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Childhood Acute Illness and Nutrition (CHAIN) Network: a protocol for a multi-site prospective cohort study to identify modifiable risk factors for mortality among acutely ill children in Africa and Asia. BMJ Open 2019; 9:e028454. [PMID: 31061058 PMCID: PMC6502050 DOI: 10.1136/bmjopen-2018-028454] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Children admitted to hospitals in resource-poor settings remain at risk of both inpatient and post-discharge mortality. While known risk factors such as young age and nutritional status can identify children at risk, they do not provide clear mechanistic targets for intervention. The Childhood Acute Illness and Nutrition (CHAIN) cohort study aims to characterise the biomedical and social risk factors for mortality in acutely ill children in hospitals and after discharge to identify targeted interventions to reduce mortality. METHODS AND ANALYSIS The CHAIN network is currently undertaking a multi-site, prospective, observational cohort study, enrolling children aged 1 week to 2 years at admission to hospitals at nine sites located in four African and two South Asian countries. The CHAIN Network supports the sites to provide care according to national and international guidelines. Enrolment is stratified by anthropometric status and children are followed throughout hospitalisation and for 6 months after discharge. Detailed clinical, demographic, anthropometric, laboratory and social exposures are assessed. Scheduled visits are conducted at 45, 90 and 180 days after discharge. Blood, stool and rectal swabs are collected at enrolment, hospital discharge and follow-up. The primary outcome is inpatient or post-discharge death. Secondary outcomes include readmission to hospital and nutritional status after discharge. Cohort analysis will identify modifiable risks, children with distinct phenotypes, relationships between factors and mechanisms underlying poor outcomes that may be targets for intervention. A nested case-control study examining infectious, immunological, metabolic, nutritional and other biological factors will be undertaken. ETHICS AND DISSEMINATION This study protocol was reviewed and approved primarily by the Oxford Tropical Research Ethics Committee, and the institutional review boards of all partner sites. The study is being externally monitored. Results will be published in open access peer-reviewed scientific journals and presented to academic and policy stakeholders. TRIAL REGISTRATION NUMBER NCT03208725.
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Bhatnagar S, Kumar R, Dua R, Basu S, Kumar P. Outcome of Children with Severe Acute Malnutrition and Diarrhea: a Cohort Study. Pediatr Gastroenterol Hepatol Nutr 2019; 22:242-248. [PMID: 31110957 PMCID: PMC6506434 DOI: 10.5223/pghn.2019.22.3.242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/21/2018] [Accepted: 09/23/2018] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Severe acute malnutrition (SAM) is an important public health problem which contributes to significant number of under five deaths. Protocol based management significantly decreases risk of deaths in children with medical complications. METHODS Outcome of children aged 2 months-5 years admitted and fulfilling definition of SAM having diarrhea (group A) was compared to children with SAM having medical complications other than diarrhea (group B). Both groups were managed according to standard recommended protocols and monitored and followed up for 12 weeks after discharge. RESULTS The average weight gain, defaulter rate, primary failure, secondary relapse rate and readmission rate were similar in both groups. Length of stay in group A was three days longer (p-value=0.039). Discharge rate was comparable with overall 68% of children successfully discharged and 50% of children reaching weight/height >-2 standard deviation at follow-up of 12 weeks. CONCLUSION The current management protocol is equally effective for managing children with SAM having diarrhea. Good adherence to management protocol of dehydration and timely modification of therapeutic feeds in children with persistent diarrhea results in satisfactory weight gain.
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Affiliation(s)
- Sakshi Bhatnagar
- Department of Pediatrics, Kalawati Saran Children's Hospital associated Lady Hardinge Medical College, New Delhi, India
| | | | - Richa Dua
- National Nutritional Rehabilitation Resource and Training Centre (NNRRTC), Kalawati Saran Children's Hospital, New Delhi, India
| | - Srikanta Basu
- Department of Pediatrics, Kalawati Saran Children's Hospital associated Lady Hardinge Medical College, New Delhi, India
| | - Praveen Kumar
- Department of Pediatrics, Kalawati Saran Children's Hospital associated Lady Hardinge Medical College, New Delhi, India
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Risk factors for death among children 0-59 months of age with moderate-to-severe diarrhea in Manhiça district, southern Mozambique. BMC Infect Dis 2019; 19:322. [PMID: 30987589 PMCID: PMC6466733 DOI: 10.1186/s12879-019-3948-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 04/03/2019] [Indexed: 02/06/2023] Open
Abstract
Background Despite major improvements in child survival rates, the number of deaths due to diarrhea remains unacceptably high. We aimed to describe diarrhea-associated mortality and evaluate risk factors for death among Mozambican children with moderate-to-severe diarrhea (MSD). Methods Between December 2007 and November 2012, children under-five with MSD were enrolled in Manhiça district, as part of the Global Enteric Multicenter study (GEMS). Clinical, epidemiological, and socio-demographic characteristics were collected. Anthropometric measurements were performed and stool samples collected upon recruitment. A follow-up visit ~ 60 days post-enrolment was conducted and verbal autopsies performed in all death cases. Results Of the 916 MSD-cases analyzed; 90% (821/916) completed 60 days follow-up and 69 patients died. The case fatality rate at follow-up was 8% (69/821), and the mortality rate 10.2 (95%CI: 7.75–13.59) deaths per 1000 persons-week at risk. Nearly half of the deaths 48% (33/69) among study participants clustered within 2 weeks of the onset of diarrhea. Typical enteropathogenic Escherichia coli (typical EPEC) and Cryptosporidium were the two pathogens associated to an increased risk of death in the univariate analysis with (HR = 4.16, p = 0.0461) and (H = 2.84, p = 0.0001) respectively. Conversely, Rotavirus infection was associated to a decreased risk of death (HR = 0.52, p = 0.0198). According to the multivariate analysis, risk factors for death included co-morbidities such as malnutrition (HR = 4.13, p < 0.0001), pneumonia/lower respiratory infection (HR = 3.51, p < 0.0001) or invasive bacterial disease (IBD) (HR = 6.80, p = 0.0009), presenting on arrival with lethargy or overt unconsciousness (HR = 1.73, p = 0.0302) or wrinkled skin (HR = 1.71, p = 0.0393), and cryptosporidium infection (HR = 2.14, p = 0.0038). When restricting the analysis to those with available HIV results (n = 191, 22% of the total study sample), HIV was shown to be a significant risk factor for death (HR = 5.05, p = 0.0009). Verbal autopsies were conducted in 100% of study deaths, and highlighted diarrhea as the main underlying cause of death 39%, (27/69); followed by HIV/AIDS related deaths 29.0% (20/69) and sepsis 11.6% (8/69). Conclusion Preventive strategies targeting Cryptosporidium, malnutrition and early identification and treatment of associated co-morbidities could contribute to the prevention of the majority of diarrhea associated deaths in Mozambican children. Electronic supplementary material The online version of this article (10.1186/s12879-019-3948-9) contains supplementary material, which is available to authorized users.
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Survival Status and Its Determinants among Under-Five Children with Severe Acute Malnutrition Admitted to Inpatient Therapeutic Feeding Centers in South Wollo Zone, Amhara Region, Ethiopia. J Nutr Metab 2019; 2019:2643531. [PMID: 31049224 PMCID: PMC6462333 DOI: 10.1155/2019/2643531] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/08/2019] [Accepted: 03/13/2019] [Indexed: 11/18/2022] Open
Abstract
Background Under nutrition is one of the leading causes of morbidity and mortality in under-five children in developing countries including Ethiopia. In Ethiopia, many children with severe acute malnutrition (SAM) are treated at inpatient therapeutic feeding centers. However, the survival status and its determinants are not well understood. Therefore, the aim of this study was to estimate the survival status and its determinants among under-five children with severe acute malnutrition admitted to inpatient therapeutic feeding centers (ITFCs). Methods A record review was conducted on 414 under-five children who were admitted with severe acute malnutrition to ITFCs in South Wollo Zone, northeast Ethiopia, between September 11, 2014, and January 9, 2016. Data were entered into Epi-Info version 7.2 and analyzed using SPSS version 20. Life table analysis was used to estimate cumulative proportion of survival. The relationship between time to recovery and covariates was determined using Cox-proportional hazards regression model. p < 0.05 was used to declare presence of significant association between recovery time and covariates. Results Of the total children recorded, 75.4% of children were recovered and discharged, 10.3% were defaulters, 3.4% died, 7.4% were nonresponders, and 3.4% were unknown. The mean (±standard deviation) time to recovery was 12 (±5.26) days, whereas the median time to recovery was 11 (interquartile range of 8–15) days. Children's breastfeeding status at admission (AHR: 1.42, 95% CI: 1.10, 1.83) and children without comorbidities at admission (AHR: 1.44, 95% CI: 1.03, 2.00) had statistically significant effect on time to recovery from SAM. Conclusion All treatment responses in this study were within the recommended and acceptable range of global standards. Policy makers, health facilities, and care providers may need to focus on the importance of breastfeeding especially for those under two years of age and give emphasis for cases with comorbidities.
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Mohseni M, Aryankhesal A, Kalantari N. Prevention of malnutrition among children under 5 years old in Iran: A policy analysis. PLoS One 2019; 14:e0213136. [PMID: 30845189 PMCID: PMC6405113 DOI: 10.1371/journal.pone.0213136] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/18/2019] [Indexed: 11/28/2022] Open
Abstract
Background Malnutrition is one of the main causes of death in children under 5 years of age and one of the most common factors threatening children’s life and health. Nutrition policy analysis and solving existing problems in children can reduce the effects of malnutrition. This study aimed to analyze the current policies of malnutrition prevention in children under five years of age in Iran. Method This study was conducted in 2017 to analyze policies using the "policy triangle framework". In order to examine the policy-making process, the Kingdon’s multiple streams model was used. A combination of two sampling methods, including purposeful and snowball sampling, was applied to select the interviewees. In relation to the implemented documents and policies, the country’s most important policies were selected based on the suggestions of policy makers as well as searching scientific databases and electronic portals. A data collection form was used to identify the current policies and documents and a semi-structured interview guide form was used for the interviews. The framework analysis and MaxQDA software were applied to analyze the data obtained from the interviews. Results The key factors affecting policies in Iran included the status of indicators as well as economic, social, structural-legal, policy and international factors. Among the most important policies and implemented programs, the following can be mentioned: growth monitoring, oral rehydration, breastfeeding, immunization, female education, family spacing, food supplementation, nutrition for children under five years of age, and control of nutritional deficiencies. Currently there is a need for a nationwide program and comprehensive document in the field of the nutrition in children under 5 years of age, which requires strengthening of the political process. Participants and stakeholders in nutrition-related policies for children under the age of five were divided into four categories of governmental, semi-governmental, non-governmental, and international organizations. Conclusion More attention should be paid to the shortage of some micronutrients, accurate implementation of breastfeeding programs, supplementary nutrition, fortification and supplementation programs for children and mothers, utilization of the advantages of each region and its resources, and better coordination between organizations and their policies, and finally strong incentives are needed to promote macro nutritional goals for children under five years of age.
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Affiliation(s)
- Mohammad Mohseni
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aidin Aryankhesal
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
- * E-mail:
| | - Naser Kalantari
- Department of Community Nutrition, Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ngari MM, Iversen PO, Thitiri J, Mwalekwa L, Timbwa M, Fegan GW, Berkley JA. Linear growth following complicated severe malnutrition: 1-year follow-up cohort of Kenyan children. Arch Dis Child 2019; 104:229-235. [PMID: 30266874 PMCID: PMC6556974 DOI: 10.1136/archdischild-2018-315641] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/03/2018] [Accepted: 09/05/2018] [Indexed: 12/04/2022]
Abstract
BACKGROUND Stunting is the most common manifestation of childhood undernutrition worldwide. Children presenting with severe acute malnutrition (SAM) are often also severely stunted. We evaluated linear growth and its determinants after medically complicated SAM. METHODS We performed secondary analysis of clinical trial data (NCT00934492) from HIV-uninfected Kenyan children aged 2-59 months hospitalised with SAM. Outcome was change in height/length-for-age z-score (HAZ) between enrolment and 12 months later. Exposures were demographic, clinical, anthropometric characteristics and illness episodes during follow-up. RESULTS Among 1169 children with HAZ values at month 12 (66% of those in original trial), median (IQR) age 11 (7-17) months and mean (SD) HAZ -2.87 (1.6) at enrolment, there was no change in mean HAZ between enrolment and month 12: -0.006Z (95% CI -0.07 to 0.05Z). While 262 (23%) children experienced minimal HAZ change (within ±0.25 HAZ), 472 (40%) lost >0.25 and 435 (37%) gained >0.25 HAZ. After adjusting for regression to the mean, inpatient or outpatient episodes of diarrhoea and inpatient severe pneumonia during follow-up were associated with HAZ loss. Premature birth and not being cared by the biological parent were associated with HAZ gain. Increases in mid-upper arm circumference and weight-for-age were associated with HAZ gain and protected against HAZ loss. Increase in weight-for-height was not associated with HAZ gain but protected against HAZ loss. No threshold of weight gain preceding linear catch-up growth was observed. CONCLUSIONS Interventions to improve dietary quality and prevent illness over a longer period may provide opportunities to improve linear growth.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Oslo, Norway,Department of Hematology, Oslo University Hospital, Oslo, Norway,Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Johnstone Thitiri
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | | | - Molline Timbwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Greg W Fegan
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - James Alexander Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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Brent B, Obonyo N, Akech S, Shebbe M, Mpoya A, Mturi N, Berkley JA, Tulloh RMR, Maitland K. Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study. JAMA Netw Open 2019; 2:e191054. [PMID: 30901050 PMCID: PMC6583281 DOI: 10.1001/jamanetworkopen.2019.1054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/04/2019] [Indexed: 01/14/2023] Open
Abstract
Importance Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited. Objective To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM). Design, Setting, and Participants A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016. Exposures Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28. Main Outcomes and Measures Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared. Results Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities. Conclusions and Relevance There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.
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Affiliation(s)
- Bernadette Brent
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Imperial College, London, United Kingdom
| | - Nchafatso Obonyo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Samuel Akech
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Mohammed Shebbe
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Ayub Mpoya
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Neema Mturi
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - James A. Berkley
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Kathryn Maitland
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Imperial College, London, United Kingdom
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Hypoallergenic and anti-inflammatory feeds in children with complicated severe acute malnutrition: an open randomised controlled 3-arm intervention trial in Malawi. Sci Rep 2019; 9:2304. [PMID: 30783173 PMCID: PMC6381085 DOI: 10.1038/s41598-019-38690-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/11/2018] [Indexed: 12/18/2022] Open
Abstract
Intestinal pathology in children with complicated severe acute malnutrition (SAM) persists despite standard management. Given the similarity with intestinal pathology in non-IgE mediated gastrointestinal food allergy and Crohn’s disease, we tested whether therapeutic feeds effective in treating these conditions may benefit children with complicated SAM. After initial clinical stabilisation, 95 children aged 6–23 months admitted at Queen Elizabeth Central Hospital, Blantyre, Malawi between January 1st and December 31st, 2016 were allocated randomly to either standard feeds, an elemental feed or a polymeric feed for 14 days. Change in faecal calprotectin as a marker of intestinal inflammation and the primary outcome was similar in each arm: elemental vs. standard 4.1 μg/mg stool/day (95% CI, −29.9, 38.15; P = 0.81) and polymeric vs. standard 10 (−23.96, 43.91; P = 0.56). Biomarkers of intestinal and systemic inflammation and mucosal integrity were highly abnormal in most children at baseline and abnormal values persisted in all three arms. The enteropathy in complicated SAM did not respond to either standard feeds or alternative therapeutic feeds administered for up to 14 days. A better understanding of the pathogenesis of the gut pathology in complicated SAM is an urgent priority to inform the development of improved therapeutic interventions.
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Bandsma RHJ, Voskuijl W, Chimwezi E, Fegan G, Briend A, Thitiri J, Ngari M, Mwalekwa L, Bandika V, Ali R, Hamid F, Owor B, Mturi N, Potani I, Allubha B, Muller Kobold AC, Bartels RH, Versloot CJ, Feenstra M, van den Brink DA, van Rheenen PF, Kerac M, Bourdon C, Berkley JA. A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial. PLoS Med 2019; 16:e1002747. [PMID: 30807589 PMCID: PMC6390989 DOI: 10.1371/journal.pmed.1002747] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 01/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase. METHODS AND FINDINGS In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite. CONCLUSIONS Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM. TRIAL REGISTRATION ClinicalTrials.gov NCT02246296.
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Affiliation(s)
- Robert H. J. Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutrition Sciences, University of Toronto, Toronto, Canada
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Greg Fegan
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
- University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Victor Bandika
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Betty Owor
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Benjamin Allubha
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anneke C. Muller Kobold
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Rosalie H. Bartels
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Christian J. Versloot
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marjon Feenstra
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Deborah A. van den Brink
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Patrick F. van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marko Kerac
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - James A. Berkley
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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Abstract
BACKGROUND Persistent diarrhoea (PD), defined as diarrhoeal symptoms for longer than 2 weeks, still forms a substantial disease burden in children under 5 years of age. This article provides an overview of the current knowledge of PD and discusses novel concepts. METHODS A literature search on PD was performed which focused on evidence on epidemiology, pathophysiology and management of the disease. RESULTS The prevalence of PD has potentially decreased over the last decades. Debate remains around the role of specific bacterial, viral and parasitic infections with PD. PD is associated with malnutrition and a compromised immune system, including that caused by HIV infection. Management includes fluid resuscitation and improving nutritional status. There is a lack of evidence on the use of antibiotic therapy for PD. There is increasing interest in nutrient-based interventions, including pre- and/or probiotics that can modify the microbiome and thereby potentially prevent or improve the outcome of PD in children. CONCLUSION As PD remains a significant health burden, multicentre clinical trials are needed to inform future treatment guidelines. ABBREVIATIONS PD, persistent diarrhoea; EED, environmental enteric dysfunction; IBD, inflammatory bowel disease; WHO, World Health Organization.
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Affiliation(s)
- Robert H J Bandsma
- a Division of Gastroenterology, Hepatology and Nutrition , Hospital for Sick Children , Toronto , Canada.,b Translational Medicine Program, Hospital for Sick Children , Toronto , Canada.,c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada
| | - Kamran Sadiq
- e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
| | - Zulfiqar A Bhutta
- c Centre for Global Child Health, Hospital for Sick Children , Toronto , Canada.,d Department of Nutrition Sciences , University of Toronto , Toronto , Canada.,e Department of Paediatrics and Child Health , Aga Khan University , Karachi , Pakistan
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61
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Teshome G, Bosha T, Gebremedhin S. Time-to-recovery from severe acute malnutrition in children 6-59 months of age enrolled in the outpatient treatment program in Shebedino, Southern Ethiopia: a prospective cohort study. BMC Pediatr 2019; 19:33. [PMID: 30691437 PMCID: PMC6348627 DOI: 10.1186/s12887-019-1407-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/17/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In Ethiopia uncomplicated severe acute malnutrition (SAM) is managed at health posts level through the outpatient therapeutic program (OTP). Yet, evidence on the treatment success rate of the program is scarce. This study determines the treatment outcomes and predictors of time-to-recovery among children 6-59 months of age with SAM managed at the health posts level in Shebedino district, Southern Ethiopia. METHODS This was a prospective cohort study that enrolled 216 children with SAM identified through a campaign conducted in May 2015 and treated over eight weeks at 25 health posts of the district. The average time-to-recovery was estimated using Kaplan-Meier survival curve and the independent predictors of the recovery were determined using multivariable Cox-proportional hazard model. The outputs of the analyses are presented via adjusted hazard ratio with 95% confidence intervals (AHR, CI). RESULTS At the end of the eight weeks of treatment 79.6% (95% CI: 74.2-85.0%) of cases recovered from SAM with a weight gain rate of 5.4 g/kg/day. The median time-to-recover was 36 days. The analysis indicated, maternal illiteracy (0.54, 0.38-0.78), severe household food insecurity (0.47, 0.28-0.79), walking for more than 1 h to receive the treatment (0.69, 0.50-0.96), diarrhoea co-morbidity (0.63, 0.42-0.91) and practicing sharing of ready to use therapeutic food (RUTF) (0.53, 0.32-0.88) were associated with slower propensity of recovery from SAM. Children who were enrolled with marasmus diagnosis showed lower recovery than children with kwashiorkor (0.30, 0.18-0.51). CONCLUSION The median time-to-recover was 36 days. Discouraging sharing of RUTF, appropriate management of diarrhoea in SAM cases and improving access to OTP sites can help to improve the treatment outcome for SAM.
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Affiliation(s)
- Genene Teshome
- Regional Health Bureau, Southern Nations, Nationalities and People’s Region, Hawassa city, Ethiopia
| | - Tafese Bosha
- School of Nutrition, Food Science and Technology, Hawassa University, Hawassa city, Ethiopia
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Kara SS, Volkan B, Erten I. Lactobacillus rhamnosus GG can protect malnourished children. Benef Microbes 2019; 10:237-244. [PMID: 30638398 DOI: 10.3920/bm2018.0071] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Malnutrition affects virtually all organ systems, and malnourished children are more prone to infections. These children have dysbiosis, but probiotics can restore the disrupted gut microbiome. We investigated the protective effects of Lactobacillus rhamnosus GG in malnourished children in terms of incidence of infection, and anthropometric and metabolic parameters. 50 intervention and 50 control patients, aged 6 months to 5 years, with body weight and height below -2 SD, were randomly and prospectively recruited. The controls received a calorie and protein-appropriate diet for 3 months, while the study group additionally received approximately 109 L. rhamnosus GG for 3 months. Infection episodes and nutritional status were compared between the groups. 38 intervention, 33 control patients completed the study and the two groups were similar at baseline. The study group had fewer upper respiratory tract infections and gastroenteritis episodes at each month and at the end of the study. Children in the study group experienced fewer total upper respiratory infections and urinary tract infections. Hospitalisation was more frequent in the control group during the third month and at the end of the study. Total infection numbers were higher in the control group at each month and at the end of the study (P<0.001 for each). Increments in body mass index (BMI) and BMI Z-scores were more pronounced in the study group (P=0.008 and P=0.02, respectively). Daily prophylactic use of L. rhamnosus GG at 109 bacteria in malnourished children prevents most infections and improves nutritional status when used together with appropriate diet.
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Affiliation(s)
- S S Kara
- 1 Department of Pediatric Infectious Diseases, Regional Training and Research Hospital, 25280 Erzurum, Turkey
| | - B Volkan
- 2 Department of Pediatric Gastroenterology, Regional Training and Research Hospital, 25280 Erzurum, Turkey
| | - I Erten
- 3 Department of Pediatrics, Regional Training and Research Hospital, 25280 Erzurum, Turkey
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63
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Alasad SMS, Salih OAM, Hassan M. Insight into potassium's role in childhood mortality due to severe acute malnutrition. Sudan J Paediatr 2019; 19:44-51. [PMID: 31384088 PMCID: PMC6589795 DOI: 10.24911/sjp.106-1513711620] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 05/08/2019] [Indexed: 11/11/2022]
Abstract
Hypokalaemia is associated with an increase in mortality in children with severe acute malnutrition (SAM) and diarrhoea. This is a descriptive cross-sectional retrospective study conducted in the Nutritional Ward at Mohamed Alamin Hamid Pediatrics Hospital in Omdurman, Sudan. It aimed to assess the frequency of hypokalaemia among children with SAM to understand the influence of hypokalaemia and potassium supplementations contributed on the children survival rates (January-December 2015). It included 215 patients with SAM and acute diarrhoea. The potassium levels of all the patients were assessed upon hospital admission and this correlated with the mortality according to the degree of hypokalaemia and treatment initiated. Hypokalaemia was evident in 70.2% of the patients. Mortality was 3.1% in normokalaemic and 13.9% in hypokalaemic patients. The patients' survival was significantly associated with their serum potassium levels and the treatment received. The survival rates have been assessed via the Multinomial Logistic Model, which reveals that normokalaemic children had a chance of 157.349 (95% confidence interval 18.479-1,339.811) times higher than that compared to the baseline children with advanced hypokalaemia with serum levels <2 mEq/l (p-value < 0.001). Children with mild hypokalaemia within the serum levels of 3.0-3.4 mEq/ml showed an increased survival chance of 549.970 (95% CI 19.293-3,238.716) times compared to the baseline children (p-value = 0.000). In patients with SAM, who presented with acute diarrhoea, there was an increase in mortality in patients with hypokalaemia compared with patients who presented with normal potassium levels. Corresponding mortality rates increased significantly with the severity of hypokalaemia. In severe hypokalaemia, there is a significant difference in mortality between patients treated with oral rehydration solutions for malnutrition in relation to patients treated with oral potassium supplements or with intravenous potassium.
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Affiliation(s)
- Sumia M. S. Alasad
- Departments of Pediatrics, Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan
- Mohammed A Hamid’s Pediatrics Hospital, Omdurman, Sudan
| | - Omaima Abdelmajeed Mohamed Salih
- Departments of Pediatrics, Faculty of Medicine, Omdurman Islamic University, Omdurman, Sudan
- Mohammed A Hamid’s Pediatrics Hospital, Omdurman, Sudan
| | - Mahmoud Hassan
- Swiss Tropical and Public Health Institute and University of Basel, Socinstrasse 59, 4001 Basel CH
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Walsh K, Calder N, Olupot-Olupot P, Ssenyondo T, Okiror W, Okalebo CB, Muhindo R, Mpoya A, Holmes E, Marchesi J, Delamare de la Villenaise de Chenevarin G, Frost G, Maitland K. Modifying Intestinal Integrity and Micro Biome in Severe Malnutrition with Legume-Based Feeds (MIMBLE 2.0): protocol for a phase II refined feed and intervention trial. Wellcome Open Res 2018; 3:95. [PMID: 30345381 PMCID: PMC6171552 DOI: 10.12688/wellcomeopenres.14706.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 11/21/2022] Open
Abstract
Background: Changes in intestinal mucosal integrity and gut microbial balance occur in severe acute malnutrition (SAM), resulting in treatment failure and adverse clinical outcomes (gram-negative sepsis, diarrhoea and high case-fatality). Transient lactose intolerance, due to loss of intestinal brush border lactase, also complicates SAM, thus milk based feeds may not be optimal for nutritional rehabilitation. Since the gut epithelial barrier can be supported by short chain fatty acids, derived from microbiota fermentation by particular fermentable carbohydrates, we postulated that an energy-dense nutritional feed comprising of legume-based fermentable carbohydrates, incorporated with lactose-free versions of standard World Health Organization (WHO) F75/F100 nutritional feeds will enhance epithelial barrier function in malnourished children, reduce and promote resolution of diarrhoea and improve overall outcome. Methods: We will investigate in an open-label trial in 160 Ugandan children with SAM, defined by mid-upper arm circumference <11.5cm and/or presence of kwashiorkor. Children will be randomised to a lactose-free, chickpea-enriched feed containing 2 kcal/ml, provided in quantities to match usual energy provision (experimental) or WHO standard treatment F75 (0.75 kcal/ml) and F100 (1 kcal/ml) feeds on a 1:1 basis, conducted at Mbale Regional Referral Hospital nutritional rehabilitation unit. The primary outcomes are change in MUAC at day 90 and survival to day 90. Secondary outcomes include: i) moderate to good weight gain (>5 g/kg/day), ii)
de novo development of diarrhoea (>3 loose stools/day), iii) time to diarrhoea resolution (if >3 loose stools/day), and iv) time to oedema resolution (if kwashiorkor) and change in intestinal biomarkers (faecal calprotectin). Discussion: We hypothesize that, if introduced early in the management of malnutrition, such lactose-free, fermentable carbohydrate-based feeds, could safely and cheaply improve global outcome by reducing lactose intolerance-related diarrhoea, improving mucosal integrity and enhancing immunity, and limiting the risk of systemic infection and associated broad-spectrum antibiotic resistance. Registration:ISRCTN 10309022.
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Affiliation(s)
- Kevin Walsh
- Department of Paediatrics, Imperial College, London, W2 1PG, UK.,Section for Nutrition Research, Department of Medicine, Imperial College, London, W12 ONN, UK
| | - Nuala Calder
- Department of Paediatrics, Imperial College, London, W2 1PG, UK
| | - Peter Olupot-Olupot
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, PO Box 1966, Uganda.,Mbale Clinical Research Institute, Mbale, PO Box 1966, Uganda
| | - Tonny Ssenyondo
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, PO Box 1966, Uganda.,Mbale Clinical Research Institute, Mbale, PO Box 1966, Uganda
| | - William Okiror
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, PO Box 1966, Uganda.,Mbale Clinical Research Institute, Mbale, PO Box 1966, Uganda
| | - Charles Bernard Okalebo
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, PO Box 1966, Uganda.,Mbale Clinical Research Institute, Mbale, PO Box 1966, Uganda
| | - Rita Muhindo
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, PO Box 1966, Uganda.,Mbale Clinical Research Institute, Mbale, PO Box 1966, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Elaine Holmes
- Division of Computational and Systems Medicine, Imperial College, London, SW7 2AZ, UK
| | - Julian Marchesi
- Centre for Digestive and Gut Health, Imperial College, London, W2 1NY, UK
| | | | - Gary Frost
- Section for Nutrition Research, Department of Medicine, Imperial College, London, W12 ONN, UK
| | - Kathryn Maitland
- Department of Paediatrics, Imperial College, London, W2 1PG, UK.,Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
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65
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Predictors of mortality among hospitalized children with severe acute malnutrition: a prospective study from Uganda. Pediatr Res 2018; 84:92-98. [PMID: 29795207 DOI: 10.1038/s41390-018-0016-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND We determined the predictors of mortality among children admitted with severe acute malnutrition (SAM). METHODS This was a prospective study nested in a randomized trial among 6-59-month-old children admitted with SAM. Socio-demographic and medical history data were collected using questionnaires and clinical examination, anthropometry and laboratory tests were performed. They were monitored daily until discharge or death during hospitalization while receiving care according to national guidelines. Predictors of death were assessed using Cox regression. RESULTS Of 400 children, 9.8% (n = 39) died during hospitalization. Predictors of mortality included diarrhoea at admission [hazard ratio [HR] 2.19, 95% confidence interval (CI): 1.06; 4.51], lack of appetite [HR 4.50, 95% CI: 1.76; 11.50], suspected sepsis [HR 2.23, 95% CI: 1.18; 4.24] and skin ulcers [HR 4.23, 95% CI: 1.26; 4.17]. Chest indrawing [HR 5.0, 95% CI: 1.53; 16.3], oxygen saturation below 94% [HR 3.92, 95% CI: 1.42; 10.83] and confirmed HIV infection [HR 3.62, 95% CI: 1.69; 7.77] also predicted higher mortality. CONCLUSION Infections were major contributors to mortality. This underscores the need for improved prevention and management of these infections among children with severe malnutrition.
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66
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Tsukano K, Sarashina S, Suzuki K. Hypoglycemia and failure of respiratory compensation are risk factors for mortality in diarrheic calves in Hokkaido, northern Japan. J Vet Med Sci 2018; 80:1159-1164. [PMID: 29863028 PMCID: PMC6068301 DOI: 10.1292/jvms.18-0109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
The aim of present study was to identify risk factors among laboratory findings for mortality in calves with diarrhea. A retrospective analysis was conducted utilizing medical records of
221 diarrheic calves (10.4 ± 3.7 days old) with no concurrent severe disorders that were treated with intravenous fluid therapy from the initial examination. Thirty-eight of the diarrheic
calves (17.2%) died within 35 days from the initial examination. Multivariate logistic regression analysis indicated that hypoglycemia (OR 3.09; 95% CI 1.22–7.87; P=0.02)
and failure of respiratory compensation (OR 2.63; 95% CI 1.05–6.62; P=0.04) were the major risk factors associated with a negative outcome in diarrheic calves. According to
the Kaplan-Meyer analysis, diarrheic calves with hypoglycemia and/or failure of respiratory compensation had a significantly shorter survival than calves without these factors.
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Affiliation(s)
- Kenji Tsukano
- School of Veterinary Medicine, Rakuno Gakuen University, 582 Midorimachi, Bunkyodai, Ebetsu, Hokkaido 069-8501, Japan.,Minami-Hokkaido Agricultural Mutual Relief Association, 74-2 Higashimae, Hokuto, Hokkaido 041-1214, Japan
| | - Shinya Sarashina
- Minami-Hokkaido Agricultural Mutual Relief Association, 25-16 Misugicho, Yakumo, Futami-gun, Hokkaido 049-3114, Japan
| | - Kazuyuki Suzuki
- School of Veterinary Medicine, Rakuno Gakuen University, 582 Midorimachi, Bunkyodai, Ebetsu, Hokkaido 069-8501, Japan
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67
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Sand A, Kumar R, Shaikh BT, Somrongthong R, Hafeez A, Rai D. Determinants of severe acute malnutrition among children under five years in a rural remote setting: A hospital based study from district Tharparkar-Sindh, Pakistan. Pak J Med Sci 2018; 34:260-265. [PMID: 29805390 PMCID: PMC5954361 DOI: 10.12669/pjms.342.14977] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: To understand and catalogue the specific determinants of this alarming rate of malnutrition among children of Tharparkar district, Sindh Pakistan. Methods: This was a hospital based analytical survey. Data was collected through a semi-structured questionnaire by interviewing mothers of the children (age 6-59 months), admitted in the hospital. Following WHO guidelines, weight and length/ height of 105 children were recorded. Study was conducted in District Headquarters Hospital, Tharparkar district of Sindh province. Results: Almost 48% children admitted in the hospital were identified with severe acute malnutrition. More males (55%) were malnourished as compared to females (45%). Maternal education, household income, family size, breastfeeding, vaccination status, and frequent infections were found to be significantly associated with the severe acute malnutrition. Conclusion: Specific interventions on promoting exclusive breastfeeding, vaccination, and timely health care seeking behaviors would definitely improve the outcomes. Nevertheless, sector wide approaches would be needed on girls’ education, poverty, and food security in the district in order to address the issue of malnutrition.
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Affiliation(s)
- Aurangzeb Sand
- Aurangzeb Sand, Health Services Academy, Islamabad, Pakistan. Taluka Hospital, Nagarparkar, Sindh, Pakistan
| | - Ramesh Kumar
- Ramesh Kumar, MBBS, MBA, MPH, PhD. Assistant Professor, Health Services Academy, Islamabad, Pakistan
| | - Babar T Shaikh
- Babar T Shaikh, Health Services Academy, Islamabad, Pakistan
| | - Ratana Somrongthong
- Ratana Somrongthong, College of Public Health Sciences, Chulalongkorn University Thailand
| | - Assad Hafeez
- Assad Hafeez, Health Services Academy, Islamabad, Pakistan
| | - Dalpat Rai
- Dalpat Rai, Taluka Hospital, Nagarparkar, Sindh, Pakistan
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68
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Intestinal pathogen clearance in children with severe acute malnutrition is unrelated to inpatient morbidity. Clin Nutr ESPEN 2018; 24:109-113. [DOI: 10.1016/j.clnesp.2018.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 09/20/2017] [Accepted: 01/09/2018] [Indexed: 01/11/2023]
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69
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Prevalence of Malnutrition Among Iran’s Under Five-Year-Old Children and the Related Factors: A Systematic Review and Meta-Analysis. IRANIAN JOURNAL OF PEDIATRICS 2018. [DOI: 10.5812/ijp.9189] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
OBJECTIVE The relation between malnutrition and exocrine pancreatic insufficiency (EPI) has been described previously, but it is unclear if malnutrition leads to EPI or vice versa. We systematically synthesized current evidence evaluating the association between malnutrition and EPI in children. METHODS Pubmed, Embase, and Cochrane databases were searched from inception until February 2017. We included cohort or case-controlled studies in children reporting on prevalence or incidence of EPI and malnutrition. Data generation was performed independently by 2 authors. Quality was assessed by using quality assessment tools from the National Heart, Lung, and Blood Institute. RESULTS Nineteen studies were divided into 2 groups: 10 studies showing EPI leading to malnutrition, and 9 studies showing malnutrition leading to EPI. Because of heterogeneity in design, definitions, and outcome measures, pooling of results was impossible. Quality was good in 4 of 19 studies. Pancreatic insufficiency was linked to decreased nutritional status in 8 of 10 articles, although this link was not specified properly in most articles. In malnourished children, improvement was seen in pancreatic function in 7 of 9 articles after nutritional rehabilitation. The link between the 2 was not further specified. Heterogeneity exists with respect to definitions, outcome measures, and study design. CONCLUSIONS There is sufficient evidence for an association between EPI and malnutrition. We could not confirm whether there is a correlation or causality between EPI or malnutrition. It was therefore not possible to draw firm conclusions from this systematic review on underlying pathophysiological mechanisms between EPI and malnutrition. More observational clinical trials are crucially needed.
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71
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Muggleton ER. Variability of response to the fluid bolus is again demonstrated. Crit Care 2017; 21:224. [PMID: 28841889 PMCID: PMC5574114 DOI: 10.1186/s13054-017-1793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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72
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Bartels RH, Bourdon C, Potani I, Mhango B, van den Brink DA, Mponda JS, Muller Kobold AC, Bandsma RH, Boele van Hensbroek M, Voskuijl WP. Pancreatic Enzyme Replacement Therapy in Children with Severe Acute Malnutrition: A Randomized Controlled Trial. J Pediatr 2017; 190:85-92.e2. [PMID: 28912050 DOI: 10.1016/j.jpeds.2017.07.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 05/26/2017] [Accepted: 07/07/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To assess the benefits of pancreatic enzyme replacement therapy (PERT) in children with complicated severe acute malnutrition. STUDY DESIGN We conducted a randomized, controlled trial in 90 children aged 6-60 months with complicated severe acute malnutrition at the Queen Elizabeth Central Hospital in Malawi. All children received standard care; the intervention group also received PERT for 28 days. RESULTS Children treated with PERT for 28 days did not gain more weight than controls (13.7 ± 9.0% in controls vs 15.3 ± 11.3% in PERT; P = .56). Exocrine pancreatic insufficiency was present in 83.1% of patients on admission and fecal elastase-1 levels increased during hospitalization mostly seen in children with nonedematous severe acute malnutrition (P <.01). Although the study was not powered to detect differences in mortality, mortality was significantly lower in the intervention group treated with pancreatic enzymes (18.6% vs 37.8%; P < .05). Children who died had low fecal fatty acid split ratios at admission. Exocrine pancreatic insufficiency was not improved by PERT, but children receiving PERT were more likely to be discharged with every passing day (P = .02) compared with controls. CONCLUSIONS PERT does not improve weight gain in severely malnourished children but does increase the rate of hospital discharge. Mortality was lower in patients on PERT, a finding that needs to be investigated in a larger cohort with stratification for edematous and nonedematous malnutrition. Mortality in severe acute malnutrition is associated with markers of poor digestive function. TRIAL REGISTRATION ISRCTN.com: 57423639.
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Affiliation(s)
- Rosalie H Bartels
- Global Child Health Group, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Céline Bourdon
- Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Isabel Potani
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Brian Mhango
- Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Deborah A van den Brink
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - John S Mponda
- Department of Pharmacy, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anneke C Muller Kobold
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Robert H Bandsma
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Wieger P Voskuijl
- Global Child Health Group, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2:66. [PMID: 29090271 PMCID: PMC5657219 DOI: 10.12688/wellcomeopenres.12357.3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18
th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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74
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2:66. [PMID: 29090271 PMCID: PMC5657219 DOI: 10.12688/wellcomeopenres.12357.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 07/13/2024] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines.
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Affiliation(s)
- Kirsty A. Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G. Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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75
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House DR, Cheptinga P, Rusyniak DE, Vreeman RC. Qualitative study of healthcare providers' current practice patterns and barriers to successful rehydration for pediatric diarrheal illnesses in Kenya. PeerJ 2017; 5:e3829. [PMID: 29018599 PMCID: PMC5633020 DOI: 10.7717/peerj.3829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/28/2017] [Indexed: 11/20/2022] Open
Abstract
Background For children worldwide, diarrhea is the second leading cause of death. These deaths are preventable by fluid resuscitation. Nasogastric tubes (NGs) have been shown to be equivalent to intravenous fluids for rehydration and recommended by the World Health Organization (WHO) for use in severe dehydration. Despite this, NGs are rarely used for rehydration in Kenya. Our objective was to evaluate clinicians’ adherence to rehydration guidelines and to identify barriers to the use of NGs for resuscitating dehydrated children. Methods A case-based structured survey was administered to pediatric care providers in western Kenya to determine their choices for alternative rehydration therapies when oral rehydration and intravenous fluids fail. Providers then participated in a qualitative, semi-structured interview to identify barriers to using nasogastric tubes for rehydration. Analysis included manual, progressive coding of interview transcripts to identify emerging central themes. Results Of 44 participants, only four (9%) followed WHO guidelines that recommend quickly switching to NG for rehydration in their case responses. Participants identified that placing intravenous lines in dehydrated children is a challenge. However, when discussing NG use, many believed NGs are not effective for rehydration. Other participants’ concerns surrounded knowledge and training regarding guidelines as well as not having NGs available. Discussion Healthcare providers in western Kenya do not report using NGs for rehydration in accordance with WHO guidelines for diarrheal illness with severe dehydration. Barriers to the use of NG tubes were lack of knowledge and availability. Education and implementation of guidelines using NG tubes for rehydration may improve outcomes of children suffering from diarrheal illness with severe dehydration.
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Affiliation(s)
- Darlene R House
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America.,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Philip Cheptinga
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Paediatrics, Moi University School of Medicine, Eldoret, Kenya
| | - Daniel E Rusyniak
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, United States of America
| | - Rachel C Vreeman
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States of America
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017. [DOI: 10.12688/wellcomeopenres.12357.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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78
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Hajare ST, Bekele G. Effect of probiotic strain Lactobacillus acidophilus (LBKV-3) on fecal residual lactase activity in undernourished children below 10 years. J Immunoassay Immunochem 2017; 38:620-628. [PMID: 28853996 DOI: 10.1080/15321819.2017.1372475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Clinically proven Lactobacillus acidophilus strain LBKV-3 intended as probiotic for humans was used to test its effect on fecal residual lactase activity in undernourished children below 10 years of age. The children were selected from malnutrition-declared area of Maharashtra (India). One of the major causes of malnutrition is lactose intolerance which leads to diarrhea. The basic consideration in selecting the probiotic strain of L. acidophilus (LBKV-3) in this investigation was the fact that the organism is isolated from human vaginal surface swab and it was found extensively studied for probiotic characteristic. LBKB3 is tested by several workers as probiotic for hypocholesterolemic activity, implantation ability, therapeutic effects on gastrointestinal (GI) and related ailments. The results of present investigation have shown that the fecal residual lactase activity significantly increased than its initial value (which was almost zero). It appeared that the fecal residual β-galactosidase activity is an indication of positive implementation abilities of the cultures under investigation. These trends were compared with the control and blank group of children receiving Dahi and buffalo milk (BM). It was observed that both these products failed to exert any significant impact on increase in residual lactase activity.
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Affiliation(s)
| | - Genene Bekele
- a Dilla University, Biotechnology , Dilla University , Dilla , Ethiopia
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79
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Houston KA, Gibb JG, Maitland K. Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review. Wellcome Open Res 2017; 2:65. [PMID: 28944301 PMCID: PMC5590082 DOI: 10.12688/wellcomeopenres.12346.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 12/11/2022] Open
Abstract
Background: Rehydration strategies in children with severe acute malnutrition (SAM) and severe dehydration are extremely cautious. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Otherwise, guidelines recommend oral or nasogastric rehydration using low sodium oral rehydration solutions. There is limited evidence to support these recommendations. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15
th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, specifically relating to intravenous rehydration, using standard search terms. Two authors assessed papers for inclusion. The primary endpoint was evidence of fluid overload. Results: Four studies were identified, all published in English, including 883 children, all of which were conducted in low resource settings. Two were randomised controlled trials and two observational cohort studies, one incorporated assessment of myocardial and haemodynamic function. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. Mortality was high overall, and particularly in children with shock managed on WHO recommendations (day-28 mortality 82%). There was no difference in safety outcomes when different rates of intravenous rehydration were compared. Conclusions: The current ‘strong recommendations’ for conservative rehydration of children with SAM are not based on emerging evidence. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy. Recent studies have reported no evidence of fluid overload or heart failure with more liberal rehydration regimens. Clinical trials are urgently required to inform guidelines on routes and rates of intravenous rehydration therapy for dehydration in children with SAM.
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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80
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Voskuijl W, Potani I, Bandsma R, Baan A, White S, Bourdon C, Kerac M. Stool frequency recording in severe acute malnutrition ('StoolSAM'); an agreement study comparing maternal recall versus direct observation using diapers. BMC Pediatr 2017; 17:140. [PMID: 28592288 PMCID: PMC5461774 DOI: 10.1186/s12887-017-0874-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/25/2017] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Approximately 50% of the deaths of children under the age of 5 can be attributed to undernutrition, which also encompasses severe acute malnutrition (SAM). Diarrhoea is strongly associated with these deaths and is commonly diagnosed solely based on stool frequency and consistency obtained through maternal recall. This trial aims to determine whether this approach is equivalent to a 'directly observed method' in which a health care worker directly observed stool frequency using diapers in hospitalised children with complicated SAM. METHODS This study was conducted at 'Moyo' Nutritional Rehabilitation Unit, Queen Elizabeth Central Hospital, Malawi. Participants were children aged 5-59 months admitted with SAM. We compared 2 days of stool frequency data obtained with next-day maternal-recall versus a 'gold standard' in which a health care worker observed stool frequency every 2 h using diapers. After study completion, guardians were asked their preferred method and their level of education. RESULTS We found poor agreement between maternal recall and the 'gold standard' of directly observed diapers. The sensitivity to detect diarrhoea based on maternal recall was poor, with only 75 and 56% of diarrhoea cases identified on days 1 and 2, respectively. However, the specificity was higher with more than 80% of children correctly classified as not having diarrhoea. On day 1, the mean stool frequency difference between the two methods was -0.17 (SD; 1.68) with limits of agreement (of stool frequency) of -3.55 and 3.20 and, similarly on day 2, the mean difference was -0.2 (SD; 1.59) with limits of agreement of -3.38 and 2.98. These limits extend beyond the pre-specified 'acceptable' limits of agreement (±1.5 stool per day) and indicate that the 2 methods are non-equivalent. The higher the stool frequency, the more discrepant the two methods were. Most primary care givers strongly preferred using diapers. CONCLUSIONS This study shows lack of agreement between the assessment of stool frequency in SAM patients using maternal recall and direct observation of diapers. When designing studies, one should consider using diapers to determining diarrhoea incidence/prevalence in SAM patients especially when accuracy is essential. TRIAL REGISTRATION NUMBER ISRCTN11571116 (registered 29/11/2013).
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Affiliation(s)
- Wieger Voskuijl
- Department of Pediatrics & Child Health, the College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Isabel Potani
- Department of Pediatrics & Child Health, the College of Medicine, University of Malawi, Blantyre, Malawi
| | - Robert Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Anne Baan
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sarah White
- Department of Public Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marko Kerac
- Leonard Cheshire Disability & Inclusive Development Centre, University College London, London, UK
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Obonyo N, Brent B, Olupot-Olupot P, Boele van Hensbroek M, Kuipers I, Wong S, Shiino K, Chan J, Fraser J, van Woensel JBM, Maitland K. Myocardial and haemodynamic responses to two fluid regimens in African children with severe malnutrition and hypovolaemic shock (AFRIM study). Crit Care 2017; 21:103. [PMID: 28468633 PMCID: PMC5415747 DOI: 10.1186/s13054-017-1679-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/28/2017] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints. METHODS A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28. RESULTS Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids. CONCLUSION Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.
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Affiliation(s)
- Nchafatso Obonyo
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Mbale Regional Referral Hospital, Mbale, Uganda
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Bernadette Brent
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
| | | | - Michael Boele van Hensbroek
- Department of Global Health and Department of Paediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Irene Kuipers
- Department of Global Health and Department of Paediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Sidney Wong
- Médecins Sans Frontières - Operational Centre Amsterdam, Plantage Middenlaan 14, 1018 DD Amsterdam, Netherlands
| | - Kenji Shiino
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Nathan, Queensland Australia
| | - Jonathan Chan
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Nathan, Queensland Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, Griffith University, Nathan, Queensland Australia
| | - Job B. M. van Woensel
- Department of Global Health and Department of Paediatrics, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Wellcome Trust Centre for Clinical Tropical Medicine and Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG UK
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82
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Versloot CJ, Voskuijl W, van Vliet SJ, van den Heuvel M, Carter JC, Phiri A, Kerac M, Heikens GT, van Rheenen PF, Bandsma RHJ. Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi. BMC Pediatr 2017; 17:112. [PMID: 28446221 PMCID: PMC5406940 DOI: 10.1186/s12887-017-0860-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). Methods In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. Results The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes. Conclusions This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings. Trial registration ISRCTN13916953 Registered: 14 January 2013.
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Affiliation(s)
- Christian J Versloot
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Wieger Voskuijl
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Sara J van Vliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Meta van den Heuvel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Jane C Carter
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Public Health, University College London, London, UK
| | - Geert Tom Heikens
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Robert H J Bandsma
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Impact of therapeutic food compared to oral nutritional supplements on nutritional outcomes in mildly underweight healthy children in a low-medium income society. Clin Nutr 2017; 37:858-863. [PMID: 28343801 DOI: 10.1016/j.clnu.2017.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/20/2017] [Accepted: 03/03/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Therapeutic foods (RUTF) are used to treat severe acute malnutrition in children 5 years and under in low and middle income countries (LMI), while liquid nutritional supplements (ONS) are used in affluent societies. With globalisation and economic growth in LMI, there will be an inclination to move towards practices applied in affluent countries. This study compared the effect of supplementation with a RUTF and an ONS, on nutritional outcomes in mildly underweight children. METHODS 68 Pakistani (5-10 y), mildly underweight (weight Z-score: -2 to -1) children randomly received either RUTF or ONS (500 kcal/day), in addition to their habitual diet for four weeks. Weight, height, skinfolds and their changes during intervention, were compared between the two groups and at follow up, post-supplementation. RESULTS All nutritional outcomes and height improved with both supplements, but net weight gain (kg) and changes from baseline for weight, height, triceps and sub-scapular thickness Z-scores did not differ between the two supplements [mean (SD), RUTF vs ONS; weight gain (kg), 0.59 (0.30) vs 0.65 (0.42), p = 0.483; weight Z-score, 0.12 (0.09) vs 0.15 (0.13), p = 0.347; height Z-score, 0.04 (0.08) vs 0.04 (0.08), p = 0.908; triceps Z-score, 0.29 (0.24) vs 0.31 (0.23), p = 0.796; subscapular Z-score, 0.37 (0.29) vs 0.31 (0.25), p = 0.385]. Weight gain (0.6 kg) for both groups was lower than anticipated (2 kg). Post-supplementation, there was a tendency for weight and height Z-score to return to baseline. CONCLUSIONS RUTF and ONS are equivalently effective in improving nutritional outcomes in children 5 to 10 y at risk of malnutrition but the observed benefit is less than expected and not sustainable. TRIAL REGISTRATION This trial was registered at www.controlled-trials.com reference: ISRCTN51555749. RCT REGISTRATION This trial was registered at www.controlled-trials.com reference: ISRCTN51555749.
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Effect of Probiotics on Diarrhea in Children With Severe Acute Malnutrition: A Randomized Controlled Study in Uganda. J Pediatr Gastroenterol Nutr 2017; 64:396-403. [PMID: 28079729 DOI: 10.1097/mpg.0000000000001515] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of the study was to assess the effect of probiotics on diarrhea during in- and outpatient treatment of children with severe acute malnutrition (SAM). METHODS A randomized, double-blind, placebo-controlled study was conducted involving 400 children admitted with SAM. Patients received 1 daily dose of a blend of Bifidobacterium animalis subsp lactis and Lactobacillus rhamnosus (10 billion colony-forming units, 50:50) or placebo during hospitalization followed by an 8- to 12-week outpatient treatment period, depending on patients' recovery rate. All outcomes were reported for in- and outpatient treatment separately. The primary outcome was number of days with diarrhea during hospitalization. Secondary outcomes included other diarrhea outcomes, pneumonia, weight gain, and recovery. RESULTS There was no difference in number of days with diarrhea between the probiotic (n = 200) and placebo (n = 200) groups during inpatient treatment (adjusted difference +0.2 days, 95% confidence interval -0.8 to 1.2, P = 0.69); however, during outpatient treatment, probiotics reduced days with diarrhea (adjusted difference -2.2 days 95% confidence interval -3.5 to -0.3, P = 0.025). There were no effects of probiotics on diarrhea incidence and severity or pneumonia, weight gain or recovery during in- or outpatient treatment. Twenty-six patients died in the probiotic versus 20 in the placebo group (P = 0.38). CONCLUSIONS Bifidobacterium animalis subsp lactis and Lactobacillus rhamnosus had no effect on diarrhea in children with SAM during hospitalization, but reduced the number of days with diarrhea in outpatient treatment by 26%. Probiotics may have a role in follow-up of hospitalized children with SAM or in community-based treatment of malnourished children, but further studies are needed to confirm this.
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85
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Incidence of Refeeding Syndrome and Its Associated Factors in South African Children Hospitalized with Severe Acute Malnutrition. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.8297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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86
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Rytter MJ, Babirekere-Iriso E, Namusoke H, Christensen VB, Michaelsen KF, Ritz C, Mortensen CG, Mupere E, Friis H. Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study. Am J Clin Nutr 2017; 105:494-502. [PMID: 28031190 DOI: 10.3945/ajcn.116.140822] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/22/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children who receive in-hospital treatment of severe acute malnutrition often have high mortality rates, and the reasons are not well understood. OBJECTIVE We assessed risk factors for death in children who were treated for malnutrition in a hospital. DESIGN In a prospective observational study of 120 children who were receiving in-hospital treatment of severe acute malnutrition in Uganda with therapeutic formulas F-75 and F-100, we collected data on symptoms, clinical findings, plasma markers of refeeding syndrome (electrolytes and phosphate), and acute phase reactants, and recorded the nutritional therapy given in hospital. RESULTS Seventeen children (14%) died. Clinical risk factors for death were the presence of oral thrush (HR: 5.0; 95% CI: 1.6, 15.2), a caretaker-reported severity of illness on a visual analog scale (HR: 1.7; 95% CI: 1.1, 2.6), impaired consciousness (HR: 16.7; 95% CI: 3.1, 90.4), and a capillary refill time >2 s (HR: 3.9; 95% CI: 1.4, 11.3). HIV infection was not associated with mortality (HR: 3.0; 95% CI: 0.7, 12.4), which was most likely due to low power. Biochemical risk factors were a plasma C-reactive protein concentration >15 mg/L on admission and low plasma phosphate that was measured on day 2 (HR: 8.7; 95% CI: 2.5, 30.1), particularly in edematous children. The replacement of F-75 with unfortified rice porridge to ameliorate diarrhea was associated with a higher risk of death, particularly if given during the first 2 d (HR: 5.0; 95% CI: 1.9, 13.3), which was an association that remained after adjustment for potential confounders (HR: 69.5; 95% CI: 7.0, 694.6). CONCLUSIONS Refeeding syndrome may occur in children who are treated for malnutrition, even with moderately low plasma phosphate, and, in particular, in children with edematous malnutrition. The replacement of F-75 with unfortified rice porridge is associated with increased risk of death, which is possibly mediated by lowering plasma phosphate. The identified clinical risk factors may potentially improve the triage of children with malnutrition. This trial was registered at www.isrctn.com as ISRCTN55092738.
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Affiliation(s)
- Maren Jh Rytter
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark;
| | - Esther Babirekere-Iriso
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.,Mwanamugimu Nutrition Unit, Directorate of Pediatrics, Mulago Tertiary Teaching Hospital, Kampala, Uganda
| | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Directorate of Pediatrics, Mulago Tertiary Teaching Hospital, Kampala, Uganda
| | - Vibeke B Christensen
- Department of Pediatrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; and
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte G Mortensen
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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87
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Dukhi N, Sartorius B, Taylor M. Mid-upper arm circumference (MUAC) performance versus weight for height in South African children (0–59 months) with acute malnutrition. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2017. [DOI: 10.1080/16070658.2016.1255483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Natisha Dukhi
- Department of Human Physiology, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Myra Taylor
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
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88
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Attia S, Versloot CJ, Voskuijl W, van Vliet SJ, Di Giovanni V, Zhang L, Richardson S, Bourdon C, Netea MG, Berkley JA, van Rheenen PF, Bandsma RH. Mortality in children with complicated severe acute malnutrition is related to intestinal and systemic inflammation: an observational cohort study. Am J Clin Nutr 2016; 104:1441-1449. [PMID: 27655441 PMCID: PMC5081715 DOI: 10.3945/ajcn.116.130518] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 08/24/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Diarrhea affects a large proportion of children with severe acute malnutrition (SAM). However, its etiology and clinical consequences remain unclear. OBJECTIVE We investigated diarrhea, enteropathogens, and systemic and intestinal inflammation for their interrelation and their associations with mortality in children with SAM. DESIGN Intestinal pathogens (n = 15), cytokines (n = 29), fecal calprotectin, and the short-chain fatty acids (SCFAs) butyrate and propionate were determined in children aged 6-59 mo (n = 79) hospitalized in Malawi for complicated SAM. The relation between variables, diarrhea, and death was assessed with partial least squares (PLS) path modeling. RESULTS Fatal subjects (n = 14; 18%) were younger (mean ± SD age: 17 ± 11 compared with 25 ± 11 mo; P = 0.01) with higher prevalence of diarrhea (46% compared with 18%, P = 0.03). Intestinal pathogens Shigella (36%), Giardia (33%), and Campylobacter (30%) predominated, but their presence was not associated with death or diarrhea. Calprotectin was significantly higher in children who died [median (IQR): 1360 mg/kg feces (2443-535 mg/kg feces) compared with 698 mg/kg feces (1438-244 mg/kg feces), P = 0.03]. Butyrate [median (IQR): 31 ng/mL (112-22 ng/mL) compared with 2036 ng/mL (5800-149 ng/mL), P = 0.02] and propionate [median (IQR): 167 ng/mL (831-131 ng/mL) compared with 3174 ng/mL (5819-357 ng/mL), P = 0.04] were lower in those who died. Mortality was directly related to high systemic inflammation (path coefficient = 0.49), whereas diarrhea, high calprotectin, and low SCFA production related to death indirectly via their more direct association with systemic inflammation. CONCLUSIONS Diarrhea, high intestinal inflammation, low concentrations of fecal SCFAs, and high systemic inflammation are significantly related to mortality in SAM. However, these relations were not mediated by the presence of intestinal pathogens. These findings offer an important understanding of inflammatory changes in SAM, which may lead to improved therapies. This trial was registered at www.controlled-trials.com as ISRCTN13916953.
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Affiliation(s)
- Suzanna Attia
- Division of Gastroenterology, Hepatology, and Nutrition
| | - Christian J Versloot
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Wieger Voskuijl
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Global Child Health Group, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands
| | - Sara J van Vliet
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands
| | - Valeria Di Giovanni
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Ling Zhang
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | | | - Céline Bourdon
- Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - James A Berkley
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom; and.,Childhood Acute Illness and Nutrition Network (CHAIN)
| | - Patrick F van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands
| | - Robert Hj Bandsma
- Division of Gastroenterology, Hepatology, and Nutrition, .,Physiology and Experimental Medicine, Peter Gilgan Centre for Research and Learning.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Groningen, University Medical Center Groningen, Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Groningen, Netherlands.,Childhood Acute Illness and Nutrition Network (CHAIN)
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89
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Bartels RH, Meyer SL, Stehmann TA, Bourdon C, Bandsma RHJ, Voskuijl WP. Both Exocrine Pancreatic Insufficiency and Signs of Pancreatic Inflammation Are Prevalent in Children with Complicated Severe Acute Malnutrition: An Observational Study. J Pediatr 2016; 174:165-70. [PMID: 27178623 DOI: 10.1016/j.jpeds.2016.04.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 03/21/2016] [Accepted: 04/06/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To assess whether pancreatic function is impaired in children with severe acute malnutrition, is different between edematous vs nonedematous malnutrition, and improves by nutritional rehabilitation. STUDY DESIGN We followed 89 children with severe acute malnutrition admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi. Stool and blood samples were taken on admission and 3 days after initial stabilization to determine exocrine pancreatic function via fecal elastase-1 (FE-1) and serum trypsinogen and amylase levels. RESULTS A total of 33 children (37.1%) had nonedematous severe acute malnutrition, whereas 56 (62.9%) had edematous severe acute malnutrition. On admission, 92% of patients showed evidence of pancreatic insufficiency as measured by FE-1 <200 μg/g of stool. Patients with edematous severe acute malnutrition were more likely to have low FE-1 (98% vs 82.8%, P = .026). FE-1 levels remained low in these individuals throughout the assessment period. Serum trypsinogen was elevated (>57 ng/mL) in 28% and amylase in 21% (>110 U/L) of children, suggesting pancreatic inflammation. CONCLUSION Exocrine pancreatic insufficiency is prevalent in children with severe acute malnutrition and especially in children with edematous severe acute malnutrition. In addition, biochemical signs suggestive of pancreatitis are common in children with severe acute malnutrition. These results have implications for standard rehabilitation treatment of children with severe acute malnutrition who may benefit from pancreatic enzyme replacement therapy. TRIAL REGISTRATION ISRCTN.com: 13916953.
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Affiliation(s)
- Rosalie H Bartels
- Global Child Health Group, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Sophie L Meyer
- University Medical Center Groningen, University of Groningen, The Netherlands
| | - Tijs A Stehmann
- University Medical Center Groningen, University of Groningen, The Netherlands
| | - Céline Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, University of Toronto, Toronto, Canada
| | - Robert H J Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, University of Toronto, Toronto, Canada; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Wieger P Voskuijl
- Global Child Health Group, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
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90
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Shahrin L, Chisti MJ, Huq S, Nishath T, Christy MD, Hannan A, Ahmed T. Clinical Manifestations of Hyponatremia and Hypernatremia in Under-Five Diarrheal Children in a Diarrhea Hospital. J Trop Pediatr 2016; 62:206-12. [PMID: 26851435 DOI: 10.1093/tropej/fmv100] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To study clinical manifestations and outcome of hyponatremia and hypernatremia in children with diarrhea. METHOD We compared children aged 0-59 months hospitalized from 1 January to 31 December 2013 with hyponatremia (serum sodium <130 mmol/l), hypernatremia (serum sodium >150 mmol/l) and normonatremia (serum sodium 135-145 mmol/l). RESULTS The case fatality was significantly higher among the children with hypernatremia and hyponatremia than normonatremia. A logistic regression analysis adjusting for potential confounders revealed that children with hyponatremia are more likely to have convulsions, have severe acute malnutrition and be of older age compared with children with normal serum sodium. Children with hypernatremia are more likely to have convulsions and dehydration than normonatremic children (for all p < 0.05). CONCLUSION Early diagnosis and prompt management of hypo- and hypernatremia by identifying simple clinical predicting factors of these two conditions in diarrheal children <5 years of age is critically important to prevent deaths in such children, especially in resource-limited settings.
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Affiliation(s)
- Lubaba Shahrin
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Mohammad Jobayer Chisti
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Sayeeda Huq
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
| | - Thamanna Nishath
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia Health System, Charlottesville, VA, 22908 USA
| | - Maria D Christy
- School of Nutrition and Health Promotion, Arizona State University, Tempe, AZ, 85004 USA
| | - Anika Hannan
- University of North Carolina at Chapel Hill, Chapel Hill, NC, 28303 USA
| | - Tahmeed Ahmed
- Centre for Nutrition and Food Security (CNFS), International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, 1212 Bangladesh
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91
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Amadi B, Imikendu M, Sakala M, Banda R, Kelly P. Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Retrospective Analysis of Three Years of a Programme in Lusaka. PLoS One 2016; 11:e0149218. [PMID: 26943124 PMCID: PMC4778761 DOI: 10.1371/journal.pone.0149218] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/28/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka. PROGRAMME ACTIVITIES AND ANALYSIS Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression. FINDINGS 1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM (RR of SAM 10.9; 95%CI 3.4,34.8; P<0.0001), and higher in children with HIV infection (RR 5.2, 95%CI 2.9, 9.0; P<0.0001). In multivariate analysis, HIV (OR 5.2; 95%CI 2.6, 10.1; P<0.0001), MUAC <11.5 cm (OR 4.1; 95%CI 2.2, 7.4; P<0.0001) and the first year of the programme (OR 1.9; 95%CI 1.0, 3.4; P = 0.04) all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality (RR 0.23; 95%CI 0.10, 0.57; P = 0.0008). INTERPRETATION Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.
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Affiliation(s)
- Beatrice Amadi
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
- * E-mail:
| | - Mercy Imikendu
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Milika Sakala
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Rosemary Banda
- Department of Paediatrics, University Teaching Hospital, Nationalist Road, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, 4 Newark Street, London, United Kingdom
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92
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Grenov B, Briend A, Sangild PT, Thymann T, Rytter MH, Hother AL, Mølgaard C, Michaelsen KF. Undernourished Children and Milk Lactose. Food Nutr Bull 2016; 37:85-99. [PMID: 26893059 DOI: 10.1177/0379572116629024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Lactose is an important energy source in young mammals, and in fully breast-fed human infants, it constitutes around 40% of the total daily energy intake. The role of lactose in feeding of undernourished infants and young children is not well described. OBJECTIVE A narrative review of the potential positive and negative effects of lactose in the treatment of undernourished children. METHODS Searches were conducted using PUBMED and Web of Science up to July 2015. Relevant references in the retrieved articles were included. RESULTS Lactose may exhibit several health benefits in young children, including a prebiotic effect on the gut microbiota and a positive effect on mineral absorption. Studies in piglets suggest there might also be a stimulating effect on growth, relative to other carbohydrates. Lactose intolerance is a potential concern for undernourished children. Most undernourished children seem to tolerate the currently recommended (low lactose level) therapeutic foods well. However, a subgroup of severely undernourished children with secondary lactase deficiency due to severe diarrhea or severe enteropathy may benefit from products with even more restricted lactose content. At limited extra costs, lactose or lactose-containing milk ingredients may have beneficial effects if added to food products for undernourished children. CONCLUSIONS Lactose may be an overlooked beneficial nutrient for young and undernourished children. Research is needed to define the balance between beneficial and detrimental effects of lactose in undernourished children at different ages and with different degrees of diarrhea and intestinal integrity.
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Affiliation(s)
- Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark Department for International Health, University of Tampere School of Medicine, Tampere, Finland
| | - Per T Sangild
- Department of Veterinary and Clinical Animal Sciences, Frederiksberg C, Denmark
| | - Thomas Thymann
- Department of Veterinary and Clinical Animal Sciences, Frederiksberg C, Denmark
| | - Maren H Rytter
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Anne-Louise Hother
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Frederiksberg C, Denmark
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93
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Singh P, Kumar P, Rohatgi S, Basu S, Aneja S. Experience and Outcome of Children with Severe Acute Malnutrition Using Locally Prepared Therapeutic Diet. Indian J Pediatr 2016; 83:3-8. [PMID: 26153390 DOI: 10.1007/s12098-015-1818-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 06/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Globally more than 1/3rd of the child deaths are attributed to under nutrition and it continues to be a major public health problem in developing countries. This research paper is an attempt towards intervention and management of severely malnourished children with the use of locally prepared therapeutic diets to bring down the case fatality rate. METHODS A cross-sectional longitudinal study was undertaken at a tertiary care hospital in North India. Children under 5 y of age fulfilling the WHO case definition of severe acute malnutrition and suffering from medical complications were enrolled and managed on standard WHO protocols using locally prepared therapeutic diet (Starter F-75 diet and Catch-up F-100 diet). RESULTS During the period of 11 mo, a total of 315 children (192 boys and 123 girls) under 5 y with severe acute malnutrition requiring in-patient care were enrolled and evaluated. The overall case fatality rate was 3.5% while average weight gain seen was 9.33 ± 8.28 g/kg body weight/day and average length of stay was 11.71 ± 7.59. The Nutrition Rehabilitation Centre (NRC) observed a cure rate of 47% and secondary failure rate of 19%. CONCLUSIONS The present study highlights the integral role of locally prepared therapeutic diet (starter F-75 and F-100) besides standardized care provided at Nutrition Rehabilitation Centre (NRC) to combat malnutrition which is a major scourge in the developing world. To sustain the benefits and prevent relapse, there is a need to integrate the services at NRC with the community-based therapeutic care to deliver continuum of care from facility to door step and vice versa.
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Affiliation(s)
- Preeti Singh
- Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Bangla Sahib Marg, New Delhi, 110001, India
| | - Praveen Kumar
- Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Bangla Sahib Marg, New Delhi, 110001, India.
| | - Shivani Rohatgi
- Department of Pediatrics, Kalawati Saran Children's Hospital, Bangla Sahib Marg, New Delhi, 110001, India
| | - Srikanta Basu
- Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Bangla Sahib Marg, New Delhi, 110001, India
| | - Satinder Aneja
- Department of Pediatrics, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, Bangla Sahib Marg, New Delhi, 110001, India
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Gebremichael DY. Predictors of nutritional recovery time and survival status among children with severe acute malnutrition who have been managed in therapeutic feeding centers, Southern Ethiopia: retrospective cohort study. BMC Public Health 2015; 15:1267. [PMID: 26689192 PMCID: PMC4687080 DOI: 10.1186/s12889-015-2593-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/10/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Malnutrition remains to be one of the most common causes of morbidity and mortality among children in developing countries. The prevalence of wasting in Ethiopia remained about 10 % for the past ten years. Mortality rate of children with severe acute malnutrition treated in inpatient set ups has remained unacceptably high. METHODS A retrospective cohort study was conducted in Southern Ethiopia. The study population were children with severe acute malnutrition aged from 6 to 59 months who have been managed at Karat and Fasha stabilization centers between September 30, 2013, and Sep. 29, 2014. The total sample size was 420 and pretested questionnaire was used. Kaplan Meier analysis was used to estimate time to nutritional recovery and Cox proportional-hazard regression analysis was carried out to determine independent predictors. RESULTS Nutritional recovery rate was 3.61 per 100 person day observations. Median nutritional recovery time was 22 and 29 days for edematous malnourished and severely wasted children respectively. The independent predictors of nutritional recovery rate were: stabilization center (AHR = 1.4, 95 % CI: 1.1-1.7), malnutrition status (AHR = 1.8, 95 % CI: 1.3-2.4), weight (AHR = 1.5, 95 % CI: 1.2-1.9), mid- upper arm circumference (AHR = 1.4, 95 % CI: 1.1-1.9), inpatient complications (AHR = 2.2, 95 % CI: 1.4-3.5) and did not lose edema within four days of inpatient treatment (AHR = 2.3, 95 % CI: 1.1-4.8). CONCLUSIONS The findings of this study confirm the probability of surviving gets slimmer with inpatient complications and staying longer in stabilization centers. So, to prevent complications and enhance recovery rate due emphasis should be given in improving early detection and treatment of severely malnourished children in Ethiopia.
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Affiliation(s)
- Delelegn Yilma Gebremichael
- Department of Public Health, Ambo University, College of Medicine and Health Sciences, P.O. Box 19, Ambo, Ethiopia.
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95
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Kvissberg MA, Dalvi PS, Kerac M, Voskuijl W, Berkley JA, Priebe MG, Bandsma RHJ. Carbohydrate malabsorption in acutely malnourished children and infants: a systematic review. Nutr Rev 2015; 74:48-58. [PMID: 26578625 PMCID: PMC4684688 DOI: 10.1093/nutrit/nuv058] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 07/12/2015] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Severe acute malnutrition (SAM) accounts for approximately 1 million child deaths per year. High mortality is linked with comorbidities, such as diarrhea and pneumonia. OBJECTIVE The aim of this systematic review was to determine the extent to which carbohydrate malabsorption occurs in children with SAM. DATA SOURCES The PubMed and Embase databases were searched. Reference lists of selected articles were checked. DATA EXTRACTION All observational and controlled intervention studies involving children with SAM in which direct or indirect measures of carbohydrate absorption were analyzed were eligible for inclusion. A total of 20 articles were selected for this review. DATA SYNTHESIS Most studies reported carbohydrate malabsorption, particularly lactose malabsorption, and suggested an increase in diarrhea and reduced weight gain in children on a lactose-containing diet. As most studies reviewed were observational, there was no conclusive scientific evidence of a causal relationship between lactose malabsorption and a worse clinical outcome among malnourished children. CONCLUSION The combined data indicate that carbohydrate malabsorption is prevalent in children with SAM. Additional well-designed intervention studies are needed to determine whether outcomes of SAM complicated by carbohydrate malabsorption could be improved by altering the carbohydrate/lactose content of therapeutic feeds and to elucidate the precise mechanisms involved.
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Affiliation(s)
- Matilda A Kvissberg
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Prasad S Dalvi
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marko Kerac
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Wieger Voskuijl
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - James A Berkley
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Marion G Priebe
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Robert H J Bandsma
- M.A. Kvissberg and R.H. Bandsma are with the Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University Medical Centre Groningen, University of Groningen, The Netherlands. P.S. Dalvi and R.H. Bandsma are with the Physiology and Experimental Medicine Program, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, Ontario, Canada. P.S. Dalvi is with the Center for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada. M. Kerac is with the Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom. W. Voskuijl is with the College of Medicine, University of Malawi, Blantyre, Malawi. J.A. Berkley is with the Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom. J.A. Berkley is with the KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. M.G. Priebe is with the Centre for Medical Biomics, University Medical Centre of Groningen, University of Groningen, The Netherlands. R.H. Bandsma is with the Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.
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96
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Ali E, Zachariah R, Dahmane A, Van den Boogaard W, Shams Z, Akter T, Alders P, Manzi M, Allaouna M, Draguez B, Delchevalerie P, Harries AD. Peanut-based ready-to-use therapeutic food: acceptability among malnourished children and community workers in Bangladesh. Public Health Action 2015; 3:128-35. [PMID: 26393015 DOI: 10.5588/pha.12.0077] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 02/19/2013] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To assess the acceptability of a ready-to-use therapeutic food (Plumpy'nut(®) [PPN]) among 1) care givers of malnourished children and 2) community health workers (CHWs) at a nutrition rehabilitation centre in an urban slum in Dhaka, Bangladesh. METHODS This was a cross-sectional semi-structured questionnaire survey conducted between April and June 2011 as part of a nutritional programme run by Médecins Sans Frontières. The study population included care givers of malnourished children aged 6-59 months who received PPN for at least 3 weeks, and CHWs. RESULTS Of the 149 care givers (93% female) interviewed, 60% expressed problems with PPN acceptability. Overall, 43% perceived the child's dissatisfaction with the taste, 31% with consistency and 64% attributed side effects to PPN (nausea, vomiting, loose motion, diarrhoea, abdominal distension and pain). It is to be noted that 47% of children needed encouragement or were forced to eat PPN, while 5% completely rejected it after 3 weeks. Of the 29 CHWs interviewed, 48% were dissatisfied with PPN's taste and consistency, and 55% with its smell. However, 91% of the care givers and all CHWs still perceived a therapeutic benefit of PPN for malnourished children. CONCLUSION Despite a therapeutic benefit, only 4 in 10 care givers perceived PPN as being acceptable as a food product, which is of concern.
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Affiliation(s)
- E Ali
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - R Zachariah
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - A Dahmane
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - W Van den Boogaard
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | | | | | - P Alders
- Brussels Operational Centre, MSF, Brussels, Belgium
| | - M Manzi
- Medical Department (Operational Research), Médecins Sans Frontières (MSF), Luxembourg, Luxembourg
| | - M Allaouna
- Brussels Operational Centre, MSF, Brussels, Belgium
| | - B Draguez
- Brussels Operational Centre, MSF, Brussels, Belgium
| | | | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
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97
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Modi P, Nasrin S, Hawes M, Glavis-Bloom J, Alam NH, Hossain MI, Levine AC. Midupper Arm Circumference Outperforms Weight-Based Measures of Nutritional Status in Children with Diarrhea. J Nutr 2015; 145:1582-7. [PMID: 25972523 PMCID: PMC4478950 DOI: 10.3945/jn.114.209718] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/21/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Undernutrition contributes to 45% of all deaths in children <5 y of age worldwide, with a large proportion of those deaths caused by diarrhea. However, no validated tools exist for assessing undernutrition in children with diarrhea and possible dehydration. OBJECTIVE This study assessed the validity of different measures of undernutrition in children with diarrhea. METHODS A prospective cohort study was conducted at an urban hospital in Bangladesh. Children <60 mo of age presenting to the hospital rehydration unit with acute diarrhea were eligible for enrollment. Study staff randomly selected 1196 children for screening, of which 1025 were eligible, 850 were enrolled, and 721 had complete data for analysis. Anthropometric measurements, including weight-for-age z score (WAZ), weight-for-length z score (WLZ), midupper arm circumference (MUAC), and midupper arm circumference z score (MUACZ), were calculated pre- and posthydration in all patients. Measurements were evaluated for their ability to correctly identify undernutrition in children with varying degrees of dehydration. RESULTS Of the 721 patients with full data for analysis, the median percent dehydration was 4%. Of the 4 measures evaluated, MUAC and MUACZ demonstrated 92-94% agreement pre- and posthydration compared with 69-76% for WAZ and WLZ. Although each 1% change in hydration status was found to change weight-for-age by 0.0895 z scores and weight-for-length by 0.1304 z scores, MUAC and MUACZ were not significantly affected by dehydration status. Weight-based measures misclassified 12% of children with severe underweight and 14% with severe acute malnutrition (SAM) compared with only 1-2% for MUAC and MUACZ. CONCLUSIONS MUAC and MUACZ were the most accurate predictors of undernutrition in children with diarrhea. WAZ and WLZ were significantly affected by dehydration status, leading to the misdiagnosis of many patients on arrival with severe underweight and SAM. This trial was registered at clinicaltrials.gov as NCT02007733.
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Affiliation(s)
- Payal Modi
- The Warren Alpert Medical School, Brown University, Providence, RI
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - Meagan Hawes
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | | | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - M Iqbal Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - Adam C Levine
- The Warren Alpert Medical School, Brown University, Providence, RI;
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98
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Kismul H, Hatløy A, Andersen P, Mapatano M, Van den Broeck J, Moland KM. The social context of severe child malnutrition: a qualitative household case study from a rural area of the Democratic Republic of Congo. Int J Equity Health 2015; 14:47. [PMID: 25986714 PMCID: PMC4446836 DOI: 10.1186/s12939-015-0175-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 05/15/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction The magnitude of child malnutrition including severe child malnutrition is especially high in the rural areas of the Democratic Republic of Congo (the DRC). The aim of this qualitative study is to describe the social context of malnutrition in a rural part of the DRC and explore how some households succeed in ensuring that their children are well-nourished while others do not. Methodology This study is based on participant observation, key informant interviews, group discussions and in-depth interviews with four households with malnourished children and four with well-nourished children. We apply social field theory to link individual child nutritional outcomes to processes at local level and to the wider socio-economic environment. Findings We identified four social fields that have implications for food security and child nutritional outcomes: 1) household size and composition which determined vulnerability to child malnutrition, 2) inter-household cooperation in the form of ‘gbisa work party’ which buffered scarcity of labour in peak seasons and facilitated capital accumulation, 3) the village associated with usufruct rights to land, and 4) the local NGO providing access to agricultural support, clean drinking water and health care. Conclusions Households that participated in inter-household cooperation were able to improve food and nutrition security. Children living in households with high pressure on productive members were at danger of food insecurity and malnutrition. Nutrition interventions need to involve local institutions for inter-household cooperation and address the problem of social inequalities in service provision. They should have special focus on households with few resources in the form of land, labour and capital.
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Affiliation(s)
- Hallgeir Kismul
- Centre for International Health, University of Bergen, 5009, Bergen, Norway.
| | | | - Peter Andersen
- Department of Geography, University of Bergen, 5020, Bergen, Norway.
| | - Mala Mapatano
- School of Public Health, University of Kinshasa, Kinshasa 1, Democratic Republic of Congo.
| | - Jan Van den Broeck
- Centre for International Health, University of Bergen, 5009, Bergen, Norway.
| | - Karen Marie Moland
- Centre for International Health, University of Bergen, 5009, Bergen, Norway.
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99
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Iannotti LL, Trehan I, Clitheroe KL, Manary MJ. Diagnosis and treatment of severely malnourished children with diarrhoea. J Paediatr Child Health 2015; 51:387-95. [PMID: 25196813 DOI: 10.1111/jpc.12711] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2014] [Indexed: 11/29/2022]
Abstract
Children with severe acute malnutrition complicated by diarrhoea require special care due to their unique physiological vulnerability and increased mortality risks. A systematic literature review (1950-2013) was conducted to identify the most effective diagnostic and therapeutic measures for the community-based management of severely malnourished children with diarrhoea. No studies directly addressed this question, so the search was broadened to include inpatient care. Of the 129 studies identified, 32 were selected for full review and found to contain varying degrees of indirectness, inconsistency and bias. Evidence from diagnostic studies point to the use of both prolonged and persistent diarrhoea as morbidity markers, rapid hypoglycaemia diagnosis and the frequent aetiological role of Cryptosporidium. Therapeutic studies suggest benefits from routine antiparasitic medication and feeding regimens with ready-to-use-therapeutic foods, lactose-free diets and zinc supplementation. Existing rehydration treatment guidelines were affirmed, but the utility of glutamine and low osmolarity feeds were inconclusive.
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Affiliation(s)
- Lora L Iannotti
- Institute for Public Health, George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri
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100
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Rytter MJH, Namusoke H, Babirekere-Iriso E, Kæstel P, Girma T, Christensen VB, Michaelsen KF, Friis H. Social, dietary and clinical correlates of oedema in children with severe acute malnutrition: a cross-sectional study. BMC Pediatr 2015; 15:25. [PMID: 25885808 PMCID: PMC4383214 DOI: 10.1186/s12887-015-0341-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/04/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Severe acute malnutrition is a serious public health problem, and a challenge to clinicians. Why some children with malnutrition develop oedema (kwashiorkor) is not well understood. The objective of this study was to investigate socio-demographic, dietary and clinical correlates of oedema, in children hospitalised with severe acute malnutrition. METHODS We recruited children with severe acute malnutrition admitted to Mulago Hospital, Uganda. Data was collected using questionnaires, clinical examination and measurement of blood haemoglobin, plasma c-reactive protein and α1-acid glycoprotein. Correlates of oedema were identified using multiple logistic regression analysis. RESULTS Of 120 children included, 77 (64%) presented with oedematous malnutrition. Oedematous children were slightly older (17.7 vs. 15.0 months, p = 0.006). After adjustment for age and sex, oedematous children were less likely to be breastfed (odds ratio (OR): 0.19, 95%-confidence interval (CI): 0.06; 0.59), to be HIV-infected (OR: 0.10, CI: 0.03; 0.41), to report cough (OR: 0.33, CI: 0.13; 0.82) and fever (OR: 0.22, CI: 0.09; 0.51), and to have axillary temperature > 37.5 °C (OR: 0.28 CI: 0.11; 0.68). Household dietary diversity score was lower in children with oedema (OR: 0.58, CI: 0.40; 85). No association was found with plasma levels of acute phase proteins, household food insecurity or birth weight. CONCLUSION Children with oedematous malnutrition were less likely to be breastfed, less likely to have HIV infection and had fewer symptoms of other infections. Dietary diversity was lower in households of children who presented with oedema. Future research may confirm whether a causal relationship exists between these factors and nutritional oedema.
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Affiliation(s)
- Maren Johanne Heilskov Rytter
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago Hospital, Kampala, Uganda.
| | - Esther Babirekere-Iriso
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago Hospital, Kampala, Uganda. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Pernille Kæstel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Tsinuel Girma
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark. .,Department of Paediatrics and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia.
| | - Vibeke Brix Christensen
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
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