E-ISSN 1858-8360 | ISSN 0256-4408
 

Original Article 


SUDANESE JOURNAL OF PAEDIATRICS

2021; Vol 21, Issue No. 1

ORIGINAL ARTICLE

A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan

Ilham Mohammed Omer (1), Bohisah Abdullah Abdalmajid Mohammed (2)

(1) Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

(2) Soba University Hospital, Khartoum, Sudan

Correspondence to:

Ilham M. Omer

Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

Email: ilhamomer777 [at] hotmail.com

Received: 15 August 2020 | Accepted: 16 December 2020

How to cite this article:

Omer IM, Mohammed BAA. A Study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudan J Paediatr. 2021;21(1): 42–47.

https://doi.org/10.24911/SJP.106-1597237251


ABSTRACT

Neonatal sepsis is one of the most critical illnesses in newborns with significant morbidity and mortality, particularly in developing countries. The present, cross-sectional, hospital-based, study was conducted to evaluate the association of red cell distribution width (RDW) with neonatal sepsis and its role as a predictive marker in the diagnosis of neonatal sepsis at Soba University Hospital, during the period July 2018 to April 2019. The study population was term neonates, aged 1-28 days, who were diagnosed with neonatal sepsis, with positive blood culture. A total of 111 full-term neonates had blood culture proven neonatal sepsis and the majority of them (100%, 90%) had positive C-reactive protein (CRP). The average RDW in this study was 19.3% and was elevated in 103 (92%) of the study participants with a significant association with positive blood culture. The majority (65%, 58.6%) of mothers of the studied neonates did not have an illness during pregnancy, 19 (17.1%) had diabetes mellitus, 9 (8.1%) had hypertension, in addition to other different conditions in 18 (16.2%). The common causes of admission of the studied newborns included respiratory distress (70%, 79%), jaundice (33%, 29.7%) and lethargy (28%, 25.2%). Staphylococcus aureus was the most common organism isolated from blood culture in 50 (45.0%) patients, and Escherichia coli was the least one, isolated in only one (0.9%) newborn. There is a significant association between positive blood culture, CRP and elevated RDW (p-value 0.01). RDW was found to be significantly elevated in the studied newborns with neonatal sepsis.


KEYWORDS

Newborn; Sepsis; Red cell distribution width; C-reactive protein; Sudan.


INTRODUCTION

Neonatal sepsis is a clinical syndrome characterised by systemic signs of infection and accompanied by bacteraemia in the first month of life [1]. It is one of the important causes of neonatal morbidity and mortality in newborns particularly in developing countries [2].

Numerous molecules have been studied as potentially useful prognostic markers in neonatal sepsis. These include C-reactive protein (CRP), procalcitonin, cytokines and CD64 [2]. Another marker that has been studied in neonatal sepsis is the red cell distribution width (RDW), a measure of the variability of red blood cells (RBCs) in size (anisocytosis) and is routinely evaluated as a part of complete blood count. Elevation of the RDW occurs in conditions of ineffective production, or increased destruction of RBCs, which commonly occur in inflammatory or infectious situations, and has been classically used as a screening index for iron deficiency—anaemia. Elevated RDW is associated with inflammatory markers such as CRP, erythrocyte sedimentation rate, interleukin-6 and tumor necrosis factor-alpha. Proinflammatory cytokines of sepsis have been shown to suppress the maturation of RBC and decrease the half-life of RBCs, resulting in the elevation of RDW values. Studies about RDW and its relation to neonatal sepsis are rare, as most of the previous studies were conducted in the adult population [3].

RBC distribution width (RDW) is usually expressed as RDW-coefficient of variation. Its significance in newborns needs more research [4]. The RDW test shows the difference in size between the smallest and largest RBCs in a sample. The average RBCs are 6-8 micrometers (μm) in diameter. Higher results of the RDW test occur if more cells are larger or smaller than normal. This can suggest the presence of an underlying condition, although not all conditions affect RDW [5]. Results may be normal or high, and the ranges are subtle. Reference intervals of RDW for neonates are higher than for older children and adults. At birth, the lower reference limit for term and late preterm neonates is 15.5%. The upper reference limit is 20% and is slightly higher (up to 23%) in preterm neonates. The mean normal range of RDW in preterm is 17.8 ± 2.1 and in term babies is 16.7 ± 1.6. The normal range for RDW values at 32-34 weeks is higher than at 35-36 gestational weeks. High RDW values at birth indicate anisocytosis; low values are related to microcytosis [6]. It is started to be apparent that RDW is related to the adverse outcome in sepsis [7].

Normal RDW does not rule out an ongoing medical condition. That is why RDW results are usually interpreted with other blood results. This combination of results provides a more complete picture of the health of RBCs and can help to diagnose a variety of conditions [8].


MATERIALS AND METHODS

This is a prospective hospital-based cross-sectional study that was conducted at Soba University Hospital (SUH) Neonatal Intensive Care Unit (NICU) during July 2018-April 2019.

SUH is located 15 km south of the centre of the capital of Sudan, Khartoum, and is considered the largest training hospital for the students of the Faculty of Medicine, University of Khartoum. The NICU in the hospital receives about 800-1,000 newborns yearly, and all of them should be born in the hospital. Obstetric Department in SUH is one of the main referral centres for high-risk pregnancies in Sudan and receives cases from the whole country including both governmental and nongovernmental sectors.

The study sample included term neonates aged from 1 to 28 days with culture positive proven neonatal sepsis who were admitted to the NICU during the study period. All newborns aged 1 to 28 days, who were diagnosed as neonatal sepsis and had positive blood cultures, were included in the study. Preterm neonates, congenital anomalies and those who underwent surgical or other invasive procedures were excluded from the study.

The sample size was calculated from the expected cases (51 per month) of neonatal sepsis admitted to the NICU during the data collection period, according to the formal statistical records. It was calculated by the formula:

n = 15 n = N/ [1 + N (e)2], where n is the sample size and N is the population size. The minimum calculated sample size was 111 participants throughout the study period.

Collected data were analysed using a master sheet and excel computer program. Qualitative variables were described in the form of frequency and percentage. The standard test of significance (Chi-Square Test) was used. p-value was considered significant if it is less than 0.05 at a confidence level of 95%.


RESULTS

One hundred and eleven term newborns with blood culture proven neonatal sepsis, who were admitted to the NICU at SUH during the period December 2018 to February 2019, were enrolled in the study. Fifty-eight (52.3%) of them were males and 53 (47.7%) were females.

Forty-six (41.4%) of the studied newborns were delivered by elective Caesarean section (CS), 41 (36.9%) by an emergency CS, 18 (16.2%) by spontaneous vaginal delivery, and 6 (5.4%) by assisted vaginal delivery. Forty three (38.7%) newborns needed resuscitation after birth. Two newborns (1.8%) had birth weight <2,000 g, 8 (7.2%) had birth weight >4,000 g and 65 (58.6%) had birth weight between 2,000-4,000 g. The most encountered clinical conditions were respiratory distress (70%, 79%), jaundice (33%, 29.7%), lethargy (28%, 25.2%), feeding problems (17%, 15.3%), hypoglycaemia (12%, 10.8%), hyper/hypothermia (9%, 8.1%), seizures (6%, 5.4%), apnea (4%, 3.6%), and two (1.8%) had shock. Mothers’ age group 20-30 years was recorded in 54 (48.6%), 30-40 years in 30 (27%), >40 years in 20 (18%), and 7 (6.3%) mothers were < 20 years. Eighty-nine (99%) mothers were on regular antenatal care. Sixty-five (58.7%) mothers had not got illness related to pregnancy, 19 (17.1%) had diabetes mellitus, 9 (8.1%) had hypertension and 19 (17.1%) had other problems. Other maternal illnesses during pregnancy included asthma in 6 (5.4%), hyperthyroidism, hypothyroidism and preeclmpsia 3 (2.7%) each, hepatitis B in 2 (1.8%), and epilepsy and cardiac disease 1 (0.9%) each.

Maternal urinary tract infection (UTI) during pregnancy was reported in 21 (18.9%) mothers followed by 18 (16.2%) premature rupture of membrane >18 hours, and 9 (8.1%) mothers had elevated temperature >38°C. Twenty-two (19.8%) mothers received antibiotics during pregnancy. The family history of the previous sibling with neonatal death was recorded in 14 (12.6%) and family history of the previous sibling with neonatal sepsis in 34 (30.6%).

The most common type of organisms isolated from blood culture was Staphylococcus aureus (50, 45.0%) followed by Pseudomonas aeruginosa (38, 34.2%), then Gram-negative bacilli (16%, 14.4%), Klebsiella pneumoniae (6%, 5.4%) and Escherichia coli (1%, 0.9%). Hundred (90.1%) patients had positive CRP and 11 (9.9%) had negative CRP.

Out of 111 neonates 69 (62%) had leukocytosis [white blood cell count (WBC) > 20,000/mm3], 18 (16.2%) had leucopenia (WBC <5,000/mm3), 21 (18.9%) had thrombocytosis [platelets (PLTs) >450,000/mm3] and 58 (52.2%) had thrombocytopenia (PLTs < 140,000/mm3).

The average RDW was 19.3% in 103 (92.7%) newborns and the maximum was 25.6% in 2 (1.8%) and the minimum was 12.6% in only 6 (5.4%) newborns. There was no correlation between high RDW and the sex of the neonate (p-value 0.37), type of delivery (p-value 0.25), mode of delivery (p-value 0.25) or need for resuscitation (p-value 0.38). Regarding the clinical signs and symptoms in presentation, there was no relation between high RDW and respiratory distress, jaundice, lethargy, hypoglycaemia, or feeding problems (p-value 0.61, 0.26, 0.18, 0.24, 0.42, respectively). Only 20 newborns with respiratory distress had the highest RDW (p-value 0.11). There was a significant correlation between high RDW and positive CRP (p-value < 0.01), but no correlation between high RDW and WBC and PLT counts (p-value 0.9). Similarly, there was no correlation between high RDW and the organisms isolated from positive blood cultures (Table 1).


DISCUSSION

In the present study, males constituted 52.3% while females were 47.7% of the studied newborns, with a ratio of 1.1: 0.9. This is similar to the results of a study from Egypt which showed that male to female ratio was 1.3:1 [9]; and almost the same as the results of a thesis done at our NICU in 2015 (Rasha, unpublished) which showed males were 52.8% and females were 47.2% , the ratio being 1.1:1.

Table 1. Correlation between RDW and organisms isolated from blood culture.

RDW group (%) Total
Mini <17 Aver 18-19 Maxi >20
Organism isolated from blood culture Gram-negative bacilli 0 13 3 16
Pseudomonas aeruginosa 0 21 17 38
Staphylococcus aureus 1 41 8 50
Klebsiella pneumoniae 0 3 3 6
Escherichia coli 0 1 0 1
Total 1 79 31 111

Aver = average; Max = maximum; Mini = minimum; RDW = red cell distribution width.*p value = 0.11 (not significant).

CS was the commonest mode of delivery among newborns with culture proven neonatal sepsis; and this is similar to the study done at our NICU in 2015 (Rasha, unpublished), which showed that CS was the most common mode of delivery among patients with neonatal sepsis. Similar results were also reported by the study from Egypt which revealed that 69.7% of newborns with sepsis were delivered by Caesarean section [9].

Regarding the clinical presentations, more than one symptom or clinical sign was observed in the same newborn. A study conducted in three Egyptian hospitals reported that the most prevalent clinical presentation was respiratory distress [9], and a study by Jajoo et al. [10] showed that hypothermia (47.5%) and respiratory distress (44%) were the common clinical presentations.

Concerning the risk factors in the present study, the majority of the mothers of the studied neonates had not any illness during pregnancy. Maternal UTI during pregnancy was present in 18.9%, followed by premature rupture of membrane for >18 hours (16.2%), and 8.1% of mothers had elevated temperature >38°C. A study conducted in the USA reported that the first week of life is associated with maternal infection and colonisation [11], and another study by Stoll et al. [12] in the USA found that the risk of infection among neonates increased with decreased gestation.

The average RDW in this study was 19.3% in 92% of the newborns, and it was very similar to the results reported by Martin et al. [13] who showed that the mean of the normal range of RDW was 19.9% with a p-value <0.001. In the present study, RDW was high in 1.8% of the studied newborns. In a study conducted by Cosar et al. [14], RDW was observed to be higher in term and near-term newborns with EONS. In the present study, CRP was positive in 90% of the studied newborns, and there was a significant association between CRP, high RDW and positive blood cultures compared to the study by Dhanalakshmi and Sivakumar [15] who found that out of 70 cases with neonatal septicaemia, blood culture was positive in 41 and only 37 had positive CRP. There was no significant association between WBC, PLT values and high RDW and no study was done to compare between the RDW and high WBC and PLT counts. There is only one study done in Egypt where RDW and other traditional biomarkers, including CRP, total WBC and PLT count were analysed in light of the clinical data [16]. RDW was significantly elevated in infants with septic shock compared with those having severe sepsis and those with sepsis (p < 0.0001). A strong positive correlation was found between RDW and CRP.

Regarding the organisms isolated from culture, less than half of the study population had S. aureus (45.0%) followed by P. aeruginosa (34.2%), then Gram-negative bacilli (14.4%), K. pneumoniae (5.4%) and E. coli (0.9%). A study conducted in South Africa [17] revealed that the predominant isolates were K. pneumoniae (32.2%), coagulase-negative staphylococci (23.72%) and methicillin-resistant S. aureus (13.13%) In a similar study from India, the isolates were Klebsiella pneumonie (36%), S. aureus (21%) and E. coli (14%).


CONCLUSIONS

RDW was found to be significantly high in the studied newborns with neonatal sepsis, and significantly associated with positive blood culture and positive CRP. We recommend that RDW be used as a predictor of neonatal sepsis and to train the residents about its use with other clinical or laboratory parameters in areas with difficult or no access to blood culture.


ACKNOWLEDGEMENTS

The authors would like to thank all the parents for their collaboration and allowing us to use their newborns’ data. We are thankful to the hospital administration for giving permission to conduct the research.


CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this article.


FUNDING

The research was funded by the authors.


ETHICAL APPROVAL

The study was approved, and an ethical clearance was given by the Ethics Committee of The Sudan Medical Specialization Board; and permission was obtained from the administrative authority of SUH. Informed consent for participation and publication was obtained from the guardians of the patients. Confidentiality was maintained at all levels.


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How to Cite this Article
Pubmed Style

Omer IM, Mohammed BAA. A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudan J Paed. 2021; 21(1): 42-47. doi:10.24911/SJP.106-1597237251


Web Style

Omer IM, Mohammed BAA. A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. http://www.sudanjp.com/?mno=124743 [Access: October 16, 2021]. doi:10.24911/SJP.106-1597237251


AMA (American Medical Association) Style

Omer IM, Mohammed BAA. A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudan J Paed. 2021; 21(1): 42-47. doi:10.24911/SJP.106-1597237251



Vancouver/ICMJE Style

Omer IM, Mohammed BAA. A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudan J Paed. (2021), [cited October 16, 2021]; 21(1): 42-47. doi:10.24911/SJP.106-1597237251



Harvard Style

Omer, I. M. & Mohammed, . B. A. A. (2021) A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudan J Paed, 21 (1), 42-47. doi:10.24911/SJP.106-1597237251



Turabian Style

Omer, Ilham Mohammed, and Bohisah Abdullah Abdalmajid Mohammed. 2021. A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudanese Journal of Paediatrics, 21 (1), 42-47. doi:10.24911/SJP.106-1597237251



Chicago Style

Omer, Ilham Mohammed, and Bohisah Abdullah Abdalmajid Mohammed. "A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan." Sudanese Journal of Paediatrics 21 (2021), 42-47. doi:10.24911/SJP.106-1597237251



MLA (The Modern Language Association) Style

Omer, Ilham Mohammed, and Bohisah Abdullah Abdalmajid Mohammed. "A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan." Sudanese Journal of Paediatrics 21.1 (2021), 42-47. Print. doi:10.24911/SJP.106-1597237251



APA (American Psychological Association) Style

Omer, I. M. & Mohammed, . B. A. A. (2021) A study of red cell distribution width and neonatal sepsis at Soba University Hospital, Khartoum, Sudan. Sudanese Journal of Paediatrics, 21 (1), 42-47. doi:10.24911/SJP.106-1597237251





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