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Amir Y, Omar M, Adler A, Abu-Moch S, Donkor ES, Cohen D, Muhsen K. The prevalence of antimicrobial drug resistance of non-typhoidal Salmonella in human infections in sub-Saharan Africa: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2024:1-14. [PMID: 38922636 DOI: 10.1080/14787210.2024.2368989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/16/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION Non-typhoidal Salmonella (NTS) bacteremia is common in sub-Saharan Africa. We examined the prevalence of antibiotic resistance to fluoroquinolones, third-generation cephalosporins, and multi-drug resistance (MDR) in NTS human isolates from sub-Saharan Africa. METHODS A systematic review was conducted using a search in Ovid Medline, Embase, and African Index Medicus of publications between 2000 and 2021. A random-effects model meta-analysis was performed using data from 66 studies that included 29,039 NTS blood and 1,065 stool isolates. RESULTS The pooled prevalence proportions of MDR were 0.685 (95% CI 0.574-0.778) and 0.214 (0.020-0.785) in blood vs. stool isolates. The corresponding estimates of fluoroquinolones resistance were 0.014 (0.008-0.025) vs. 0.021 (0.012-0.036) and third-generation cephalosporins resistance 0.019 (0.012-0.031) vs. 0.035 (0.006-0.185). Similar results were found for children and adults. Resistance prevalence to these antibiotics in blood isolates increased between 2000-2010 and 2011-2021. The guidelines employed to determine antimicrobial resistance and epidemiological characteristics (e.g. sample size, study duration) correlated with the resistance prevalence. CONCLUSIONS The prevalence of MDR and resistance to fluoroquinolones and third-generation cephalosporins in NTS in sub-Saharan Africa is alarming. EXPERT OPINION Standardized surveillance of antimicrobial drug resistance in NTS in sub-Saharan Africa is warranted to guide healthcare policymaking and antibiotic stewardship programs.
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Affiliation(s)
- Yonatan Amir
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Muna Omar
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Amos Adler
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Clinical Microbiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sereen Abu-Moch
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Eric S Donkor
- Department of Medical Microbiology, University of Ghana Medical School, Accra, Ghana
| | - Dani Cohen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Gashu C, Kassa Y, Geremew H, Mulugeta M. Assessing the survival time of hospitalized patients in Eastern Ethiopia during 2019-2020 using the Bayesian approach: A retrospective cohort study. Health Sci Rep 2024; 7:e2135. [PMID: 38812715 PMCID: PMC11131042 DOI: 10.1002/hsr2.2135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 05/07/2024] [Accepted: 05/07/2024] [Indexed: 05/31/2024] Open
Abstract
Background and Aims Severe acute malnutrition remains a significant health challenge, particularly in low- and middle-income countries. The aim of this study was to determine the survival time of under-five children with severe acute malnutrition. Methods A retrospective cohort study was conducted at a hospital, focusing on under-five children with severe acute malnutrition. The study included 322 inpatients admitted to the Chiro hospital in Chiro, Ethiopia, between September 2019 and August 2020, whose data was obtained from medical records. Survival functions were analysed using Kaplan‒Meier plots and log-rank tests. The survival time of severe acute malnutrition was further analysed using the Cox proportional hazards model and Bayesian parametric survival models, employing integrated nested Laplace approximation methods. Results Among the 322 patients, 118 (36.6%) died as a result of severe acute malnutrition. The estimated median survival time for inpatients was found to be 2 weeks. Model selection criteria favored the Bayesian Weibull accelerated failure time model, which demonstrated that age, body temperature, pulse rate, nasogastric (NG) tube usage, hypoglycemia, anemia, diarrhea, dehydration, malaria, and pneumonia significantly influenced the survival time of severe acute malnutrition. Conclusions This study revealed that children below 24 months, those with altered body temperature and pulse rate, NG tube usage, hypoglycemia, and comorbidities such as anemia, diarrhea, dehydration, malaria, and pneumonia had a shorter survival time when affected by severe acute malnutrition under the age of five. To reduce the death rate of children under 5 years of age, it is necessary to design community management for acute malnutrition to ensure early detection and improve access to and coverage for children who are malnourished.
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Affiliation(s)
- Chalachew Gashu
- Department of StatisticsCollege of Natural and Computational Science, Oda Bultum UniversityChiroEthiopia
| | - Yoseph Kassa
- Department of StatisticsCollege of Natural and Computational Science, Oda Bultum UniversityChiroEthiopia
| | - Habtamu Geremew
- Department of NursingCollege of Health Science, Oda Bultum UniversityChiroEthiopia
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Sturgeon JP, Mufukari W, Tome J, Dumbura C, Majo FD, Ngosa D, Chandwe K, Kapoma C, Mutasa K, Nathoo KJ, Bourke CD, Ntozini R, Bwakura-Dangarembizi M, Amadi B, Kelly P, Prendergast AJ. Risk factors for inpatient mortality among children with severe acute malnutrition in Zimbabwe and Zambia. Eur J Clin Nutr 2023; 77:895-904. [PMID: 37553508 PMCID: PMC10473959 DOI: 10.1038/s41430-023-01320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND/OBJECTIVES Malnutrition underlies 45% of deaths in children under-5 years annually. Children hospitalised with complicated severe acute malnutrition (SAM) have unacceptably high mortality. We aimed to identify variables from early hospital admission (baseline factors) independently associated with inpatient mortality in this cohort to identify those most at risk. SUBJECTS/METHODS Observational study of 745 children aged 0-59 months admitted with complicated SAM at three hospitals in Zimbabwe/Zambia. Children underwent anthropometry and clinical assessment by a study physician within 72 h of enrolment, and caregivers provided sociodemographic data. Children were followed-up daily until discharge/death. A multivariable survival analysis identified the baseline factors independently associated with mortality. RESULTS 70/745 (9.4%) children died in hospital. Age between 6-23 months [aHR 6.53, 95%CI 2.24-19.02], higher mid-upper arm circumference [aHR 0.73, 95%CI 0.59-0.89], presence of oedema [aHR 2.22, 95%CI 1.23-4.05], shock [aHR 8.18, 95%CI 3.79-17.65], sepsis [aHR 3.13, 95%CI 1.44-6.80], persistent diarrhoea [aHR 2.27, 95%CI 1.18-4.37], lack of a toilet at home [aHR 4.35, 95%CI 1.65-11.47], and recruitment at one Harare site [aHR 0.38, 95%CI 0.18-0.83] were all independently associated with inpatient mortality. Oedematous children had a significantly higher birthweight [2987 g vs 2757 g, p < 0.001] than those without oedema; higher birthweight was weakly associated with mortality [aHR 1.50 95%CI 0.97-2.31]. CONCLUSIONS Children with oedema, low MUAC, baseline infections, shock and lack of home sanitation had a significantly increased risk of inpatient mortality following hospitalisation for complicated SAM. Children with high-risk features may require additional care. A better understanding of the pathophysiology of SAM is needed to identify adjunctive interventions.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe.
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK.
| | - Wadzanai Mufukari
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Kusum J Nathoo
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, 16 Lauchlan Avenue, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, 4 Newark Street, London, E1 2AT, UK
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Kyomugisa B, Were TP, Rujumba J, Munube D, Lorraine O, Kiguli S. "Prevalence, outcome and factors associated with dysglycemia among critically ill children presenting to Fort Portal Regional Referral Hospital: A cross sectional study". RESEARCH SQUARE 2023:rs.3.rs-2734736. [PMID: 37205509 PMCID: PMC10187377 DOI: 10.21203/rs.3.rs-2734736/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Introduction Dysglycemia has been shown to influence outcome among critically ill children. We aimed to determine the prevalence, outcome and factors associated with dysglycemia among critically ill children aged one month to 12 years presenting to Fort Portal regional referral hospital. Methods The study employed a descriptive, cross-sectional design for prevalence and factors associated, and longitudinal observational study design to determine the immediate outcome. Critically ill children aged one month to 12 years were systematically sampled and triaged at outpatient department using World Health Organization emergency signs. The random blood glucose was evaluated on admission and at 24 hours. Verbal and written informed consent/assent were obtained after stabilization of the study participants. Those that had hypoglycemia were given Dextrose 10% and those with hyperglycemia had no intervention. Results Of the 384 critically ill children, dysglycemia was present in 21.7% (n = 83), of those 78.3% (n = 65) had hypoglycemia and 21.7% (n = 18) had hyperglycemia. The proportion of dysglycemia at 24 hours was 2.4% (n = 2). None of the study participants had persistent hypoglycemia at 24 hours. The cumulative mortality at 48hours was 3.6% (n = 3). At 48 hours 33.2% (n = 27) had stable blood glucose levels and were discharged from the hospital. After multiple logistic regression, obstructed breathing (AOR 0.07(0.02-0.23), inability to breastfeed/drink (AOR 2.40 (1.17-4.92) and active convulsions (AOR 0.21 (0.06-0.74), were the factors that were significantly associated with dysglycemia among critically ill children. The results will guide in the revision of policies and treatment protocols to facilitate better management of children at risk of dysglycemia nationally. Conclusions Dysglycemia was found to affect one in five critically ill children aged one month to 12 years presenting to Fort Portal Regional Referral Hospital. Dysglycemia outcomes are good with early intervention.
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Affiliation(s)
- Beatrice Kyomugisa
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
| | - Thereza Piloya Were
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
| | - Deogratious Munube
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
| | - Oriokot Lorraine
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, College of Health sciences, Makerere University, P.O BOX 7072 Kampala, Uganda
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Sigh S, Roos N, Chhoun C, Laillou A, Wieringa FT. Ready-to-Use Therapeutic Foods Fail to Improve Vitamin A and Iron Status Meaningfully during Treatment for Severe Acute Malnutrition in 6-59-Month-old Cambodian Children. Nutrients 2023; 15:nu15040905. [PMID: 36839263 PMCID: PMC9961841 DOI: 10.3390/nu15040905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Abstract
Severe acute malnutrition (SAM) remains a global health concern. Studies on the impact of ready-to-use therapeutic foods (RUTFs) on micronutrient status during SAM treatment are almost nonexistent. The objective was to investigate the impact of RUTFs on the iron and vitamin A status of 6-59-month-old children receiving SAM treatment. Biomarkers of vitamin A status (retinol-binding protein, RBP), iron status (ferritin and soluble transferrin receptor, sTfR), and inflammation (C-reactive protein, CRP, and alpha-1 acid glycoprotein, AGP) were collected at admission and discharge (week 8) during an RUTF effectiveness trial. Vitamin A deficiency was defined as RBP <0.70 µmol/L, low body iron as body iron (BI) <0 mg/kg and deficient iron stores as ferritin <12 µg/L. Data were available for 110 and 75 children at admission and discharge, respectively. There was no significant difference in haemoglobin, ferritin, sTfR, BI or RBP concentrations between admission and discharge. At discharge, BI was 0.2 mg/kg lower, and there was a tendency towards a slightly lower RBP concentration, but the prevalence of vitamin A deficiency was low at admission and discharge (6% and 3%, respectively). The small impact of both RUTFs on improving vitamin A and iron status during SAM treatment calls for further research on the bioavailability of micronutrients to enhance the effectiveness of SAM treatment on micronutrient status.
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Affiliation(s)
- Sanne Sigh
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark
- Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, 186 Preah Norodom Boulevard, Phnom Penh 12101, Cambodia
- Correspondence: ; Tel.: +855-(0)95-201-308
| | - Nanna Roos
- Department of Nutrition, Exercise, and Sports, Faculty of Science, University of Copenhagen, Rolighedsvej 26, 1958 Frederiksberg C, Denmark
| | - Chamnan Chhoun
- Department of Fisheries Post-Harvest Technologies and Quality Control, Fisheries Administration, 186 Preah Norodom Boulevard, Phnom Penh 12101, Cambodia
| | - Arnaud Laillou
- Nutrition Section, UNICEF West and Central Africa Region, Dakar 29720, Senegal
| | - Frank T. Wieringa
- UMR QualiSud, Institut de Recherche Pour le Développement (IRD), 34394 Montpellier, France
- Qualisud, University of Montpellier, Avignon University, CIRAD, Institut Agro, IRD, Université de la Réunion, 34394 Montpellier, France
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Musiime V, Kiggwe A, Beinomugisha J, Kakooza L, Thembo-Mwesige J, Nkinzi S, Naguti E, Atuhaire L, Segawa I, Ssengooba W, Mukonzo JK, Babirekere-Iriso E, Musoke P. Strategies to Reduce Mortality Among Children Living With HIV and Children Exposed to HIV but Are Uninfected, Admitted With Severe Acute Malnutrition at Mulago Hospital, Uganda (REDMOTHIV): A Mixed Methods Study. Front Pediatr 2022; 10:880355. [PMID: 35813373 PMCID: PMC9263204 DOI: 10.3389/fped.2022.880355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/02/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Children living with HIV (CLHIV) and children who are exposed to HIV but uninfected (CHEU) are at increased risk of developing malnutrition. Severely malnourished children have high mortality rates, but mortality is higher in CLHIV/CHEU. This study aims to investigate whether empiric use of an antibiotic with greater antimicrobial sensitivity (ceftriaxone) than standard-of-care (ampicillin plus gentamicin) will reduce mortality among CLHIV/CHEU admitted with severe acute malnutrition. METHODS This is an open label randomized controlled trial involving 300 children; 76 CLHIV and 224 CHEU. The participants are being randomized to receive 1 week of ceftriaxone (n = 150) or standard-of-care (ampicillin/gentamicin) (n = 150), in addition to other routine care. The trial's primary outcome is in-hospital mortality. Secondary outcomes are: length of hospitalization; weight-for-height, weight-for-age and height-for-age z-scores; and pattern/antimicrobial sensitivity of pathogens. In addition, 280 severely malnourished children of unknown serostatus will be tested for HIV at admission to determine the prevalence and factors associated with HIV-infection. Furthermore, all the CLHIV on LPV/r will each provide sparse pharmacokinetic (PK) samples to evaluate the PK of LPV/r among malnourished children. In this PK sub-study, geometric means of steady-state LPV PK parameters [Area Under the Curve (AUC) 0-12h , maximum concentration (Cmax) and concentration at 12 h after dose (C12h)] will be determined. They will then be put in pharmacokinetic-pharmacodynamic (PK-PD) models to determine optimal doses for the study population. DISCUSSION This study will ascertain whether antibiotics with higher sensitivity patterns to common organisms in Uganda and similar settings, will produce better treatment outcomes. The study will also provide insights into the current pattern of organisms isolated from blood cultures and their antimicrobial sensitivities, in this population. In addition, the study will ascertain whether there has been a significant change in the prevalence of HIV-infection among children presenting with severe malnutrition in the WHO recommended option B plus era, while determining the social/structural factors associated with HIV-infection. There will also be an opportunity to study PK parameters of antiretroviral drugs among severely malnourished children which is rarely done, and yet it is very important to understand the dosing requirements of this population. TRIAL REGISTRATION ClinicalTrials.gov, identifier: NCT05051163.
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Affiliation(s)
- Victor Musiime
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda.,Department of Research, Joint Clinical Research Centre, Kampala, Uganda
| | - Andrew Kiggwe
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Judith Beinomugisha
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lawrence Kakooza
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Josam Thembo-Mwesige
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sharafat Nkinzi
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Erusa Naguti
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Loice Atuhaire
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Ivan Segawa
- Makerere University Lung Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Willy Ssengooba
- BSL 3 Mycobacteriology Laboratory, Department of Medical Microbiology, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jackson K Mukonzo
- Department of Pharmacology and Therapeutics, School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Esther Babirekere-Iriso
- Mwanamugimu Nutrition Unit, Directorate of Paediatrics and Child Care, Mulago National Referral Hospital, Kampala, Uganda
| | - Philippa Musoke
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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7
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Wen B, Brals D, Bourdon C, Erdman L, Ngari M, Chimwezi E, Potani I, Thitiri J, Mwalekwa L, Berkley JA, Bandsma RHJ, Voskuijl W. Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs. BMC Med 2021; 19:222. [PMID: 34538239 PMCID: PMC8451091 DOI: 10.1186/s12916-021-02074-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM. METHODS This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell's concordance index (C-index) and time-dependent area under the curve (tAUC). RESULTS Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77-0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74-0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively. CONCLUSIONS This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children. TRIAL REGISTRATION NCT02246296.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Lauren Erdman
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Isabel Potani
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Biomedical Sciences, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands. .,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya. .,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi. .,Amsterdam Center for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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8
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Karunaratne R, Sturgeon JP, Patel R, Prendergast AJ. Predictors of inpatient mortality among children hospitalized for severe acute malnutrition: a systematic review and meta-analysis. Am J Clin Nutr 2020; 112:1069-1079. [PMID: 32885807 PMCID: PMC7528552 DOI: 10.1093/ajcn/nqaa182] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/12/2020] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Malnutrition underlies 45% of under-5 deaths globally. Severe acute malnutrition (SAM) is the most serious form of undernutrition, characterized by wasting with or without edema. Mortality remains high (10%-40%) among children requiring hospitalization for complicated SAM. OBJECTIVES We aimed to systematically document the factors independently associated with inpatient mortality in children with SAM. METHODS Embase, Ovid MEDINE, the Cochrane Library, and clinicaltrials.gov were searched for articles published between January 2000 and January 2020, using a prespecified protocol. Eligible studies included children aged ≤59 mo hospitalized with SAM and used multivariable analysis to assess the baseline factors independently associated with inpatient mortality. Random-effects meta-analysis, stratified by the stated measure of effect, was used where >20% of studies included the same factor in analyses. RESULTS Twenty-eight of 1432 studies fulfilled inclusion criteria: 19 studies included all children with SAM and 9 included specific subgroups of children with SAM. All 19 main studies were from 8 countries across Africa, with a median of 400 children/study. The mean inpatient mortality was 15.7% (95% CI: 10.4%, 21.0%) and HIV prevalence ranged from 2.1% to 51%. Nine factors were included in the meta-analysis, stratified by HR and OR. HIV infection (HR: 4.32; 95% CI: 2.31, 8.08), weight-for-height z score (WHZ) (OR: 0.44; 95% CI: 0.24, 0.80), diarrhea (HR: 2.84; 95% CI: 1.40, 5.75), pneumonia (HR: 1.89; 95% CI: 1.19, 3.02), presence of shock (HR: 3.67; 95% CI: 2.24, 6.03), and lack of appetite (HR: 2.16; 95% CI: 1.48, 3.16) were associated with increased mortality, whereas child age and sex were not. The association between edema and mortality was difficult to ascertain from the available studies. CONCLUSIONS HIV infection, diarrhea, pneumonia, shock, lack of appetite, and lower WHZ are independent predictors of inpatient mortality in children with SAM. These factors may help to risk-stratify children being hospitalized with complicated SAM.This systematic review/meta-analysis protocol was registered at www.crd.york.ac.uk/prospero as CRD42019152267.
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Affiliation(s)
| | - Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Rajvi Patel
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, United Kingdom
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Ashine YE, Ayele BA, Aynalem YA, Yitbarek GY. Time to Death and its Predictor Among Children Under Five Years of Age with Severe Acute Malnutrition Admitted to Inpatient Stabilization Centers in North Shoa Zone, Amhara Region, Ethiopia . NUTRITION AND DIETARY SUPPLEMENTS 2020. [DOI: 10.2147/nds.s249045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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10
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Vonasek BJ, Chiume M, Crouse HL, Mhango S, Kondwani A, Ciccone EJ, Kazembe PN, Gaven W, Fitzgerald E. Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi. Paediatr Int Child Health 2020; 40:148-157. [PMID: 32242509 DOI: 10.1080/20469047.2020.1747003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood. METHODS Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression. RESULTS Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44). CONCLUSION HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.
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Affiliation(s)
- Bryan J Vonasek
- Department of Pediatrics, Baylor College of Medicine , Houston, USA
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu Central Hospital , Lilongwe, Malawi.,College of Medicine, University of Malawi , Lilongwe, Malawi
| | - Heather L Crouse
- Department of Pediatrics, Baylor College of Medicine , Houston, USA
| | - Susan Mhango
- Baylor College of Medicine Children's Foundation Malawi , Lilongwe, Malawi
| | | | - Emily J Ciccone
- Department of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, USA
| | | | - Wilfred Gaven
- Malawi College of Health Sciences , Lilongwe, Malawi
| | - Elizabeth Fitzgerald
- Department of Pediatrics, University of North Carolina at Chapel Hill , Chapel Hill, USA
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11
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Nduhukire T, Atwine D, Rachel L, Byonanebye JE. Predictors of in-hospital mortality among under-five children with severe acute malnutrition in South-Western Uganda. PLoS One 2020; 15:e0234343. [PMID: 32589637 PMCID: PMC7319331 DOI: 10.1371/journal.pone.0234343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) affects about 13 million under-five children (U5), with an estimated one million dying every year. In this study we aimed at determining the in hospital mortality and its associated factors among U5s admitted with SAM. METHODS This was a prospective cohort study of children 6 months to 5 years with SAM admitted at Mbarara Regional Referral Hospital (MRRH) between June and August 2015. Care-takers were interviewed to collect socio-demographic and clinical information. Children under-went physical examination and had blood drawn for HIV, serum glucose, malaria, full blood count, culture and serum electrolytes investigation. Children were managed according to WHO treatment guidelines for SAM. All participants were followed up for a maximum period of 30 days. The proportion of U5 deaths within the first 48 hours and during the entire admission period was calculated. Using Poisson regression analysis, predictors of in-hospital mortality were analyzed with STATA/IC 11.0. RESULTS We enrolled 122 children, median age of 15 months [IQR:11-24], 58.2% males, 90% immunized, 81% ill for more than 2 weeks before admission, 71% from lower health facilities and majority with unknown HIV status(76%). Overall, 13 (10.7%) children died in hospital. Seven (5.7%) died within the first 48 hours. Intravenous (IV) fluid administration significantly predicted in-hospital mortality (adjusted IRR: 7.2, 95%CI: 2.14-24.08, p = 0.001). CONCLUSION The in-hospital mortality in U5s with SAM was lower than that previously reported in central Uganda. Intravenous fluid administration significantly predicted overall in-hospital mortality. While Administration of intravenous fluids is still the main stay of managing severely malnourished children with shock, more research needs to be conducted in order to review the parameters presently used to assess children for shock with a view of diagnosing and managing shock in these children when it is still early. Adequate guidance on use of IV fluids in management of severely malnourished children should be prioritized during continuous medical education for healthcare workers and in the treatment guidelines.
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Affiliation(s)
- Timothy Nduhukire
- Department of Pediatrics and Child Health, Kabale University, Kabale, Uganda
- * E-mail:
| | | | - Luwaga Rachel
- Department of Nursing, Bishop Stuart University, Mbarara, Uganda
| | - Joseph E. Byonanebye
- Department of Biomedical Sciences, Marquette University, Milwaukee, Winconsin, United States of America
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Ghazawy ER, Bebars GM, Eshak ES. Survival status and mortality predictors among severely malnourished under 5 years of age children admitted to Minia University maternity and children hospital. BMC Pediatr 2020; 20:233. [PMID: 32429871 PMCID: PMC7236451 DOI: 10.1186/s12887-020-02146-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Though effective treatment programs for severely malnourished children are available, mortality rate among children with acute malnutrition continue to rise and little is known about its long-term outcomes and potential predictors of its in-hospital and post-discharge mortality. The aim of this study was to assess the survival status and predictors for mortality in severely malnourished children admitted to Minia University Maternity and Children Hospital. METHODS A retrospective cohort study which included 135 children under 5 years of age who were admitted to the nutrition rehabilitation ward with severe acute malnutrition (SAM) during the period from January to December 2018. Data were collected from the inpatient's hospital records and the children's parents/guardians were interviewed using a detailed structured questionnaire that inquired about demographic and socioeconomic variables. The logistic and Cox regressions were used to assess the factors associated with the SAM's mortality. RESULTS A total of 135 children were enrolled into the study. Death rate during hospitalization was 9.6%. The survival rate at the end of the fourth week of admission was 82.4%. There were 6.7% post-discharge deaths among 104 alive discharged children which occurred within 8 weeks after discharge. The adjusted HRs (95% CIs) for total SAM deaths were 1.57 (1.10-2.99) in children < 12 vs ≥ 12 months old; 4.79 (2.23-6.10) in those with WAZ < -3SD, 2.99 (1.16-4.66) in those with edema at admission and 3.44 (1.07-9.86) in children with complications. The respective ORs (95%CIs) for in-hospital SAM deaths in the same groups of children were 2.64 (1.22-6.43), 8.10 (2.16-11.67), 3.04 (1.70-6.06) and 3.71 (1.59-6.78). The main predictor for the SAM's post-discharge mortality was illiteracy of mothers; the adjusted HR (95%CI) was 7.10 (1.58-31.93; p = 0.01). CONCLUSIONS Age, WAZ, edema and complications at admission were predictors for both in-hospital and total SAM mortality, while mother's education contributed to the early post-discharge mortality. The identification of predictors for mortality is an important preliminary step for interventions aiming to reduce morbidity and mortality.
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Affiliation(s)
- Eman Ramadan Ghazawy
- Public Health and Preventive Medicine department, Faculty of medicine, El-Minia University. University St, El-Minia, 1666 Egypt
| | | | - Ehab Salah Eshak
- Public Health and Preventive Medicine department, Faculty of medicine, El-Minia University. University St, El-Minia, 1666 Egypt
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13
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Nalwanga D, Musiime V, Kizito S, Kiggundu JB, Batte A, Musoke P, Tumwine JK. Mortality among children under five years admitted for routine care of severe acute malnutrition: a prospective cohort study from Kampala, Uganda. BMC Pediatr 2020; 20:182. [PMID: 32331517 PMCID: PMC7181483 DOI: 10.1186/s12887-020-02094-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 04/20/2020] [Indexed: 02/07/2023] Open
Abstract
Background Mortality among children under 5 years of age admitted to malnutrition units in sub-Saharan Africa remains high. The burden of HIV infection, a major risk factor for mortality among patients with severe acute malnutrition (SAM), has reduced due to concerted prevention and treatment strategies. None the less, anecdotal reports from the malnutrition unit at Uganda’s National Referral Hospital (NRH) indicate that there is high mortality among patients with severe acute malnutrition (SAM) in routine care. Uganda has recently adopted the revised World Health Organization (WHO) treatment guidelines for SAM to improve outcomes. The mortality among children with SAM in routine care has not been recently elucidated. We report the magnitude and factors associated with mortality among children under 5 years of age admitted to the NRH for routine care of SAM. Methods This was a cohort study of all severely malnourished children admitted to the NRH between June and October 2017. The primary outcome was two-week mortality. Mortality was calculated using simple proportions and Cox regression analysis was used to determine factors associated with time to mortality. Data was entered into Epidata and analysed using Stata v14. Results Two-hundred-sixty (98.5%) children: 59.6% male; mean age 14.4 (SD 9.4) months, completed two weeks of follow-up. Of these, 25.2% (95% CI 19.9–30.4%) died. In-hospital mortality was 20.7% (95% CI15.9–25.6%). The prevalence of HIV infection was 12.2%. Factors associated with mortality included: positive HIV status (AHR 2.2, (95% CI; 1.2–4.2), p = 0.014), bacteraemia (AHR 9 (95% CI 3.4–23.0), p < 0.001, and low glomerular filtration rate (eGFR), AHR 3.2; (95% CI 1.7–6.3), p = 0.001). Conclusions A 25% mortality among children with severe malnutrition remains unacceptably high despite significant reduction in HIV prevalence. Children with SAM who are HIV infected, have eGFR below 60 mL/min/1.73m2 or have bacteraemia, are more likely to die. Further studies to explore the relationship between eGFR and mortality among children with SAM are needed. Studies to establish efficacious antibiotics are urgently required to inform treatment guidelines for children with SAM.
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Affiliation(s)
- Damalie Nalwanga
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.
| | - Victor Musiime
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda.,Research Department, Joint Clinical Research Centre, P. O. Box 10005, Kampala, Uganda
| | - Samuel Kizito
- Clinical Epidemiology Unit, Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, P. O Box 7072, Kampala, Uganda
| | - John Baptist Kiggundu
- Clinical Epidemiology Unit, Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, P. O Box 7072, Kampala, Uganda
| | - Anthony Batte
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - Philippa Musoke
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, P. O. Box 7072, Kampala, Uganda
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14
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Wagnew F, Dessie G, Takele WW, Tadesse A, Islam SMS, Mulugeta H, Haile D, Negesse A, Abajobir AA. A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia. BMC Public Health 2019; 19:1175. [PMID: 31455292 PMCID: PMC6712890 DOI: 10.1186/s12889-019-7466-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/11/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia. METHODS A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran's Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger's test for publication bias. RESULT Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected. CONCLUSION Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.
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Affiliation(s)
- Fasil Wagnew
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Getenet Dessie
- College of Health Sciences, Bahirdar University, Bahirdar, Ethiopia
| | | | - Aster Tadesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | | | - Henok Mulugeta
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Dessalegn Haile
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Ayenew Negesse
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | - Amanuel Alemu Abajobir
- Faculty of Medicine/school of Public Health, The University of Queensland, Brisbane, Australia
- African Population and Health Research Center, Maternal and Child Wellbeing Unit, Nairobi, Kenya
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15
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Sarmin M, Afroze F, Sharifuzzaman, Alam T, Shaly NJ, Ahmed T, Chisti MJ. Predictor of Death in Diarrheal Children Under 5 Years of Age Having Severe Sepsis in an Urban Critical Care Ward in Bangladesh. Glob Pediatr Health 2019; 6:2333794X19862716. [PMID: 31384628 PMCID: PMC6647208 DOI: 10.1177/2333794x19862716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/23/2019] [Accepted: 06/03/2019] [Indexed: 01/20/2023] Open
Abstract
We aimed to identify clinical predictors of fatal outcome in children under 5
years of age having diarrhea and severe sepsis and treated in the Intensive Care
Unit of the Dhaka Hospital of icddr,b from October 2010 through September 2011.
Among 191 enrolled children, 70 (37%) died and were considered to be cases,
while the remaining 121 (63%) who survived constituted the controls. The cases
more often had shortness of breath (SOB), septic shock, dehydrating diarrhea
compared with the controls (for all, P < .05). After
adjusting for potential confounders using logistic regression analysis, the
likelihood of death was higher in children who had septic shock and SOB and
lower in children having dehydrating diarrhea (for all, P <
.05). Thus, SOB can trigger an early alarm for sepsis recognition; otherwise,
these children can end up with fatality from septic shock. In resource-poor
settings, early identification of these predictors can alleviate death.
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Affiliation(s)
- Monira Sarmin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Afroze
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharifuzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmina Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nusrat Jahan Shaly
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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16
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Desyibelew HD, Baraki AG, Dadi AF. Mortality rate and predictors of time to death in children with severe acute malnutrition treated in Felege-Hiwot Referral Hospital Bahir Dar, Northwest Ethiopia. BMC Res Notes 2019; 12:409. [PMID: 31307556 PMCID: PMC6631743 DOI: 10.1186/s13104-019-4467-x] [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] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives This study aimed to determine mortality rate, time to death and factors affecting the time to death among children with severe acute malnutrition admitted to therapeutic feeding unit of Felege Hiwot Referral Hospital, Bahirdar. Result A total of 401 children with severe acute malnutrition who were admitted to therapeutic feeding units from September 2012 to January 2016 were included in the study. The incidence of death rate was 8.47% (95% CI 6.11%, 11.65%). The median time to death was 3 days (Inter Quartile Range of 4 days). Children’s of age > 24 months (AHR = 0.27; 95% CI 0.1, 0.73), fully vaccinated status (AHR = 0.16; 95% CI 0.07, 0.36), HIV infection (AHR = 3.82; 95% CI 1.3, 11.15) and congestive heart failure (AHR = 6.98; 95% CI 2.42, 20.09) were significant predictors of mortality among children admitted for severe acute malnutrition.
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Affiliation(s)
- Hanna Demelash Desyibelew
- Department of Public Health Nutrition, College of Medicine and Health Sciences, Bahirdar University, Bahir Dar, Ethiopia
| | - Adhanom Gebreegziabher Baraki
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Abel Fekadu Dadi
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.,Flinders University, Health Sciences Building, Sturt Road, Bedford Park, Adelaide, SA, 5001, Australia
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17
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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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Opoka RO, Ssemata AS, Oyang W, Nambuya H, John CC, Karamagi C, Tumwine JK. Adherence to clinical guidelines is associated with reduced inpatient mortality among children with severe anemia in Ugandan hospitals. PLoS One 2019; 14:e0210982. [PMID: 30682097 PMCID: PMC6347145 DOI: 10.1371/journal.pone.0210982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia. METHODS We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of 'severe anemia (SA)' were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA. RESULTS A total of 1,131 children were assigned a clinical diagnosis of 'severe anemia' in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22]. CONCLUSION Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
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Affiliation(s)
- Robert O. Opoka
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew S. Ssemata
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Oyang
- Children’s Ward, Lira Regional Referral Hospital, Lira, Uganda
| | - Harriet Nambuya
- Nalufenya Children’s Ward, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Charles Karamagi
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - James K. Tumwine
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Treatment Outcome of Severe Acute Malnutrition and Its Determinants among Pediatric Patients in West Ethiopia. Int J Pediatr 2018; 2018:8686501. [PMID: 30154873 PMCID: PMC6091446 DOI: 10.1155/2018/8686501] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/30/2018] [Accepted: 07/18/2018] [Indexed: 11/18/2022] Open
Abstract
Background Malnutrition is a silent killer that is underreported, underaddressed, and as a result underprioritized. It is reported that severe acute malnutrition is the commonest reason for pediatrics hospital admission in many poor countries; 25 to 30% of children with severe malnutrition die during hospital admissions. Objective To determine treatment outcome of severe acute malnutrition and identify its determinants among pediatric patients in pediatrics ward of Nekemte Referral Hospital. Methods A retrospective hospital-based cross-sectional study was done from November 2015 to April 2017. Data had been collected by using checklist for recording information from patient card and register book. Association between independent variables and depend variable was assessed using bivariate and stepwise multivariable logistic regression, respectively. Level of statistical significance was declared at p value < 0.05. Results Out of 205 admitted children with severe acute malnutrition, 137 (66.8%) cases were cured from SAM, 9 (4.4%) cases were died because of SAM, and (16.6%) cases were defaulter from SAM management, and 25 (12.2%) cases were transferred out. Multivariable logistic regression showed that children admitted with both edema and wasting AOR = 8.30, 95% CI (1.72, 40.09) P=0.008, children without hypothermia AOR = 2.91, 95%CI (1.10, 7.69) P=0.031, children who stay 8-14 days AOR = 3.86, 95%CI (1.01, 14.75) P=0.048, children without pneumonia AOR = 7.82, 95%CI (2.74, 222.29) P=0.001, children without anemia AOR = 3.22, 95%CI (1.04, 9.97) P=0.042, and children without HIV AOR = 9.21, 95% CI (2.20, 38.54) P=0.002 were more likely to be cured from severe acute malnutrition. Conclusion Treatment outcome of severe acute malnutrition in this study is good. It shows that around three-fourths of the children were cured. Factors such as admission criteria, hypothermia, length of stay, pneumonia, anemia, and presence of HIV were associated with treatment response.
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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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Abstract
The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.
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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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Rudd KE, Tutaryebwa LK, West TE. Presentation, management, and outcomes of sepsis in adults and children admitted to a rural Ugandan hospital: A prospective observational cohort study. PLoS One 2017; 12:e0171422. [PMID: 28199348 PMCID: PMC5310912 DOI: 10.1371/journal.pone.0171422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 01/20/2017] [Indexed: 12/29/2022] Open
Abstract
Objectives Limited data are available on sepsis in low-resource settings, particularly outside of urban referral centers. We conducted a prospective observational single-center cohort study in May 2013 to assess the presentation, management and outcomes of adult and pediatric patients admitted with sepsis to a community hospital in rural Uganda. Methods We consecutively screened all patients admitted to medical wards who met sepsis criteria. We evaluated eligible patients within 24 hours of presentation and 24–48 hours after admission, and followed them until hospital discharge. In addition to chart review, mental status evaluation, peripheral capillary oxygen saturation, and point-of-care venous whole blood lactate and glucose testing were performed. Results Of 56 eligible patients, we analyzed data on 51 (20 adults and 31 children). Median age was 8 years (IQR 2–23 years). Sepsis accounted for a quarter of all adult and pediatric medical ward admissions during the study period. HIV prevalence among adults was 30%. On enrollment, over half of patients had elevated point-of-care whole blood lactate, few were hypoglycemic or had altered mental status, and one third were hypoxic. Over 80% of patients received at least one antibiotic, all severely hypoxic patients received supplemental oxygen, and half of patients with elevated lactate received fluid resuscitation. The most common causes of sepsis were malaria and pneumonia. In-hospital mortality was 3.9%. Conclusions This study highlights the importance of sepsis among adult and pediatric patients admitted to a rural Ugandan hospital and underscores the need for continued research on sepsis in low resource settings.
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Affiliation(s)
- Kristina E. Rudd
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Leonard K. Tutaryebwa
- Department of Paediatrics and Child Health, Bwindi Community Hospital, Kanungu, Uganda
| | - T. Eoin West
- International Respiratory and Severe Illness Center, University of Washington, Seattle, Washington, United States of America
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, Washington, United States of America
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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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Girum T, Kote M, Tariku B, Bekele H. Survival status and predictors of mortality among severely acute malnourished children <5 years of age admitted to stabilization centers in Gedeo Zone: a retrospective cohort study. Ther Clin Risk Manag 2017; 13:101-110. [PMID: 28176953 PMCID: PMC5271381 DOI: 10.2147/tcrm.s119826] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Despite the existence of standard protocol, many stabilization centers (SCs) continue to experience high mortality of children receiving treatment for severe acute malnutrition. Assessing treatment outcomes and identifying predictors may help to overcome this problem. Therefore, a 30-month retrospective cohort study was conducted among 545 randomly selected medical records of children <5 years of age admitted to SCs in Gedeo Zone. Data was entered by Epi Info version 7 and analyzed by STATA version 11. Cox proportional hazards model was built by forward stepwise procedure and compared by the likelihood ratio test and Harrell's concordance, and fitness was checked by Cox-Snell residual plot. During follow-up, 51 (9.3%) children had died, and 414 (76%) and 26 (4.8%) children had recovered and defaulted (missed follow-up for 2 consecutive days), respectively. The survival rates at the end of the first, second and third weeks were 95.3%, 90% and 85%, respectively, and the overall mean survival time was 79.6 days. Age <24 months (adjusted hazard ratio [AHR] =2.841, 95% confidence interval [CI] =1.101-7.329), altered pulse rate (AHR =3.926, 95% CI =1.579-9.763), altered temperature (AHR =7.173, 95% CI =3.05-16.867), shock (AHR =3.805, 95% CI =1.829-7.919), anemia (AHR =2.618, 95% CI =1.148-5.97), nasogastric tube feeding (AHR =3.181, 95% CI =1.18-8.575), hypoglycemia (AHR =2.74, 95% CI =1.279-5.87) and treatment at hospital stabilization center (AHR =4.772, 95% CI =1.638-13.9) were independent predictors of mortality. The treatment outcomes and incidence of death were in the acceptable ranges of national and international standards. Intervention to further reduce deaths has to focus on young children with comorbidities and altered general conditions.
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Affiliation(s)
- Tadele Girum
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite
| | - Mesfin Kote
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch
| | - Befikadu Tariku
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch
| | - Henok Bekele
- Department of Planning, Adare Hospital, Southern Region Health Bureau, Hawassa, Ethiopia
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Chiabi A, Malangue B, Nguefack S, Dongmo FN, Fru F, Takou V, Angwafo F. The clinical spectrum of severe acute malnutrition in children in Cameroon: a hospital-based study in Yaounde, Cameroon. Transl Pediatr 2017; 6:32-39. [PMID: 28164028 PMCID: PMC5253267 DOI: 10.21037/tp.2016.07.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major health problem, and the cause of more than half of childhood deaths in children less than 5 years in developing countries. Globally, 20 million children under 5 years of age are severely malnourished according to the World Health Organization (WHO). In Cameroon, the prevalence of SAM remains high and estimated at 1.9% in 2011 and 1.3% in 2014. The aim of this study was to determine the epidemiology, clinical aspects and outcome of SAM at the Yaounde Gynaeco-Obstetric and Pediatric Hospital (YGOPH). METHODS We retrospectively reviewed the medical records of children hospitalized in the YGOPH for SAM over a period of 8 1/2 years (from September 2006 to March 2015). We included the medical records of children under 15 years of age who were hospitalized in the pediatric unit of the YGOPH for the management of SAM. Data was collected using a data entry form and was analyzed with Epi info version 3.5.4 software. Data was considered statistically significant for P less than 0.05. RESULTS The prevalence of SAM was 2.72%. The median age was 9 months (range, 23 days-112 months). The most represented age group was 6 to 12 months with 34.6% of the children. The most frequent symptoms on admission were: wasting (58.1%) and fever (53.6%). The mean interval between the onset of symptoms and admission was 30.36 days. Marasmus was the most frequent clinical form of SAM observed in 88.8% of the children. Respiratory tract infections were the most common comorbidities and were present in 45 patients (25.1%), followed by malaria in 15.1% of cases. The sero-prevalence of human immuno deficiency virus (HIV) was 43.75% amongst the 32 children whose HIV status was known. Dehydration was the most frequent complication, with an occurrence of 29.6%. A total of 58.7% of patients were discharged following clinical improvement and the mortality rate was 15%. The average duration of hospitalization was 8.25 days. CONCLUSIONS SAM is a frequently encountered pathology in this context with a high mortality, thus the need to step up prevention strategies. Health education during pediatric consultations and vaccination sessions on the appropriate feeding of the young infant and the child should be reinforced.
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Affiliation(s)
- Andreas Chiabi
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon;; Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
| | - Berthe Malangue
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Seraphin Nguefack
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon;; Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
| | - Félicitée Nguefack Dongmo
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon;; Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
| | - Florence Fru
- Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
| | - Virginie Takou
- Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
| | - Fru Angwafo
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon;; Gynaeco-Obstetric and Pediatric Hospital Yaounde, Yaounde, Cameroon
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Tickell KD, Denno DM. Inpatient management of children with severe acute malnutrition: a review of WHO guidelines. Bull World Health Organ 2016; 94:642-651. [PMID: 27708469 PMCID: PMC5034633 DOI: 10.2471/blt.15.162867] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 02/01/2023] Open
Abstract
Objective To understand how the World Health Organization’s (WHO’s) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes. Methods In December 2015, we searched Google scholar and WHO’s website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials. Findings WHO’s guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion – unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research – i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented. Conclusion WHO’s guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.
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Affiliation(s)
- Kirkby D Tickell
- Department of Epidemiology, University of Washington, Seattle, United States of America (USA)
| | - Donna M Denno
- Departments of Pediatrics and Global Health, University of Washington, 6200 NE 74th Street, Suite 110, Box 354920, Seattle, WA 98115, USA
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Kambale RM, Kasengi JB, Kivukuto JM, Cubaka LM, Mungo BM, Balaluka GB. [Infectious profile and mortality of children aged 0-5 years admitted with severe acute malnutrition: a retrospective cohort study conducted in the Therapeutic Nutritional Center in Bukavu, Republic of Congo]. Pan Afr Med J 2016; 23:139. [PMID: 27279964 PMCID: PMC4885721 DOI: 10.11604/pamj.2016.23.139.8370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/27/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction La malnutrition constitue une toile de fond sur laquelle se greffent plusieurs infections. L'objectif de ce travail est de déterminer les infections les plus létales, la durée médiane de séjour et le gain pondéral médian journalier des enfants malnutris. Méthodes Étude de cohorte rétrospective des enfants malnutris de 0 à 59 mois hospitalisés au Centre Nutritionnel et Thérapeutique de Bukavu du 1er janvier 2011 au 31 décembre 2013. L’évaluation du risque de survenue de décès par complication infectieuse a été faite par la mesure du risque relatif. Nous avons utilisé le test de Mann-Whitney pour comparer les médianes. Les Odd ratio ajustés par régression logistique et leurs intervalles de confiance à 95% du risque de mortalité ont été donnés pour chaque cause infectieuse. Résultats Au total, 574 enfants avaient été inclus. Cinq cent vingt et un (90.8%) enfants étaient sortis guéris, 10 (1.7%) avaient abandonné le traitement et 43 (7.5%) étaient décédés. La durée médiane de séjour était de 19 (13-26) jours et le gain pondéral médian journalier était de 7 (3-13) g/kg/j. Il existait une association statistiquement significative entre la mortalité et le sepsis / choc septique (p = 0,0004), la méningite (p = 0,00001), et l'infection à VIH (p = 0,02). Conclusion Une meilleure prise en charge de la malnutrition aigüe dans notre région devrait se baser sur la mise en place des unités spécialisées et bien équipées pour la prise en charge de la malnutrition associées aux infections sévères.
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Affiliation(s)
- Richard Mbusa Kambale
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | - Joe Bwija Kasengi
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | | | - Liévin Murhula Cubaka
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | - Bruno Masumbuko Mungo
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
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Nyeko R, Calbi V, Ssegujja BO, Ayot GF. Treatment outcome among children under-five years hospitalized with severe acute malnutrition in St. Mary’s hospital Lacor, Northern Uganda. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0058-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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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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Irena AH, Bahwere P, Owino VO, Diop EI, Bachmann MO, Mbwili-Muleya C, Dibari F, Sadler K, Collins S. Comparison of the effectiveness of a milk-free soy-maize-sorghum-based ready-to-use therapeutic food to standard ready-to-use therapeutic food with 25% milk in nutrition management of severely acutely malnourished Zambian children: an equivalence non-blinded cluster randomised controlled trial. MATERNAL & CHILD NUTRITION 2015; 11 Suppl 4:105-19. [PMID: 23782554 PMCID: PMC6860345 DOI: 10.1111/mcn.12054] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Community-based Management of Acute Malnutrition using ready-to-use therapeutic food (RUTF) has revolutionised the treatment of severe acute malnutrition (SAM). However, 25% milk content in standard peanut-based RUTF (P-RUTF) makes it too expensive. The effectiveness of milk-free RUTF has not been reported hitherto. This non-blinded, parallel group, cluster randomised, controlled, equivalence trial that compares the effectiveness of a milk-free soy-maize-sorghum-based RUTF (SMS-RUTF) with P-RUTF in treatment of children with SAM, closes the gap. A statistician randomly assigned health centres (HC) either to the SMS-RUTF (n = 12; 824 enrolled) or P-RUTF (n = 12; 1103 enrolled) arms. All SAM children admitted at the participating HCs were enrolled. All the outcomes were measured at individual level. Recovery rate was the primary outcome. The recovery rates for SMS-RUTF and P-RUTF were 53.3% and 60.8% for the intention-to-treat (ITT) analysis and 77.9% and 81.8% for per protocol (PP) analyses, respectively. The corresponding adjusted risk difference (ARD) and 95% confidence interval, were -7.6% (-14.9, 0.6%) and -3.5% (-9,6., 2.7%) for ITT (P = 0.034) and PP analyses (P = 0.257), respectively. An unanticipated interaction (interaction P < 0.001 for ITT analyses and 0.0683 for PP analyses) between the study arm and age group was observed. The ARDs were -10.0 (-17.7 to -2.3)% for ITT (P = 0.013) and -4.7 (-10.0 to 0.7) for PP (P = 0.083) analyses for the <24 months age group and 2.1 (-10.3,14.6)% for ITT (P = 0.726) and -0.6 (-16.1, 14.5) for PP (P = 0.939) for the ≥24 months age group. In conclusion, the study did not confirm our hypothesis of equivalence between SMS-RUTF and P-RUTF in SAM management.
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Affiliation(s)
| | - Paluku Bahwere
- Valid International, Oxford, UK
- Centre of research in Epidemiology, biostatistics and clinical research, School of Public Health, Free University of Brussels, Brussels, Belgium
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Frison S, Checchi F, Kerac M. Omitting edema measurement: how much acute malnutrition are we missing? Am J Clin Nutr 2015; 102:1176-81. [PMID: 26377162 DOI: 10.3945/ajcn.115.108282] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 08/20/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Acute malnutrition is a major public health issue in low-income countries. It includes both wasting and edematous malnutrition, but the terms wasting and acute malnutrition are often used interchangeably. Little is known about the burden of edematous malnutrition, and few large-scale surveys measure it. OBJECTIVE Most acute malnutrition might be captured by the measurement of wasting alone, but this is unknown. This article aims to fill this gap. DESIGN This article presents a secondary data analysis of 852 nutrition cross-sectional survey data sets of children aged 6-59 mo. The data sets assembled included surveys from East, West, South, and Central Africa; the Caribbean; and Asia. The overlap between edematous malnutrition and wasting was assessed, and the impact of including/excluding edema on acute malnutrition prevalence estimates was evaluated. RESULTS The prevalence of edematous malnutrition varied from 0% to 32.9%, and children were more likely to have bilateral edema in Central and South Africa (OR: 4; 95% CI: 2.8, 5.6). A large proportion of children with edematous malnutrition were not wasted [62% and 66% based on midupper arm circumference (MUAC) and weight-for-height (WFH), respectively], and most were not severely wasted (83% and 86% based on MUAC and WFH, respectively). When wasting and global acute malnutrition prevalence estimates as well as severe wasting and severe acute malnutrition prevalence estimates overall were compared, the differences between estimates were small (median of 0.0% and mean of 0.3% based on WFH and MUAC for global estimates and slightly higher median of 0.1% and mean of 0.4% based on MUAC and WFH, respectively, for the severe forms), but the picture was different at the regional level. CONCLUSIONS The terms acute malnutrition and wasting should not be used interchangeably. The omission of the measurement of edema can have important repercussions, especially at the nutrition program level.
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Affiliation(s)
- Severine Frison
- Department of Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom, and
| | - Francesco Checchi
- Faculty of Public Health and Policy, LSHTM & Humanitarian Technical Unit, Save the Children, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom, and
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Mpimbaza A, Sears D, Sserwanga A, Kigozi R, Rubahika D, Nadler A, Yeka A, Dorsey G. Admission Risk Score to Predict Inpatient Pediatric Mortality at Four Public Hospitals in Uganda. PLoS One 2015. [PMID: 26218274 PMCID: PMC4517901 DOI: 10.1371/journal.pone.0133950] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Mortality rates among hospitalized children in many government hospitals in sub-Saharan Africa are high. Pediatric emergency services in these hospitals are often sub-optimal. Timely recognition of critically ill children on arrival is key to improving service delivery. We present a simple risk score to predict inpatient mortality among hospitalized children. Between April 2010 and June 2011, the Uganda Malaria Surveillance Project (UMSP), in collaboration with the National Malaria Control Program (NMCP), set up an enhanced sentinel site malaria surveillance program for children hospitalized at four public hospitals in different districts: Tororo, Apac, Jinja and Mubende. Clinical data collected through March 2013, representing 50249 admissions were used to develop a mortality risk score (derivation data set). One year of data collected subsequently from the same hospitals, representing 20406 admissions, were used to prospectively validate the performance of the risk score (validation data set). Using a backward selection approach, 13 out of 25 clinical parameters recognizable on initial presentation, were selected for inclusion in a final logistic regression prediction model. The presence of individual parameters was awarded a score of either 1 or 2 based on regression coefficients. For each individual patient, a composite risk score was generated. The risk score was further categorized into three categories; low, medium, and high. Patient characteristics were comparable in both data sets. Measures of performance for the risk score included the receiver operating characteristics curves and the area under the curve (AUC), both demonstrating good and comparable ability to predict deathusing both the derivation (AUC =0.76) and validation dataset (AUC =0.74). Using the derivation and validation datasets, the mortality rates in each risk category were as follows: low risk (0.8% vs. 0.7%), moderate risk (3.5% vs. 3.2%), and high risk (16.5% vs. 12.6%), respectively. Our analysis resulted in development of a risk score that ably predicted mortality risk among hospitalized children. While validation studies are needed, this approach could be used to improve existing triage systems.
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Affiliation(s)
- Arthur Mpimbaza
- Child Health & Development Centre, Makerere University, College of Health Sciences, Kampala, Uganda
- Infectious Diseases Research Collaboration, Kampala, Uganda
- * E-mail:
| | - David Sears
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, United States of America
| | | | - Ruth Kigozi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Denis Rubahika
- National Malaria Control Program, Ministry of Health Uganda, Kampala, Uganda
| | - Adam Nadler
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, United States of America
| | - Adoke Yeka
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Public Health, Makerere University, College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, United States of America
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Jarso H, Workicho A, Alemseged F. Survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from 2010 to 2012, Jimma, Ethiopia: a retrospective longitudinal study. BMC Pediatr 2015; 15:76. [PMID: 26174805 PMCID: PMC4502938 DOI: 10.1186/s12887-015-0398-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background Although community based treatment of severe acute malnutrition has been advocated for in recent years, facility based treatment of severe acute malnutrition is still required. Therefore, information on the treatment outcomes of malnutrition and potential predictors of mortality among severely malnourished children admitted to hospitals is critical for the improvement of quality care. Thus, the aim of this study was to assess survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from September 11, 2010 to September 10, 2012. Methods Retrospective longitudinal study was conducted at Jimma University Specialized Hospital. From September 11, 2010 to September 10, 2012 available data from severely malnourished children admitted to the hospital were reviewed. Data were analyzed using SPSS version 20 for windows. Bivariate and multivariable analyses were performed by Kaplan-Meier and Cox regression to identify clinical characteristics associated with mortality. Result A total of 947 children were enrolled into the study. An improvement, death and abscond rate were 77.8, 9.3 and 12.9 % respectively. The median duration from admission to death was 7 days. The average length of stay in the hospital and average weight gain were 17.4 days and 10.4 g/kg/day respectively. The main predictors of earlier hospital deaths were age less than 24 months (AHR = 1.9, 95 % CI [1.2–2.9]), hypothermia (AHR = 3.0, 95 % CI [1.4–6.6]), impaired consciousness level (AHR = 2.6, 95 % CI [1.5–4.5]), dehydration (AHR = 2.3, 95 % CI [1.3–4.0]), palmar pallor (AHR = 2.1, 95 % CI [1.3–3.3]) and co-morbidity/complication at admission (AHR = 3.7, 95 % CI [1.9–7.2]). Conclusion The treatment outcomes (improvement rate, death rate, average length of stay in the hospital and average weight gain) were better than most reports in the literatures and in agreement with minimum international standard set for management of severe acute malnutrition. Intervention to further reduce earlier deaths should focus on young children with hypothermia, altered mental status, dehydration, anemia and comorbidities.
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Affiliation(s)
- Habtemu Jarso
- Department of Epidemiology, College of Health Science, Jimma University, P.O.Box 378, Jimma, Ethiopia.
| | - Abdulhalik Workicho
- Department of Epidemiology, College of Health Science, Jimma University, P.O.Box 378, Jimma, Ethiopia.
| | - Fessahaye Alemseged
- Department of Epidemiology, College of Health Science, Jimma University, P.O.Box 378, Jimma, Ethiopia.
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The impact of anemia on child mortality: an updated review. Nutrients 2014; 6:5915-32. [PMID: 25533005 PMCID: PMC4277007 DOI: 10.3390/nu6125915] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/21/2014] [Accepted: 12/02/2014] [Indexed: 11/17/2022] Open
Abstract
Iron deficiency anemia and child mortality are public health problems requiring urgent attention. However, the degree to which iron deficiency anemia contributes to child mortality is unknown. Here, we utilized an exhaustive article search and screening process to identify articles containing both anemia and mortality data for children aged 28 days to 12 years. We then estimated the reduction in risk of mortality associated with a 1-g/dL increase in hemoglobin (Hb). Our meta-analysis of nearly 12,000 children from six African countries revealed a combined odds ratio of 0.76 (0.62–0.93), indicating that for each 1-g/dL increase in Hb, the risk of death falls by 24%. The feasibility of a 1-g/dL increase in Hb has been demonstrated via simple iron supplementation strategies. Our finding suggests that ~1.8 million deaths in children aged 28 days to five years could be avoided each year by increasing Hb in these children by 1 g/dL.
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Abstract
Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
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Key Words
- Antibiotics,
- Children,
- Diarrhoea,
- HIV,
- Infection,
- Malaria
- Malnutrition,
- Measles,
- Pneumonia,
- Sepsis,
- Tuberculosis,
- Urinary tract infection,
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Rose AM, Hall CS, Martinez-Alier N. Aetiology and management of malnutrition in HIV-positive children. Arch Dis Child 2014; 99:546-51. [PMID: 24406803 PMCID: PMC4033118 DOI: 10.1136/archdischild-2012-303348] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 12/30/2022]
Abstract
Worldwide, more than 3 million children are infected with HIV and, without treatment, mortality among these children is extremely high. Both acute and chronic malnutrition are major problems for HIV-positive children living in resource-limited settings. Malnutrition on a background of HIV represents a separate clinical entity, with unique medical and social aetiological factors. Children with HIV have a higher daily calorie requirement than HIV-negative peers and also a higher requirement for micronutrients; furthermore, coinfection and chronic diarrhoea due to HIV enteropathy play a major role in HIV-associated malnutrition. Contributory factors include late presentation to medical services, unavailability of antiretroviral therapy, other issues surrounding healthcare provision and food insecurity in HIV-positive households. Treatment protocols for malnutrition have been greatly improved, yet there remains a discrepancy in mortality between HIV-positive and HIV-negative children. In this review, the aetiology, prevention and treatment of malnutrition in HIV-positive children are examined, with particular focus on resource-limited settings where this problem is most prevalent.
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Affiliation(s)
- Anna M Rose
- Department of Genetics, UCL Institute of Ophthalmology, London, UK
- UCL Medical School, London, UK
| | - Charles S Hall
- UCL Medical School, London, UK
- UCL Institute of Global Health, London, UK
| | - Nuria Martinez-Alier
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
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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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Abejew AA, Tamir AS, Kerie MW. Retrospective analysis of mortalities in a tertiary care hospital in Northeast Ethiopia. BMC Res Notes 2014; 7:46. [PMID: 24443798 PMCID: PMC3899922 DOI: 10.1186/1756-0500-7-46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 01/16/2014] [Indexed: 05/08/2023] Open
Abstract
Background Mortalities in the health care set up are prevalent, and causes are multifactorial with variations from area to area and also from ward to ward in the same health care set up. Analysis of mortalities and its causes in Ethiopian hospitals including Dessie Referral Hospital is not adequately known. Thus, the aim of this study is to determine the prevalence of mortalities and its causes in the Dessie Referral Hospital, Northeast Ethiopia. Methods A retrospective analysis of mortalities during a three year period (September 2010–2012) was conducted in the Dessie Referral Hospital from August-September, 2012. All in hospital mortalities in the hospital during the last three years were included in the study. Data were collected from patient discharge recording books. Finally, data were entered into SPSS windows version 16.0 and descriptive statistics were generated to meet the study objective. Results During the last 3 years there were 1,481 (4.8%) mortalities in the hospital. Around 60.0% of the mortalities were among male patients, and two third of the mortalities were among patients aged 15 years or older. The majority of the mortalities (38.9%) were in the medical ward followed by pediatric (34.6%) and surgical (18.2%) wards. Most of the mortalities (34.8%) occurred during 2011 while least was in 2012 (31.8%). HIV/AIDS (14.8%), pneumonia (9.9%), and sepsis/shock (7.6%) were the three most common causes of mortality in the hospital during the three year period. On average, patients stayed for 2.86 (±2. 99) days in the wards before mortality. Conclusion Mortalities in the wards of the Dessie Referral Hospital were high and the causes were mainly of infectious origin, HIV/AIDS and its complications being the most common causes. This calls for an integrated effort to reduce in hospital mortalities by equipping the hospital and its health care providers with the skills and medical supplies required for proper management of the most common causes of in hospital mortality reported in this study.
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Callens SFJ, McKellar MS, Colebunders R. HIV care and treatment for children in resource-limited settings. Expert Rev Anti Infect Ther 2014; 6:181-90. [DOI: 10.1586/14787210.6.2.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tylleskär T. Et budsjettkutt som ikke er til å leve med. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:314. [DOI: 10.4045/tidsskr.13.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Girma T, Kæstel P, Mølgaard C, Michaelsen KF, Hother AL, Friis H. Predictors of oedema among children hospitalized with severe acute malnutrition in Jimma University Hospital, Ethiopia: a cross sectional study. BMC Pediatr 2013; 13:204. [PMID: 24314329 PMCID: PMC3866507 DOI: 10.1186/1471-2431-13-204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 11/27/2013] [Indexed: 11/29/2022] Open
Abstract
Background Severe acute malnutrition has two main clinical manifestations, i.e., oedematous and non-oedematous. However, factors associated with oedema are not well established. Methods Children 0.5-14 years of age with SAM (MUAC < 11.0 cm or weight-for-height < 70 % of median and/or nutritional oedema) admitted to the nutrition unit were included. Information on infections before and during admission was collected together with anthropometry. Predictors of oedema was analysed separately for younger (< 60 months) and older children (≥ 60 months). Results 351 children were recruited (median age: 36 months (interquartile range 24 to 60); 43.3% females). Oedema was detected in 61.1%. The prevalence of oedema increased with age, peaked at 37–59 months (75%) and declined thereafter. Infection was more common in the younger group (33% vs. 8.9%, p < 0.001) and in this group children with oedema had less infections (25.2% vs. 45.1%, p = 0.001). In the older group the prevalence of infections was not different between oedematous and non-oedematous children (5.5% v. 14.3%, p = 0.17). In the younger group oedema was less common in children with TB (OR = 0.20, 95% CI: 0.06, 0.70) or diarrhea (OR = 0.40, 95% CI: 0.21, 0.73). Conclusions The proportion of oedema in SAM peaked at three to five years of age and a considerable proportion was above 5 years. Furthermore, the prevalence of infection seemed to be lower among children with oedema. Further studies are needed to better understand the role of infection-immunity interaction.
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Affiliation(s)
- Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia.
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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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Chisti MJ, Salam MA, Ashraf H, Faruque ASG, Bardhan PK, Hossain MI, Shahid ASMSB, Shahunja KM, Das SK, Imran G, Ahmed T. Clinical risk factors of death from pneumonia in children with severe acute malnutrition in an urban critical care ward of Bangladesh. PLoS One 2013; 8:e73728. [PMID: 24040043 PMCID: PMC3767805 DOI: 10.1371/journal.pone.0073728] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 07/22/2013] [Indexed: 01/08/2023] Open
Abstract
Background Risks of death are high when children with pneumonia also have severe acute malnutrition (SAM) as a co-morbidity. However, there is limited published information on risk factors of death from pneumonia in SAM children. We evaluated clinically identifiable factors associated with death in under-five children who were hospitalized for the management of pneumonia and SAM. Methods For this unmatched case-control design, SAM children of either sex, aged 0–59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during April 2011 to July 2012 with radiological pneumonia were studied. The SAM children with pneumonia who had fatal outcome constituted the cases (n = 35), and randomly selected SAM children with pneumonia who survived constituted controls (n = 105). Results The median (inter-quartile range) age (months) was comparable among the cases and the controls [8.0 (4.9, 11.0) vs. 9.7 (5.0, 18.0); p = 0.210)]. In logistic regression analysis, after adjusting for potential confounders, such as vomiting, abnormal mental status, and systolic hypotension (<70 mm of Hg) in absence of dehydration, fatal cases of severely malnourished under-five children with pneumonia were more often hypoxemic (OR = 23.15, 95% CI = 4.38–122.42), had clinical dehydration (some/severe) (OR = 9.48, 95% CI = 2.42–37.19), abdominal distension at admission (OR = 4.41, 95% CI = 1.12–16.52), and received blood transfusion (OR = 5.50, 95% CI = 1.21–24.99) for the management of crystalloid resistant systolic hypotension. Conclusion and Significance We identified hypoxemia, clinical dehydration, and abdominal distension as the independent predictors of death in SAM children with pneumonia. SAM children with pneumonia who required blood transfusion for the management of crystalloid resistant systolic hypotension were also at risk for death. Thus, early identification and prompt management of these simple clinically recognizable predictors of death and discourage the use of blood transfusion for the management of crystalloid resistant systolic hypotension may help reduce deaths in such population.
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Affiliation(s)
- Mohammod Jobayer Chisti
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
- * E-mail:
| | | | - Hasan Ashraf
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
| | - Abu S. G. Faruque
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Pradip Kumar Bardhan
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
| | - Md Iqbal Hossain
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Dhaka Hospital, icddr,b, Dhaka, Bangladesh
| | - Abu S. M. S. B. Shahid
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K. M. Shahunja
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sumon Kumar Das
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Gazi Imran
- Dhaka Shishu (Children) Hospital, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Nantanda R, Hildenwall H, Peterson S, Kaddu-Mulindwa D, Kalyesubula I, K.Tumwine J. Bacterial aetiology and outcome in children with severe pneumonia in Uganda. ACTA ACUST UNITED AC 2013; 28:253-60. [DOI: 10.1179/146532808x375404] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Musoke PM, Fergusson P. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings. Am J Clin Nutr 2011; 94:1716S-1720S. [PMID: 22089437 PMCID: PMC3226024 DOI: 10.3945/ajcn.111.018374] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
More than 2 million children globally are living with HIV infection and >90% of these reside in sub-Saharan Africa. Severe acute malnutrition (SAM) remains a major problem for HIV-infected children who live in resource-limited settings (RLS), and SAM is an important risk factor for mortality. SAM in HIV-infected children is associated with complications including electrolyte disorders, micronutrient deficiencies, and severe infections, which contribute to the high mortality. Access to antiretroviral therapy (ART) has significantly improved the survival of HIV-infected children, although the response to ART of children with SAM remains undocumented in the literature. Immune and virologic responses to ART in RLS are similar to those of infected children in resource-rich settings, but delays in initiation of therapy have led to a high early mortality. Antiretroviral drug toxicities have been described in children who receive therapy and may affect their quality of life and long-term survival. Metabolic complications of ART include lipodystrophy, dyslipidemia, lactic acidosis, insulin resistance, and osteopenia. These complications have been well described in adults and children from developed countries, but data from RLS are limited, and these complications may be compounded by SAM. In this article we review the epidemiology, clinical presentation, and complications of SAM in HIV-infected children and the metabolic complications of HIV-infected children in the era of ART, and discuss future research priorities for RLS.
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Affiliation(s)
- Philippa M Musoke
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda.
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Akech SO, Karisa J, Nakamya P, Boga M, Maitland K. Phase II trial of isotonic fluid resuscitation in Kenyan children with severe malnutrition and hypovolaemia. BMC Pediatr 2010; 10:71. [PMID: 20923577 PMCID: PMC2973932 DOI: 10.1186/1471-2431-10-71] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 10/06/2010] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Children with severe malnutrition who develop shock have a high mortality. Contrary to contemporaneous paediatric practice, current guidelines recommend use of low dose hypotonic fluid resuscitation (half-strength Darrows/5% dextrose (HSD/5D). We evaluated the safety and efficacy of this guideline compared to resuscitation with a standard isotonic solution. METHODS A Phase II randomised controlled, safety and efficacy trial in Kenyan children aged over 6 months with severe malnutrition and shock including children with severe dehydration/shock and presumptive septic shock (non-diarrhoeal shock). Eligible children were randomised to HSD/5D or Ringer's Lactate (RL). A maximum of two boluses of 15 ml/kg of HSD/5D were given over two hours (as recommended by guidelines) while those randomised to RL received 10 ml/kg aliquots half hourly (maximum 40 ml/kg). Primary endpoint was resolution of shock at 8 and 24 hours. Secondary outcomes included resolution of acidosis, adverse events and mortality. RESULTS 61 children were enrolled: 41 had shock and severe dehydrating diarrhoea, 20 had presumptive septic shock; 69% had decompensated shock. By 8 hours response to volume resuscitation was poor with shock persisting in most children:-HSD/5D 15/22 (68%) and RL14/25 (52%), p = 0.39. Oliguria was more prevalent at 8 hours in the HSD/5D group, 9/22 (41%), compared to RL-3/25 (12%), p = 0.02. Mortality was high, HSD/5D-15/26(58%) and RL 13/29(45%); p = 0.42. Most deaths occurred within 48 hours of admission. Neither pulmonary oedema nor cardiogenic failure was detected. CONCLUSIONS Outcome was universally poor characterised by persistence of shock, oliguria and high case fatality. Isotonic fluid was associated with modest improvement in shock and survival when compared to HSD/5D but inconclusive due to the limitations of design and effectiveness of either resuscitation strategy. Although isotonic fluid resuscitation did not result in cardiogenic heart failure, as previously feared, we conclude that the modest volumes used and rate of infusion were insufficient to promptly correct shock. The adverse performance of the recommended fluid resuscitation guideline for severe malnutrition should prompt clinical investigation of isotonic fluids for resuscitation of compensated shock, defining rate and volumes required to inform future guidelines. TRIAL REGISTRATION The trial is registered as ISCRTN: 61146418.
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Affiliation(s)
- Samuel O Akech
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Japhet Karisa
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Phellister Nakamya
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Mwanamvua Boga
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, UK
- Wellcome Trust Centre for Clinical Tropical Medicine, Imperial College, London, UK
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Bunn J, Thindwa M, Kerac M. Features associated with underlying HIV infection in severe acute childhood malnutrition: a cross sectional study. Malawi Med J 2010; 21:108-12. [PMID: 20345019 DOI: 10.4314/mmj.v21i3.45645] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Up to half of all children presenting to Nutrition Rehabilitation Units (NRUs) in Malawi with severe acute malnutrition (SAM) are infected with HIV. There are many similarities in the clinical presentation of SAM and HIV. It is important to identify HIV infected children, in order to improve case management. This study aims to identify features suggestive of HIV in children with SAM. METHODS All 1024 children admitted to the Blantyre NRU between July 2006 and March 2007 had demographic, anthropometric and clinical characteristics documented on admission. HIV status was known for 904 children, with 445 (43%) seropositive and 459 (45%) seronegative. Features associated with HIV were determined. RESULTS Associations were found for the following signs: chronic ear discharge (OR 14.6, 95%CI 5.8-36.7), lymphadenopathy (6.4, 3.5-11.7), clubbing (4.9, 2.6-9.4), marasmus (4.9, 3.5-6.8), hepato-splenomegally (3.2, 1.8-5.6), and oral candida (2.4, 1.8-3.27). Any one of these signs was present in 74% of the HIV seropositive, and 38% of HIV uninfected children. A history of recurrent respiratory infection (OR 9.6, 4.8-18.6), persistent fever, recent outpatient attendance, or hospital admission were also associated with HIV. Persistent diarrhoea was no more frequent in HIV (OR 1.1). Orphaning (OR 2.1, 1.4-3.3) or a household contact with TB (OR 1.7, 1.1-2.6), were more common in HIV. Each of these features were present in >10% of seropositive children. HIV infected children were more stunted, wasted, and anaemic than uninfected children. CONCLUSIONS Features commonly associated with HIV were often present in uninfected children with SAM, and HIV could neither be diagnosed, nor excluded using these. We recommend HIV testing be offered to all children with SAM where HIV is prevalent.
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Nyeko R, Kalyesubula I, Mworozi E, Bachou H. Lactose intolerance among severely malnourished children with diarrhoea admitted to the nutrition unit, Mulago hospital, Uganda. BMC Pediatr 2010; 10:31. [PMID: 20459633 PMCID: PMC2881080 DOI: 10.1186/1471-2431-10-31] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2009] [Accepted: 05/06/2010] [Indexed: 11/24/2022] Open
Abstract
Background Lactose intolerance is a common complication of diarrhoea in infants with malnutrition and a cause of treatment failure. A combination of nutritional injury and infectious insults in severe protein energy malnutrition reduces the capacity of the intestinal mucosa to produce lactase enzyme necessary for the digestion of lactose. The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk. However, some of these children may be lactose intolerant, possibly contributing to the high rate of unfavorable treatment outcomes. This study was therefore designed to establish the prevalence of lactose intolerance and associated factors in this population. Methods A descriptive cross sectional study involving 196 severely malnourished children with diarrhoea aged 3-60 months was done in Mwanamugimu Nutrition Unit (MNU), Mulago hospital between October 2006 and February 2007. Results During the study period, 196 severely malnourished children with diarrhoea were recruited, 50 (25.5%) of whom had evidence of lactose intolerance (stool reducing substance ≥ 1 + [0.5%] and stool pH < 5.5) and it occurred more commonly in children with kwashiorkor 27/75 (36.0%) than marasmic-kwashiorkor 6/25 (24.0%) and marasmus 17/96 (17.7%). Oedematous malnutrition (p = 0.032), perianal skin erosion (p = 0.044), high mean stool frequency (p = < 0.001) and having ≥2 diarrhoea episodes in the previous 3 months (p = 0.007) were the independent predictors of lactose intolerance. Other factors that were significantly associated with lactose intolerance on bi-variate analysis included: young age of 3-12 months; lack of up to-date immunization; persistent diarrhoea; vomiting; dehydration, and abdominal distension. Exclusive breastfeeding for less than 4 months and worsening of diarrhoea on initiation of therapeutic milk were the other factors. Conclusions The prevalence of lactose intolerance in this study setting of 25.5% is relatively high. Routine screening by stool pH and reducing substances should be performed especially in the severely malnourished children with diarrhoea presenting with oedematous malnutrition, perianal skin erosion, higher mean stool frequency and having had ≥2 diarrhoea episodes in the previous 3 months. Use of lactose-free diets such as yoghurt should be considered for children found to have evidence of lactose intolerance and whose response on standard therapeutic milk formula is poor.
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Affiliation(s)
- Richard Nyeko
- Department of Paediatrics and Child Health, St. Mary's hospital Lacor, Gulu, Uganda P.O Box 180, Gulu, Uganda.
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Sztam KA, Fawzi WW, Duggan C. Macronutrient supplementation and food prices in HIV treatment. J Nutr 2010; 140:213S-23S. [PMID: 19939991 PMCID: PMC3361012 DOI: 10.3945/jn.109.110569] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.
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Affiliation(s)
- Kevin A. Sztam
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115,To whom correspondence should be addressed. E-mail:
| | - Wafaie W. Fawzi
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
| | - Christopher Duggan
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
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