Initial clinical presentation, diagnostic evaluation and emergency provider clinical impression of febrile children less than five years old presenting to the emergency medicine department at Muhimbili National Hospital in Dar es salaam, Tanzania

Abstract

BACKGROUND: Fever is one of the most common reasons for pediatric emergency department visits, accounting for as many as 20% of all presentations. A variety of diagnostic tests, including blood, urine and CSF testing, as well as chest radiography and pathogen-specific rapid diagnostic tests (RDT) may be useful in the evaluation of the febrile child and appropriate diagnostic testing may vary based on age and clinical presentations. While there are many published recommendations for the evaluation of febrile children less than five years old in the acute care setting, little is known about the actual diagnostic management and ultimate emergency provider clinical impression of febrile children less than five years old in limited-resource settings. AIM OF STUDY: To describe the clinical presentations, diagnostic evaluation, treatment and emergency provider clinical impression of febrile children less than five years old at the MNH EMD in Dar Es Salaam, Tanzania. METHODS: This was a observational descriptive study conducted from August through November 2012 at the MNH EMD, a tertiary care center with approximately 36,000 EMD visits per year. We enrolled a convenience sample of children less than five years old who presented with fever or reported fever. Treating physicians prospectively completed a standardized data collection form. RESULTS: We enrolled 105 febrile children less than five years old in the study with the median age of 14 months. Sixty-four percent were male. Since Muhimbili is a tertiary referral hospital, the majority of the patients (54.3%) were referred. The predominant symptoms from this cohort of febrile children less than five years old were xi poor feeding (47.6%) vomiting (42.9%), cough (34.3), difficulty in breathing (28.6%), diarrhea (22.9%), abdominal distension (14.3%), and convulsions (13.3%). Seventy-eight percent had at least one vital sign abnormality, while 82% had an abnormal physical examination findings. Point-of care tests included random blood glucose on all children under 5 (100%), malaria RDT on 103 (98.1%), urine dipstick on 30 (28.6s%), rapid HIV test on 26 (24.80 %) and venous blood gases on 59 patients (56.19%). While in the EMD, most children less than five years old received at least one therapeutic treatment: 73 (70%) received at least one antibiotic, 13 (12%) received anti-malarial medication, 57 (54%) received intravenous fluids and 43 (41%) received an anti-pyretic. The top emergency physician clinical impressions are also reported. CONCLUSION: In MNH EMD, a range of diagnostic tests are used to determine cause of fever though testing results do not always correspond with reported clinical impressions. In referred patients, administration of antipyretics, antibiotics, and anti- malarial prior to ED arrival was common. Bacterial infections were very common among children under 5 years who were tested. RECOMMENDATIONS: 1) We recommend the development of a symptom-based diagnostic testing protocol to rationalize our approach to diagnosis and management of febrile children under 5 years. 2) We recommend execution of larger prospective study with definitive testing to further characterize the etiology of febrile illnesses in acute care settings in this region.