Frequency and Associated Factors of Parental Refusal to Perform Lumbar Puncture in Children with Suspected Central Nervous System Infection: A Cross-sectional Study

Abstract

ObjectiveLumbar puncture (LP) is a useful procedure which is performed for both diagnosis and treatment of numerous conditions affecting children and adults. The purpose of this study was to determine the frequency and cause of increased parental refusal to perform LP in the pediatric population.MethodA cross-sectional study was conducted from January 2018 to June 2019 at the Civil Hospital, Dow University of Health Sciences, pediatric department, Civil Hospital, Karachi. Over the 18-month time period, a total of 215 patients who had indications of LP were selected from the in-patient pediatrics department; the age range was between newborn to 12 years of age. The mode of research was a questionnaire and interview-based method that was conducted with guardians of minor patients to understand the extent of their knowledge and awareness about the LP procedure as well as its complication and the role of culture, education background, and financial status of the families which may lead to an increased likelihood of refusal.ResultThe frequency of LP refusal amongst the 215 families of the patients that were interviewed was found to be 32.6%. Mean age of the respondents was 30.98 years. The decision for LP was not significantly affected by the subjects’ gender (p=0.1), by the religious communities to which the families belonged (p=0.9), their ethnicities (0.52), or by the families’ financial status (p=0.4). It was observed that when indications for performing LP were appropriately explained, there was a significantly greater number of consents given as compared to when they were not made clear (p=0.009). Explaining the complications of the procedure did not considerably impact the decision for refusal of the procedure (p=0.1). The multi-variable logistic regression analysis model was applied to determine the likelihood of variables affecting refusal of LP and the logistic regression model was found to be statistically significant, χ2 (8) = 38.2 p < 0. 001.ConclusionLack of knowledge about the LP procedure and fear of ramification plays a conspicuous role in the denial of LP procedure by the guardians of minor patients. A better, simpler approach using standardized consent forms by the doctors may lead to the removal of the information gaps and can provide a better understanding about the concerned risks, the primary indications, and the benefits of this procedure to the guardians.

Parental Refusal to Lumbar Puncture: Effects on Treatment, Hospital Stay and Leave Against Medical Advice

“…Several other studies support our findings [1][2][3][4]. Our literature search revealed that parental LP refusal is significantly associated with LAMA.…”

“…Lumbar puncture (LP) is an important procedure for the diagnosis and management of central nervous system (CNS) infections in children and adults, and refusal to this procedure is an issue that is encountered worldwide with a refusal rate as low as 5% in the United States to 24.7% in Malaysia, and even much higher refusal rates are observed in Iran and Kuwait of about 62% and 80%, respectively [1,2]. The refusal rate varies with the cultural beliefs of a population and their knowledge about the procedure [1][2][3][4]. A study by Ahmad et al including 215 patients with indications for LP, of which 70 (32.6%) families refused LP for their children, revealed that the most common reason for the parental refusal to LP was fear of limb paralysis (64.2%), followed by fear of death (31.3%), while in 19.4% of the cases, the parents considered the procedure unnecessary [4].…”

“…The refusal rate varies with the cultural beliefs of a population and their knowledge about the procedure [1][2][3][4]. A study by Ahmad et al including 215 patients with indications for LP, of which 70 (32.6%) families refused LP for their children, revealed that the most common reason for the parental refusal to LP was fear of limb paralysis (64.2%), followed by fear of death (31.3%), while in 19.4% of the cases, the parents considered the procedure unnecessary [4].…”

Epidemiology of findings of lumbar puncture among pediatric patients

“…In the study of Khakshour et al, that examined 91 children admitted to Imam Reza Hospital in who underwent LP, 57.1% of the patients were male and 42.9% were female, which was consistent with the current study [ 7 ]. In the present study, most patients were in the age group of 8 weeks to 1 year (38.9%) and 1–3 years (25.5%).…”

Defeating Paediatric Tuberculous Meningitis: Applying the WHO “Defeating Meningitis by 2030: Global Roadmap”

“…This highlights the pivotal role of frontline clinicians in obtaining informed consent for the lumbar puncture as part of the routine diagnostic approach. Parental refusal to perform lumbar punctures in children with suspected central nervous system infection is common in low-middle income (LMIC) settings; a cross-sectional study of 215 families of Pakistani children who had indications for lumbar puncture showed that 33% refused [ 35 ]. Common reasons for refusal were lack of knowledge about the risks of the procedure (30%) and fear of paralysis of lower limbs (49%).…”