Diagnosis Frequency % Bronchopneumonia 11 PEM 10 Severe Malaria 4 Malignancy 4 Diarrhoeal Disease 4 Meningitis 3 Tuberculosis 3 Measles 3 Septicaemia 2 SCA 2 UTI 1 Osteomyelitis 1 Others 8 Total Reasons for DAMA Frequency (%) Child is better or has improved 7 (28.00) No funds for further care 9 (36.00) Not satisfied with treatment plans 1 (4.00) Going to seek alternative care 2 (8.00) Family disharmony 1 (4.00) Reasons not stated 4 (16.00) Total 25 ( 100.00) Social Class DAMA (%) Absconded (%) High 3 (5.36) 0 (0.00) Middle 6 (10.71) 8 (14.26) Low 10 (17.86) 16 (28.57) Unknown 6 (10.71) 7 (12.50) Total 25 (44.64) 31 (55.36) Duration of Hospital Stay DAMA (%) Absconded (%) <1 day 1(1.79) 0 (0.00) 2-4 days 2 (3.57) 3 (5.36) 5-7 Days 7 (12.50) 5 (8.92) 8-10 Days 10 (17.86) 7 (12.50) 11-14 days 3 (5.36) 10 (17.86) >14 days 2(3.57) 5 (8.79) Total 25 (44.64) 31 (55.36) Premature Discharge from the Paediatric Wards of ABU Teaching Hospital: A 3– year Review Umar LW, Musa S, Bugaje MA, Ogunrinde GO, Musa A, Adeoye GO Department of Paediatrics Ahmadu Bello University Teaching Hospital, Zaria INTRODUCTION Parental/caregiver decision to prematurely terminate hospital care for their children either against medical advice or by absconding poses threats to healthy survival of children and ex- poses them to risks of harmful alternatives. The associated child right issues expose responsi- bility gaps of caregivers and the health system. Absconding events are multi-factorial and un- derstanding these factors could help improve adherence to hospital care. OBJECTIVE To determine the prevalence of and identify the factors associated with premature dis- charge of hospitalized children. METHODOLOGY A review of case notes of children whose caregivers signed and left with them against medical advice (DAMA) and those who were taken away unnoticed from January 2007 to December 2009 was conducted. Socio -demographic, clinical and other rele- RESULTS There were 56 cases out of 2858 admissions, giving a prevalence of 1.96%. For the three-year period under review, this gives an average of 1.7 cases per month. Figure I shows the proportion of children that were discharged after completing hospital care as prescribed by their managing team versus those prematurely discharged (DAMA/ Absconded). Figure I: Prevalence of premature discharge from Pediatric Wards of ABUTH Table I shows the distribution of children prematurely discharged from the paediatric wards by sex and age category. There were 39 males and 17 females with a male: fe- male ratio of 2.3:1. Under-five children constituted 64.3% of those prematurely dis- charged. Table I: Gender and age distribution of children prematurely discharged from Paediatric wards of ABUTH Figure II shows the type of premature discharge. Thirty -one (55.3%) children were taken away by caregivers unnoticed (absconded) while for the remaining, caregivers signed and left against medical advice (DAMA). Figure II: Categories of premature discharge from Pediatric Wards of ABUTH Table II shows the diagnoses of the children whose caregivers absconded with them or were discharged against medical advice from paediatric wards. The commonest di- agnoses were bronchopneumonia and PEM. Other diagnoses include diarrhoeal dis- eases, malignancies, severe malaria, tuberculosis and measles. Table II: Diagnoses of children prematurely discharged from Pediatric Wards of ABUTH The frequency of premature discharge by days of the week is shown in figure III. Ma- jority of DAMA occurred on weekdays while there was no difference between week- days and weekends for those who absconded. Figure III: Distribution of premature discharge from Pediatric Wards of ABUTH by days Table III shows the duration of hospital stay. DAMA mostly occurred within ten days (9.2±3.6) while absconding occurred within two weeks of admission (13.7±5.2). Table III: Duration of hospital stay for children prematurely discharged from Pediatric Wards of ABUTH Social class of the care-givers/parents is given in Table IV. Twenty-six (46.2%) of the children were from the low socio-economic background. There was no child from the high socio- economic class that absconded. Table IV: Social class of parents/care-givers of children prematurely discharged from Pe- diatric Wards of ABUTH Reasons given to prematurely terminate care for those discharged against medical advice is presented in Table V. The commonest reasons for DAMA were poverty related and perception of improvement. There were no reasons stated for absconding from care. Table V: Reasons for premature discharge in by caregivers of children discharged against medical advice in ABUTH DISCUSSION This study showed a prevalence of 1.96% for all categories of premature discharge of children admitted in the Pae- diatric wards of ABUTH Zaria. This prevalence is comparable to other studies from across Nigeria in children. 1-2 It however markedly differs from the 4.3% reported among neonates in Port Harcourt. 3 This may be explained by the dissimilarity of the study population between our study and that from Port Harcourt which reported on DAMA amongst neonates. Some reports have shown that DAMA has a higher prevalence amongst neonates. 1-2 Our study segregated 2 categories of premature discharge of children from hospital admission as those taken away by caregivers unnoticed for any reason (55.3% absconded) and those whose caregivers signed and left against med- ical advice (44.7% DAMA). Most other studies 1-3 either did not make the distinction or simply analyzed them as a single group of children discharged against medical advice. Differences were observed in this study between these types with regards the duration of hospital stay, with majority of DAMA occurring during working hours of week- days although no such difference was found for those that absconded. This could have significance with regards to prevention of DAMA, especially because of its implication. The leading diagnoses for the children in this study were bronchopneumonia and PEM. Other diagnoses include di- arrhoeal diseases, malignancies, severe malaria, tuberculosis and measles. This is in keeping with the types of cases seen over the period in the hospital. It is also in keeping with other studies on children. 1-2 It is noteworthy that the children’s care was prematurely terminated while being taken away with residual problems. Some of the other diag- noses are usually associated with poor prognosis and high treatment costs which make the parents want to abandon hospital care prematurely. The study shows DAMA mostly occurred within ten days (9.2±3.6) of admission while absconding occurred within two weeks of admission (13.7±5.2). The duration of hospital stay in this study is slightly longer than in most other studies, although comparison will be difficult because the study population is not the same. 4-9 Social class of care-givers/parents appears to have a significant impact on the rates of DAMA and absconding as 46.2% of the children in this study were from the low socio -economic background while no child from the high so- cio-economic class absconded. This is similar to findings from other studies. 1-2, 10-11 Inability to cope with accruing hospital bills may have resulted from poor socio -economic background of families of these children. That most of those who absconded did so during the late hours of the night or during visiting hours might have to do with at- tempts to evade payment of outstanding hospital bills. The commonest reasons for DAMA in this study were poverty related issues and perception of improvement, a finding that is similar with what was reported in other studies. 1-3, 5 Other reasons advanced include dissatisfaction with treatment plans, recourse to alternative treatment and in one instance, family discord. Although it was not pos- sible to find out reasons for absconding from care, it may be reasonable to extrapolate that the same reasons would apply as found with decisions for DAMA. CONCLUSION Socio-economic factors strongly influence utilization of in -patient medical care for children. There is a need to edu- cate parents/caregivers on implications of premature termination of hospital care, make health care affordable and develop institutional discharge policy to protect child rights. REFERENCES 1.Okoromah CN, Egri-Qkwaji MT. Profile of and control measures for paediatric discharges against medical advice. Niger Postgrad Med J. 2004 Mar;11(1):21-5. 2.Ibekwe, RC, Muoneke VU, Nnebe-Agumadu UH, Amadife MU. Factors Influencing Discharge against Medical Advice among Paediatric Patients in Abakaliki, Southeast- ern Nigeria. J Trop Pediatr 2009; 55: 39 – 43 3.Opara PI and Eke GK. Discharge against medical advice amongst neonates admitted into a Special Care Baby Unit in Port Harcourt, Nigeria. The Internet Journal of Pedi- atrics and Neonatology. 2010;12(2). 4.Alebiosu CO, Raimi TH. A study of hospital patients’ discharge against medical advice in the Ogun State University Teaching Hospital, Sagamu, Nigeria. Nigeria Medical Practitioner. 2001;40:33–35. 5.Eze B, Agu K, Nwosu J. Discharge against medical advice at a tertiary center in southeastern Nigeria: sociodemographic and clinical dimensions. 6.Onyiruka AN. Discharge of hospitalised under fives against medical advice in Benin City, Nigeria. Nig J Clin Pract. 2007;10:200–204. 7.Aliyu ZY. Discharge against medical advice: socio demographic, clinical and financial perspectives. Int J Clin Pract. 2002;56:325–327. 8.O’Hara D, Hart W, McDonald I. Leaving hospital against medical advice. J Qual Clin Pract. 1996;16:157–164. 9.Ohanaka FC. Discharge against medical advice. Trop Doc. 2003; 33:191–192. 10.Hong LE, Ling FC. Discharge of children from hospital against medical advice. J Singapore Paediatr Soc. 1992;34:34–38. 11.Onyiruka AN. Discharge of hospitalised under fives against medical advice in Benin City, Nigeria. Nig J Clin Pract. 2007;10:200–204. Characteristic DAMA Absconded Total Gender: Male 17 (30.36%) 22 (39.29%) 39 (69.64%) Female 8 ( 14.29%) 9 (16.07%) 17 (30.36%) Age Category: < 1 year 5 (8.93%) 7 (12.50%) 12 (21.43%) 1 – 5 years 11 (19.64%) 13 (23.21%) 24 (42.86%) > 5 Years 9 (16.07%) 11 (19.64%) 20 (35.71%)