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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2024; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/19/2024] Open
Abstract
Background Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial will reappraise current recommendations with mortality as the primary outcome. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling children in Uganda, Kenya, Nigeria and Niger aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration (IV) given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is mortality to 96 hours and for oral rehydration a change in sodium levels at 24 hours post-randomisation. Secondary outcomes include measures assessing safety (evidence of pulmonary oedema or heart failure); change in sodium from post-iv levels for those in Stratum A; perturbations of electrolyte abnormalities (severe hyponatraemia <125 mmols/L or hypokalaemia. Discussion If the trial shows that rehydration strategies for non-malnourished children are safe and improve mortality in SAM this could prompt revisions to the current treatment recommendations or may prompt future Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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Gardner Yelton SE, Ramos LC, Reuland CJ, Evangelista PPG, Shilkofski NA. Implementation and evaluation of a shock curriculum using simulation in Manila, Philippines: a prospective cohort study. BMC MEDICAL EDUCATION 2022; 22:606. [PMID: 35932072 PMCID: PMC9354294 DOI: 10.1186/s12909-022-03669-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Shock causes significant morbidity and mortality in children living in resource-limited settings. Simulation has been successfully used as an educational tool for medical professionals internationally. We sought to improve comfort and knowledge regarding shock recognition and fluid management by implementing a pediatric shock curriculum using simulation as an assessment for trainees in Manila, Philippines. METHODS We assessed a shock curriculum focused on patients with malnutrition in a prospective cohort study, using a written test and a videotaped simulation-based objective standardized clinical examination. Implementation occurred in March 2020 with 24 Filipino pediatric residents at a single institution in Manila. Outcomes included time to initiation of fluid resuscitation, improvement in confidence, knowledge on a written assessment, and performance in simulation. Results were compared pre- and post-intervention using Wilcoxon signed-rank test. RESULTS The time to initiation of fluids did not change between the baseline simulation (median [interquartile range] = 71.5 seconds [52-116.5]) and the final simulation (68 seconds [52.5-89]; P = 0.42). Confidence in identifying shock and malnutrition, managing hypovolemic shock, managing septic shock, and placing intraosseous access all increased (P < 0.01) post-intervention. Written test scores showed no improvement, but performance in simulation, measured using a checklist, improved from a total score of 10 [8.5-11] to 15 [13-16] (P < 0.01). CONCLUSION In our study of a simulation-based shock education program, we showed improvement in confidence and knowledge as measured by a resuscitation checklist. It is feasible to establish a successful simulation-based education program in a low-resource setting.
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Affiliation(s)
- Sarah E Gardner Yelton
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA.
| | - Lorelie Cañete Ramos
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | | | - Paula Pilar G Evangelista
- Department of Pediatric Critical Care, Philippine Children's Medical Center, Quezon City, Philippines
| | - Nicole A Shilkofski
- Department of Anesthesiology and Critical Care Medicine, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, 1800 Orleans Street, Room 6349 D1, Baltimore, MD, 21287, USA
- Department of Pediatrics, Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2021; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial is the first step in reappraising current recommendations. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling Ugandan and Kenyan children aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is urine output (mls/kg/hour at 8 hours post-randomisation), and for oral rehydration a change in sodium levels at 24 hours post-randomisation. This trial will also generate feasibility, safety and preliminary data on survival to 28 days. Discussion. If current rehydration strategies for non-malnourished children are safe in SAM this could prompt future evaluation in Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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Kambale RM, Nancy FI, Ngaboyeka GA, Kasengi JB, Bindels LB, Van der Linden D. Effects of probiotics and synbiotics on diarrhea in undernourished children: Systematic review with meta-analysis. Clin Nutr 2020; 40:3158-3169. [PMID: 33446418 DOI: 10.1016/j.clnu.2020.12.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 11/14/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Undernutrition predisposes children to a greater incidence and duration of diarrhea. No review and meta-analysis have yet been conducted to assess effectiveness of probiotics and synbiotics in undernourished children. AIMS To assess the effectiveness of probiotics and synbiotics on diarrhea in undernourished children. METHODS Randomized, double-blind, placebo-controlled trials evaluating the effects of probiotics and synbiotics on diarrhea in undernourished children were searched from 1990 to May 2020. Recommendations of the Cochrane Handbook and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement were followed. RESULTS The systematic review identified 15 trials with 6986 patients. The meta-analysis revealed that treatment with probiotic or synbiotic reduced significantly both the duration of diarrhea [Weighted mean difference (WMD) = -1.05 day, 95% CI (-1.98, -0.11)] and the hospital stay duration [Standard mean difference (SMD) = -2.87 days, 95% CI (-5.33, -0.42)], especially in specific patient subsets. In both groups, similar rates of vomiting and nutritional recovery were observed. No probiotics or synbiotics-related adverse effects were reported. Subgroup analyses showed that probiotic and synbiotic treatment were more effective in reducing risk of diarrhea in outpatients [Risk ratio (RR) = 0.86, 95%CI (0.75-0.98)]. CONCLUSION This meta-analysis supports the potential beneficial roles of probiotics and synbiotics on diarrhea in undernourished children.
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Affiliation(s)
- Richard Mbusa Kambale
- Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium; Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo; General Pediatrics, Pediatric Department, Hôpital Provincial Général de Référence de Bukavu, Democratic Republic of Congo.
| | - Fransisca Isia Nancy
- Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo; General Pediatrics, Pediatric Department, Hôpital Provincial Général de Référence de Bukavu, Democratic Republic of Congo
| | - Gaylord Amani Ngaboyeka
- Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo; General Pediatrics, Pediatric Department, Hôpital Provincial Général de Référence de Bukavu, Democratic Republic of Congo
| | - Joe Bwija Kasengi
- Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo; General Pediatrics, Pediatric Department, Hôpital Provincial Général de Référence de Bukavu, Democratic Republic of Congo
| | - Laure B Bindels
- Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium; Metabolism and Nutrition Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels, Belgium
| | - Dimitri Van der Linden
- Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium; Pediatric Infectious Diseases, General Pediatrics, Pediatric Department, Cliniques universitaires Saint Luc, Brussels, Belgium
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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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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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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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8
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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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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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Silverman JA, Chimalizeni Y, Hawes SE, Wolf ER, Batra M, Khofi H, Molyneux EM. The effects of malnutrition on cardiac function in African children. Arch Dis Child 2016; 101:166-71. [PMID: 26553908 DOI: 10.1136/archdischild-2015-309188] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/11/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Cardiac dysfunction may contribute to high mortality in severely malnourished children. Our objective was to assess the effect of malnutrition on cardiac function in hospitalised African children. DESIGN Prospective cross-sectional study. SETTING Public referral hospital in Blantyre, Malawi. PATIENTS We enrolled 272 stable, hospitalised children ages 6-59 months, with and without WHO-defined severe acute malnutrition. MAIN OUTCOME MEASURES Cardiac index, heart rate, mean arterial pressure, stroke volume index and systemic vascular resistance index were measured by the ultrasound cardiac output monitor (USCOM, New South Wales, Australia). We used linear regression with generalised estimating equations controlling for age, sex and anaemia. RESULTS Our primary outcome, cardiac index, was similar between those with and without severe malnutrition: difference=0.22 L/min/m(2) (95% CI -0.08 to 0.51). No difference was found in heart rate or stroke volume index. However, mean arterial pressure and systemic vascular resistance index were lower in children with severe malnutrition: difference=-8.6 mm Hg (95% CI -12.7 to -4.6) and difference=-200 dyne s/cm(5)/m(2) (95% CI -320 to -80), respectively. CONCLUSIONS In this largest study to date, we found no significant difference in cardiac function between hospitalised children with and without severe acute malnutrition. Further study is needed to determine if cardiac function is diminished in unstable malnourished children.
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Affiliation(s)
- Jonathan A Silverman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA University of Washington School of Public Health, Seattle, Washington, USA
| | - Yamikani Chimalizeni
- Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Stephen E Hawes
- University of Washington School of Public Health, Seattle, Washington, USA
| | - Elizabeth R Wolf
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Maneesh Batra
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA University of Washington School of Public Health, Seattle, Washington, USA
| | - Harriet Khofi
- Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
| | - Elizabeth M Molyneux
- Department of Paediatrics, University of Malawi College of Medicine, Blantyre, Malawi
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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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Obonyo N, Maitland K. Fluid management of shock in severe malnutrition: what is the evidence for current guidelines and what lessons have been learned from clinical studies and trials in other pediatric populations? Food Nutr Bull 2014; 35:S71-8. [PMID: 25069297 PMCID: PMC6882676 DOI: 10.1177/15648265140352s111] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Management of shock in children with severe malnutrition remains controversial. To date, the evidence supporting either benefit or harm of fluid resuscitation or rehydration is weak. This issue, however, is not unique to children with severe malnutrition; pediatric guidelines worldwide have a weak level of evidence and remain unsupported by appropriate clinical studies. In this review we give an overview of the current recommendations in other pediatric populations and appraise the strength of evidence supporting these. We summarize results from the only controlled trial ever undertaken, FEAST (Fluid Expansion As Supportive Therapy), which was conducted in resource-poor hospitals involving 3,141 African children with severe febrile illnesses and shock, including large subgroups with sepsis and malaria but excluding children with severe malnutrition. This high-quality trial provided robust evidence that fluid resuscitation increased the risk of death, leading to an excess mortality of 3 in every 100 children receiving fluid boluses, compared with controls receiving no boluses. These findings may have particular relevance to management of septic shock in children with severe malnutrition. However, they cannot be extrapolated to children with gastroenteritis, since this condition was not included in the trial. Current observational studies under way in East Africa may provide insights into myocardial and hemodynamic function in severe malnutrition, including responses to fluid challenge in those complicated by gastroenteritis. Such studies are an essential step for setting the research agenda regarding fluid management of shock in severe malnutrition.
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Brewster DR. Inpatient management of severe malnutrition: time for a change in protocol and practice. ACTA ACUST UNITED AC 2013; 31:97-107. [DOI: 10.1179/146532811x12925735813887] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Brent B, Obonyo N, Maitland K. Tailoring management of severe and complicated malnutrition: more research is required first. Pathog Glob Health 2013; 106:197-9. [PMID: 23265419 DOI: 10.1179/2047772412z.00000000061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Vygen SB, Roberfroid D, Captier V, Kolsteren P. Treatment of severe acute malnutrition in infants aged <6 months in Niger. J Pediatr 2013; 162:515-521.e3. [PMID: 23092531 DOI: 10.1016/j.jpeds.2012.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/25/2012] [Accepted: 09/04/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report a nutritional rehabilitation program in Niger for the management of severe acute malnutrition in infants aged <6 months. STUDY DESIGN This is a presentation of a case series (n = 632) of young infants who were admitted to a nutrition rehabilitation program in 2010-2011. The main characteristics of the inpatient treatment protocol where the use of diluted F-100 milk via a supplementary suckling technique until exclusive breastfeeding was reinitialized, coaching of mothers on infant feeding, and intensive antibiotic therapy as indicated during the stabilization phase. Semistructured interviews were conducted with 103 mothers. RESULTS Rates of recovery, mortality, and default were 85% (537 of 632), 6% (37 of 632), and 9% (55 of 632), respectively. The majority of infants had an infectious disease at study entry (81%), particularly acute watery diarrhea and respiratory tract infections. Infection on admission was a predictor of death during treatment (OR, 3.9; 95% CI, 1.6-9.2). Anorexia at entry was a risk factor for treatment failure (OR, 4.4; 95% CI, 1.71-11.1). Interviews revealed a very low rate of exclusive breastfeeding (3%), with delayed initiation in 68% of cases. Traditional beliefs, perceived insufficiency of breast milk, and psychological problems played important roles in feeding choices. CONCLUSION Severe acute malnutrition in infants aged <6 months can be successfully treated by managing cases as inpatients with an adapted protocol, intensive clinical supervision, and intensive drug treatment if indicated. Whether similar outcomes are achievable in community-based programs remains to be verified. Effective interventions for improving breastfeeding practices are needed.
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Affiliation(s)
- Sabine B Vygen
- Institute of Tropical Medicine and International Health, Charité Medical University, Berlin, Germany; Médecins Sans Frontières, Geneva, Switzerland.
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Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One 2012; 7:e38321. [PMID: 22675542 PMCID: PMC3366921 DOI: 10.1371/journal.pone.0038321] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 05/03/2012] [Indexed: 01/27/2023] Open
Abstract
Background Severe acute malnutrition (SAM) accounts for two million deaths worldwide annually. In those hospitalised with SAM, concomitant infections and diarrhoea are frequent complications resulting in adverse outcome. We examined the clinical and laboratory features on admission and outcome of children with SAM and diarrhoea at a Kenyan district hospital. Methods A 4-year prospective descriptive study involving 1,206 children aged 6 months to 12 years, hospitalized with SAM and managed in accordance with WHO guidelines. Data on clinical features, haematological, biochemical and microbiological findings for children with diarrhoea (≥3 watery stools/day) were systematically collected and analyzed to identify risk factors associated with poor outcome. Results At admission 592 children (49%) had diarrhoea of which 122 (21%) died compared to 72/614 (12%) deaths in those without diarrhoea at admission (Χ2 = 17.6 p<0.001). A further 187 (16%) children developed diarrhoea after 48 hours of admission and 33 died (18%). Any diarrhoea during admission resulted in a significantly higher mortality 161/852 (19%) than those uncomplicated by diarrhoea 33/351 (9%) (Χ2 = 16.6 p<0.001). Features associated with a fatal outcome in children presenting with diarrhoea included bacteraemia, hyponatraemia, low mid-upper arm circumference <10 cm, hypoxia, hypokalaemia and oedema. Bacteraemia had the highest risk of death (adjusted OR 6.1; 95% C.I 2.3, 16.3 p<0.001); and complicated 24 (20%) of fatalities. Positive HIV antibody status was more frequent in cases with diarrhoea at admission (23%) than those without (15%, Χ2 = 12.0 p = 0.001) but did not increase the risk of death in diarrhoea cases. Conclusion Children with SAM complicated by diarrhoea had a higher risk of death than those who did not have diarrhoea during their hospital stay. Further operational and clinical research is needed to reduce mortality in children with SAM in the given setting.
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Affiliation(s)
- Alison Talbert
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Nahashon Thuo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Japhet Karisa
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Charles Chesaro
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Eric Ohuma
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - James Ignas
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher Toromo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sarah Atkinson
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Kathryn Maitland
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Clinical Tropical Medicine, Faculty of Medicine, Imperial College, Norfolk Place, London, United Kingdom
- * E-mail:
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Abstract
BACKGROUND The practice of glycemic control with intravenous insulin in critically ill patients has brought clinical focus on understanding the effects of hypoglycemia, especially in children. Very little is published on the impact of hypoglycemia in this population. We aimed to review the existing literature on hypoglycemia in critically ill neonates and children. METHODS We performed a systematic review of the literature up to August 2011 using PubMed, Ovid MEDLINE and ISI Web of Science using the search terms "hypoglycemia or hypoglyc*" and "critical care or intensive care or critical illness". Articles were limited to "all child (0-18 years old)" and "English". RESULTS A total of 513 articles were identified and 132 were included for review. Hypoglycemia is a significant concern among pediatric and neonatal intensivists. Its definition is complicated by the use of a biochemical measure (i.e., blood glucose) for a pathophysiologic problem (i.e., neuroglycopenia). Based on associated outcomes, we suggest defining hypoglycemia as <40-45 mg/dl in neonates and <60-65 mg/dl in children. Below the suggested threshold values, hypoglycemia is associated with worse neurological outcomes, increased intensive care unit stay, and increased mortality. Disruptions in carbohydrate metabolism increase the risk of hypoglycemia incritically ill children. Prevention of hypoglycemia, especially in the setting of intravenous insulin use, will be best accomplished by the combination of accurate measuring techniques, frequent or continuous glucose monitoring, and computerized insulin titration protocols. CONCLUSION Studies on hypoglycemia in critically ill children have focused on spontaneous hypoglycemia. With the current practice of maintaining blood glucose within a narrow range with intravenous insulin, the risk factors and outcomes associated with insulin-induced hypoglycemia should be rigorously studied to prevent hypoglycemia and potentially improve outcomes of critically ill children.
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Oshikoya KA, Senbanjo IO. Pathophysiological changes that affect drug disposition in protein-energy malnourished children. Nutr Metab (Lond) 2009; 6:50. [PMID: 19951418 PMCID: PMC2794862 DOI: 10.1186/1743-7075-6-50] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Accepted: 12/01/2009] [Indexed: 12/02/2022] Open
Abstract
Protein-energy malnutrition (PEM) is a major public health problem affecting a high proportion of infants and older children world-wide and accounts for a high childhood morbidity and mortality in the developing countries. The epidemiology of PEM has been extensively studied globally and management guidelines formulated by the World Health Organization (WHO). A wide spectrum of infections such as measles, malaria, acute respiratory tract infection, intestinal parasitosis, tuberculosis and HIV/AIDS may complicate PEM with two or more infections co-existing. Thus, numerous drugs may be required to treat the patients. In-spite of abundant literature on the epidemiology and management of PEM, focus on metabolism and therapeutic drug monitoring is lacking. A sound knowledge of pathophysiology of PEM and pharmacology of the drugs frequently used for their treatment is required for safe and rational treatment. In this review, we discuss the pathophysiological changes in children with PEM that may affect the disposition of drugs frequently used for their treatment. This review has established abnormal disposition of drugs in children with PEM that may require dosage modification. However, the relevance of these abnormalities to the clinical management of PEM remains inconclusive. At present, there are no good indications for drug dosage modification in PEM; but for drug safety purposes, further studies are required to accurately determine dosages of drugs frequently used for children with PEM.
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Affiliation(s)
- Kazeem A Oshikoya
- Pharmacology Department, Lagos State University College of Medicine, PMB 21266, Ikeja, Lagos, Nigeria
- Paediatrics Department, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
- Academic Division of Child Health, University of Nottingham, The Medical School, Royal Derby Children's Hospital, Uttoxeter Road, Derby DE22 3DT, UK
| | - Idowu O Senbanjo
- Paediatrics Department, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
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Ruben AR. Undernutrition and obesity in indigenous children: epidemiology, prevention, and treatment. Pediatr Clin North Am 2009; 56:1285-302. [PMID: 19962022 DOI: 10.1016/j.pcl.2009.09.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Over the past 50 years there has been a shift in nutritional problems amongst Indigenous children in developed countries from under-nutrition and growth faltering to overweight and obesity; the major exception is small numbers of Indigenous children predominately living in remote areas of Northern Australia. Nutritional problems reflect social disadvantage and occur with disproportionately high incidence in all disadvantaged subgroups. There is limited evidence of benefit from any strategies to prevent or treat undernutrition and obesity; there are a limited number of individual studies with generalizable high grade evidence of benefit. Potential solutions require a whole of society approach.
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Affiliation(s)
- Alan R Ruben
- Northern Territory Clinical School, P.O. Box 41326, Casuarina, NT 0811, Australia.
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Ritchie BK, Brewster DR, Davidson GP, Tran CD, McNeil Y, Hawkes JS, Butler RN. 13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health. Pediatrics 2009; 124:620-6. [PMID: 19581263 DOI: 10.1542/peds.2008-2257] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Environmental enteropathy syndrome may compromise growth and predispose to infectious diseases in children in the developing world, including Australian Aboriginal children from remote communities of the Northern Territory. In this study, we described the use of a biomarker (13)C-sucrose breath test (SBT) to measure enterocyte sucrase activity as a marker of small intestinal villus integrity and function. METHODS This was a hospital-based prospective case-control study of Aboriginal and non-Aboriginal children with and without acute diarrheal disease. Using the SBT, we compared 36 Aboriginal case subjects admitted to a hospital (18 diarrheal and 18 nondiarrheal disease), with 7 healthy non-Aboriginal control subjects. Intestinal permeability using the lactulose/rhamnose (L/R) ratio on a timed 90-minute blood test was performed simultaneously with the SBT. The SBT results are expressed as a cumulative percentage of the dose recovered at 90 minutes. RESULTS Aboriginal children with acute diarrheal disease have a significantly decreased absorptive capacity, as determined by the SBT, with a mean of 1.9% compared with either Aboriginal children without diarrhea (4.1%) or non-Aboriginal (6.1%) control subjects. The mean L/R ratio in the diarrhea group was 31.8 compared with 11.4 in Aboriginal children without diarrhea. There was a significant inverse correlation between the SBT and the L/R ratio. CONCLUSIONS The SBT was able to discriminate among Aboriginal children with diarrhea, asymptomatic Aboriginal children with an underlying environmental enteropathy, and healthy non-Aboriginal controls. This test provides a noninvasive, easy-to-use, integrated marker of the absorptive capacity and integrity of the small intestine and could be a valuable tool in evaluating the efficacy of interventions aimed at improving gut health.
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Affiliation(s)
- Brett K Ritchie
- aInfectious Diseases Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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22
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Joint BAPEN and Nutrition Society Symposium on 'Feeding size 0: the science of starvation'. Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock. Proc Nutr Soc 2009; 68:274-80. [PMID: 19490738 DOI: 10.1017/s0029665109001359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The systematic failure to recognise and appropriately treat children with severe malnutrition has been attributed to the elevated case-fatality rates, often as high as 50%, that still prevail in many hospitals in Africa. Children admitted to Kilifi District Hospital, on the coast of Kenya, with severe malnutrition frequently have life-threatening features and complications, many of which are not adequately identified or treated by WHO guidelines. Four main areas have been identified for research: early identification and better supportive care of sepsis; evidence-based fluid management strategies; improved antimicrobial treatment; rational use of nutritional strategies. The present paper focuses on the identification of children with sepsis and on fluid management strategies.
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