Clinician’s adherence to world health organisation guidelines and short-term outcome of management of neonatal seizures at Moi Teaching and Referral Hospital, Eldoret, Kenya

Abstract

Background: Neonatal seizures are the most common manifestation of neurological disease in New Born Units and have been associated with increased mortality and morbidity among survivors which underlies the need for early initiation of treatment. However, it continues to offer both diagnostic and therapeutic challenges to clinicians. Although it is clear that diagnosis requires prolonged electroencephalography monitoring accompanied by observation, many newborn units lack the technology and therefore rely on direct observation for diagnosis. Therapeutic challenges have been occasioned by lack of standardized protocols which was the basis of development of the World Health Organisation guidelines that has the potential of improving outcome. The local approach to diagnosis and the extent to which clinicians follow the guidelines is unknown. Objective: To determine the clinical characteristics, adherence to World Health Organization (WHO) guidelines by clinicians and short-term outcomes in the management of neonates with clinical neonatal seizures in Moi Teaching and Referral Hospital newborn unit. Methods: A prospective descriptive study of newborns admitted to newborn unit from January 2014 to July 2014. Nurses and doctors working in the unit were trained on recognition of neonatal seizures by direct observation. They were asked to record the observed behavior or motor movement in the patient’s file and inform the researcher or research assistant of the same. The researcher or research assistant used a data collection tool to collect the required data from the newborns who met the inclusion criteria. The neonates were then followed up every 48 hours until death or discharge from the unit. Data was analyzed using STATA version 13 at 95% confidence interval. Categorical variables were summarized as frequencies and the corresponding percentages while continuous variables were summarized as mean, median and standard deviation. Results: A total of 158 neonates were included in the study, and 31.6% had clinical neonatal seizures. The median age at admission was 4 (IQR: 1-48) hours. The male to female ratio was 1.5:1. Most of the neonates were born at term (82%). In univariate analysis, birth weight and gestation age were significantly associated with neonatal seizures (P = 0.001). The most frequent seizure type observed was tonic focal at 36%. Overall, Adherence to WHO guidelines was found to be inadequate. Compared to the WHO guidelines, only 12% and 16% of the neonates who had suspected sepsis and meningitis had blood cultures and lumbar punctures done respectively. None of the neonates had calcium levels checked while 64% had random blood sugar levels. The first line anticonvulsant was Phenobarbital. The median time taken to control seizures was 24 hours (IQR 0.17-48). Of the 50 participants, 44% died. A longer time taken to control seizures was associated with a higher mortality (p=0.006). Conclusion: About a third of admitted neonates had seizures and almost half of them died. There was inadequate adherence to the WHO guidelines in the management of neonatal seizures. Recommendations: There is need to reduce the prevalence of neonatal seizures through vigorous study of its aetiology and subsequent prevention. A future study should look at the reason for none adherence to WHO recommended guidelines in care of neonatal seizures at MTRH.