Abstract
Background: The emergence of acute neurological manifestations in children necessitates immediate intervention. Despite low- and middle-income countries (LMICs) bearing the highest burden of neurological diseases, there is a scarcity of diagnostic and therapeutic resources. Here we characterize the association between clinical phenotypes, premortem management, and final confirmed causes of death in children under-5 who had neurological manifestations before their death, to identify current gaps and improve strategies to enhance child survival.
Methods: We analyzed data collected from seven LMICs as part of the Child Health and Mortality Prevention Surveillance (CHAMPS) study. Cases with a chain of events leading to death established by a specialist panel were assessed. Deceased children under-5 who were born alive and had available premortem neurological evaluations were included in a descriptive analysis.
Findings: Among 2127 codified cases, 1330 (62·5%) had a neurological evaluation recorded. Over half (727/1330, 54·7%) presented with neurological manifestations during their illness prior to death. The most common neurological ICD-10 diagnoses related to death were hypoxic events (308/1330, 23·2%), meningoencephalitis (135/1330, 10·2%) and cerebral malaria (68/1330, 5·11%). There were 12 cases of overlapping hypoxic events and meningoencephalitis, and no cases with meningoencephalitis and cerebral malaria. Neurological manifestations were similar among diagnoses, and no combination of symptoms was accurate in differentiating them without complementary tools. However, only 18% meningitis cases had a lumbar puncture (LP) performed prior to death. Nearly 90% of deaths following neurological manifestations were considered preventable.
Interpretation: Neurological manifestations were frequent prior to death. However, clinical findings were insufficient to differentiate the most common underlying neurological diagnoses. The low rate of LPs performance was especially worrying, suggesting a challenge in quality of care of children presenting with neurological manifestations. Therefore, better diagnostic and therapeutic quality of care is necessary to reduce under-5 mortality caused by these conditions.
Funding: Bill & Melinda Gates Foundation (OPP1126780).
Declaration of Interest: I, Sara Ajanovic, first author of the manuscript, declare no competing interests.
Ethical Approval: Ethics committees overseeing investigators at each site, and at Emory University (Emory Institutional Review Board (IRBA): 00091706), approved overall and site-specific protocols.
Keywords: Neurological, Meningitis, Cerebral malaria, Malaria, Hypoxic events, Neonates, Infants, Children, Mortality, Lumbar Punctures