ORIGINAL

Niger J Paed 2013; 40 (3): 232 –237

Pattern and outcome of admissions

as seen in the paediatric emergency

ward of the Niger Delta University

Teaching Hospital Bayelsa State,

Nigeria

Duru C

Peterside O

Akinbami F

DOI:http://dx.doi.org/10.4314/njp.v40i3,6

Accepted: 10th January 2013

Abstract Objective: To describe

the pattern and outcome of child-

hood illnesses seen in a paediatric

emergency ward of a tertiary centre

in the Niger Delta region of

diarrhoeal disease 389 (22.2%),

respiratory tract infections 162

(9.2%) and anaemic heart failure

112(6.4%). Peak admissions period

and mortality were in the months of

January, May and December.

There were 799 transfers, 710

discharges, 94 discharges against

medical advice and 20 referrals.

Over the period, 133 children died

giving a mortality rate of 7.6%.

Major causes of mortality were

anaemic heart failure 32(24.1%),

malaria 26 (19.6%), septicaemia 17

(12.8%) and diarrhoeal disease 15

(11.3%).

(

)

Duru C

Peterside O, Akinbami F

Department of Paediatrics and Child

Health, Niger Delta University

Hospital, Okolobri, Bayelsa State.

Email: chikamerenu@yahoo.com

Tel: +2348034302438

Nigeria.

Methods: Admission records of all

children seen in the Children’s

Emergency Ward (CHEW) between

st

the 1 of January 2008 and 31 of

December 2011 were retrospec-

tively reviewed and analysed.

Results: A total of 1756 children

were admitted into the emergency

st

ward over a four yea_sr_t period (1

January 2008 to 31 December

2

011). The age range was one

month to 18 years with a mean of

6.6 months. There was a male pre-

Conclusions: Infections are the

major cause of morbidity and mor-

tality in the study environment with

the under-fives being the most

vulnerable.

3

ponderance with a male to female

ratio of 1.4:1. Majority, 1386

(

78.9%) of the patients were below

the age of five years. The mean

duration of stay was 2.2 days.

The major causes of admission

were malaria, 562 (32.0%),

Key words: children, under-fives,

emergency room, admissions,

morbidity, mortality

Introduction

It will also help in defining priority areas which will

help policy makers in planning disease preventive and

intervention programmes for the Paediatric population.

1

The attainment of the Millennium Development Goal 4

can only be achieved by concerted and focused efforts

aimed at reducing childhood morbidity and mortality.

Knowledge of the pattern of admissions into the paediat-

ric emergency unit of a tertiary centre would provide

valuable information on the p_,r₃ogress of the preventive

Materials and Methods

Study centre

2

programmes already in place. It would help to provide

data which would assist in policy making and health

reforms which in turn would further strengthen primary

health care.

The Niger Delta University Teaching hospital is located

in Okolobri, a semi-urban area in Bayelsa State. It was

formerly a general hospital but was converted to a teach-

ing hospital in September 2007. The Children’s Emer-

gency Ward (CHEW), is a six bedded ward located

within the Accident and Emergency complex of the

hospital. Children who present to the hospital as emer-

gencies are first managed at the CHEW and either

discharged when they are well or transferred to the

children’s ward when they are stable to continue

management.

This is the first report from the Niger Delta University

Teaching Hospital (NDUTH) showing the pattern of

paediatric emergency admissions with the aim of high-

lighting the disease pattern among the Paediatric popula-

tion in Bayelsa State, the Delta region of Nigeria. Infor-

mation obtained is hoped to add to existing data from

other parts of Nigeria in order to highlight areas in the

health care systems which need to be strengthened.

2

33

and 728 females (41.5%) with a male: female ratio of

.4:1. The ages of the children ranged from one month

Sampling

1

Retrospective recor_sd_t s of all children admit_st_ted into the

CHEW between 1 January 2008 and 31 December

to 18 years with a mean age of 36.6 months. Out of all

the children admitted, 1386 (78.9%) were under-fives

with 785 (56.6% of them) being between the ages of 12

to 59 months (see table 1 and 2). The total duration of

stay ranged from 1 to 10 days with a mean of 2.2 days.

2

011 were retrieved, reviewed and analyzed. The data

extracted from the records included the age, sex, diagno-

sis, duration of stay and outcome. The outcome was

classified as discharged, died, transferred to the Paediat-

ric wards, referred out to another centre or discharged

against medical advice (DAMA). The duration of stay of

all the patients was also obtained from the records irre-

spective of their outcome.

Table 1: Age and sex distribution among the 1756 children

admitted into CHEW

Age(months)

No of patients

Male

Female

% of total

1

-<12

2-<60

601

785

337

471

220

1028

264

314

150

728

34.2

44.7

21.1

100.0

Diagnostic criteria

≥

Total

60

370

1756

Diagnosis of malaria was on the basis of a positive

blood film for malaria parasite and/or a satisfactory

clinical response to antimalarials. A diagnosis of diar-

rheal disease was made based on a history of diarrhoea

with/out vomiting and abdominal pain. Anaemic heart

failure was diagnosed on the basis of the presence of the

three cardinal clinical features of heart failure

Table 2: Age distribution according to disease condition

Disease condition

Age

(

)

1- 2

230

Total

(%)

years

<

1

3-4

101

>5

130

(

tachycardia, tachypnoea, tender hepatomegaly) with a

Malaria

101

243

93

562

(32.0)

haematocrit level of less than 5g/dl.

A case of febrile seizures was made in the presence of

fever and seizures in the absence of any intracranial in-

fection which was made by performing a lumbar punc-

ture after any contra indication to this had been ruled

out. The diagnosis of septicaemia was made on the pres-

ence of a positive blood culture and/or clinical findings.

Pneumonia and other infectious diseases were diagnosed

by the presence of positive clinical and /or laboratory

findings. A diagnosis of Paediatric HIV/AIDS was made

in the presence of a positive antigen/ antibody test for

HIV and/or positive clinical findings. Other disease con-

ditions were identified by their characteristic clinical

features.

Diarrhoeal disease

117

48

12

17

9

389

(22.2)

Respiratory Tract

Infections

162 (9.2)

Anaemic heart

failure

Febrile

seizures

Protein Energy Mal-

nutrition

33

17

18

46

40

12

20

21

0

13

1

112 (6.4)

79 (4.5)

31(1.8)

1

Infections

Septicaemia,

Meningitis, Mea-

sles,

63

33

12

40

148(8.4)

(

Ethical approval

HIV/AIDS, Tetanus)

Others(Sickle cell

disease, Asthma,

Trauma,

Surgical conditions,

Burns Accidental

poisonings)

20

32

26

110

188

(10.7)

Ethical approval was obtained from the Research and

Ethics committee of the Niger Delta University Teach-

ing Hospital.

Data analysis

Miscellaneous

13

18

5

49

85(4.8)

1756

The data was entered into an Excel spreadsheet and ana-

lyzed by calculation of means, percentages and ratios.

Test of significance between proportions was assessed

using Chi-square and a p value < 0.05 was considered

significant at a 95% confidence interval.

6

01

576

209

370

(

34.2) (32.8) (11.9) (21.1)

(100.0)

HIV/AIDS- Human immunodeficiency Virus/Acquired Immunodefi-

ciency Syndrome,

Discharges against medical advice

Results

General characteristics of the patients

Of the 94 children discharged against medical advice, 55

were male while 39 were female with a male/ female

ratio of 1.4:1. Severe malaria 29 (30.9%), diarrheal dis-

ease 25 (26.6%) and respiratory tract infections 9 (9.6%)

were the major disease conditions they presented with.

Seventy-five (80%) of the children discharged against

medical advice were less than 5 years old.

A total of 1805 children were admitted over a four year

st

period (1 January 2008 to 31 December 2011) but the

data for 1756 (97.3%) were analyzed as the remaining

4

9 children had incomplete data in the medical records.

Of the 1756 children, there were 1028 males (58.5%)

2

34

The proportion of males that were discharged against

medical advice was equal to the proportion of females

(

5.4%) ( Table 4).

Table 3: Causes of admission and patient outcome

Disease condition

Total (%)

Outcome

Transfers

Discharges

Deaths

DAMA

Referred

Malaria

562(32.0)

389(22.2)

269(47.9)

175(45.0)

26(4.6)

15(3.9)

237(42.2)

174(44.7)

29(5.2)

25(6.4)

1(0.2)

0(0.0)

Diarrheal disease

Respiratory tract infection

Anaemic heart failure

Febrile seizures

162(9.2)

112(6.4)

79(4.5)

54(33.3)

37(33.0)

44(55.7)

2(6.5)

10(6.2)

32(28.6)

5(6.3)

87(53.7)

41(36.7)

26(32.9)

21(67.7)

81(54.7)

98(52.1)

34(40.0)

799(45.5)

9(5.6)

2(1.8)

4(5.1)

1(3.2)

6(4.1)

14(7.4)

4(4.7)

94(5.4)

2(1.2)

0(0.0)

4(2.7)

5(2.7)

8(9.4)

20(1.1)

Protein Energy Malnutrition

Infections(Septicaemia, Meningitis,

Measles, HIV/AIDS, Tetanus)

Others (Sickle cell disease Asthma,

Trauma, Surgical conditions, Burns,

Accidental poisonings)

31(1.8)

7(22.6)

26(17.6)

6(3.2)

148(8.4)

188(10.7)

85(4.8)

31(20.9)

65(34.6)

33(38.8)

710(40.4)

Miscellaneous

6(7.1)

Total %

1756(100.0)

133(7.6)

DAMA- Discharges against Medical Advice, , HIV/AIDS- Human

Table 4: Age and sex distribution among the 94 children dis-

charged against medical advice

Table 5: Major causes of mortality in the 1756 admitted

patients

Age (months) No of patients

Male

Female

% of Total

Disease condition

No

of

case

s

No that

died

CFR %Total % of Total

(%)

Mor-

tality

Admis-

sions

1

≥

–< 12

2-<60

60

32

43

19

18

25

12

14

18

7

34.0

45.8

20.2

n =133

n = 1756

Anaemic heart

failure

Malaria

112

32

26

28.6

4.6

24.1

1.8

Total

94

55

39

100.0

562

19.6

1.5

Septicaemia

Diarrheal disease

Respiratory Tract

Infection

Protein Energy

Malnutrition

Febrile seizures

Meningitis

Paediatric HIV/

AIDS

Burns

Measles

Trauma

56

17

15

10

7

5

4

30.4

3.9

6.2

12.8

11.3

7.5

5.3

3.8

1.0

0.9

0.6

0.4

0.3

0.2

Mortality pattern

389

162

31

79

30

One hundred and thirty three children died over the pe-

riod giving an overall mortality rate of 7.6%. There were

22.6

3.0

6

1

9 males and 64 females with a male: female ratio of

.1:1. Proportional mortality rate for males was 69

6.3

13.3

13.6

22

26

51

42

3

2

1

2.3

1.5

0.8

0.2

0.4

0.1

0.6

(

6.7%) and for females 64(8.8%) with no significant sex

2

difference (χ = 2.63, p = 0.10). One hundred and thir-

teen (85%) patients who died were aged less than 5years

with 57 (50% of them) being less than one year.

19.2

7.7

3.9

23.8

7.1

Surgical conditions

Miscellaneous

Though anaemic heart failure constituted 6.4% (112) of

all admissions, it was the cause of death in the majority;

85

6

4.5

0.3

3

2 (24.1%). This was followed by malaria and its other

CFR- Case Fatality Rate, HIV/AIDS- Human immunodeficiency

Virus/Acquired Immunodeficiency Syndrome

complications 26 (19.6%), septicaemia 17 (12.8%), diar-

rhoeal diseases 15 (11.3%) and respiratory tract infec-

tions 10 (7.5%). Causes of mortality in the miscellane-

ous group included acute renal failure, Guillien barre

syndrome, enterocutaneous fistula and congenital biliary

atresia (table 5).

diseases occurred predominantly in the dry season in the

months of December and January. Respiratory tract in-

fections showed three peaks of occurrence in March,

July and October (Fig 2). Other disease conditions

showed no significant monthly variation in occurrence

or mortality.

Seasonal pattern of admissions

As shown in fig 1, there were more admissions in the

month of December, followed by May and January

which corresponded to the peak periods of mortality.

Children presenting with diagnosis of malaria, anaemic

heart failure and febrile seizures were noticed to present

mainly between the months of May to July which corre-

sponded to the peak of the wet, rainy season. Diarrhoeal

2

35

7

Fig 1: Monthly variation in number of admissions and

Mortalities

Okechukwu and Nwalozie in Abuja (80.1%) and

6

Bamgboye and Familusi in Ibadan(86.4%). This high-

lights the vulnerability of this age group and emphasizes

the need to step up preventive and curative

programmes in the treatment of childhood illnesses.

The peak periods of childhood admissions were in the

months of January, May and December which corre-

sponded to the peaks of the dry and rainy season in this

environment.₃These findings are similar to reports from

1

Singhi et al in India with busiest months in May and

5

December and Ibeziako and Ibekwe in Enugu who

observed highest admissions in January and Septembe₁r₂.

This is however in contrast to findings from Roy et al

in India who reported highest admissions in the months

of August to November. In the present series, mortality

was also noted to peak in the months of January and₆

May which was similar to reports from Bamgboye et al

in Ibadan.

Malaria, anaemic heart failure, diarrhoeal disease and

respiratory tract infections accounted for the major

causes of mortality among the paediatric emergency

patients in the present series._-₆This is similar to findings

Fig 2: Monthly variation of occurrence of some of the major

causes of morbidity

4

from other Nigerian studies. All the above mentioned

diseases are largel₁y₄ preventable with simple and cost

effective measures. Malaria can be prevented by use of

insecticide treated bed nets and malaria chemoprophy-

laxis but it has been reported that only 8% of under-fives

in Sub-Saharan Africa sleep under bed nets while only

one in 3 children are treated with malaria chemoprophy-

15

laxis. In a paper reviewing the evidence for beneficial

effects of malaria chemoprophylaxis, it was reported

that chemoprophylaxis has the potential to reduce child-

hood clinical malaria attacks, with significant reduction

1

6

in hospital admissions and mortality. Diarrhoeal dis₁₅-

eases can be prevented by simple hygienic practices

while the incidence of respiratory infections can be sig-

nificantly reduced by administration of childhood vac-

cines against causative organisms like Haemophilus

influenza type B and Streptococcus pneumonia in addi-

tion to the vaccines currently included in the N₁₀igerian

National Programme for Immunization schedule.

Discussion

The cases of malaria, anaemic heart failure and febrile

seizures were noted to peak during the rainy season in

the months of May to July which suggests the role of

malaria as an important cause of anaemia and febrile

seizures in this environment. The leading role of malaria

as a cause of childhood morbidity and mortality in this

series h₄a_, s₅_,₈also been documented by oth₁e₁ r authors from

This study shows that infectious diseases are the major

cause of childhood admissions in this environment. This

is despite the various preventive programmes such as the

Roll Back Malaria, Baby Friendly Initiative and Control

2

of Diarrheal diseases put in place to curb the scourge.

These findings a₄r_-e₁₀similar to th₁o₁ se from studies in other

Nigeria

and other African countries.

parts of Nigeria

and Africa.

The prevalence of diarrhoeal diseases during the months

of January and December which corresponds to the dry

s₇_,e₁a₇s_,₁o₈n was similarly observed in other Nigerian studies.

The NDUTH where the present study was carried

The male predominance in terms of childhood admis-

sions in the present series i₄s similar to findings by Abhu-

limhen-Iyoha and Okolo in Benin and Ibeziako and

5

Ibekwe in Enugu of 1.3:1 and 1.4:1 respectively.

out serves patients from the host community which is a

rural community as well as other surrounding rural com-

munities. The increased prevalence of diarrhoeal dis-

eases during the dry season may be explained by the fact

that residents in these communities get their drinking

water from rain during the rainy season and from surface

water which is likely to be contaminated by faecal waste

Though₁₀the reason proposed for this has not been estab-

lished, it may be related to the increased biological

1

2

vulnerability of males to infection.

The finding of majority (78.9%) of admissions in the

under five age group in this study is similar to reports

4

from Abhulimhen and Okolo in Benin (70.2%),

2

36

2

4

during the dry season. It has been shown that unsafe

drinking water and poor environmental sa₁n₉itation con-

tribute significantly to childhood diarrhoea.

Antia-obong in Calabar has suggested late presenta-

tion in the hospital as one of the major contributing fac-

tors to high childhood mortality in our environment.

This is certainly a possibility as our hospital is the only

tertiary centre in the community and subserves other

primary and secondary health centres. Also accessibility

from most of the neighbouring communities is a chal-

lenge as the only source of transport from most of these

communities is₁b₅ y sea due to lack of roads. Ac₂c₅ording to

Olusegun et al in Nigeria and Mondal et al in Bang-

ladesh, contributors to child mortality includes accessi-

bility to health care services and the risk of child mortal-

ity decreases with wider access to safe treatment places.

Respiratory tract infections showed peak occurrences in

the months of March, July and October whic₂h₀ corre-

sponds to the peak of the rainy season. Akanbi in Be-

nin similarly reported more episodes of respiratory tract

infections in t₃he rainy season which was in contrast to

1

Singhi et al who noted more cases in December/

January. Along with malaria and acute diarrheal disease,

it is one of the major ₃c_,a₂u₀_,s₂e₁s of under-five mortality

alone or in combination.

The outcome of admissions show a good transfer rate

out of the Emergency ward as well as a good discharge

rate which was similar to findings in other studies in

4

, 5

Nigeria. The rate of discharges against medical advice

in the present series (5.₂4₁%) was notably lower than re-

ports from Okechukwu in Abuja (7.4%) and Onyiriuka

Conclusions

22

in Benin(6.3%). Possible explanations for the lower

Infectious diseases are the major causes of childhood

admissions in our environment. Achievement of the

Millennium Development Goal 4 of reducing child

rates of DAMA in our series could be the fact that neo-

nates were not included in our study unlike the others.

Though in this study, no reasons were given for the de-

sire of the parents to DAMA, poverty a₅_,n₂d₁_,₂i₂gnorance as

contributing factors have been reported.

1

mortality by two-thirds from the 1990 rate will depend

on renewed efforts to prevent and control malaria, acute

respiratory infections and diarrhoea in the African re-

gion. Health intervention programmes such as the

I₂₆ntegrated Management of₂₇Childhood Illnesses (IMCI),

and Primary health care which have been shown to

significantly reduce childhood morbidity need to be

intensified.

This study revealed an overall mortality rate of 7.6%,

w₉hich is lower than the 8.4% reported by Adeboye et al

though neonatal mortality was inclusive in their study.

4

Abhulimhen-Iyoha and Okolo in Beninreported a rate

5

of 4.4% while Ibeziako and Ibekwe reported 5.1% from

Enugu. The reason for the comparably higher mortality

rate in the present series is not immediately clear but

may be due to environmental factors as the hospitals in

the Benin and Enugu series were both located in urban

centres as opposed to the present series where the hospi-

tal is locat₂e₃d in a rural area. According to Mesike and

Mojekwu, environmental risk factors account for one-

fifth of the to₁t₃al disease burden in low income countries.

Singhi et al in India compared the outcome of Paedi-

atric emergency patients in an urban versus a rural hos-

pital. They found that mortality was higher in the rural

area.

Author’s contributions

Chika D collected the data, analyzed it and wrote the

manuscript. Oliemen Peterside conceived the study and

revised the manuscript. Felix Akinbami revised the

manuscript and supervised the conduct of the study.

Conflict of interest: None

Funding: None

Acknowledgements

Peak mortality was noted in the ages of 12 to 59 months

We acknowledge the contributions of the doctors and

the nurses of the Children’s Emergency ward of the hos-

pital in the management of these patients. We are also

grateful to the record officers of the unit for their assis-

tance.

5

whic₄h was in contrast to findings from Enugu andCala-

2

bar where peak mortality was noted in the 7 to 12

month age groups. We were unable to determine the

causes of this high mortality from our study; however

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