


1 Department of Anatomical Pathology, Edo University, Iyamho, Edo State, Nigeria
2 Department of Pathology, University College Hospital, Ibadan, Nigeria

Date of Submission05-Apr-2022
Date of Decision20-May-2022
Date of Acceptance22-Jul-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Sebastian Anebuokhae Omenai
Department of Anatomical Pathology, Edo State University, Uzairue, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_30_22

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  Abstract 


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

How to cite this URL:
Omenai SA, Ezenkwa US, Egbo HO, Ogun GO. Autopsy trends in paediatric mortalities in a Nigerian tertiary hospital. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:176-9. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/176/364684




  Introduction Top


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.[1] 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.[1] 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.[2] Most peadiatric deaths tend to occur before the age of five years accounting for as much as 80% of cases.[2],[3] More than half of these deaths (57%) occur within 24 hours of admission.[4] Causes of death vary, among the most commonly reported were malaria, protein-energy malnutrition and birth asphyxia.[3],[4],[5]

Autopsies are important as a quality assurance instrument in medical practice.[6] Some African and Indian studies have documented relatively high paediatric autopsy rates ranging from 10.6% to 30.5%.[5],[7] 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.[4],[6],[8] 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.[9],[10] This study aims to provide autopsy data on paediatric mortality in a Nigerian tertiary hospital.


  Materials and Methods Top


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.[11] 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.[12]

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 Top


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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Table 1: Causes of mortality by age group

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Table 2: Infectious disease-causing deaths in childhood

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Table 3: Malignant neoplasms resulting in childhood mortality

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  Discussion Top


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.[13] 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.[14] 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%.[15] 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.[4] 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.[16]

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.[16] Forae et al., in their review, documented that malaria was the main infective cause of death in those under 5 years old.[2] 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.[17],[18]

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.[2] 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.[10]

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.[2],[5] 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.[19] 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.[9]

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.[5] 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 Top


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.

Ethical clearance

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Children: Improving Survival and Well-Being. WHO Facts Sheet; 2020. Available from: https://icd.who.int/ct11/icd11_mms/en/release. [Last accessed on 2022 Feb 28].  Back to cited text no. 1
    
2.
Forae GD, Uchendu OJ, Igbe AP. An audit of paediatric mortality patterns in a Nigerian teaching hospital. Niger Med J 2014;55:130-3.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Abhulimhen-Iyoha BI, Okolo AA. Morbidity and mortality of childhood illnesses at the emergency paediatric unit of the University of Benin Teaching Hospital, Benin City. Niger J Paediatr 2012;39:71-4.  Back to cited text no. 3
    
4.
Adeboye MA, Ojuawo A, Ernest SK, Fadeyi A, Salisu OT. Mortality pattern within twenty-four hours of emergency paediatric admission in a resource-poor nation health facility. West Afr J Med 2010;29:249-52.  Back to cited text no. 4
    
5.
Dalal SR, Jadhav MV, Deshmukh SD. Autopsy study of pediatric deaths. Indian J Pediatr 2002;69:23-5.  Back to cited text no. 5
    
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Wittekind C, Gradistanac T. Post-mortem examination as a quality improvement instrument. Dtsch Arztebl Int 2018;115:653-8.  Back to cited text no. 6
    
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Meel BL. Mortality of children in the Transkei region of South Africa. Am J Forensic Med Pathol 2003;24:141-7.  Back to cited text no. 7
    
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Cardoso MP, Bourguignon DC, Gomes MM, Saldiva PH, Pereira CR, Troster EJ. Comparison between clinical diagnoses and autopsy findings in a pediatric Intensive Care Unit in São Paulo, Brazil. Pediatr Crit Care Med 2006;7:423-7.  Back to cited text no. 8
    
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Onyiriuka AN. Morbidity and mortality patterns of post-neonatal paediatric medical admissions in a large mission hospital in Benin City, Nigeria. J Biomed Sci Res 2005;4:49-58.  Back to cited text no. 9
    
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George IO, Alex-Hart BA, Frank-Briggs AI. Mortality pattern in children: A hospital based study in Nigeria. Int J Biomed Sci 2009;5:369-72.  Back to cited text no. 10
    
11.
Gilbert-Barness E, Spicer DE, Steffensen TS. Handbook of Pediatric Autopsy Pathology. 2nd ed. New York, NY: Springer; 2014. p. 10-47.  Back to cited text no. 11
    
12.
International Classification of Diseases (ICD). Available from https://www.who.int/standards/classifications/classification-of-diseases. [last accessed on 2022 Mar 02].  Back to cited text no. 12
    
13.
Nwafor R, Ugiagbe R, Akhiwu R. A retrospective study of paediatric medicolegal autopsies at the University of Benin Teaching Hospital, Benin City, Nigeria. J Med Biomed Res 2013;12:76-80.  Back to cited text no. 13
    
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UNICEF. Infant, Under-Five and Maternal Mortality Rates. UNICEF Website. 2015;(Dhs 2013):2. Available from: https://www.unicef.org/nigeria/media/1636/file/Nigeria-equity-profile-health.pdf.pdf. [last accessed on 2022 Mar 02].  Back to cited text no. 14
    
15.
Adedini SA, Odimegwu C, Imasiku EN, Ononokpono DN, Ibisomi L. Regional variations in infant and child mortality in Nigeria: A multilevel analysis. J Biosoc Sci 2015;47:165-87.  Back to cited text no. 15
    
16.
Craver R, Springer J, Begue R. Infections in a children's hospital autopsy population. Fetal Pediatr Pathol 2014;33:135-44.  Back to cited text no. 16
    
17.
Godson MC, Nnamdi MJ. Environmental determinants of child mortality in Nigeria. J Sustain Dev 2011;5:65-75.  Back to cited text no. 17
    
18.
Maródi L. Neonatal innate immunity to infectious agents. Infect Immun 2006;74:1999-2006.  Back to cited text no. 18
    
19.
Yaya S, Bishwajit G, Okonofua F, Uthman OA. Under five mortality patterns and associated maternal risk factors in sub-Saharan Africa: A multi-country analysis. PLoS One 2018;13:e0205977.  Back to cited text no. 19
    


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    Tables

  [Table 1], [Table 2], [Table 3]



 

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