| dc.description.abstract | Background: Fever is a common presentation of children with sickle cell anaemia (SCA).
Outpatient management of selected patients with SCA and fever is safe, effective and reduces
hospital admissions in high income countries. The effectiveness of this approach, however, is
heavily reliant on stringent guidelines and rigorous follow up procedures. At the Mulago hospital
sickle cell clinic (MHSCC), a select group of patients with SCA and fever are managed on
outpatient basis, as guided by the clinic’s fever protocol. Challenges with follow up and limited
laboratory capacity to investigate for the causes of fever may contribute to poor outcomes in our
setting. Presently, the outcomes of this management are unknown.
Objectives: To determine the immediate outcomes and factors associated with poor outcomes in
children with sickle cell anemia and fever managed as outpatients at the MHSCC
Methods: Children aged 0-12 years with confirmed SCA, presenting to the MHSCC from October
2018 to February 2019, with documented axillary temperature of 37.5 °C or more, were
prospectively enrolled and followed up for seven days to assess fever resolution, hospitalization
or death. Children were recruited after a decision to treat as an outpatient had been made by a non
study clinician after obtaining written informed consent and assent. Guided by a standardized
questionnaire, a detailed history and physical exam, review of the laboratory tests done, as well as
treatment prescribed and received by the enrolled patients was carried out. On day 7, a final
interview, guided by a (second) standardized questionnaire, was carried out to assess for the study
outcomes of fever resolution, return to the sickle cell clinic, hospitalization and death in the first 7
days following outpatient management for fever, as well as factors associated with hospitalization.
Statistical analyses were performed using the Chi-squared distribution and Fisher’s exact test for
measures < 0.2. A p-value of <0.05 was considered to be significant.
Results
Data from a total of 220 children were analyzed. By day 7, 200/220 (90.9%) enrolled participants
had fever resolution, with the majority 108/200 (54.0%), reporting fever resolution by day 2
following treatment at the clinic. Hospitalization in the first 7 days following treatment at the clinic
occurred in 23/220 (10.5%) study participants. Most of the hospitalized patients 14/23 (60.9%),
were 60 months of age or older. The most common reasons for admission were vasoocclusive
crises and acute chest syndrome/severe pneumonia, each accounting for 12/23 (52.2%). At
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multivariate analysis, axillary temperature of 38.0℃ or more (AOR 7.36 95% CI 1.09-49.81, P=
0.041), not being on malaria chemoprophylaxis ( AOR 21.84 95% CI 2.97-160.85, P=0.002), chest
pain at enrolment ( AOR 7.91 95% CI 1.32-47.28, P=0.023), pain in the extremities at enrolment
(AOR 39.40 95% CI 4.13-375.5, P=0.001) and the caregiver not having attained secondary level
education ( AOR 0.09 95% CI 0.02-0.61, P=0.013) were associated with hospitalization. There
was no death among the enrolled participants in the first 7 days following outpatient treatment at
the clinic for fever.
Conclusions and Recommendations
Ninety percent of children with SCA treated for fever had it resolved by day 7. However, 1 in
every 10 children with a febrile episode needed hospitalization, with children aged 60 months and
above being at the highest risk. In order to reduce hospitalization rates in children with SCA
presenting with fever, we recommend careful follow up for children older than 60 months of age,
with axillary temperature of 38.0℃ and above, pain in the extremities and chest, and those children
not on malaria prophylaxis. Future research is needed to study children with SCA aged 60 months
and above since they have the highest risk for hospitalization. | en_US |
