Pattern of Emergency Neurologic Morbidities in Children: DISCUSSION

14 Oct
2009

Pattern of Emergency Neurologic Morbidities in Children DISCUSSION

Children with emergency neurologic morbidities accounted for 15.6% in this study, similar to previous reports from other parts of Nigeria. Those aged five years and under accounted for the majority (77.0%) of the children studied with the modal age group of 1-2 years. The predominance of children in this age is due to their vulnerability to febrile convulsion, which is caused by a variety of infections common in this age group, such as acute respiratory and urinary tract infections and malaria. Malaria is also more severe in this age group, especially in those under three years old, due in part to lack of partial immunity than older children and adults. About 90% of the neurologic morbidities in this study were of infectious origin. Malaria (febrile convulsion and cerebral malaria) and meningitis were the greatest culprits. These two morbidities were more frequently seen in the under-5s, whereas, meningitis—though encountered in all age groups— was the most frequent neurologic morbidity in children older than five years of age. This observed pattern in the older age group may be explained by the decline in the frequency and severity of malaria after the age of five years due to acquired partial immunity, and, secondly, febrile convulsion rarely occurs after the age of five years. The standard practice in our center is to commence treatment empirically for both cerebral malaria and meningitis for children five years of age or under presenting with fever and convulsion or alteration of consciousness until results of investigations are obtained. Culture-proven cases of meningitis are few in our center even in the presence of CSF biochemistry and pleo-cytosis suggestive of meningitis. This may be due to widespread and inappropriate use of antibiotics in the community before presentation to the hospital, and sometimes parents cannot afford the cost of investigations before the start of treatment. However, the organisms isolated in the few culture-proven cases include Neisseria meningitides and Streptococcus pneumoniae. In a previous study from this center, N meningitides was the commonest organism isolated in culture-proven cases of meningitis in children one month to 16 years of age.

The seasonal variation observed in the incidence of these emergency neurologic morbidities with a sharp increase in the third quartile of the year (July to September) is similar to other reports. This sharp increase is a result of an increase in the incidence of febrile convulsion and cerebral malaria during this period of the year when the rainy season is at its peak, and it creates an environment conducive for increased vector breeding and malaria transmission.
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Of the noninfectious causes of neurologic morbidities, alcohol-induced coma deserves special mention. All the cases were children under the age of five years who accidentally ingested alcohol (locally brewed gin). In our community, locally brewed gin is often soled, bought and stored in any bottle, including soft drink bottles, and kept within reach of children who are attracted either by the soft drink bottle or because the content is colorless like water. The lack of legislation controlling the production and sale of locally brewed gin in safe and child-protective caps perpetuates the risk of alcohol intoxication in children in Nigeria. In children less than five years of age, the risk of hypoglycemia following alcohol intoxication is high. All the children in this study had hypoglycemia and recovered consciousness rapidly after correction.

The mortality rate of 15.8% in this study is higher than 7.7% reported from the southeastern part of Nigeria. This difference may be due to differences in the pattern of the neurologic morbidities that may exist between regions. Cerebral malaria, the second most common neurologic morbidity in this study, did not feature in their report, while afebrile seizures were far more common in their report (15.8%) compared to 5% in this study. It is noteworthy that cerebral malaria and meningitis, which are largely preventable diseases, are the chief causes of death especially in children aged five years and under who accounted for three-quarters of the deaths recorded in this study, similar to findings from other centers in Nigeria. Differentiating between cerebral malaria and meningitis clinically is difficult as both present with convulsion and altered sensorium. Therefore, at presentation in this center, children aged five years or under are commenced on treatment for both conditions concomitantly until one is excluded after laboratory investigations. This approach ensures that no time is wasted, since most of these patients are brought late to the hospital by their parents or caregivers.
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The high mortality rate in this study is due in part to late presentation to the hospital. This factor highlighted by previous reports cannot be overemphasized, because it is still rampant and perpetuated by poverty and ignorance. The dearth of adequate health facilities, especially in rural areas, and cost of admission and drugs that are often not affordable by majority of the populace leads to self-medication at home and patronage of unqualified and traditional medicine practitioners. Antibiotics are often part of the self medication practice albeit at substandard or suboptimal doses, which leads to resistance and poor response to therapy and failure to isolate bacterial organisms in blood or CSF. Resorting to the hospital either by self-referral or by these peripheral medicine practitioners occurs only when the illness is worsened. This practice contributes to the high percentage of deaths in children in general, which occurs within 24 hours of admission to the hospital. This was the case in this study, in which 67.2% of the deaths occurred within 24 hours of admission, similar to other reports.
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Control of malaria through the “Roll Back Malaria” program and prevention of meningitis will go a long way in reducing the incidence of emergency neurologic morbidity and mortality in children in developing African countries. Health education of the populace to reduce or eliminate harmful traditional medical practices, including self medication and delay in seeking treatment in hospitals, is also suggested.

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