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Neurology
Original research
Clinical profile and outcomes of paediatric patients with acute seizures: a prospective cohort study at an urban emergency department of a tertiary hospital in Tanzania
  1. Frida Shayo1,2,
  2. Hendry R Sawe1,2,
  3. Gimbo M Hyuha1,2,
  4. Baraka Moshi3,4,
  5. Masuma A Gulamhussein1,2,
  6. Raya Mussa1,2,
  7. Winnie Mdundo1,2,
  8. Shamila Rwegoshora1,
  9. Juma A Mfinanga2,
  10. Said Kilindimo1,2,
  11. Ellen J Weber5
  1. 1Emegency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
  2. 2Emergency Medicine, Muhimbili National Hospital, Dar es salaam, Tanzania
  3. 3Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
  4. 4Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
  5. 5Emergency Medicine, University of California San Francisco, San Francisco, California, USA
  1. Correspondence to Dr Frida Shayo; frishahappy{at}gmail.com

Abstract

Objective Children with seizures require immediate and appropriate intervention in the emergency department (ED). This study describes the clinical profile and outcome of paediatric patients with seizures at the ED in a country with limited resources.

Design A prospective, observational cohort study of paediatric patients with seizure presenting to an ED conducted over a six-month period from 1 August 2019 to 31 January2020.

Setting The study was conducted at the ED of Muhimbili National Hospital, a level 1 trauma centre located in Dar es Salaam, Tanzania.

Participants Paediatric patients aged 1 month to 14 years presenting at the ED with acute seizure, defined as any seizure occurring from 24 hours to 7 days prior to the visit, were included in this study. Patients were consecutively enrolled during times a research assistant was present in the department. Newborns, children with repeat visits or no signs of life on arrival were excluded.

Outcome The primary outcome was the proportion of paediatric patients presenting with seizures and their mortality rate; secondary outcome was risk factors for mortality.

Result During the study period, 1011 children were seen in the department, of whom 114 (11.3%) (95% CI 9.3% to 13.3%) presented with seizures. Median age was 24 months (IQR 9–60), 78.1% were under 5 years and 55.3% were males. The majority 76 (66.7%) of the patients presented with generalised seizures. Half 58 (50.9%) of patients presented with fever. Meningitis was the most common aetiology, diagnosed in 30 (26.3%). Overall mortality was 16.7% (95% CI 10.3% to 24.8%). Using negative log binominal analysis, fever (relative risk, RR 2.7), altered mental status (RR 21.1), hypoxia (RR 3.3), abnormal potassium (RR 2.4) and clinical diagnosis of meningitis (RR 3.4) were statistically significantly associated with mortality.

Conclusions Findings from this study revealed higher incidence of paediatric patients with seizures than that reported in high-income countries and other low-income and middle-income countries. The acuity of illness was high, with 16.7% mortality rate. The presence of fever, altered mental status, hypoxia, abnormal potassium levels and meningitis diagnosis were associated with higher risk of mortality. Further research is needed to develop interventions to improve outcomes in paediatric patients with seizures in our setting.

  • Paediatric neurology
  • Epilepsy
  • ACCIDENT & EMERGENCY MEDICINE

Data availability statement

Data are available on reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjopen-2022-069922

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This is a prospective study conducted in the emergency department (ED) of a tertiary-level hospital, where participants are referred from all over the nation.

    • Data were collected in period of 6 months, and all patients were followed until the final outcome occurred.

    • Not every patient has performed all routinely tests, and this can limit the ability to determine associations between outcome and test results.

    • While patients were enrolled consecutively when a research assistant was present, and representative shifts were chosen, we were not able to recruit 24/7, resulting in screening less than a quarter of the ED population during study period.

    Background

    Acute seizures are a common presenting complaint in children visiting emergency departments (ED).1–4 In high-income countries (HICs), seizures occur in about 1% of the paediatric population and account for 2%–5% of paediatric ED visits.1 However, in low-income and middle-income countries (LMICs), the proportion of children presenting to EDs with seizures is as high as 18.5%.2 3 Globally, male children younger than 5 years of age are the most affected group, and the risk declines with increasing age.1 2 4

    Simple febrile seizure is the most common presentation and has a good outcome.1 4 However, in LMICs, complex seizures are more frequent and can be due to central nervous system (CNS) infection (eg, meningitis, encephalitis), which may lead to poor clinical outcome.1 3

    In HICs, the majority of the patients who present with seizures can be directly discharged home after thorough examination and investigation for underlying illnesses.1 However, in LMICs, there is a high rate of hospital admission and mortality.2 3 5

    Acute seizure management must occur simultaneously with the diagnostic assessment and should address reversible life-threatening causes, taking into consideration the most likely aetiology in a particular region or setting, for example, an area with endemic Malaria.6–9 Due to different aetiologies and outcomes of paediatric seizures in different settings, more information is needed.2 7 9

    This study aimed to characterise the demographic, clinical characteristics and outcome of children presenting to a national hospital in Tanzania with seizure. We also set out to determine the predictors of death in children with seizure. Emergency medicine is in its early stages in LMICs and knowing this information can allow emergency physicians to focus efforts and resources on those with the highest risk of death, in order to provide appropriate management and disposition, and improve outcome.

    Methods

    Study design

    This was a prospective cohort study of paediatric patients with acute seizures presenting to the ED of Muhimbili National Hospital in Tanzania between 1 August 2019 and 31 January 2020.

    Study setting

    Muhimbili National Referral Hospital is a level 1 trauma centre located in Dar es Salaam, Tanzania. The hospital has a 1500 bed capacity, with an average of 1000–1200 admissions per week. Muhimbili’s ED is the first public ED in the country. It is staffed with emergency physicians, postgraduate students in an emergency medicine training programme, medical officers, critical care nurses and nursing officers. The ED is the entry point to the hospital for most of the patients admitted and an average of 200 patients are seen daily, including 15–20 paediatric cases daily. More than half of paediatric patients seen in the ED are admitted. At the time of the study, there was one room for paediatric resuscitations, staffed by two nurses and one doctor per shift. Also, at the time, there were 20 paediatric intensive care unit beds with one nurse attending 1–2 patients, depending on severity.

    Study participants

    All patients aged 1 month to 14 years old who presented to the ED with an acute seizure were eligible for the study. Acute seizure was defined as any seizure occurring from 24 hours to 7 days prior to the visit. Newborns (less than 28 days) were not included in this study as this age group is not seen at our ED setting. We included patients only up to 14 years as this is the cut-off age for paediatric care in our facility. We excluded all children whose parent or guardian did not consent for the study, repeat visits and those patients with no signs of life on arrival.

    Study protocol

    A research assistant was present in the ED for four 12-hour shifts each week, varying between day and night shifts. Patients with the presenting complaint of seizure at triage were consecutively approached. The mother or caregiver gave written consent before data collection. A standardised case report form (CRF) was used to record demographic information, and description of seizure(s), vital signs, comorbidities, associated symptoms, history of trauma, bedside, laboratory and radiological investigations (eg, blood sugar, serum electrolytes, rapid test for malaria, blood gases and CT scans, if ordered) were also documented. The research assistant recorded any intervention performed in the ED (eg, administration of glucose, antipyretic, intravenous fluid, antibiotic and antiepileptic (eg, diazepam, phenytoin and phenobarbitone)). All patients received standard care according to the ED’s acute seizure protocol adopted from the African Federation of Emergency Medicine. Primary diagnosis made by the treating ED physician and disposition were recorded (discharge, admission, death at the ED). Admitted patients were followed until discharge and their final hospital diagnosis documented on the CRF. Information bias was overcome by using International Classification of Diseases-10 (ICD-10) diagnosis.

    Outcomes

    Primary outcomes were proportion of paediatric patients who presented with acute seizures during the hours of enrolment and mortality rate of enroled patients presenting with seizure; secondary outcome was risk factors for mortality. Candidate risk factors were chosen based on review of literature.

    Sample size and data analysis

    The sample size was calculated based on the proportion of children attending the ED with seizure, using a 95% CI with the width of 5%. Chen et al in Taiwan found that 7.8% of paediatric patients presented with seizures and based on this incidence, the estimated minimum sample size was 114 patients.10

    Using online data Capture Software (REDCap), data were downloaded into Microsoft Excel (V.7.2.2, Vanderbilt, Nashville, Tennessee, USA) and then exported to STATA V.15 for analysis. Descriptive statistics for categorical data were summarised as frequency and percentage, and continuous data were summarised as median with IQR. Negative log binomial analysis was used to establish the variables associated with mortality which are reported as relative risk (RR). Findings with p<0.05 were considered statistically significant.

    Patient and public involvement

    Patients and the public were not involved in the design of the study. The results of our study will be disseminated through open-access publication.

    Results

    Sociodemographic characteristics of study participants

    During the study period, a total of 3616 paediatric patients visited the ED; 1011 (28.0%) presented during the hours a research assistant was present and were screened. There were 114 (11.3%) (95% CI 9.3% to 13.3%) patients who met inclusion criteria. All parents/caregivers of patients who met the study criteria consented. (figure 1). The median age was 24 months (IQR 9–60 months) and 63 (55.3%) were male. The majority 89 (78.1%) of participants were below 5 years old. Most patients 80 (70.2%) were referred from lower-resourced facilities and 86 (75.4%) were triaged as highest acuity on arrival. Most patients had no history of any chronic disease prior to seizure onset; however, cerebral palsy was the leading comorbidity among those with comorbidities (table 1).

    Figure 1
    Figure 1

    Flow chart of paediatrics screened and included in the study. EMD, emergency medical department.

    View this table:
    Table 1

    Sociodemographic and clinical characteristics of paediatric patients with seizures (N=114)

    Patient presentation at ED

    Generalised tonic clonic 76 (66.7%) was the most common type of seizure among those presenting. Half 58 (50.9%) of the participants presented with fever and 51 (45.9%) with an altered level of consciousness on arrival. Among all participants, 14 patients (12.5%) presented with hypoxia (SPO2 less than 94%) while 5 (5.8%) patients had hypoglycaemia. Sodium and potassium were checked in 86 (75.4% of patients) 31.4% of those tested had abnormal potassium and 58.1% had abnormal sodium. Malaria rapid test was performed on 88 patients, among whom 5 (5.7%) had a positive test. HIV point-of-care test was performed in 19 patients and 1 (5.3%) tested positive (table 2).

    View this table:
    Table 2

    Clinical characteristics of paediatric patients with seizures (N=114)

    ED management and diagnosis

    Thirty-three patients had seizures during their stay in the ED; 26 (78.8%) responded to diazepam and the remainder required both diazepam and phenobarbitone. Among all patients, 17 underwent CT scans of which 47.1% were abnormal. Antibiotics were given to 62 (54.4%) patients in the ED.

    The most common ED diagnosis was meningitis 30 (26.3%). Of the 20 patients who had blood cultures drawn in the hospital, 7 (35%) had bacterial growth. Of the nine who had a lumbar puncture, only one had an abnormal CSF analysis. In the hospital, 11 patients had an EEG, with 8 (72.7%) reported abnormal (table 2).

    Disposition and outcomes

    Among the 114 patients enrolled, 15 (13.2%) were discharged home from the ED, 93 (81.6%) were admitted to the ward and 6 (5.3%) died in the ED. Among those admitted, 18 (15.8%) patients were admitted to the ICU, the remaining 75 (65.8%) went to the paediatrics general ward. Overall, 19 children died in hospital, for a mortality rate of 16.7% (95% CI 10.3 to 24.8). Most deaths 17 (89.5%) occurred in children less than 5 years old (table 3).

    View this table:
    Table 3

    Outcomes of patients with seizure (N=114) (95% CI 09.3 to 13.3)

    Risk of mortality

    In the multivariable analysis, children under 5 had twice the risk of dying. In all age groups, those presenting to the ED with fever, altered mental status, or hypoxia and those with an ED diagnosis of meningitis had significantly increased risk of death. The use of more than one medication to control seizures in the ED increased the risk of dying but the association was not statistically significant (table 4).

    View this table:
    Table 4

    Characteristics associated with mortality among paediatric patients with seizures (N=114)

    Discussion

    In this prospective study at a tertiary hospital in a low resource country, we found that, during the hours of screening, 11.3% (95% CI 9.3% to 13.2%) of paediatric patients presented with the chief complaint of seizures. The mortality rate was 16.7% (95% CI 10.3% to 24.8%) and the risk of death was greater in patients presenting with altered mental status, abnormal potassium, hypoxia and fever. An ED provisional diagnosis of meningitis was also associated with a significantly increased risk of mortality.

    Compared with HICs, the proportion of children presenting to our ED with seizures was much higher.1 This is likely due to the fact that children in low-resource settings have a greater number of risk factors not seen in HICs, for example, more exposure to infectious diseases, and a higher rate of cerebral palsy, as shown in a study in Uganda where prevalence of CP was found to be 19%.11

    As in most studies, a large proportion of children with seizures presented with fever. However, few (7.9%) had simple febrile seizures. Studies done in HICs have found the majority of children who present with seizures and fever have simple febrile seizures without serious underlying disease and have a good outcome.1 4 12 As in our study, studies in LMICs have found that the majority who present with fever have serious illness and poor outcome.3 12 13 CNS infection is a more frequent cause of seizures in LMICs than in HICs.2 7 Meningitis was present in 26% of our patients, and malaria in an additional 5 (4.4%), similar to other studies in LMICs.2 3 7 12 13 Empiric antibiotics were given in 60 (54.4%) children with seizure and fever. There is a concern about giving antibiotics to children with febrile seizures unnecessarily. One prior study in the USA found that 65% of children with febrile seizures were given antibiotics for a presumed respiratory infection, which was likely to be viral.14 However, the serious underlying diseases found in our cohort suggest that there may be greater justification for the use of empiric antibiotics in our setting.

    Hypoglycaemia is considered a common cause of seizures in children; hence measuring a point-of-care glucose level on every seizing child is standard practice in an ED. Taherian et al found hypoglycaemia to be the second most common cause of seizures in children.15 However, hypoglycaemia was found in less than 5% of children in our study, as in a study by Alenezi et al from Egypt.15 16 This could be explained by the fact that Muhimbili National Hospital is a tertiary hospital where most patients with seizures are referred from other hospitals, and the more obvious, treatable causes were likely to have been treated before referral.

    In this study, the overall mortality was substantially higher than other studies in HICs. In a study in Taiwan, Chen et al found a mortality rate of 7.8%, but a study in Pakistan by Ojha et al, found a mortality rate similar to ours of 16.7%.9 12 The high mortality observed in our study may be due to the fact that the patients were referred from lower-resourced facilities and thus were the most severely ill with serious pathology. The majority of the patients who presented with seizure were under 5 years of age, consistent with studies in both LMICs and HICs.1–4 9 10

    Conclusions

    Findings from this study in a tertiary hospital in a limited income country revealed a higher incidence of paediatric patients presenting with seizures than reported in HICs and other LMICs. The acuity of illness was high with mortality rate of 16.7% (95% CI 10.3% to 24.8%), presence of fever, altered mental status, hypoxia, abnormal potassium levels and meningitis diagnosis were associated with higher risk of mortality. These findings contrast with those of HICs. Further research is needed to determine ways to improve outcomes in paediatric patients with seizures in low resource areas.

    Data availability statement

    Data are available on reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and ethical approval was obtained from the Muhimbili University of Health and Allied Sciences Research Committee with IRB no MNH/TRCU/IRB/Permission/2019/146. Permission to collect data obtained from the responsible institution, MNH participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    First and foremost, I would like to thank God for His grace throughout my entire residency training. Second i would like to thank all research assistants, medical record team, paediatric ward team and paediatric ICU team for their support. Lastly, I would like to pass my gratitude to Muhimbili University of Health and Allied Sciences and Muhimbili National Hospital for granting permission to conduct this study and all who participants agreed to participate in this study.

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    Footnotes

    • Contributors FS conceived and designed the study, acquired, analysed and interpreted the data, drafted the original manuscript, and revised the manuscript. HRS contributed to the conception and design of the study, data acquisition, entry, validation, and analysis and critical revision of the manuscript. EJW contributed to the design of the study, data validation and analysis and critical revision of the manuscript. JAM contributed to the conception and design of the study, SK, BM and MAG contributed to the data review and analysis, RM contributed to the conception and design of the study, data review, and analysis participated in conducting the pilot study to test methodology of this study. and contributed to revision of the manuscript WM contributed to conception and design of the study, data validation, review, analysis and also critically revised the manuscript, GMH contributed to the conception and design of the study, data validation, and review and manuscript writing and revising, S SR contributed to the conception and design of the study, data validation, review, analysis and critically revised the manuscript. All authors read and approved the final manuscript. FS acts as guarantor for the study.

    • Funding The principal investigator and researchers used their own funds to support the data collection and logistics.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.