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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 2  |  Page : 120-124

Pediatric “brought in dead”: Analysis of the characteristics and probable causes in a Nigerian tertiary hospital


1 Department of Paediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
2 Department of Paediatrics, University of Nigeria College of Medicine/Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria

Date of Submission08-Mar-2021
Date of Decision26-May-2021
Date of Acceptance20-Jun-2021
Date of Web Publication3-Mar-2022

Correspondence Address:
Benedict O Edelu
Department of Paediatrics, University of Nigeria College of Medicine/Teaching Hospital, Ituku/Ozalla, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_8_21

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  Abstract 

Background: Information obtained from the “brought in dead” (BID) cases is important in understanding the challenges in seeking health care and help in policy making. Objective: This study was conducted to describe the characteristics of children presenting to Enugu State University Teaching Hospital (ESUTH), Enugu as BID and probable causes of death. Materials and Methods: This descriptive study was conducted in the Children Emergency Room (CHER) of ESUTH. Information from all cases of BID children presenting to the CHER of ESUTH between May 2016 and April 2020 was recorded in a register after the confirmation of death. A probable diagnosis was made by verbal autopsy. Data were entered and analyzed with Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL). Results were presented as tables, bar chart, and prose. Results: There were 124 cases of BID, accounting for 2.2% of the total presentations and 43.1% of the mortalities. Their ages ranged from one month to 192 months, with a median age of 12 months. Majority (61, 49.2%) of the dead children were infants. There was an almost equal sex distribution with 63 males and a male-to-female ratio of 1:1. Probable causes of death included acute gastroenteritis (AGE), severe anemia, sepsis, acute encephalitic syndrome, and aspiration. None of the cases was referred from a health facility. There was a bimodal peak for the annual presentation (January and October). Most of the presentations were during the day (86, 69.4%). None of the parents gave consent for autopsy. Conclusion: The rate of children dying before receiving health care in our hospital is high; there is an urgent need for continuous mass mobilization within the communities to improve the health-seeking behaviors, and also to teach them to recognize danger signs in children.

Keywords: Brought-in-dead, children, hospital, Nigeria, pediatrics


How to cite this article:
Ndu IK, Edelu BO, Nduagubam OC, Ogbuka FN, Asinobi IN. Pediatric “brought in dead”: Analysis of the characteristics and probable causes in a Nigerian tertiary hospital. Int J Med Health Dev 2022;27:120-4

How to cite this URL:
Ndu IK, Edelu BO, Nduagubam OC, Ogbuka FN, Asinobi IN. Pediatric “brought in dead”: Analysis of the characteristics and probable causes in a Nigerian tertiary hospital. Int J Med Health Dev [serial online] 2022 [cited 2022 May 24];27:120-4. Available from: https://www.ijmhdev.com/text.asp?2022/27/2/120/339035




  Background Top


The details of any death is essential for effective policy formulation in order to address and prioritize various public health issues in any society.[1],[2] Ideally, all deaths should be registered and the cause of death data should be obtained from accurate medical certification; however, most low- and middle-income countries (LMIC) have a low death registration rate and inaccurate vital statistics.[1],[3],[4] In these countries, a significant number of deaths occur at home with some of the deaths recorded in health facilities occurring before their arrival. These are called BID or “dead on arrival” (DOA) cases.[5],[6],[7],[8],[9],[10]

Death determination is primarily clinical based on direct observation or examination of the patient, once preconditions have been fulfilled and confounding conditions excluded; it is the point where the brain has ceased functioning and there is no possibility for it to resume.[11] In 2015, Byrne et al.[12] proposed the proxy case definition as the optimal case definition for patients presumed DOA based on its excellent predictive utility and construct validity. The proxy definition (PROXY) is based on presenting vital signs, defined as heart rate (HR) = 0, systolic blood pressure (SBP) = 0, and Glasgow Coma Scale (GCS) score motor component = 1. Nevertheless, a broad definition of DOA may include patients who were either declared DOA to an emergency department with no resuscitation attempt or those who died after failed resuscitation.[12]

Unfortunately, the burden of these deaths is disproportionately high in developing countries.[13],[14],[15],[16] In Nigeria, BIDs accounted for 3.6%–86.1% of reported mortalities in adult emergency departments.[6],[7],[8],[9],[10] However these deaths are not well characterized in terms of the pattern, characteristics, and causes when compared with in-hospital deaths and most reviews of emergency room mortalities exclude BIDS.[6] A similar pattern is seen in pediatric mortality reviews, and there is a dearth of information regarding BID in children.

The background information of the BID cases is one of the key factors for understanding the challenges that obstruct the deceased from accessing the facilities before death.[1] In developed countries, knowledge of the underlying causes of these deaths has improved the implementation of protocols to help prevent premature deaths.[12] However, only a few publications have analyzed BID cases in LMIC, including the African nations.[5],[12],[17] More often than not, the causes of death in most BID cases and other preventable deaths are neglected in LMICs due to the lack of investigations, protocols, and poor autopsy uptake rates.[12],[18],[19],[20],[21]

This study was designed to describe the characteristics of children presenting as BID and the probable causes of death at the CHER of ESUTH, Enugu. The findings of this study may help to improve strategies for minimizing the occurrence of “out of hospital” deaths.


  Materials and Methods Top


Setting

This descriptive study was conducted in the CHER of ESUTH, Parklane, Enugu. The tertiary hospital receives cases from within and around Enugu state, and it provides 24-h pediatric emergency services. The emergency room is manned by doctors of all cadres, from interns to consultants. Ethical approval was obtained from the hospital research and ethics committee (ESUTHP/C-MAC/RA/034/Vol.1/295).

Data collection

All cases of BID children at the CHER of ESUTH between May 2016 and April 2020 were recorded in a register after the confirmation of death. A patient was described as BID if at presentation there was neither heartbeat nor respiration and the pupils were dilated and fixed.[11] For every BID child, several demographic parameters and history of illness were obtained. These included the following: name of child, sex, age, residence, time of presentation, symptoms of the disease, events preceding presentation, any relevant past medical history, and any obvious observation on examination. A probable diagnosis was made based on the information obtained (verbal autopsy). Those who presented with fever and convulsion of acute onset were classified as having Acute Encephalitis Syndrome (AES).[18]

Data management and analyses

Data were entered and analyzed with Statistical Package for Social Sciences (SPSS) version 20 (Chicago, IL). Descriptive statistics was used to determine frequencies, median values, and percentages. Results were presented as tables, bar chart, and prose.


  Results Top


There were a total of 5730 presentations, with 288 mortalities in the children emergency room over the study period. Of these, 124 cases were BID, accounting for 2.2% of the total presentations and 43.1% of the mortalities. Their ages ranged from one month to 192 months, with a median age of 12 months. Majority (61, 49.2%) of the dead children were infants. There was an almost equal sex distribution with 63 males, and a male-to-female ratio of 1:1. [Table 1] shows the age and sex distribution. One hundred and twenty two (98.4%) were of Christian religion, whereas the remaining two (1.6%) were Muslims. Majority of the cases (99, 79.8%) were from urban areas, whereas the rest were from rural areas. The probable causes of death in the BID children included AGE (30.6%), acute encephalitic syndrome (12.9%), sepsis (11.3%), severe anemia (8.9%), and aspiration (8.9%); see [Table 2].
Table 1: Age and sex distribution of the BID children

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Table 2: Probable diagnoses in the BID children

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None of the cases was referred from another health facility. There was a bimodal peak for the annual presentation (January and October); see [Figure 1]. Most of the presentations were during the day (86, 69.4%), between 6:00 am and 6:00 pm, whereas the rest presented at night. None of the parents gave consent for autopsy.
Figure 1: Distribution of cases by month of presentation

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  Discussion Top


This study attempted to draw attention to the high burden of children who are pronounced dead at presentation to the hospital for conditions that are otherwise treatable and/or preventable. Such situations are occasioned by delayed presentation. Delayed presentation is usually due to lack of symptom recognition, financial constraints, over-dependence on self-medication, indiscriminate patronage of patent medicine dealers, reliance on herbal treatment, and even cultural beliefs.[22],[23],[24],[25]

In the present study, infants were most commonly affected; probably due to their relative vulnerability to infections as a result of lower immune status. Their relatively small body mass makes them less able to withstand diseases, similar to older children and adults. This also supports the preponderant contribution of infant mortality to the national under-five mortality rate.[26]

AGE was the most probable cause of death in our study. AGE has remained one of the greatest killers of children outside the hospital, and this is mainly due to dehydration. The implication is that the health education given to mothers in the hospitals and media on the importance of oral rehydration therapy for every child with diarrhea and or vomiting has not made an appreciable impact on the target population. Traditional beliefs and practices associated with diarrhea, such as the belief that diarrhea is due to teething and should not be treated, may be a contributory factor.[27],[28]

AES ranked high among the probable causes of death. Most causes of fever with convulsions in children such as meningitis, encephalitis, and cerebral malaria do not readily result in death without an opportunity to present to health-care facilities, but the practice of self-medication and resorting to unorthodox means of managing convulsions in our society may be militating factors against the early presentation of these children.

Severe anemia was responsible for about 9% of the deaths. Prompt blood transfusion may be the difference between life and death in cases of severe anemia; unfortunately, many caregivers, either out of an inability to identify a severely pale child or reluctance to transfusion, present very late when the heart has already failed.

It is not surprising that most of the cases were from urban areas, as the hospital is located within the urban area. However, the relatively smaller number from rural areas may be due to low patronage of the teaching hospital by these rural dwellers. This may be attributed to financial, transportation, and other logistical problems.[23],[24] Many of these rural dwellers may never bother presenting to the hospital even after the demise of the children. Ignorance, financial difficulties, and religious extremism may also lead to deaths at religious facilities rather than health facilities. Such mortality cases are usually not accounted for.

Ideally, all the cases of BID should have an autopsy done; however, the acceptability of such, especially for children, is very poor in our society. In our study, none of the parents consented to autopsy. The reasons for this refusal may include ignorance, fear of mutilation of the body, cultural and religious beliefs, as well the desire to quickly bury the child.[21],[29] Every affected caregiver presenting to the emergency room with a case of BID must be given adequate medical counseling to prevent future occurrence. In doing so, care should be taken to avoid inflicting on the caregivers a psychological feeling of guilt while making them appreciate the importance of seeking care early.


  Conclusion Top


The rate of BID children to our hospital is unacceptably high; there is an urgent need for continuous mass mobilization and health education within the communities to improve the health-seeking behaviors of the people, and also to teach them to recognize danger signs in children. In addition, the knowledge of basic life support (CPR) by caregivers may assist in getting these children to the hospital alive.

Limitations of the study

This study relied on symptoms and history to arrive at the causes of death. Reliance on only symptoms and history of the illness may not give the real cause of death. Autopsy would have helped but was not done on any of the dead children because of a lack of consent by the parents.

Acknowledgment

The authors wish to acknowledge the contribution of the nurses in the CHER of ESUTH, Parklane, Enugu, Nigeria for their assistance in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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