Recent changes in malaria transmission have likely altered the aetiology and outcome of childhood coma in sub-Saharan Africa. The authors conducted this study to examine change in incidence, aetiology, clinical presentation, mortality and risk factors for death in childhood non-traumatic coma over a 6-year period.
Retrospective analysis of prospectively collected data.
Secondary level health facility: Kilifi, Coast, Kenya.
Children aged 9 months to 13 years admitted with acute non-traumatic coma (Blantyre Coma Score =2) between January 2004 and December 2009 to Kilifi District Hospital, Kenya. Exclusion criteria: delayed development, epilepsy and sickle cell disease.
During the study period, 665 children (median age 32 (IQR 20–46) months; 46% were girls) were admitted in coma. The incidence of childhood coma declined from 93/100 000 children in 2004 to 44/100 000 children in 2009. There was a 64% overall drop in annual malaria-positive coma admissions and a 272% overall increase in annual admissions with encephalopathies of undetermined cause over the study period. There was no change in case death of coma. Vomiting, breathing difficulties, bradycardia, profound coma (Blantyre Coma Score=0), bacteraemia and clinical signs of meningitis were associated with increased risk of death. Seizures within 24 h prior to admission, and malaria parasitaemia, were independently associated with survival, unchanging during the study period.
The decline in the incidence and number of admissions of childhood acute non-traumatic coma is due to decreased malaria transmission. The relative and absolute increase in admissions of encephalopathy of undetermined aetiology could represent aetiologies previously masked by malaria or new aetiologies.
This study examines change in incidence, aetiology, clinical presentation, mortality and risk factors for death in childhood acute non-traumatic coma over a 6-year period of documented change in malaria transmission in rural coastal Kenya.
There is an overall decline in childhood coma presentation over the study period, with a significant drop in malaria-positive coma admissions.
There is relative and absolute increase in coma admissions of undetermined aetiology.
There is an urgent need to examine for the role of viruses, metabolic derangements, vascular pathologies and other conditions in the aetiology of childhood non-traumatic coma.
Strengths and limitations of this study
The study is based on prospectively collected data in a setting where recommended standard clinical care is consistent and for which the catchment area is well delineated.
A number of children with acute coma likely die before arrival in hospital, and a few others are seen in a smaller hospital, which refers most of their comatose patients to the hospital in the study. Thus, the incidence figures are minimum incidences, likely an underestimation of the actual incidence.