MEDICATION HISTORY DOCUMENTATION IN REFERRAL LETTERS OF CHILDREN PRESENTING AT THE EMERGENCY UNIT OF A TEACHING HOSPITAL IN LAGOS, NIGERIA.

BACKGROUND: Medical literature has demonstrated that referral hospitals often receive inadequate information about the care and medications their patients received from referring hospitals. OBJECTIVE: This study aimed to assess the completeness of referral letters, especially the medication history, for patient presenting at the children emergency room of a teaching hospital in Lagos, Nigeria. METHOD: A pro forma form was developed to obtain from the referral letters the demographic information of children referred to the emergency room of the Lagos University Teaching Hospital (LUTH), Idiaraba, over a period of three months. The nature of the referring centre, tentative diagnoses made at the referring centre, duration of illness prior to referral, vital signs and physical examination findings, investigation results, and treatment given were also extracted from the letters. In addition, we extracted from the letters the name, dosage, frequency and duration of use of medicines administered at the referring centres. Parents were also interviewed about the details of medicines used prior to presentation of their child at the referring centres. RESULTS: Among those referred with a letter, 100 patients met the inclusion criteria and constituted those evaluated in this study. Most of the patients were referred from general hospitals (31%), another tertiary hospital (29%), and private hospitals/clinics (24%). Gender (30%) and tentative diagnoses (12%) were omitted in the referral letters. However, information about the weight (82%), vital signs (57%), physical examination findings (44%), treatment given (92%), and medication history (71%) were much more omitted in the referral letters. CONCLUSION: Medication history as well as many other data points is infrequently reported in referral letters to a tertiary care hospital in Lagos, Nigeria. Standard referral guidelines may be useful to improve documentation of medication history.

A prospective study of adverse events to antiretroviral therapy in HIV- infected adults in Ekiti State, Nigeria.

OBJECTIVES: Highly active antiretroviral therapy (HAART); the-current standard of antiretroviral therapy for Human Immunodeficiency Virus (HIV) infected persons, has been documented to drastically, reduce the number of cases of Acquired Immune Deficiency Sypdrome (AIDS). However, adverse. events are a challenge to the use of HAART. This study intends to determine the nature and incidence of suspected advcrse events to prescribed anti retroviral drugs in treatment centers in Ekiti State. METHOD: One hundred and twenty participants were enrolled and followed up over a period of six months. At each clinic visit, there was an administration of a detailed interviewer questionnaire that was completed by the attending pharmacist together with the participant. The form is designed to obtain information on the demographics of the patients, WHO clinical stage of their HIV infection, HAART regimen for the patients, and suspected adverse events associated with the antiretroviral drugs used by the patients. RESULTS: Tenofovir/Lamivudine/Eifavirenz (72.5%), Zidovudinc/Lamiv.udin/Nevirapine (16.7%), Zidovudine/Lamivudiine/ElafIvirenz (6.7%), Tenofovir/ Lamivudine/Nevirapine (3.3%), and Abacavir/ Lamivudine/Nevirapine (0.8%) were the HAART regimens prescribed to the patients. About half (57%) of the participants reported clinical adverse events; 92% of which were reported within two weeks of HAART initiation. Most of the reported adveise events were nausea (14.5%), abdominal discomfort (8.2%), and insomnia (7.5%). A few (6%) of those who reported adverse events required regimen switch or drug substitution. CONCLUSIONS: Antiretroviral drugs exposure often presents with adverse events, an observation similar to other studies. Most of the clinical adverse events were not severe or life threatening.

Lack of a significant change in caffeine metabolism in underweight children as determined by the caffeine breath test.

OBJECTIVE: Limited data from pharmacokinetic studies in underweight and severely malnourished children have indicated an impaired activity of their hepatic enzymes. We used the caffeine breath test to assess the metabolising activity of cytochrome P450 1A2 (CYP1A2) enzyme in underweight children. METHODS: Underweight children from the paediatric outpatient clinic, Lagos State University Teaching Hospital, Ikeja in Nigeria, were studied. After an overnight fast, 15 underweight children took 3 mg/kg labelled caffeine orally. Breath samples were collected in duplicate at -20, -10 and -1 min and at 15 min intervals for 2 h. The mean cumulative per cent dose recovered (CPDR) of labelled caffeine in the expired carbon dioxide was determined over the study period. This was repeated after 2-6 weeks of nutritional rehabilitation. RESULTS: The mean areas under the enrichment-time curve before and after nutritional rehabilitation were 0.539±0.320 and 0.620±0.322 atom per cent excess minute, respectively. The difference between the two values was not statistically significant (p=0.528). The mean CPDR in the exhaled carbon dioxide of the underweight children over a period of 2 h was 7.56±4.01% and 7.95±3.68% before and after nutritional rehabilitation, respectively, and there was no significant difference in the mean values (p=0.603). CONCLUSIONS: The metabolism of caffeine was not significantly affected in underweight children compared with after 2-6 weeks of nutritional rehabilitation. This suggests that hepatic CYP1A2-metabolising activity was not significantly impaired in underweight children.

Acute Pain Management in Children with Sickle Cell Anaemia during Emergency Admission to a Teaching Hospital in Lagos; Nigeria

Background. Optimal pain management in children with sickle cell anaemia (SCA) begins with accurate and thorough pain assessment. However; little or no evidence of this practice exists among SCA patients in developing countries. Objectives. To evaluate pain management in children with SCA during emergency admission. Methods. Children with SCA who were =12 years old; on admission for a painful crisis and who were not using herbal remedies for pain relief; were prospectively studied at the Lagos University Teaching Hospital (LUTH) over a period of 1 year. A proforma data collection form was used to obtain information about the demographics of the patients and their parents; as well as pain score; and non-pharmacological and pharmacological treatments documented in the patients' case files. Pain was assessed for each patient using the Wong-Bakers Faces Pain Rating Scale. Results. The median age and weight of the patients were 4 years and 16 kg; respectively. Pain assessment by the physicians was documented in 10 (8.3%) patients. However; among those assessed for pain by the researchers; 90 (75%) had a moderate pain score of 5 - 8. Fluid therapy (n=110; 91.7%) and prayers (n=120; 100%) were the most common non-pharmacological therapies administered to the patients while admitted. Analgesics; either in combinations or as a single medicine; were administered to 100 (83.3%) patients. Paracetamol (n=90; 75%) and pentazocine (n=80; 66.7%) were the most frequently used analgesics. The dosage of the analgesics prescribed did not conform to the recommendations of the World Health Organization (WHO). Conclusion. The SCA children in this study were managed sub-optimally with analgesics. Pain management among this group of children did not fully conform to the guidelines of the WHO

Use of complementary medicines among HIV-infected children in Lagos, Nigeria.

BACKGROUND: Complementary medicine (CM) use is common among children with chronic illnesses such as epilepsy and asthma. Lack of data on the profile of CM use among children with human immunodeficiency virus (HIV) infection necessitated this study. METHODS: Parents or caregivers of HIV-infected children attending the paediatric HIV-clinic in a teaching hospital in Lagos, Nigeria, were randomly selected and interviewed with a semi-structured (open- and close-ended) questionnaire. Clinical details of the patients were extracted from their case files. RESULTS: A total of 187 parents/caregivers were interviewed. Most of the parents/caregivers (181; 96.8%) have used CMs for their children. Mind-body interventions (181; 36.6%) and biological products (179; 36.2%) were frequently used. Relatives, friends and neighbours influenced CM use in 37.1% of the children. CMs were used mostly to treat weight loss (79; 43.7%), cold (40; 22.1%), and fever (39; 21.6%). CONCLUSION: CM use is common among HIV-infected children in Lagos.

Pharmacoepidemiology of antiretroviral drugs in a teaching hospital in Lagos, Nigeria.

OBJECTIVE: Prescribing, adherence, and adverse drug events to HAART in a large antiretroviral programme in Lagos was evaluated. DESIGN: A retrospective 5 year open cohort study. SETTING: The AIDS Prevention Initiative in Nigeria (APIN) clinic at LUTH is one of the United States Presidential Emergency Plan for AIDS Relief (PEP-FAR) funded centers for HIV relief program in Nigeria Participants The case files of 390 patients on HAART and attending the APIN clinic were reviewed sequel to random selection. MAIN OUTCOME MEASURES: Demographics of the patients and pattern of antiretroviral (ARV) combination drugs prescribed were extracted from their case files. The details of the adverse drug events (ADEs) were extracted from drug toxicity forms regularly filled for each patient. A Chi-square test with Yates correction was used to determine the association between adherence and therapeutic outcome. RESULTS: A total of 2944 prescriptions were assessed. Zidovudine + lamivudine + nevirapine (35.87%) and stavudine + lamivudine + nevirapine (35.63%) were the most frequently prescribed combinations. Over 2000 ADEs were reported with cough (13.3%), fever (8.75%) and skin rashes (8.01%) being the most frequently reported. Drug adherence was associated with good therapeutic outcome (χ(2) = 115.60, p<0.0001). CONCLUSIONS: Zidovudine + lamivudine + nevirapine was the most frequently prescribed ARV combination. Cough was the most frequently reported ADE. Interventions aimed at rational prescribing of ARV drugs and improving adherence to antiretroviral drugs is essential for good therapeutic outcome in the treatment of HIV infection.

Medication administration errors among paediatric nurses in Lagos public hospitals: an opinion survey.

OBJECTIVE: There is paucity of data on paediatric medicine administration error (MAE) in developing countries. This study aimed to investigate the experience of MAEs among paediatric nurses working in public hospitals in Lagos, Nigeria. DESIGN: A confidential, self-reporting questionnaire was the instrument for the study. SETTING: Public hospitals in Lagos, Nigeria with established paediatric services and departments. PARTICIPANTS: Paediatric nurses. METHODS: The questionnaire was administered to 75 nurses working in public hospitals in Lagos to obtain information on the experience of medication errors during their entire career, as well as to know their views on the nature of MAEs and the contributing factors. RESULTS: Fifty nurses responded to give a response rate of 66.7%. All the participants were females with a mean ± s.d age of 35.3 ± 10.7 years. Thirty two (64%) had committed at least one medication error over the course of their career. Wrong dose error (24; 48%) and wrong timing of medicine administration (20; 40%) were the MAEs frequently committed by the participants. The consequences of the errors included shock (23; 46%), restlessness (21; 42%), disorientation (11; 22%), and respiratory depression (10; 20%). Increased workload (26; 52%) and not double checking medicine doses (12; 24%) were the major factors the nurses perceived to be contributing to MAEs. Only 15(30%) nurses had reported MAEs to their superiors. Fear of intimidation, retribution or being punished (11; 22%) and lack of policies in place to report errors (13; 26%) were the two major barriers to reporting MAEs. Half (50%) of the nurses indicated that policies were available in their work places to prevent medication errors. CONCLUSIONS: Medication administration errors were frequently committed by the participants and resulted in some inconsequential effects, morbidity and deaths. Appropriate measures should be implemented to prevent future occurrences of MAEs.

Obesity and blood pressure levels of adolescents in Abeokuta, Nigeria.

BACKGROUND: We determined the prevalence of general and central obesity and their relationship with blood pressure levels among adolescents in Abeokuta, Nigeria. METHODS: We selected 423 adolescents from seven schools in Abeokuta, Nigeria, using a multistage random-sampling technique. Body mass index (BMI), waist circumference (WC) and blood pressures were measured. RESULTS: Twenty-one (5%) children had general obesity and 109 (24.5%) had central obesity. Of those with general obesity, 20 (95.1%) children were centrally obese. With simple linear regression analysis, BMI and WC explained 10.7 and 8.4%, respectively of the variance in systolic blood pressure (SBP), and 3.6 and 2.7%, respectively of the variance in diastolic blood pressure (DBP). Following logistic regression analysis, BMI was the major factor determining SBP levels (OR 0.8, 95% CI: 0.65-0.99, p < 0.05). CONCLUSION: BMI remains an important anthropometric screening tool for high blood pressure in Nigerian adolescents.

Micturitional dryness and attitude of parents towards enuresis in children attending outpatient unit of a tertiary hospital in Abeokuta, Southwest Nigeria.

BACKGROUND: There is significant variability of the age at which children achieve dryness. OBJECTIVES: We determine the age at achievement of micturational dryness and attitude of parents about enuresis among urban Nigerian children. METHOD: A total of 346 questionnaires were administered to parents of children between the ages of 12 - 180 months who came for routine paediatric care at the outpatient unit of Federal Medical Centre, Abeokuta. RESULTS: At age 36 months, 86 (51.8 %) and 34 (20.5 %) out of 166 children had achieved dryness at daytime and night time respectively. Achievement of dryness was significantly related to low maternal education (p = 0.022) and low social class (p = 0.009). Twenty-four (26.7 %) children had nocturnal enuresis. Four (4.4 %) of these children also had diurnal enuresis. All the parents/guardians were aware about enuresis but only 9.8 % correctly identified it as a health problem. Even though none of the children with enuresis ever visited health facility for their problem, a statistically significant proportion of the parents desire to discuss with health practitioners (p = 0.015). CONCLUSIONS: The proportion of children achieving dryness by age 36 months is very small when compared with children from developed parts of the world. There is also a high prevalence of enuresis which are not reported. Therefore, health workers in the tropics should as a routine enquire about enuresis in their daily paediatric care particularly for those children from polygamous homes and high social class.

Changes in the nutritional status of school children and adolescents in Abeokuta, Nigeria between 1983 and 2006.

BACKGROUND: The prevalence of overweight and obesity among children is increasing worldwide with significant health and social consequences. OBJECTIVE: The aim of this study was to determine the current nutritional status and its changes between 1983 and 2006 among school children and adolescents in a south western Nigeria town. METHODS: five hundred and seventy children aged 5 to 19 years from randomly selected primary and secondary schools in Abeokuta, Nigeria had their weights and height measured using standard techniques. The data obtained were compared with data obtained from a similar cross sectional survey carried out in 1983. The National Centre for Health Statistics/World Health Organisation guidelines and cut-off points were used to determine the degree of underweight and stunting. Obesity prevalence was assessed using weight for age greater than 120 % of expected. RESULTS: The mean age of the participants was 12.2 + 3.41 years, 296 (51.5 %) were males. The mean Weight-for-Age Z -score and Height-for-Age Z-score were -1.2773 + 1.14 and -0.8569 + 1.19 respectively. The prevalence rates of underweight and stunting were 24.7 % and 17.4 % respectively. Using weight greater than 120 % of expected weight for age, five (1.7 %) male and 7 (2.6 %) female children were obese compared to 3.3 % male and 5.1 % female children who were obese in 1983. CONCLUSIONS: The prevalence of overweight and obesity has remained relatively unchanged between 1983 and 2006. However,under-nutrition remains a major nutritional problem among school children and adolescents in Abeokuta, Nigeria.

Micturitional Dryness and Attitude of Parents Towards Enuresis in Children Attending Outpatient unit of a Tertiary Hospital in Abeokuta; Southwest Nigeria

Background: There is significant variability of the age at which children achieve dryness. Objectives: We determine the age at achievement of micturational dryness and attitude of parents about enuresis among urban Nigerian children. Method: A total of 346 questionnaires were administered to parents of children between the ages of 12 - 180 months who came for routine paediatric care at the outpatient unit of Federal Medical Centre; Abeokuta. Results: At age 36 months; 86 (51.8) and 34 (20.5) out of 166 children had achieved dryness at daytime and night time respectively. Achievement of dryness was significantly related to low maternal education (p = 0.022) and low social class (p= 0.009). Twenty-four (26.7) children had nocturnal enuresis. Four (4.4) of these children also had diurnal enuresis. All the parents/guardians were aware about enuresis but only 9.8correctly identified it as a health problem. Even though none of the children with enuresis ever visited health facility for their problem; a statistically significant proportion of the parents desire to discuss with health practitioners (p = 0.015). Conclusions: The proportion of children achieving dryness by age 36 months is very small when compared with children from developed parts of the world. There is also a high prevalence of enuresis which are not reported. Therefore; health workers in the tropics should as a routine enquire about enuresis in their daily paediatric care particularly for those children from polygamous homes and high social class

Providing safe medicines for children in Nigeria: The impediments and remedies.

Promoting safety of medicines for children is a global concern which has prompted the World Health Organization (WHO) to launch a campaign of "Making Medicines Child Size". Children in Nigeria were once victims of unethical clinical medicine trials and repeated victims of use of fake and adulterated medicines. Considering the magnitude of harms children had suffered in Nigeria from the use of medicines, there is a need for literature review to identify the factors preventing children from accessing safe medicines and to suggest remedies to the problems. Lack of access to up- to- date medicine information, lack of training and research in pediatric clinical pharmacology, deficiencies in undergraduate and postgraduate teaching of medicine risk management and clinical pharmacology and therapeutics, irrational medicine use due to lack of pediatric focus on essential medicine list and inappropriate home storage of medicines by parents, lack of evidence- based medicine (EBM) practice, lack of national adverse drug reaction surveillance among children, and weak national drug policies were the major problems identified. It is to be hoped that development and provision of a pediatric national drug formulary for health professionals in Nigeria, creating a comprehensive national pediatric drug research network in collaborations with developed countries, reviewing the undergraduate and postgraduate curriculum in pediatrics to include teaching of basic elements of rational prescribing, drug dose calculations, adverse drug reactions and pharmacovigilance, increasing access to essential medicines for children, postgraduate teaching of EBM, and strengthening of the national drug policies would improve children's access to safe medicines in Nigeria.

Adverse event monitoring of artemesinin combination therapy in Nigeria: the challenges and limitations of the study.

Artemesinin combination therapies (ACTs) are first line antimalarial drugs in malaria endemic regions of the world as recommended by the World Health Organization. ACTs are relatively new in Nigeria and there is little experience with their use. The pharmacovigilance of ACT drugs has been advocated in African countries so as to establish their safety in the African population. There is an on-going adverse event monitoring of the ACT drugs in Nigeria and a preliminary result has been published by the National Agency for Food and Drug Administration and Control. This commentary aims to discuss the challenges and limitations of the on-going pharmacovigilance of ACT drugs in Nigeria and proffer useful suggestions on how to overcome the problems.

Physical activity and body mass index of school children and adolescents in Abeokuta, Southwest Nigeria.

BACKGROUND: Physical inactivity and sedentary lifestyles are known to predispose to overweight and obesity. These lifestyles are also known to track from childhood into adulthood with consequent cardiovascular and metabolic problems. This study aimed to describe the frequency of physical activity and the relationship between physical activity and body mass index of urban Nigerian school children and adolescents. METHODS: Children from seven schools in Abeokuta, southwest Nigeria were selected using a multi-staged random sampling technique. RESULTS: Of 570 children, 411 (72.1%) were involved in moderate to vigorous physical activities. Involvement in physical activity was higher in older children (P<0.001), males (P<0.001), and children of mothers with a higher educational level (P=0.03). Eleven (1.9%) children were overweight or obese whereas 163 (28.6%) were underweight. There were more children with underweight than overweight among the subject population with a high level of physical activity (35.6% vs. 4.4%, P=0.499). CONCLUSIONS: A large proportion of the children in urban Nigeria participate in physical activity. The prevalence of overweight and obesity is low but undernutrition is a major nutritional problem among these children.

Adverse Event Monitoring of Artemesinin Combination Therapy in Nigeria: the Challenges and Limitations of the Study

Artemesinin combination therapies (ACTs) are first line antimalarial drugs in malaria endemic regions of the world as recommended by the World Health Organization. ACTs are relatively new in Nigeria and there is little experience with their use. The pharmacovigilance of ACT drugs has been advocated in African countries so as to establish their safety in the African population. There is an on-going adverse event monitoring of the ACT drugs in Nigeria and a preliminary result has been published by the National Agency for Food and Drug Administration and Control. This commentary aims to discuss the challenges and limitations of the on-going pharmacovigilance of ACT drugs in Nigeria and proffer useful suggestions on how to overcome the problems

Waist circumference values of Nigerian children and adolescents.

AIMS: This study aimed to determine the waist circumference (WC) of apparently healthy Nigerian children and adolescents and to compare the obtained values with available data for children from other parts of the world. METHODS: A representative sample of children from 7 schools in Abeokuta, a state capital in South West Nigeria, was selected using the multi-staged random sampling technique. The sample population consisted of 570 children with ages ranging from 5 to 19 years. RESULTS: WC increased with age in both sexes. The mean value of WC of children aged 5-9 years was about the same in both sexes (p = 0.113). However, in children older than 9 years, females had higher WCs than males (p = 0.000). Comparison of the 50th percentile WC of Nigerian children with that of American and Spanish children showed that both Nigerian male and female children had the lowest WC values. However, the values were similar to British male children up to 9 years and female children up to 14 years. CONCLUSION: The WC value varied with age, sex and race. These data are expected to serve as a baseline against which future data can be compared.