Nigerian Journal of Paediatrics

Pattern of mortality among childhood emergencies at the Niger Delta University Teaching Hospital Bayelsa State Nigeria

Niger J Paediatr 2019; 46 (2): 55 – 60

ORIGINAL

Duru C

CC – BY Pattern of mortality among Child-

Paul NI

Peterside O

hood emergencies at the Niger

Akinbami F

Delta University Teaching

Hospital, Bayelsa State, Nigeria

DOI:http://dx.doi.org/10.4314/njp.v46i2.3

Accepted: 26th June 2019

Abstract: Background:

hospital. Majority of the deaths,

Regular and periodic assessment

115 (82.7%) were children under

Paul NI,

(

)

of pattern of childhood mortality

the age of 5 years out of which

Department of Paediatrics,

in the Children emergency room

51.3% were infants. The common

and child health, University of

(CHER) is important to define

causes of death were septicaemia

Port Harcourt Teaching Hospital,

common childhood killer

(34.8%)

and

severe

malaria

Port Harcourt, River State Nigeria

diseases, notify responsible au-

(34.8%) among the under-fives

thorities and outline measures to

and meningitis (25.0%) and HIV/

Duru C, Peterside O, Akinbami F

prevent and curb them.

TB (20.8%) among those above

Department of Paediatrics,

Objectives: The aim of this study

the age of 5 years. The highest

and child health,

was to describe the pattern of

number of mortalities were re-

Niger Delta University Teaching

childhood mortality seen in the

corded in the months of February

Hospital, Okolobri Bayelsa State,

CHER of a tertiary centre in the

to April and there was a decline in

Nigeria

Niger Delta region- Bayelsa State

annual mortality rates over the five

of Nigeria over a 5 year period

year period however, this was not

(1 January 2014 to 31 Decem-

statistically significant.

ber 2018)

Conclusions: Childhood mortality

Methods: The admission records

is high in Bayelsa State especially

of all the children admitted into

among the under-fives. Most of the

the CHER of the Department of

deaths are preventable. Strengthen-

Paediatrics of the Niger Delta

ing of the existing programmes

University Teaching

Hospital

such as malaria control practices,

(NDUTH), Bayelsa State were

good antenatal care, training and

retrospectively reviewed and ana-

retraining of health workers, exten-

lysed.

sion of immunization services be-

Results: One hundred and thirty

yond infancy and good access to

nine out of 1,949children admit-

health care services is advocated to

ted over the study period died,

reduce Childhood mortality

giving

mortality

rate

7.1%.Out of 139 children who

Key words: Mortality, Children,

died, 88 (63.3%) of them died

Emergency Room, Bayelsa, Niger

within 24 hours of arrival at the

Delta

Introduction

In Nigeria, Childhood mortality remains unacceptably

high despite the various childhood disease preventive

programmes put in place to control the scourge. Various

Childhood mortality is an indication of a country’s de-

velopment and portrays its priorities and values. In re-

studies done in Nigeria have shown that the major

cent times, childhood mortality has been reported to be

causes of childhood mortality are largely preventable

steady

decline

globally

from

1990

diseases.

4-9

Factors noted to contribute to the high child-

2017. However, in Sub-Saharan Africa, it still remains

hood mortalities in Nigeria have been late presentation,

high as 1 in 13 children will still die before their 5

unavailability of health services and poor transportation

birthday.

These childhood deaths have been largely

to mention a few.

5-9

attributed to common childhood illnesses such as pneu-

monia, diarrhoeal diseases and malaria with malnutrition

Children, unlike adults are more unlikely to withstand

as an important underlying factor. Studies have shown

the effect of certain diseases for prolonged periods.

that majority of these deaths could have been avoided by

Thus, they deserve more immediate attention to enable

easily preventable and treatable interventions which are

them have better chance of survival. The CHER pro-

simple and affordable.

vides care for children who require prompt life-saving

measures, thus an effective CHER may reduce

childhood mortality.

clinical features with or without positive cerebrospinal

This study was carried out to describe the pattern of

fluid culture or abnormal biochemical analysis while

childhood mortality in the CHER at the Niger Delta

that of malignancies were based on clinical features,

University Teaching Hospital, Bayelsa State. The infor-

ultrasound report and biopsy results.

mation obtained is hoped to contribute to the available

data in Nigeria in a bid to assist in policy making and

Data analysis

health care reforms.

The data obtained was entered into an Excel spreadsheet

and was analyzed by calculation of means, percentages

and ratios. A test of significance between proportions

Materials and methods

and means was assessed using Chi square and T-test and

Study centre

a p value <0.05was considered significance at 95% con-

fidence interval.

The Niger Delta University Teaching hospital is located

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

Ethical approval

referral centre for the surrounding primary and secon-

dary health centres in the locality and also attends to

Ethical approval was obtained from the Research and

patients from neighbouring states. It is equipped with a

Ethics committee of the Niger Delta University Teach-

twenty bedded Paediatric Emergency room where Paedi-

ing Hospital (NDUTH/REC/0049/2017).

atric medical and surgical emergencies of children more

than 28days and up to eighteen years are attended to and

stabilized before onward admission to the Paediatric

wards. The CHER is manned by consultants, resident

Results

doctors, house physicians and nursing staff who provide

General characteristics of the patients that died

twenty four hours inpatient care. Asides manpower, the

CHER has basic equipment necessary for resuscitation,

A total of one thousand, nine hundred and forty-nine

stabilization and diagnosis of the common emergencies

(1,949) children were admitted over the five year period

(1 January 2014 to 31 December 2018).There were

and this includes electric and manual suction machines,

nebulizers, oxygen cylinders, cardiac monitors and a

1107males and 842females with a male/female ratio of

defibrillator, endotracheal tubes, pulse oxymeters, a

1.3:1. Over the study period, 139 children died giving an

functional Automated External Defibrillator (AED), side

overall mortality rate of 7.1%. Of those who died, 68

laboratory and a dedicated pharmacy.

(48.9%)were male and 71(51.1%)were female (M: F

0.9:1). There was no statistical significant difference

Sampling

between the sexes (p>0.05)Eighty eight (63.3%) of them

died before 24 hours of arrival at the hospital, 24

This was a retrospective study. The admission register,

(17.3%) deaths occurred within 24 - 48 hours of admis-

case notes and mortality review registers of the children

sion and 27(19.4%) deaths occurred after the first 48

admitted into the Children’s emergency room (CHEW)

hours of admission.

of the Department of Paediatrics and Child Health of the

Niger Delta University Teaching Hospital, Bayelsa State

Age and sex distribution of mortality

over a five year period(1 January 2014 to 31 Decem-

ber 2018) were reviewed and analysed. All children ad-

Out of the 139children who died, 115(82.7%) of the

mitted into the CHER within this period were selected.

children were less than 5 years old. Out of the under –

Data obtained included the socio-demographic charac-

fives, 59(51.3%) of deaths were infants. Twenty-four

teristics of the subjects, the principal clinical diagnosis,

(24) children above the age of 5 years died and this con-

duration of hospital stay before death and the month of

stituted 17.3% of the total mortality (See Table 1)

admission.

The principal diagnosis was based on the final assess-

Table 1: Age and sex distribution of mortality

ment by the managing unit and as documented after

Age at death

Sex

No of deaths

weekly mortality reviews. It was based on the presenting

Male

Female

clinical features, with or without the results of labora-

No (%)

tory tests. For example, the diagnosis of malaria was

1-12 months

28(41.2)

31(43.7)

59(42.4)

confirmed by a positive malaria rapid diagnostic test

>12-60 months

25(36.7)

31(43.7)

56(40.3)

(RDT) and or by the presence of malaria parasites in the

>60 months

15(22.1)

9(12.6)

24(17.3)

blood film. Patients with respiratory tract infections with

68(48.9)

71(51.1)

139(100.0)

or without bronchopneumonia were diagnosed based

either clinically or by chest radiographs or both. HIV/

Causes of mortality

AIDS was based on two positive HIV rapid diagnostic

tests as recommended by WHO on a patient with fea-

Among the children between the ages of 1 month and 5

tures of the WHO clinical case definition of HIV/AIDS

years, the major causes of death were septicaemia in 40

in African. Diagnosis of meningitis was based on the

(34.8%), severe malaria in 40 (34.8%), diarrhoeal dis-

ease in 16(13.9), respiratory tract infections in 15(13.0%

Fig 1: Monthly admissions and mortality rate (2014-2018)

and protein energy malnutrition 8(6.9%). Whereas in the

children who were above the age of five, Meningitis in 6

(25.0%) and HIV/Tuberculosis in 5(20.8%) were the

major causes of death. (See tables 2 and 3)

Table 2: Causes of death in the postneonatal age group less

than 5 years old(n-115)

*Cause of death

Age (months)

Total

% Mortal-

ity

>1- 12

>12-60

Septicaemia

34.8

Severe malaria

34.8

Diarrhoeal disease

13.9

Bronchopneumonia

9.6

Protein Energy Mal-

6.9

nutrition

Paediatric HIV/AIDS

6.1

Measles& Pertussis

3.5

Cardiac conditions

2.6

Discussion

Meningitis

1.7

Burns

1.7

This study showed an over all childhood mortality rate

Malignancies

0.9

of 7.1%. This finding is within the unacceptably high

Surgical conditions

0.9

range of (4.4-15.8%) reported from other Nigerian stud-

4-9, 11-17

ies.

The prevalence in this study was higher than

*Some had more than one cause of death

that reported by Abhulimen-Iyoba et al in Benin

(4.4%), George et al in Port Harcourt (4.5%), and Ibe-

ziako et al in Enugu (5.1%) but lower than that re-

Table 3: Causes of mortality in children over the age of 5

ported from Ayoola et al in Ibadan (9.5%), Fajolu et al

years (n=24)

in Lagos (11.1%), Bilikisi et al in Gasau (11.2%) and

Cause of death

No of deaths

% of mortality

Okechukwu et al in Abuja (15.8%) The finding of

Meningitis

25.0

HIV/AIDS±Tuberculosis

20.8

lower mortality rates in the South- South and South-East

Malignancies

16.7

studies when compared to studies from the South-West

Surgical conditions

12.5

and Northern Nigeria may be due to some differences in

Tetanus

8.3

health seeking behaviour in people from these regions or

Sickle cell disease

8.3

to a yet unidentified geographical factors. However,

Burns

4.2

more of the studies with higher mortality rates recruited

Asthma

4.2

neonates in the study sample and considering the impact

Note: HIV/AIDS- Human Immunodeficiency Virus/ Acquired

of neonatal deaths on childhood mortality rate this meth-

Immunodeficiency Syndrome

odology will give a higher rate. The lower mortality rate

of 7.1% from this present study may be due to improved

Annual and monthly pattern in mortality rate

health seeking behaviour from the local communities

that mainly patronise our sub urban located hospital due

There was no significant decrease in the annual mortal-

to the up scaling in infrastructure and health care person-

ity rate over the years (Table 4, 4a and 4b).Majority of

nel over the years. Lending support to this is the finding

the admissions occurred in the months of April to May

of a higher mortality rate of 7.6% in a previous study in

though there was no significant increase in mortalities

the same centre on outcome of emergency admissions in

the CHER by Duru et al .

over the months (Fig 1)

The finding of a higher male preponderance in children

Table 4: Annual admissions and mortalities (2014-2018)

visiting the CHER has been documented in other studies

Year

Admissions

Total

Deaths

Total

Mortal-

and may be related to the biological vulnerability of

ity rate

males to infection. It may also emphasize the premium

(%)

Male

Fe-

Male

Female

placed on the male child in terms of priority in bringing

male

to the hospital for medical attention. However, the pro-

2014

280

198

478

7.9

2015

264

216

480

7.1

portion of males dying in this study is in contradistinc-

2016

140

111

251

8.8

tion to other studies where more males died. Could it be

2017

210

168

378

7.4

that many more females are left unattended to in the

2018

213

149

362

4.7

communities and so are dying at the community level

Total

1107

842

1949

68(48.9)

71(51.1)

139

7.1

rather than in hospitals? This may require a community

(56.8)

(43.2)

(100.0

(100.0)

)

based childhood mortality study.

P-value = 0.96, χ2 =0.002 ( admissions); p-value = 0.24, χ2

More than eighty percent of the deaths were under five

=1.366 (mortality)

deaths with infant mortality being more than 50%. This

is similar to findings from other studies.

7-18

It reflects the

tetanus - diphtheria toxoid vaccine (Td) are recom-

mended every ten years throughout a person’s life . It is

vulnerability of young children dying from probably low

immunity and also the need for quick and prompt diag-

hereby suggested that a clause be added to the present

nosis and treatment in this age group when they fall ill.

NPI schedule, advising three extra doses of TT between

Sepsis, severe malaria, diarrhoeal disease, pneumonia

ages four to six years and 11 to 12 years (entry into pri-

and protein energy malnutrition were the commonest

mary school and secondary school, respectively) for all

causes of death seen in our study and this is similar to

children as recommended by the CDC advisory commit-

8-18, 21-23

report from other studies.

These preventable

tee. In order to ensure compliance, these booster doses

causes of death has persistently remained the same

of TT could be made prerequisites for entry into these

showing little or no change in the mortality pattern in

schools.

Nigeria. These are disease that are associated with pov-

erty, poor sanitary and living conditions and since no

The children who died from HIV/AIDS infection also

significant progress has been made in the living stan-

had co-existing tuberculosis and severe acute malnutri-

tion which is tandem with other studies. Early detection

dards of the people with persisting poor socioeconomic

status, it becomes a herculean task to curb these dis-

of childhood and maternal HIV disease and these oppor-

eases.

tunistic infections in children can mitigate against these

deaths as these conditions are treatable. In children,

In this study, severe malaria (especially severe anaemia

more than 90% of Paediatric HIV/AIDS infection are

and cerebral malaria) and septicaemia were found to be

from mother to child transmission and can be prevented

the leading cause of death. However, recent studies have

with an effective Prevention of Mother To Child Trans-

shown that malaria is no longer the leading cause of

mission (PMTCT) program which is began from the

ante natal care (ANC).

under-five mortality in sub Saharan Africa, being topped

The importance of ANC, an

by respiratory tract infections and diarrhoeal diseas-

effective HIV/AIDS prevention, treatment and care pro-

es .This emphasises the need to expedite on malaria

gram with early infant diagnosis of HIV/AIDS need not

control programs- use of Insecticide Treated Nets (ITNs)

be overemphasized. These further highlights the need to

and Indoor Residual Spraying (IRS) in this sub region.

intensify improvement in hygiene and sanitation, easy

In children older than five years, infections such as men-

access to clean water, strengthening of immunization

ingitis, HIV/AIDS and tetanus were still prominent as

and attendance to ante natal care (ANC) in all ages in

leading causes of death, though more deaths from non-

this sub-region. Also in children with HIV/AIDS, early

infectious diseases like malignancies, surgical condi-

assessment and initiation of Highly Active Anti-

tions and sickle cell disease occurred in this age group

Retroviral Therapy (HAART) with proper counselling

compared with the younger age group. It was interesting

on adherence, use of cotrimoxazole prophylaxis against

to note that meningitis was the commonest cause of

opportunistic infections and regular follow up have been

death in those over the age of 5 years and this has been

found to improve outcome of children with these dis-

eases.

documented be Ayoola et al in Ibadan where it contrib-

uted 7.2% of deaths in children over 5years. This may

be due to lack of booster doses of vaccines. Post neona-

Attention must also be paid to deaths from non-

tal tetanus was also a cause of mortality in those above

infectious causes in this age group. Similar to findings

from Ayoola et al in Ibadan, deaths due to sickle cell

the age of five years unlike in many other studies.

13-15, 24

anaemia were only found in children above 5 years who

All of these children except one presented very late and

had various types of crisis and infections including ma-

they all had severe tetanus and so succumbed to the dis-

laria. . One child died from severe dehydration and acute

ease. Contributory factors for this could be the lack of

kidney injury (AKI) due to burns. Burns is an uncom-

booster doses of tetanus immunization given after the

mon cause of death in many CHER as most cases are

primary series in infancy. It would also be worthy to

managed in the burns unit by surgeons. However, the

look further into the immunization practices such as cold

prevalent sale of fake kerosene products, a common

chain breaks and availability of potent vaccines to these

practice in our environment is a leading cause of home

group of children. Protection from tetanus infection by

accidents and common cause of burns in children

tetanus toxoid (given as pentavalent vaccine) received in

The finding of highest mortalities in the months of Feb-

infancy begins to wane shortly after and studies have

ruary to April corresponds with findings from

Bamgboye et al in Ibadan. This period corresponds with

shown that the current National Programme on Immuni-

sation (NPI) recommended by the WHO for developing

the peak of the rainy season which is associated with the

countries of which three doses of pentavalent vaccine

prominence of water borne and other communicable

are given during infancy with no provision for booster

diseases.

doses, is inadequate for tetanus prevention during child-

hood. The CDC’s Advisory Committee on Immuniza-

In our study, there was no statistically significant change

tion Practices (ACIP) currently recommends administra-

in the annual mortality rate though the rate reduced from

tion of three doses of a tetanus containing vaccine in

8.8% in 2016 to 4.7% in 2018. This slight improvement

infancy, with booster doses between 15 and 18 months

in the mortality rate compared to previous years could

old; and between four and six years old. Another booster

be attributed to the fact that the hospital had been better

dose is recommended at 11-12 years of age. After these

equipped and funded since its conversion to a tertiary

booster doses of tetanus vaccines, booster doses with

centre from a general hospital with a subsequent im-

provement in patient care.

Author’s contributions: Chika Duru collected the data,

analysed it and wrote the first draft of the manuscript.

This study highlights the fact that childhood mortality in

Oliemen Peterside conceived the study and wrote the

Bayelsa is high especially among under-fives. It also

manuscript. Nsirimobu Ichendu Paul wrote and dis-

shows that the causes of deaths are similar to what ob-

cussed the results of the manuscript and reviewed the

tains in other part of the country and that majority of

final draft. Felix Akinbami supervised the study. All the

these deaths are preventable. Emphasis on preventive

authors revised the manuscript and approved the final

practices such as malaria control practices, good antena-

draft.

tal care, training and retraining of health workers, exten-

Conflict of interest: None

sion of immunization services beyond infancy and good

Funding: None

access to health care services would be a positive step to

controlling this scourge.

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