Pattern of Emergency Neurologic Morbidities

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Pattern of Emergency Neurologic Morbiditiesin ChildrenGabriel E. Ofovwe, Michael 0. Ibadin, Peter 0. Okunola, and Bibian OfoegbuBenin City, Nigeria and Manchester, United Kingdom

Background: Neurologic morbidities seen in the children'semergency facility of the University of Benin Teaching Hospi-tal, Nigeria, over a five-year period (July 1996-June 2001)was evaluated to determine the pattern and outcome.Notes and ward records of patients with neurologic morbidi-ties were retrieved. Data obtained from these sourcesinclude age, sex principal diagnosis, duration of stay andoutcome. Six-hundred-four out of 3,868 patients (15.6%) hadneurologic morbidity. Children five years of age and underwere 466 (77.2%), and modal age group was 1-2 years.Febrile convulsion was the most common neurologic mor-bidity seen (35.1%) followed by cerebral malana (28.0%) andthen meningitis (27.0%). An increased incidence of casesoccurred during the rainy season. Sixty-four out of 406 withcomplete records (15.8%) died. Forty-seven (67.2%) diedwithin 24 hours of admission. Cerebral malana and meningi-tis accounted for all the deaths.

Preventable infectious diseases are the major causes ofemergency neurologic morbidifies and mortality. The majontydie within 24 hours largely due to a delay in presentation tothe hospital. Effective malaria control and prevention ofmeningitis would reduce the incidence of neurologic mor-bidities and, if this is coupled with health education of thepopulace on the importance of attending health facility ear-ly, mortality from these causes would be greatly reduced.

Key words: emergency U neurologic U morbidity Uchildren

© 2005. From the Department of Child Health, University of Benin TeachingHospital, Benin City, Nigera (Ofovwe, Ibadin, Okunola) and Pendlebury Chil-dren's Hospital, Manchester, UK (Ofoegbu). Send correspondence andreprnt requests forJ NatI Med Assoc. 2005;97:488-492 to: Gabrel E. Ofovwe,Department of Child Health, University of Benin Teaching Hospital, PMB 1111,Benin City, Nigera; e-mail: [email protected], [email protected]

INTRODUCTIONDelay in presentation to a hospital is a common

problem in African populations,' sometimes result-ing in innocuous problems presenting as emergencycases. Neurologic morbidities, either primary or sec-ondary to other systemic diseases in children, con-stitute a significant proportion of these emergencycases. The pattern of neurologic emergencies is like-ly to vary from one country to another and amongregions in the same country. Assessment of the pat-tern of emergency morbidities is needed from timeto time in planning health policies and distributionof scarce resources in developing African countrieswhere facilities for emergency pediatric care aregrossly inadequate. This report describes the patternof neurologic morbidities in children admitted to thechildren's emergency care facility of a teaching hos-pital in midwestern Nigeria.

MATERIALS AND METHODSBenin City is the capital of Edo State in southern

Nigeria which is holoendemic for malaria (BruceChwat). There are two distinct seasonal periods-rainy season, which spans from April to September,and dry season from October to March. Benin Cityis cosmopolitan and has one tertiary hospital, Uni-versity of Benin Teaching Hospital (UBTH); onesecondary, Central Hospital; and numerous privateclinics and hospitals.

The study was done in the Children's EmergencyRoom (CHER) of the Department of Child Health,UBTH. CHER provides care for children aged onemonth to 16 years who require prompt life-savingmeasures and then are discharged as soon as possiblefrom the unit, preferably within 24 hours of admis-sion either by transfer to the main pediatric ward orhome to continue treatment as an outpatient.2 The unithas a capacity for 20 patients, one bay each for treat-ment and resuscitation, nurses and doctors. The unithas full compliment of medical and nursing staffsupervised by a consultant pediatrician. It also has amedical records unit. Patients are referred from the

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EMERGENCY NEUROLOGIC MORBIDITIES IN CHILDREN

general practice clinic ofUBTH or from peripheralhealth facilities within and outside Benin City. Rou-tinely, all patients attending the unit are evaluatedclinically by detailed history and thorough physicalexamination. For patients with central nervous systemsymptoms, neurologic examination include assess-ment of level of consciousness using the Blantyrecoma scale (modified Glasgow coma scale), pupillaryexamination and fundoscopy for signs of raisedintracranial pressure, cranial nerves, signs ofmeningeal irritation, muscle tone, power and reflexes.Laboratory investigations include cerebrospinal fluid(CSF) examination (indicated when there are signs ofmeningeal irritation, first episode of convulsion withfever, complex febrile convulsion and coma), bloodfilm for malaria parasite, levels ofblood glucose, ureaand electrolytes and blood culture. Meningitis wasdefined as elevated CSF protein plus hypoglycor-rhachia (CSF glucose <2.2 mmol/l) or CSF glucoseless than two-thirds of simultaneous blood glucoselevel, CSF ploecytosis with or without positive cul-ture. Cerebral malaria was defined as the presence ofan altered sensorium, P. falciparum parasitemia andnormal CSF

For this study, ward records, such as admissionand discharge registers, during a five-year period(July 1996-June 2001) were examined to identifycases whose main diagnosis were neurologic innature. Notes of these identified cases were thenretrieved from the medical records and examined fur-ther. Only case notes with definitive diagnosis afterthe laboratory investigation were selected. Dataobtained from these sources included age, sex, princi-pal diagnosis, duration of stay in CHER and outcome.

Statistical analysis was done using SPSS 10.0 forMicrosoft® Windows.

RESULTSSix-hundred-four patients were admitted with

neurological morbidity consisting of 15.6% out atotal of 3,868 patients admitted during the five-yearperiod. One-hundred-ninety-eight patients (32.8%)had incomplete records with regards to outcome. Abreakdown of the number of patients per year isshown in Table 1.

Males consisted of 321/604 (53.1%), whilefemales were 283/604 (46.9%), giving a ratio of1.1: 1. The age ranged from one month to 16 years,with modal age group of 1-2 years. Children agedfive years and under constituted 77.2% ofthe patientsstudied. Neonates were not included, because they areadmitted into a special care baby unit that caters tocritically ill children in this category. Table 2 showsthe age group distribution ofthe patients.

The three major neurological morbidities seenduring the period under study were febrile convul-sion, 212/604 (35.1%); cerebral malaria, 169/604(28.0%); and meningitis, 163/604 (27.0%). Togeth-er, these three accounted for 92.0% of all neurologi-cal morbidities seen. Other morbidities seen areshown in Table 3.

In children aged five years and under, febrileconvulsion was the most common neurological mor-bidity (42.5%), followed by cerebral malaria(32.2%) and meningitis (19.9%). In children aged5-10 years and those above 10 years, meningitis wasthe commonest, 37.8% and 69.6% respectively.

Figure 1 shows the seasonal variation in the inci-dence ofthe neurological morbidities. The incidenceof febrile convulsion and cerebral malaria was high-est in the third quartile of the year (July to Septem-ber), with febrile convulsion being significantlyhighest in August, while the incidence of meningitiswas about equal in the second, third and fourth quar-tiles (April to December). Of the 406 patients withcomplete records, 64 (15.8%) died, while 342(84.2%) were either discharged home or transferredto the main pediatric ward. Cerebral malaria andmeningitis accounted for all the deaths, 38/64(59.4%) and 26/64 (40.6%), respectively. Forty-three (67.2%) of the 64 deaths occurred within 24hours of admission, while 47 (73.5%) within 48hours and 17 (26.6%) after 48 hours. Children agedfive years and under accounted for 48 (75.0%),while those ages 5-10 years accounted for nine(14.1%); those above 10 years were seven (10.9%).

DISCUSSIONChildren with emergency neurologic morbidities

accounted for 15.6% in this study, similar to previ-

Table 1. Distribuflon of Patients Admifted per Year

Year Number of Neurologic Cases Percent Total Number of Admissions Percent of Total Admissions1996 76 12.6 490 14.71997 133 22.0 879 15.11998 130 21.5 800 16.31999 120 19.9 672 17.92000 85 14.1 628 13.52001 60 9.9 399 15.0Total 604 100.0 3,868 15.6

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ous reports from other parts of Nigeria.3-5 Thoseaged five years and under accounted for the majority(77.0%) of the children studied with the modal agegroup of 1-2 years. The predominance of children inthis age is due to their vulnerability to febrile con-vulsion, which is caused by a variety of infectionscommon in this age group, such as acute respiratoryand urinary tract infections and malaria.8 Malaria isalso more severe in this age group, especially inthose under three years old, due in part to lack ofpartial immunity6'7 than older children and adults.About 90% of the neurologic morbidities in thisstudy were of infectious origin. Malaria (febrile con-vulsion and cerebral malaria) and meningitis werethe greatest culprits. These two morbidities weremore frequently seen in the under-5s, whereas,meningitis-though encountered in all age groups-was the most frequent neurologic morbidity in chil-dren older than five years of age. This observed pat-tern in the older age group may be explained by thedecline in the frequency and severity ofmalaria afterthe age of five years due to acquired partial immuni-ty, and, secondly, febrile convulsion rarely occursafter the age of five years. The standard practice inour center is to commence treatment empirically forboth cerebral malaria and meningitis for childrenfive years of age or under presenting with fever andconvulsion or alteration of consciousness until

Table 2. Age Group Distribution of Patients

Age Group Number Percent<1 145 24.0>1-2 155 25.7>2-3 92 15.2>3-5 74 12.3>5-10 82 13.6>10 56 9.3Total 604 100.0

results of investigations are obtained. Culture-proven cases of meningitis are few in our centereven in the presence of CSF biochemistry and pleo-cytosis suggestive of meningitis. This may be due towidespread and inappropriate use of antibiotics inthe community before presentation to the hospital,and sometimes parents cannot afford the cost ofinvestigations before the start of treatment. Howev-er, the organisms isolated in the few culture-provencases include Neisseria meningitides and Strepto-coccus pneumoniae. In a previous study from thiscenter, N. meningitides was the commonest organ-ism isolated in culture-proven cases of meningitis inchildren one month to 16 years of age.10

The seasonal variation observed in the incidenceof these emergency neurologic morbidities with asharp increase in the third quartile of the year (Julyto September) is similar to other reports.5 This sharpincrease is a result of an increase in the incidence of

Table 3. Distribution of Neurological Morbiditles

Neurologic Morbidity Number PercentFebrile convulsion 212 35.1Cerebral malaria 169 28.0Meningitis 163 27.0Epileptic seizures 30 5.0Head injury 7 1.2Encephalitis 6 1.0Alcohol induced coma 3 0.5Gullian Barre syndrome 3 0.5Psychosis 3 0.5Tetanus 3 0.5Syncope 2 0.3Hydrocephalus 1 0.2ICSOL 1 0.2Migraine 1 0.2Total 604 100.0

ICSOL = Intracranial space-occupying lesion

Table 4. Distribution of Neurologic Morbidifles by Age Groups

Age GroupsOne Month to Five Years >5 years-10 years >10 years Total

N (%) N (%) N (%) N (%)Neurologic MorbidityFebrile convulsion 198 (42.5) 13 (15.9) 1 (1.8) 212Meningitis 93 (19.9) 31 (37.8) 39 (69.6) 163Cerebral malaria 150 (32.2) 18 (21.9) 1 (1.8) 169Epileptic seizures 11 (2.4) 12 (14.6) 7 (12.5) 30Encephalitis 6 (1.3) 0 (0.0) 0 (0.0) 6Gullian Barre Syndrome 0 ( 0.0) 2 (2.4) 1 (1.8) 3Syncope 0 (0.0) 1 (1.2) 1 (1.8) 2Alcohol coma 3 (0.6) 0 (0.0) 0 (0.0) 3Tetanus 0 (0.0) 2 (2.4) 1 (1.8) 3Others 5 (1.1) 3 (3.7) 5 (8.9) 13Total 466 82 56 604



febrile convulsion and cerebral malaria during thisperiod of the year when the rainy season is at itspeak, and it creates an environment conducive forincreased vector breeding and malaria transmission.

Of the noninfectious causes of neurologic mor-bidities, alcohol-induced coma deserves specialmention. All the cases were children under the ageof five years who accidentally ingested alcohol(locally brewed gin). In our community, locallybrewed gin is often soled, bought and stored in anybottle, including soft drink bottles, and kept withinreach of children who are attracted either by the softdrink bottle or because the content is colorless likewater. The lack of legislation controlling the produc-tion and sale of locally brewed gin in safe and child-protective caps perpetuates the risk of alcohol intox-ication in children in Nigeria. In children less thanfive years of age, the risk ofhypoglycemia followingalcohol intoxication is high.9 All the children in thisstudy had hypoglycemia and recovered conscious-ness rapidly after correction.

The mortality rate of 15.8% in this study is higherthan 7.7% reported from the southeastern part ofNigeria.' This difference may be due to differences inthe pattern of the neurologic morbidities that mayexist between regions. Cerebral malaria, the secondmost common neurologic morbidity in this study, didnot feature in their report, while afebrile seizures werefar more common in their report (15.8%) compared to5% in this study. It is noteworthy that cerebral malariaand meningitis, which are largely preventable dis-eases, are the chief causes of death especially in chil-dren aged five years and under who accounted forthree-quarters of the deaths recorded in this study,

similar to findings from other centers in Nigeria.5Differentiating between cerebral malaria and menin-gitis clinically is difficult as both present with convul-sion and altered sensorium. Therefore, at presentationin this center, children aged five years or under arecommenced on treatment for both conditions con-comitantly until one is excluded after laboratoryinvestigations. This approach ensures that no time iswasted, since most ofthese patients are brought late tothe hospital by their parents or caregivers.

The high mortality rate in this study is due in partto late presentation to the hospital. This factor high-lighted by previous reports cannot be overempha-sized, because it is still rampant and perpetuated bypoverty and ignorance. The dearth of adequatehealth facilities, especially in rural areas, and cost ofadmission and drugs that are often not affordable bymajority of the populace leads to self-medication athome and patronage of unqualified and traditionalmedicine practitioners. Antibiotics are often part ofthe self medication practice albeit at substandard orsuboptimal doses, which leads to resistance andpoor response to therapy and failure to isolate bacte-rial organisms in blood or CSE Resorting to the hos-pital either by self-referral or by these peripheralmedicine practitioners occurs only when the illnessis worsened. This practice contributes to the highpercentage of deaths in children in general, whichoccurs within 24 hours of admission to the hospital.This was the case in this study, in which 67.2% ofthe deaths occurred within 24 hours of admission,similar to other reports.

Control of malaria through the "Roll BackMalaria" program and prevention of meningitis will

Figure 1. Seasonal variation in the incidence of neurologic morbidities

0a January-March U ApiJune U Ju-September U October-December9080

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go a long way in reducing the incidence of emer-gency neurologic morbidity and mortality in chil-dren in developing African countries. Health educa-tion of the populace to reduce or eliminate harmfultraditional medical practices, including self medica-tion and delay in seeking treatment in hospitals, isalso suggested.

REFERENCES1. Atakouma DY, Gbetoglo D, Tursz A, et al. An epidemiological study ofhealth care-seeking behavior by children under the age of five years athospital emergency services in Togo. Rev Epidemiol Sante Publique.1999;47:(Suppl 2)2:75-91.2. Diakparomre MA, Obi JO. The pattern of pediatric emergencies in theUniversity of Benin Teaching Hospital. Nig J Paediatr. 1980;7:43-45.3. Bamgboye EA, Familusi JB. Morbidity trends at the children's emergencyroom, University College Hospital, Ibadan, Nigera. Afr J Med Sci. 1990;49-56.4. Ighogboja IS, Angyo 1, Okolo AA, et al. Morbidity and mortality pattern ofpediadric emergencies in Jos, Nigeria. Nig Med Pract. 1995;15-18.5. Iloeje SO. Pediatric neurologic emergencies at the University of NigeriaTeaching Hospital, Enugu. West Afr J Med. 1997;1 6:2:80-84.

6. Bruce-Chwatt LJ. Malaria in African infants and children in southernNigeria. Ann Trop Med Parasitol. 1 952;46:1 94-195.7. Ofovwe EG, Eregie CO. Observations on the relative frequency of severemalaria in young children in University of Benin Teaching Hospital, BeninCity, Nigeria. Ann Biomed Sci. 2002;30-37.8. Obi JO, Ejeheri NA, Alakija W. Childhood febrile seizures (Benin City expe-rience). Ann Trop Paediatr. 1994;1 4:211-214.9. Lamminpaa A. Alcohol intoxication in childhood and adolescents. Eur JPediatr. 1994:12:868-872.10. Akpede 0, Abiodun 0, Sykes M, et al. Childhood bacteria meningitisbeyond the neonatal period in Southern Nigeria: Changes in organisms/antibiotic susceptibility. East Afr Med J. 1994:1:11-17. 1

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Pattern of Emergency Neurologic Morbidities

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