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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 1-5

A review of pediatric mortalities in the emergency units of Nigerian tertiary hospitals


Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria

Date of Submission09-Dec-2019
Date of Decision23-Jan-2020
Date of Acceptance09-Feb-2020
Date of Web Publication03-Apr-2020

Correspondence Address:
Dr. Ogochukwu N Iloh
Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, 400002.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_37_19

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  Abstract 

Background: Information on causes of death is needed to assess trends in disease burden, prioritize interventions, plan for their delivery, and ascertain the effectiveness of disease-specific interventions. The aim of this study was to review the postneonatal mortality pattern in the different pediatric emergency units of the tertiary hospitals across the country, and to propose ways of strengthening the emergency units for more effective health service delivery. Materials and Methods: Available literature on mortality in pediatric emergency units across the tertiary health institutions in Nigeria was reviewed. Neonates as well as studies that combined ward admissions with emergency room admissions were excluded. Analysis was mainly descriptive and results presented using prose, tables, and charts. Results: A total of 11 studies were analyzed. The crude mortality rate was 82 per 1000 admissions. Approximately 60% of the deaths occurred within the first 24h of presentation. The major causes of death were severe malaria (17.9%), sepsis (14.5%), acute gastroenteritis (13.7%), pneumonia (8.9%), and protein-energy malnutrition (97.7%). Sepsis and severe anemia had the highest case fatality rates, with 20.0% and 19.6%, respectively. Late presentation, unconsciousness, seizure, and severe pallor were some of the identified risk factors. Conclusion: Communicable diseases remain the major cause of mortality in our emergency units. Strengthening and restructuring of the emergency units in terms of manpower and services will help in lowering the mortality rates.

Keywords: Emergency, mortality, Nigeria, pediatrics


How to cite this article:
Edelu BO, Igbokwe OO, Iloh ON. A review of pediatric mortalities in the emergency units of Nigerian tertiary hospitals. Int J Med Health Dev 2020;25:1-5

How to cite this URL:
Edelu BO, Igbokwe OO, Iloh ON. A review of pediatric mortalities in the emergency units of Nigerian tertiary hospitals. Int J Med Health Dev [serial online] 2020 [cited 2020 Aug 15];25:1-5. Available from: http://www.ijmhdev.com/text.asp?2020/25/1/1/281891




  Introduction Top


Planning for the right intervention measures for an emergency department requires a good knowledge of the causes and pattern of morbidity and mortality within the environment. Information on causes of death is needed to assess trends in disease burden in relation to national and international objectives, prioritize interventions, plan for their delivery, and ascertain the effectiveness of disease-specific interventions.[1],[2]

Majority of the sick children admitted into the pediatric wards are through the emergency room. Each year thousands of children visit the emergency departments in hospitals around the country. Emergency medicine has continued to develop over the years, and is now a recognized subspecialty in most developed countries and many developing countries.

Majority of the deaths reported in children from different parts of the country occur in the emergency room.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Therefore, a well-structured and organized children emergency unit may be the key to improvement in the morbidity and mortality. However, to be able to achieve this, an audit of the situation around the country is necessary.

This study aimed at reviewing the mortalities in children emergency departments in tertiary institutions in different parts of the country.


  Materials and Methods Top


A search for all the literature on mortality in children emergency units in Nigerian tertiary institutions was conducted using Google search. Keywords included in the search were children, pediatrics, mortality, deaths, emergency room, and Nigeria. Several searches were made using different combinations of the words. Available literature was reviewed. Studies that combined ward admissions with emergency room admissions were excluded, likewise those that studied ward admissions or neonatal mortality alone. Neonates were also excluded. Relevant data were extracted from the papers. The years of study (distinct from year of publication of paper) were noted. Analysis was mainly descriptive. Necessary calculations were performed, including total frequency and case fatality rates (CFRs). Results were reported in form of prose, tables, and figures.


  Results Top


A total of 18 papers published between 1989 and 2015 were reviewed. However, only 11 fulfilled the inclusion criteria. The years of study for these studies ranged from 1986 to 2014. All the studies were retrospective. The average admissions in the hospitals per annum were 1406 (451–3155), with a male:female ratio of 1.3:1. [Table 1] shows the mortality rates in the various pediatric emergency units by location as well as the proportion of mortalities that occurred within 24h of admission into the emergency unit. The crude mortality rate ranged from 39 to 158, with a mean of 82 per 1000 admissions. Approximately 60% of the deaths occur within the first 24h of presentation.
Table 1: Total mortality and 24-h mortality rates in Nigeria’s emergency pediatric units

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[Figure 1] shows the overall causes of death. Severe malaria (17.9%), sepsis (14.5%), acute gastroenteritis (13.7%), pneumonia (8.9%), and protein-energy malnutrition (7.7%) were the major causes of death. In all the papers, the diagnoses were obtained by a combination of clinical features and laboratory tests. In some cases such as malaria, the diagnoses were confirmed by microscopy or malaria rapid diagnostic tests. Blood cultures, full blood count, and clinical features were combined in most studies to make a diagnosis of sepsis. Meningitis was confirmed by cerebrospinal fluid analysis in most of the cases. [Table 2] shows the major causes of mortalities by location, whereas [Table 3] shows the top case fatalities. In terms of case fatality, the diseases that had the highest CFRs were sepsis (20.0%), severe anemia (19.6%), severe malnutrition (18.95), human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (17.1%), and meningitis (15.5%).
Figure 1: Causes of mortality in Nigeria’s emergency pediatric units. AGE = acute gastroenteritis, SCA = sickle cell anemia. *Values are in percentages

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Table 2: Principal causes of mortality by hospital

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Table 3: Top case fatality rates in the tertiary hospitals

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  Discussion Top


This review gives a comparative insight into the rates and causes of mortality in the emergency pediatric units of Nigerian tertiary hospitals. Mortality rate is a reflection of the severity of illness and the quality of treatment of patients in pediatric emergency departments.[14] The crude mortality rate in pediatric emergency departments across the country is high, with some institutions recording over 100 deaths per 1000 admissions [Table 1]. The concern with the figures stems from the fact that these tertiary institutions are supposed to be the centers of excellence in the country with the best facilities and personnel to handle pediatric emergency cases. One would have expected that the more recent studies would have recorded less mortality rates than older studies, but this was not the case, thus giving the impression that no significant improvement has been recorded over the years despite the increase in the number of health personnel around the country over the years.

Majority of pediatric emergency mortalities occur within the first 24h of admission in hospitals and this has largely been attributed to preventable causes.[15] Some of these preventable causes include poor health-care seeking behavior, delay in referral, using traditional medicine for initial treatment of illnesses at home, and poverty.[16] More than half of the mortalities in the different pediatric emergency departments reviewed occurred within the first 24h, thus making the first 24h the most critical time to address the problems of children presenting to emergency rooms. To do this effectively, bearing in mind the aforementioned reasons why some of these mortalities occur, centers may have to adopt protocols that emphasize triaging of all patients that present to the emergency unit as well as a quick evaluation or assessment for life-threatening problems and intervention as the case may be before a detailed history and examination is carried out. This suggests a deviation from the traditional practice of clerking an acutely ill child before intervention. A qualitative study of 21 hospitals in seven developing countries found that poor triage of incoming patients and inadequate provision of emergency care jeopardized the lives of arriving patient.[17]

The major causes of the death were severe malaria, sepsis, acute gastroenteritis, pneumonia, malnutrition, and meningitis. Literature from some African countries such as Ghana, Kenya, Tanzania, Zambia, Sierra Leone, and Mozambique also confirm bacterial infections such as pneumonia, gastroenteritis, and meningitis as major causes of childhood morbidity and mortality.[18],[19],[20] Bacterial infections, specifically diarrhea and respiratory infections, were also documented to be the commonest cause of morbidity and mortality in the pediatric emergency department of a tertiary care teaching and referral hospital in Kabul, Afghanistan.[21] These findings may suggest that in the developing world, bacterial infections and some degree of underlying malnutrition are still a significant cause of childhood morbidity and mortality. This calls for more concerted efforts by governments to ensure the success of the sustainable development goals and hence significantly reduces under-five mortality rate.

In terms of case fatality, children with a diagnosis of sepsis, severe anemia, severe malnutrition, HIV/AIDS, and/or meningitis were more likely to die, with as much as one in four to five children dying. The study in the pediatric emergency department of a teaching hospital in Nnewi, Anambra state of Nigeria documented that almost half of the patients with sepsis presented more than a week after the onset of symptoms.[13] This delay could be a significant factor in the high CFR of this disease.

Although malaria caused the most deaths, the case fatality was comparably low (3.9%). It can therefore be inferred that the efforts by World Health Organization (WHO) and other nongovernmental organizations to aid distribution of millions of long-lasting insecticide treated nets as part of the global malaria control strategy as well as the over-the-counter usage of artemisinin-based combination drugs, which are widely available are paying off to reduce the prevalence of malaria case fatalities.

Severe anemia had the second highest CFR of 19.6% among the documented mortalities in pediatric emergency units in Nigeria. It is one cause of death that can easily be prevented with the establishment of safe blood banks in all secondary and tertiary institutions with improvement in their delivery times. Education of health personnel to recognize anemia early enough and refer to places where safe blood transfusion can be obtained will go a long way to curbing the deaths from anemia. This buttresses the observation of Turner et al.[22] that most deaths in resource-constrained setting arise from preventable and reversible causes.


  Conclusion/Recommendations Top


Our children emergency units in this country are far from standard and thus do not allow for optimal practice. The revitalization of the primary and secondary health-care facilities in the country will also help in bringing healthcare closer to the people to avoid undue delays in presentation. In addition, a robust National Health Insurance scheme which will include all citizens will go a long way to encourage early presentation to the hospitals as out of pocket expenditure will be significantly reduced. There is also a need to develop appropriate guidelines for emergency triage and treatment as the implementation of such can significantly decrease the time required to assess children in need of urgent medical attention. The impact of training and retraining of health workers working in the pediatric emergency units in these hospitals, as well as those in the primary and secondary facilities which serve as source of referrals, cannot be over emphasized. It is also important to equip and maintain these hospitals with the basic facilities necessary to run an emergency unit. There is also a need for personnel working in the emergency units to be motivated positively to enable them put in their best whenever a child presents with a life-threatening condition. Finally, there is an urgent need to develop a mechanism that will enable quick transfusion of children who urgently need blood in all our tertiary health facilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al; Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes of child mortality in 2008: A systematic analysis. Lancet 2010;375:1969-87.  Back to cited text no. 2
    
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Aikhionbare HA, Yakubu AM, Naida AM. Mortality pattern in the emergency paediatric unit of Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Cent Afr J Med 1989;35:393-6.  Back to cited text no. 3
    
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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
    
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George IO, Tabansi PN. An audit of cases admitted in the children emergency ward in a Nigerian Tertiary Hospital. Pak J Med Sci 2010;27:740-3.  Back to cited text no. 7
    
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Edelu BO, Eze JN, Oguonu T, Ndu IK. Morbidity and mortality pattern in the children emergency unit of the University of Nigeria Teaching Hospital Enugu. Orient J Med 2014;26:73-8.  Back to cited text no. 8
    
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Ezeonwu B, Chima O, Oguonu T, Ikefuna A, Nwafor I. Morbidity and mortality pattern of childhood illnesses seen at the children emergency unit of Federal Medical Center, Asaba, Nigeria. Ann Med Health Sci Res 2014;4:S239-44.  Back to cited text no. 9
    
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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. 11
    
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Anyanwu OU, Ezeanosike OB, Ezeonu CT. Pattern and outcome of admissions at the children emergency room at the Federal Teaching Hospital Abakaliki. Afr J Med Health Sci 2014;13:6.  Back to cited text no. 12
  [Full text]  
13.
Ndukwu CI, Onah SK. Pattern and outcome of postneonatal pediatric emergencies in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South East Nigeria. Niger J Clin Pract 2015;18:348-53.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Jofiro G, Jemal K, Beza L, Heve TB. Prevalence and associated factors of paediatric emergency mortality at Tilur Anbessa Specialized Tertiary Hospital: A 5 year retrospective case review study. BMC Paediatr 2018;18:316.  Back to cited text no. 14
    
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Moss WJ, Ramakrishnan M, Storms D, Henderson Siegle A, Weiss WM, Lejnev I, et al. Child health in complex emergencies. Bull World Health Organ 2006;84:58-64.  Back to cited text no. 15
    
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Okposio MM, Unior MO, Ukpeteru FO. Sociodemographic determinants of mortality in hospitalized under-five children at a secondary health care centre in the Niger Delta. Int J Trop Dis Health 2012;2:173-8.  Back to cited text no. 16
    
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Nolan T, Angos P, Cunha AJ, Muhe L, Qazi S, Simoes EA, et al. Quality of hospital care for seriously ill children in less-developed countries. Lancet 2001;357:106-10.  Back to cited text no. 17
    
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Petit PL, van Ginneken JK. Analysis of hospital records in four African countries, 1975-1990, with emphasis on infectious diseases. J Trop Med Hyg 1995;98:217-27.  Back to cited text no. 18
    
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Sacarlal J, Nhacolo AQ, Sigaúque B, Nhalungo DA, Abacassamo F, Sacoor CN, et al. A 10 year study of the cause of death in children under 15 years in Manhiça, Mozambique. Bmc Public Health 2009;9:67.  Back to cited text no. 20
    
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Prasad AN. Disease profile of children in Kabul: The unmet need for health care. J Epidemiol Community Health 2006;60:20-3.  Back to cited text no. 21
    
22.
Turner EL, Nielsen KR, Jamal SM, von Saint André-von Arnim A, Musa NL. A review of pediatric critical care in resource-limited settings: A look at past, present, and future directions. Front Pediatr 2016;4:5.  Back to cited text no. 22
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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