Hydrops fetalis

A descriptive study was conducted in the pediatric inpatient unit of Gulhane Military Medical Academy, to investigate the morbidity and mortality characteristics of 532 infants hospitalized between January 1 and December 31, 2001, for treatment purposes. Of the study participants, 55.8% were boys and 44.2% were girls. The most common cause of hospitalization was neonatal hyperbilirubinemia (19.7%). The most common admission month was January (12.4%). Of 532 infants, 510 (95.9%) were discharged, whereas 22 patients died in the hospital. Twenty-one patients died in the neonatal period, and respiratory distress syndrome and neonatal sepsis were identified as the most common causes of death. Our finding of associations between male gender and low birth weight and hospital death is consistent with previous knowledge. Despite the high frequencies of pneumonia and gastroenteritis as admission diagnoses, the finding of only one pneumonia-related death and no gastroenteritis-related deaths in the study population is pleasing.

Introduction

Infancy is a high-risk period of life for morbidity and death. In developing countries, in particular, infant deaths represent the major part of all deaths.1 In Turkey also, the proportion of infant deaths among all deaths is quite high.2 Despite a decreasing rate in past decades, the countrywide proportion of infant deaths in provinces and central districts was 8.6% in 1999, and deaths occurred mainly in the first month of life.2

It has been reported recently that the annual number of deaths at

In developing countries such as Turkey, limited resources require that health priorities be selected wisely and child health-related research is clearly warranted, to identity high-risk groups and to suggest appropriate preventive and therapeutic approaches for decreasing morbidity and mortality rates among children. This descriptive study aims to identify the sociodemographic, morbidity, and mortality characteristics and associated risk factors (such as admission diagnosis and length of hospitalization) for infants hospitalized in the Department of Pediatrics of the Gulhane Military Medical Academy (GMMA) between January 1 and December 31, 2001.

Methods

The study was conducted in the Department of Pediatrics of the GMMA, located in Ankara, which is the largest military hospital in Turkey, with a 50-bed pediatric hospital (with 15 beds for neonates and 12 beds for infants). All infants, 0 to 365 days of age, who were hospitalized for at least 24 hours in the pediatric inpatient clinic between January 1 and December 31, 2001, were included in the study. Data were collected retrospectively from patients' medical charts, between December 2001 and January 2002, using a standardized data collection form.

This descriptive study included a total of 532 infants who were hospitalized for longer than 24 hours. This group made up 42.5% of all 0- to 15-year-old children admitted to the clinic for various reasons during the study period. The variables included in the study were birth weight and gender of the infant, length of hospitalization, month of hospitalization, admission diagnosis, and hospital outcome.

All health care personnel (N = 3) responsible for data collection were trained before the study, they used a standardized data collection form and procedures, and they were all tested for reliability before the data collection process. The data collection process took 30 days. Statistical analyses were conducted using the SPSS version 10.0 statistical software package (SPSS, Chicago, Illinois) and included calculation of frequencies, percentages, and cross-tabulations. Statistical differences between groups were investigated using χ^sup 2^ tests.

Results

Between January 1 and December 31, 2001, 1,613 children (0-14 years) were hospitalized in the pediatric inpatient unit of the GMMA. Of these, 1,253 were hospitalized for more than 24 hours, with 532 (42.5%) being 0 to 365 days old. The study included all 532 infants eligible for the study. Of these, 55.8% were boys and 29.8% had low birth weights. Information on gender and birth weight characteristics of the infants is presented in Table I.

The length of hospitalization ranged from 1 to 97 days, with an average of 6.7 ± 9.9 days (median, 3 days). Approximately 40% of participants stayed in the hospital for ≤2 days, whereas 18% stayed for > 10 days. Twenty-two patients, 21 of whom were in the neonatal period, died in the hospital. The proportion of discharges in the study period was 95.9%. The most common admission month was January (12.4%) and admission rates were lowest in December (5.3%), which suggests a statistically significant difference in the distribution of admissions during the year (χ^sup 2^ test = 28.42, df = 11, p

The distribution of admission diagnoses is presented in Table III. Neonatal hyperbilirubinemia was the most common admission diagnosis (19.7%), followed by prematurity, pneumonia, acute gastroenteritis, and neonatal sepsis.

Of the 22 deaths, one infant, who had an admission diagnosis of pneumonia, was 10 months of age; the rest of the infants (95.5%) were in the neonatal period when they died. Respiratory distress syndrome, neonatal sepsis, and prematurity were the causes of 59.3% of all deaths. For 27.4% of deaths, respiratory distress syndrome was reported as the underlying cause of death. Among the reportedly respiratory/circulatory insufficiency-related deaths, two patients had cardiac pathological conditions (aortic insufficiency and left hypoplastic heart), one had intracranial bleeding attributable to birth trauma, and one developed hypovolemic shock after a traffic accident. The distribution of causes of death is presented in Table IV.

Discussion

In this study, 64.8% (N = 345) of infants hospitalized during the 1-year study period were infants ≤28 days of age. The majority of admissions occurred in January, and admissions seemed to have a decreasing order of frequency in February and March. The number of admissions was lowest in December, which could be at least partially explained by the holiday season; both Ramadan and the New Year's holidays were in December in 2001.

Hyperbilirubinemia is a common health problem among newborns, and pathological hyperbilirubinemia appears in the first day of life.16 In this study, hyperbilirubinemia was the most common cause of admissions (19.7%).

Acute gastroenteritis, the fourth most common cause of admission in the study population, is known as a common cause of hospitalization in the childhood period. This finding is consistent with the results of studies reported from Spain, France, and the United States.17-19 In 1999 in Turkey, 70.4% (N = 305) of all diarrhea-related childhood deaths occurred in infancy and 1.9% of all infant deaths that occurred in provinces and districts nationwide were related to diarrhea.2 However, no gastroenteritis- or diarrhea-related death was detected in this study. There is only one comparable national study, which was conducted in Diyarbakir, Eastern Turkey, studying the 825 deaths that occurred in Diyarbakir Pediatric Hospital between 1999 and 2001. That study reported that 81.1% of all childhood deaths were among children

In verbal autopsy studies conducted in Bangladesh and Egypt, acute respiratory tract infections constituted 25% of all childhood deaths4 and were second to diarrhea in the list of the most common causes of deaths among children ≤5 years of age,21 respectively. Similarly, pneumonia was reported as the second most common cause of death among children ≤5 years of age in India and constituted 19.7% of all deaths in that age group.6 In 1999 in Turkey, pneumonia-related deaths were reported as 5.8% of all infant deaths detected in provinces and districts nationwide and 61.6% (N = 923) of all pneumoniarelated childhood deaths occurred during the first year of life.2 Lung infections were reported as the cause of death for 20.1% of all hospital deaths that occurred during a 3-year period in Diyarbakir Pediatric Hospital and were responsible for 52.4% of all postneonatal deaths.20 In the GMMA study, only one baby died as a result of pneumonia; the patient was a 10-month-old baby, born at 1,680 g. Given the population-based nature of verbal autopsy studies, in contrast to the hospital-based GMMA study, the results may not be comparable.

Bronchiolitis, the most common cause of acute respiratory tract infections among children in developed countries,7,22 was reported among the 10 most common causes of admissions in the GMMA study. Acute otitis media, a common health problem that usually occurs secondary to upper respiratory tract infections among children 3 months to 3 years of age,16 was responsible for 2.1% of all admission diagnoses in the GMMA study.

Sepsis usually occurs in the neonatal period among infants. Neonatal sepsis is defined as an invasive bacterial infection occurring in the first 4 weeks of life. The incidence of neonatal sepsis ranges between 0.5 and 8 cases per 1,000 live births.16 All 24 infants with an admission diagnosis of sepsis were in the neonatal age group.

Of the 22 infants who died in the hospital, all except one 10-month-old child, who died as a result of pneumonia, were neonates (95.5%). Deaths occurred as a result of respiratory distress syndrome (n = 6), sepsis (n= 5), prematurity (n = 2), acute renal insufficiency (n = 1), intestinal perforation (n = 1), hydrops fetalis (n = 1), traffic accident-related hypovolemic shock (n = 1), intracranial bleeding attributable to birth trauma (n = 1), aortic insufficiency (n = 1), pneumonia (n = 1), necrotizing enterocolitis (n = 1), and left hypoplastic heart (n = 1). In accordance with a disadvantage for boys reported in the literature,23-25 the number of deaths among boys was 1.2 times that among girls in the GMMA study.

Babies born before the completion of 37 weeks of gestation are considered premature babies. These babies usually weigh

A limitation of the study was that data collection in the study was based on reviews of medical charts. Incomplete records were common, particularly for infants hospitalized for only 1 day (n = 105).

Conclusions

Our finding of associations between male gender and low birth weight and hospital death is consistent with previous knowledge. Despite the high frequencies of pneumonia and gastroenteritis as admission diagnoses, the finding of only one pneumonia-related death and no gastroenteritis-related deaths in the study population is pleasing. This could be at least partially explained by the high educational and socioeconomic status of the military personnel and the high rates of accessibility to medical care in this group. Finally, the study findings confirmed the importance of a standardized, continuous, valid data collection system, which should be available at all health care units and should be used properly by all health care personnel.

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Guarantor: CAPT Selim Kiliç

Contributors; CAPT Selim Kiliç*; Sabahat Tezcan, MD PhD[dagger]; MAJ M. Emre Tasçilar[double dagger]; Banu Çakir, MD PhD[dagger]; MAJ Halil Ibrahim Aydin[double dagger]; Col Metin Hasde§; Brig Gen Erdal Gökçay[double dagger]

* Department of Epidemiology and Public Health, Gulhane Military Medical Academy, Ankara, Turkey.

[dagger] Department of Public Health, Hacettepe University, Ankara, Turkey.

[double dagger] Department of Pediatrics, Gulhane Military Medical Academy, Ankara, Turkey.

§ Department of Public Health, Gulhane Military Medical Academy, Ankara, Turkey.

Reprints: Selim Kiliç, Halk Sagligi AD, Gülhane Askeri Tip Akademisi, 06018, Etlik/Ankara, Turkey.

This manuscript was received for review in June 2003. The revised manuscript was accepted for publication in March 2004.

Reprint & Copyright © by Association of Military Surgeons of U.S., 2005.

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