Development Of guidelines For Early Diagnosis Of Childhood Brain Tumors At Kenyatta National Hospital

Abstract

Background-Brain tumors are the second commonest tumors after leukemia and the commonest solid tumors in children. Childhood brain tumors (CBT) are the commonest cause of cancer related deaths in children and adolescents. Delayed diagnosis is a common occurrence which is associated with increased morbidity and mortality. The development of guidelines will help in the early diagnosis and management of childhood brain tumors in Kenya and Sub-Saharan Africa and provide better outcomes. Objective To develop clinicalguidelines for early diagnosis of childhood brain tumors atKenyatta National Hospital. Methodology First, a cross–sectional study on childhood brain tumors at KNH was done to review the pattern of presentation,PSI and establish reasons for late diagnosis. Sample included all patients between 0-12 years presenting with childhood brain tumors in KNH during the study period of seven months who meet the inclusion criteria.An informed consent was taken from the caregiver and an assent for the patients between the age of 7-12 years. A questionnaire was used to collect the required data through an interview(symptoms of CBT,PSI and reasons for late diagnosis) and physical examination of the patient(neurological signs of CBT)Medical records(file, imaging and laboratory results) were also reviewed and findings recorded(type and location of tumor) Secondly, the Delphi survey. The results of the cross sectional study were used to formulate statements for the Delphi Questionnaire. The questionnaire was presented to Neurosurgeons and Paeditricians from UoN and KNH.The members ranked their agreement to each statement using the Likert scale. The feedback was analysed and the rankings for each statement was collated. The statements that reached the level of consensus (equal to or more than 80% of the respondents’ score of 7-9) were xiii accepted. The statements that reached consensus were outlined into the final guideline document. The statements that did not achieve consensus were eliminated. Data management and results Questionnaires were coded and data entered into a password protected database. The data was analysed using the Statistical Package for Social Sciences(SPSS) by use of descriptive statistics(mean, median). Bar graphs, tables and pie charts were used for presentation of results Results Sixty-one children with brain tumor between the ages of 0-12 years who met the inclusion criteria for the cross-sectional study. A total of 25 signs and symptoms were recorded.The most common signs and symptomswere;headache(75.4%),nausea/vomiting(70.5%),lethargy &school difficulties(39.3%) and focal motor weakness (32.8%). The PSI ranged from one week to 3 years with a median PSI of 3 months and a mean PSI of 7.7 +/- 9.6 months. The predominant reason for delayed diagnosis was lack of health worker expertise (59%) followed by lack of awareness by the parent/guardian (8.2%) Delphi results: 18(72%) of the statements achieved consensus while 7(28%) did not meet the consensus threshold and were eliminated.The 18 statements formed the final guideline Conclusion The findings have outlined the varied presentation of CBT with headache as the most common (75.4%) at KNH. The study has clearly demonstrated delayed diagnosis of brain tumors in children at KNH. (Median PSI of 3 months and a mean of 7.7 +/- 9.6 months.) The main reason for the delayed diagnosis (prolonged PSI) was lack of expertise by the health worker (59%). Therefore, the guideline will assist the health worker primarily by providing the varied presentation pattern of CBT as well as imaging recommendations for children with brain tumors.