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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2024; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/19/2024] Open
Abstract
Background Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial will reappraise current recommendations with mortality as the primary outcome. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling children in Uganda, Kenya, Nigeria and Niger aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration (IV) given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is mortality to 96 hours and for oral rehydration a change in sodium levels at 24 hours post-randomisation. Secondary outcomes include measures assessing safety (evidence of pulmonary oedema or heart failure); change in sodium from post-iv levels for those in Stratum A; perturbations of electrolyte abnormalities (severe hyponatraemia <125 mmols/L or hypokalaemia. Discussion If the trial shows that rehydration strategies for non-malnourished children are safe and improve mortality in SAM this could prompt revisions to the current treatment recommendations or may prompt future Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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Alemu Y, Abdissa A, Mekonnen Z, Sharew B, Johansen ØH, Bjørang O, Langeland N, Hanevik K, Moyo SJ. Prevalence and assemblage of Giardia duodenalis in a case-control study of children under 5 years from Jimma, Southwest Ethiopia. Parasitol Res 2023; 123:38. [PMID: 38091122 PMCID: PMC10719145 DOI: 10.1007/s00436-023-08029-5] [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: 06/07/2023] [Accepted: 11/14/2023] [Indexed: 12/17/2023]
Abstract
Giardia duodenalis is a common pathogenic intestinal protozoan parasite with high prevalence in developing countries, especially among children. The distribution of giardia assemblages among humans and their clinical relevance remains controversial. This study aimed to determine the prevalence and assemblage of Giardia among children under 5 years of age in Jimma, Southwest Ethiopia. Employing a case-control design, 606 children presenting with diarrhea at Jimma university medical center and Serbo Health Center were enrolled from December 2016 to July 2018 along with 617 matched controls without diarrhea. Giardia was detected and typed using real-time PCR. Univariate and multivariate regression analysis was performed. The total prevalence of Giardia was 41% (501/1223) and did not differ significantly between cases and controls (40% vs 42%). Prevalence increased by age, with the highest prevalence seen in children aged ≥ 25 months. Children without diarrhea with a history of diarrhea during the last month were more likely to be Giardia positive compared to children with no history diarrhea (OR 1.8 and 95%CI; 1.1-2.9). Regardless of current diarrhea symptoms, assemblage B predominated with 89%, followed by assemblage A (8%) and mixed infection assemblage A and B (3%). We report a high prevalence of Giardia by PCR detection in Jimma, Ethiopia, with assemblage B being predominant. There was a similar distribution of Giardia assemblages between children with and without diarrhea. Increasing age was a risk factor for Giardia infection. Community-based prevention and control strategies need to be employed to decrease the risk of giardia infection.
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Affiliation(s)
- Yonas Alemu
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Department of Microbiology, Immunology and Parasitology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Zeleke Mekonnen
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Bizuwarek Sharew
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Øystein H Johansen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Ola Bjørang
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- National Center for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Kurt Hanevik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- National Center for Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Sabrina J Moyo
- Department of Clinical Science, University of Bergen, Bergen, Norway.
- Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
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3
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Ahmed SM, Brintz BJ, Talbert A, Ngari M, Pavlinac PB, Platts-Mills JA, Levine AC, Nelson EJ, Walson JL, Kotloff KL, Berkley JA, Leung DT. Derivation and external validation of a clinical prognostic model identifying children at risk of death following presentation for diarrheal care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001937. [PMID: 37368867 DOI: 10.1371/journal.pgph.0001937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023]
Abstract
Diarrhea continues to be a leading cause of death for children under-five. Amongst children treated for acute diarrhea, mortality risk remains elevated during and after acute medical management. Identification of those at highest risk would enable better targeting of interventions, but available prognostic tools lack validation. We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build clinical prognostic models (CPMs) to predict death (in-treatment, after discharge, or either) in children aged ≤59 months presenting with moderate-to-severe diarrhea (MSD), in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using repeated cross-validation. We used data from the Kilifi Health and Demographic Surveillance System (KHDSS) and Kilifi County Hospital (KCH) in Kenya to externally validate our GEMS-derived CPM. Of 8060 MSD cases, 43 (0.5%) children died in treatment and 122 (1.5% of remaining) died after discharge. MUAC at presentation, respiratory rate, age, temperature, number of days with diarrhea at presentation, number of people living in household, number of children <60 months old living in household, and how much the child had been offered to drink since diarrhea started were predictive of death both in treatment and after discharge. Using a parsimonious 2-variable prediction model, we achieved an area under the ROC curve (AUC) of 0.84 (95% CI: 0.82, 0.86) in the derivation dataset, and an AUC = 0.74 (95% CI 0.71, 0.77) in the external dataset. Our findings suggest it is possible to identify children most likely to die after presenting to care for acute diarrhea. This could represent a novel and cost-effective way to target resources for the prevention of childhood mortality.
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Affiliation(s)
- Sharia M Ahmed
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Ben J Brintz
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, United States of America
| | - Alison Talbert
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Patricia B Pavlinac
- Department of Global Health, Global Center for Integrated Health of Women, Adolescents and Children (Global WACh), University of Washington, Seattle, WA, United States of America
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States of America
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Eric J Nelson
- Department of Pediatrics and Environmental and Global Health, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States of America
| | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Karen L Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research, Kilifi, Kenya
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, United States of America
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Derivation and external validation of a clinical prognostic model identifying children at risk of death following presentation for diarrheal care. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.08.23285625. [PMID: 36798150 PMCID: PMC9934800 DOI: 10.1101/2023.02.08.23285625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Diarrhea continues to be a leading cause of death for children under-five. Amongst children treated for acute diarrhea, mortality risk remains elevated during and after acute medical management. Identification of those at highest risk would enable better targeting of interventions, but available prognostic tools lack validation. We used clinical and demographic data from the Global Enteric Multicenter Study (GEMS) to build predictive models for death (in-treatment, after discharge, or either) in children aged ≤59 months presenting with moderate-to-severe diarrhea (MSD), in Africa and Asia. We screened variables using random forests, and assessed predictive performance with random forest regression and logistic regression using repeated cross-validation. We used data from the Kilifi Health and Demographic Surveillance System (KHDSS) and Kilifi County Hospital (KCH) in Kenya to externally validate our GEMS-derived clinical prognostic model (CPM). Of 8060 MSD cases, 43 (0.5%) children died in treatment and 122 (1.5% of remaining) died after discharge. MUAC at presentation, respiratory rate, age, temperature, number of days with diarrhea at presentation, number of people living in household, number of children <60 months old living in household, and how much the child had been offered to drink since diarrhea started were predictive of death both in treatment and after discharge. Using a parsimonious 2-variable prediction model, we achieve an AUC=0.84 (95% CI: 0.82, 0.86) in the derivation dataset, and an AUC=0.74 (95% CI 0.71, 0.77) in the external dataset. Our findings suggest it is possible to identify children most likely to die after presenting to care for acute diarrhea. This could represent a novel and cost-effective way to target resources for the prevention of childhood mortality.
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5
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Johansen ØH, Abdissa A, Bjørang O, Zangenberg M, Sharew B, Alemu Y, Moyo S, Mekonnen Z, Langeland N, Robertson LJ, Hanevik K. Oocyst Shedding Dynamics in Children with Cryptosporidiosis: a Prospective Clinical Case Series in Ethiopia. Microbiol Spectr 2022; 10:e0274121. [PMID: 35699433 PMCID: PMC9430463 DOI: 10.1128/spectrum.02741-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Knowledge on the duration of Cryptosporidium oocyst shedding, and how shedding may be affected by subtypes and clinical parameters, is limited. Reduced transmission may be a secondary benefit of cryptosporidiosis treatment in high-prevalence areas. We conducted a prospective clinical case series in children of <5 years presenting with diarrhea to a health center and a hospital in Ethiopia over an 18-month period. Stool samples were collected repeatedly from children diagnosed with cryptosporidiosis for up to 60 days. Samples were examined, and Cryptosporidium shedding was quantified, using auramine phenol, immunofluorescent antibody staining, and quantitative PCR (qPCR). In addition, species determination and subtyping were used to attempt to distinguish between new infections and ongoing shedding. Duration and quantity of shedding over time were estimated by time-to-event and quantitative models (sex- and age-adjusted). We also explored how diarrheal severity, acute malnutrition, and Cryptosporidium subtypes correlated with temporal shedding patterns. From 53 confirmed cryptosporidiosis cases, a median of 4 (range 1 to 5) follow-up stool samples were collected and tested for Cryptosporidium. The median duration of oocyst shedding was 31 days (95% confidence interval [CI], 26 to 36 days) after onset of diarrhea, with similar estimates from the quantitative models (31 days, 95% CI 27 to 37 days). Genotype shift occurred in 5 cases (9%). A 10-fold drop in quantity occurred per week for the first 4 weeks. Prolonged oocyst shedding is common in a pediatric clinical population with cryptosporidiosis. We suggest that future intervention trials should evaluate both clinical efficacy and total parasite shedding duration as trial endpoints. IMPORTANCE Cryptosporidiosis is an important cause of diarrhea, malnutrition, and deaths in young children in low-income countries. The infection spreads from person to person. After infection, prolonged release of the Cryptosporidium parasite in stool (shedding) may contribute to further spread of the disease. If diagnosis and treatment are made available, diarrhea will be treated and deaths will be reduced. An added benefit may be to reduce transmission to others. However, shedding duration and its characteristics in children is not well known. We therefore investigated the duration of shedding in a group of young children who sought health care for diarrhea in a hospital and health center in Ethiopia. The study followed 53 children with cryptosporidiosis for 2 months. We found that, on average, children released the parasite for 31 days after the diarrhea episode started. Point-of-care treatment of cryptosporidiosis may therefore reduce onward spread of the Cryptosporidium parasite within communities and households.
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Affiliation(s)
- Øystein H. Johansen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Ola Bjørang
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Mike Zangenberg
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - Bizuwarek Sharew
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Yonas Alemu
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Sabrina Moyo
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Zeleke Mekonnen
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lucy J. Robertson
- Parasitology, Department of Paraclinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Kurt Hanevik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Johansen ØH, Abdissa A, Zangenberg M, Mekonnen Z, Eshetu B, Sharew B, Moyo S, Sommerfelt H, Langeland N, Robertson LJ, Hanevik K. A comparison of risk factors for cryptosporidiosis and non-cryptosporidiosis diarrhoea: A case-case-control study in Ethiopian children. PLoS Negl Trop Dis 2022; 16:e0010508. [PMID: 35666717 PMCID: PMC9203008 DOI: 10.1371/journal.pntd.0010508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 06/16/2022] [Accepted: 05/17/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Cryptosporidiosis is a major cause of diarrhoea in young children in low-and-middle-income countries. New interventions should be informed by evidence pertaining to risk factors and their relative importance. Inconsistencies in the literature may to some extent be explained by choice of methodology, furthermore, most previous risk factor studies compared cryptosporidiosis cases to diarrhoea cases of other aetiologies rather than with controls without diarrhoea.
Methodology/Principal findings
We investigated a broad set of factors in under-2-year-olds presenting with diarrhoea to a hospital and a health center in southwestern Ethiopia. We applied quantitative cut-offs to distinguish between cryptosporidiosis and incidental Cryptosporidium infection or carriage, a hierarchical causal framework to minimize confounding and overadjustment, and a case-case-control design, to describe risk factors for both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Moderate and severe acute malnutrition were strongly associated with both cryptosporidiosis and non-cryptosporidiosis diarrhoea. Previous healthcare attendance and low maternal education were only associated with cryptosporidiosis, whereas unsafe child stool disposal, prematurity and early cessation of exclusive breastfeeding were significantly associated with non-cryptosporidiosis diarrhoea only. By estimation of population attributable fractions, socioeconomic factors—specifically low maternal education—and public tap water use, were apparently more important risk factors for cryptosporidiosis than for non-cryptosporidiosis diarrhoea.
Conclusions/Significance
Nutritional management of moderate acute malnutrition may be an effective intervention against cryptosporidiosis, particularly if combined with targeted therapy for cryptosporidiosis which, again, may mitigate nutritional insult. Focused caregiver education in healthcare settings and follow-up of children with acute malnutrition may prevent or improve outcomes of future episodes of cryptosporidiosis.
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Affiliation(s)
- Øystein Haarklau Johansen
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
- * E-mail:
| | - Alemseged Abdissa
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Mike Zangenberg
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
- Department of Immunology and Microbiology, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Zeleke Mekonnen
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Beza Eshetu
- Department of Paediatrics, Jimma Medical Centre, Jimma University, Jimma, Ethiopia
| | - Bizuwarek Sharew
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Sabrina Moyo
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
- Cluster for Global Health, Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Nina Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Lucy J. Robertson
- Parasitology, Department of Paraclinical Sciences, Faculty of Veterinary Medicine, Norwegian University of Life Sciences, Ås, Norway
| | - Kurt Hanevik
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Gonzales GB, Njunge JM, Gichuki BM, Wen B, Ngari M, Potani I, Thitiri J, Laukens D, Voskuijl W, Bandsma R, Vanmassenhove J, Berkley JA. The role of albumin and the extracellular matrix on the pathophysiology of oedema formation in severe malnutrition. EBioMedicine 2022; 79:103991. [PMID: 35398787 PMCID: PMC9014367 DOI: 10.1016/j.ebiom.2022.103991] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND While fluid flows in a steady state from plasma, through interstitium, and into the lymph compartment, altered fluid distribution and oedema can result from abnormal Starling's forces, increased endothelial permeability or impaired lymphatic drainage. The mechanism of oedema formation, especially the primary role of hypoalbuminaemia, remains controversial. Here, we explored the roles of albumin and albumin-independent mechanisms in oedema formation among children with severe malnutrition (SM). METHODS We performed secondary analysis of data obtained from two independent clinical trials in Malawi and Kenya (NCT02246296 and NCT00934492). We then used an unconventional strategy of comparing children with kwashiorkor and marasmus by matching (discovery cohort, n = 144) and normalising (validation cohort, n = 98, 2 time points) for serum albumin. Untargeted proteomics was used in the discovery cohort to determine plausible albumin-independent mechanisms associated with oedema, which was validated using enzyme-linked immunosorbent assay and multiplex assays in the validation cohort. FINDINGS We demonstrated that low serum albumin is necessary but not sufficient to develop oedema in SM. We further found that markers of extracellular matrix (ECM) degradation rather than markers of EG degradation distinguished oedematous and non-oedematous children with SM. INTERPRETATION Our results show that oedema formation has both albumin-dependent and independent mechanisms. ECM integrity appears to have a greater role in oedema formation than EG shedding in SM. FUNDING Research Foundation Flanders (FWO), Thrasher Foundation (15122 and 9403), VLIR-UOS-Ghent University Global Minds Fund, Bill & Melinda Gates Foundation (OPP1131320), MRC/DfID/Wellcome Trust Global Health Trials Scheme (MR/M007367/1), Canadian Institutes of Health Research (156307), Wellcome Trust (WT083579MA).
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Affiliation(s)
- Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherland,Department of Internal Medicine and Paediatrics, Laboratory of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,VIB-UGent Center for Inflammation Research, Ghent, Belgium,Corresponding author at: Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherland.
| | - James M. Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Corresponding author at: The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.
| | - Bonface M Gichuki
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bijun Wen
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Debby Laukens
- Department of Internal Medicine and Paediatrics, Laboratory of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi,Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherland,Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, the Netherland
| | - Robert Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi
| | - Jill Vanmassenhove
- Department of Internal Medicine and Paediatrics, Renal Division, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - James A Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Nuffield Department of Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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8
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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: 1] [Impact Index Per Article: 0.3] [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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9
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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2021; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial is the first step in reappraising current recommendations. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling Ugandan and Kenyan children aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is urine output (mls/kg/hour at 8 hours post-randomisation), and for oral rehydration a change in sodium levels at 24 hours post-randomisation. This trial will also generate feasibility, safety and preliminary data on survival to 28 days. Discussion. If current rehydration strategies for non-malnourished children are safe in SAM this could prompt future evaluation in Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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10
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Bragança Lima MV, Hinderaker SG, Ogundipe OF, Owiti PO, Kadai B, Maikere J. Association between cholera treatment outcome and nutritional status in children aged 2-4 years in Nigeria. Public Health Action 2021; 11:80-84. [PMID: 34159067 DOI: 10.5588/pha.20.0078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Cholera can aggravate or precipitate malnutrition, and children with severe acute malnutrition (SAM) have a higher incidence and longer duration of diarrhoea. OBJECTIVE To describe 1) characteristics of and treatment outcomes in children aged 2-4 years with cholera, 2) the case fatality rate (CFR) in all children treated, and 3) the associations between nutritional status, hydration status, treatment administered and hospital outcomes. DESIGN An observational cohort study of children admitted to one cholera treatment centre in Maiduguri, Nigeria, with a focus on children aged 2-4 years. CFRs were examined by cross tabulation and mean length of stay (LOS) using analysis of variance. RESULTS SAM was identified in 24% of children aged 2-4 years. The CFR for children aged 2-4 years was 1.4%. As the sample size was small, we did not find any association between nutritional status and death due to cholera. The proportion of children discharged within 2 days was 79%, and the longest stay was 8 days. In general, health facility LOS increased with severity of malnutrition. CONCLUSION Our study found that nutritional status affected the LOS, but was unable to find an association between malnutrition and fatality among children aged 2-4 years.
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Affiliation(s)
- M V Bragança Lima
- Operational Centre Brussels, Médecins sans Frontières, Brussels, Belgium
| | | | - O F Ogundipe
- Operational Centre Brussels, Médecins sans Frontières, Brussels, Belgium
| | - P O Owiti
- International Union Against Tuberculosis and Lung Disease, Paris, France
| | - B Kadai
- Planning, Research & Statistics Department, Ministry of Health, Borno State, Maiduguri, Nigeria
| | - J Maikere
- Operational Centre Brussels, Médecins sans Frontières, Brussels, Belgium
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11
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Kamugisha JGK, Lanyero B, Nabukeera-Barungi N, Nambuya-Lakor H, Ritz C, Mølgaard C, Michaelsen KF, Briend A, Mupere E, Friis H, Grenov B. Weight and mid-upper arm circumference gain velocities during treatment of young children with severe acute malnutrition, a prospective study in Uganda. BMC Nutr 2021; 7:26. [PMID: 34140028 PMCID: PMC8212498 DOI: 10.1186/s40795-021-00428-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 04/01/2021] [Indexed: 11/23/2022] Open
Abstract
Background Weight gain is routinely monitored to assess hydration and growth during treatment of children with complicated severe acute malnutrition (SAM). However, changes in weight and mid-upper arm circumference (MUAC) gain velocities over time are scarcely described. We assessed weight and MUAC gain velocities in 6–59 mo-old children with complicated SAM by treatment phase and edema status. Methods This was a prospective study, nested in a randomized/probiotic trial (ISRCTN16454889). Weight and MUAC gain velocities were assessed by treatment phase and edema at admission using linear mixed-effects models. Results Among 400 children enrolled, the median (IQR) age was 15.0 (11.2;19.2) months, 58% were males, and 65% presented with edema. During inpatient therapeutic care (ITC), children with edema vs no edema at admission had negative weight gain velocity in the stabilization phase [differences at day 3 and 4 were − 11.26 (95% CI: − 20.73; − 1.79) g/kg/d and − 13.09 (95% CI: − 23.15; − 3.02) g/kg/d, respectively]. This gradually changed into positive weight gain velocity in transition and eventually peaked at 12 g/kg/d early in the rehabilitation phase, with no difference by edema status (P > 0.9). During outpatient therapeutic care (OTC), overall, weight gain velocity showed a decreasing trend over time (from 5 to 2 g/kg/d), [difference between edema and non-edema groups at week 2 was 2.1 (95% CI: 1.0;3.2) g/kg/d]. MUAC gain velocity results mirrored those of weight gain velocity [differences were − 2.30 (95% CI: − 3.6; − 0.97) mm/week at week 1 in ITC and 0.65 (95% CI: − 0.07;1.37) mm/week at week 2 in OTC]. Conclusions Weight and MUAC gain velocities among Ugandan children with complicated SAM showed an increasing trend during transition and early in the rehabilitation phase, and a decreasing trend thereafter, but, overall, catch-up growth was prolonged. Further research to establish specific cut-offs to assess weight and MUAC gain velocities during different periods of rehabilitation is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s40795-021-00428-0.
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Affiliation(s)
- Jolly G K Kamugisha
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark.
| | - Betty Lanyero
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda
| | - Nicolette Nabukeera-Barungi
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Harriet Nambuya-Lakor
- Mwanamugimu Nutrition Unit, Department of Pediatrics, Mulago National Referral Hospital, P.O. Box 7051, Kampala, Uganda.,Department of Pediatrics, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark.,Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Arvo building, Arvo Ylpön katu 34, FIN-33014 Tampere University, Tampere, Finland
| | - Ezekiel Mupere
- Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
| | - Benedikte Grenov
- Department of Nutrition, Exercise and Sports, University of Copenhagen, 1958, Frederiksberg C, Denmark
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12
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Ngari MM, Obiero C, Mwangome MK, Nyaguara A, Mturi N, Murunga S, Otiende M, Iversen PO, Fegan GW, Walson JL, Berkley JA. Mortality during and following hospital admission among school-aged children: a cohort study. Wellcome Open Res 2021; 5:234. [PMID: 33195820 PMCID: PMC7656274 DOI: 10.12688/wellcomeopenres.16323.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya. Methods: A retrospective cohort study of children 5−12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality. Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74−116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3−38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria. Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Christina Obiero
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Martha K Mwangome
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Amek Nyaguara
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Sheila Murunga
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Mark Otiende
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Oslo, Norway.,Department of Haematology, Oslo University Hospital, Oslo, Norway.,Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Gregory W Fegan
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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13
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Ngari MM, Obiero C, Mwangome MK, Nyaguara A, Mturi N, Murunga S, Otiende M, Iversen PO, Fegan GW, Walson JL, Berkley JA. Mortality during and following hospital admission among school-aged children: a cohort study. Wellcome Open Res 2021; 5:234. [PMID: 33195820 PMCID: PMC7656274 DOI: 10.12688/wellcomeopenres.16323.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2020] [Indexed: 11/03/2023] Open
Abstract
Background: Far less is known about the reasons for hospitalization or mortality during and after hospitalization among school-aged children than among under-fives in low- and middle-income countries. This study aimed to describe common types of illness causing hospitalisation; inpatient mortality and post-discharge mortality among school-age children at Kilifi County Hospital (KCH), Kenya. Methods: A retrospective cohort study of children 5-12 years old admitted at KCH, 2007 to 2016, and resident within the Kilifi Health Demographic Surveillance System (KHDSS). Children discharged alive were followed up for one year by quarterly census. Outcomes were inpatient and one-year post-discharge mortality. Results: We included 3,907 admissions among 3,196 children with a median age of 7 years 8 months (IQR 74-116 months). Severe anaemia (792, 20%), malaria (749, 19%), sickle cell disease (408, 10%), trauma (408, 10%), and severe pneumonia (340, 8.7%) were the commonest reasons for admission. Comorbidities included 623 (16%) with severe wasting, 386 (10%) with severe stunting, 90 (2.3%) with oedematous malnutrition and 194 (5.0%) with HIV infection. 132 (3.4%) children died during hospitalisation. Inpatient death was associated with signs of disease severity, age, bacteraemia, HIV infection and severe stunting. After discharge, 89/2,997 (3.0%) children died within one year during 2,853 child-years observed (31.2 deaths [95%CI, 25.3-38.4] per 1,000 child-years). 63/89 (71%) of post-discharge deaths occurred within three months and 45% of deaths occurred outside hospital. Post-discharge mortality was positively associated with weak pulse, tachypnoea, severe anaemia, HIV infection and severe wasting and negatively associated with malaria. Conclusions: Reasons for admissions are markedly different from those reported in under-fives. There was significant post-discharge mortality, suggesting hospitalisation is a marker of risk in this population. Our findings inform guideline development to include risk stratification, targeted post-discharge care and facilitate access to healthcare to improve survival in the early months post-discharge in school-aged children.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Christina Obiero
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Martha K Mwangome
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Amek Nyaguara
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Sheila Murunga
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Mark Otiende
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Gregory W Fegan
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Departments of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, P.O Box 230 - 80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
- Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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14
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Tickell KD, Sharmin R, Deichsel EL, Lamberti LM, Walson JL, Faruque ASG, Pavlinac PB, Kotloff KL, Chisti MJ. The effect of acute malnutrition on enteric pathogens, moderate-to-severe diarrhoea, and associated mortality in the Global Enteric Multicenter Study cohort: a post-hoc analysis. LANCET GLOBAL HEALTH 2020; 8:e215-e224. [PMID: 31981554 PMCID: PMC7025322 DOI: 10.1016/s2214-109x(19)30498-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 01/09/2023]
Abstract
Background Host vulnerabilities associated with acute malnutrition could facilitate the ability of specific enteric pathogens to cause diarrhoea and associated mortality. Using data from the Global Enteric Multicenter Study, we assessed whether acute malnutrition modifies the association between common enteric pathogens and moderate-to-severe diarrhoea, and whether associations between enteric pathogens and death were modified by acute malnutrition. Methods Children with moderate-to-severe diarrhoea and age-matched and community-matched controls were included in this post-hoc analysis if their mid-upper arm circumference had been measured and if they were older than 6 months of age. Acute malnutrition was defined as mid-upper arm circumference below 12·5 cm, capturing both severe acute malnutrition (<11·5 cm) and moderate acute malnutrition (≥11·5 cm and <12·5 cm). We tested whether acute malnutrition modified associations between enteric pathogens and moderate-to-severe diarrhoea in conditional logistic regression models. Among children with moderate-to-severe diarrhoea, Cox proportional hazards regression evaluated the modifying effect of acute malnutrition on the relationship between pathogens and 60-day fatality rate. Findings The age, site, and co-infection adjusted odds ratios (aORs) for moderate-to-severe diarrhoea associated with typical enteropathogenic Escherichia coli among children aged 6–11 months was 2·08 (95% CI 1·14–3·79) in children with acute malnutrition, and 0·97 (0·77–1·23) in children with better nutritional status, compared with healthy controls. Enterotoxigenic E coli producing heat-stable toxin among children aged 12–23 months also had a stronger association with moderate-to-severe diarrhoea in children with acute malnutrition (aOR 7·60 [2·63–21·95]) than among similarly aged children with better nutritional status (aOR 2·39 [1·76–3·25]). Results for Shigella spp, norovirus, and sapovirus suggested they had a stronger association with moderate-to-severe diarrhoea than other pathogens among children with better nutritional status, although Shigella spp remained associated with moderate-to-severe diarrhoea in both nutritional groups. 92 (64%) of 144 children with moderate-to-severe diarrhoea who died had acute malnutrition. Pathogen-specific 60-day fatality rates for all pathogens were higher among children with acute malnutrition, but no individual pathogen had a significantly larger increase in its relative association with mortality. Interpretation Acute malnutrition might strengthen associations between specific pathogens and moderate-to-severe diarrhoea. However, the strong link between acute malnutrition and mortality during moderate-to-severe diarrhoea in children is not limited to specific infections, and affects a broad spectrum of enteric pathogens. Interventions addressing acute malnutrition could be an effective way to lower the mortality of both childhood malnutrition and diarrhoea. Funding The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya.
| | - Rumana Sharmin
- International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Emily L Deichsel
- Center for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | | | - Judd L Walson
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA; Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - A S G Faruque
- International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Karen L Kotloff
- Center for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Mohammod J Chisti
- Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya; International Centre for Diarrheal Disease Research (icddr, b), Dhaka, Bangladesh
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15
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Ahn E, Ouma C, Loha M, Dibaba A, Dyment W, Kim J, Beck NS, Park T. Do we need to reconsider the CMAM admission and discharge criteria?; an analysis of CMAM data in South Sudan. BMC Public Health 2020; 20:511. [PMID: 32299403 PMCID: PMC7164168 DOI: 10.1186/s12889-020-08657-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 04/05/2020] [Indexed: 11/20/2022] Open
Abstract
Background Weight-for-height Z-score (WHZ) and Mid Upper Arm Circumference (MUAC) are both commonly used as acute malnutrition screening criteria. However, there exists disparity between the groups identified as malnourished by them. Thus, here we aim to investigate the clinical features and linkage with chronicity of the acute malnutrition cases identified by either WHZ or MUAC. Besides, there exists evidence indicating that fat restoration is disproportionately rapid compared to that of muscle gain in hospitalized malnourished children but related research at community level is lacking. In this study we suggest proxy measure to inspect body composition restoration responding to malnutrition management among the malnourished children. Methods The data of this study is from World Vision South Sudan’s emergency nutrition program from 2006 to 2012 (4443 children) and the nutrition survey conducted in 2014 (3367 children). The study investigated clinical presentations of each type of severe acute malnutrition (SAM) by WHZ (SAM-WHZ) or MUAC (SAM-MUAC), and analysed correlation between each malnutrition and chronic malnutrition. Furthermore, we explored the pattern of body composition restoration during the recovery phase by comparing the relative velocity of MUAC3 with that of weight gain. Results As acutely malnourished children identified by MUAC more often share clinical features related to chronic malnutrition and minimal overlapping with malnourished children by WHZ, Therefore, MUAC only screening in the nutrition program would result in delayed identification of the malnourished children. Conclusions The relative velocity of MUAC3 gain was suggested as a proxy measure for volume increase, and it was more prominent than that of weight gain among the children with SAM by WHZ and MUAC over all the restoring period. Based on this we made a conjecture about dominant fat mass gain over the period of CMAM program. Also, considering initial weight gain could be ascribed to fat mass increase, the current discharge criteria would leave the malnourished children at risk of mortality even after treatment due to limited restoration of muscle mass. Given this, further research should be followed including assessment of body composition for evidence to recapitulate and reconsider the current admission and discharge criteria for CMAM program.
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Affiliation(s)
- Eunyong Ahn
- Korea Basic Science Institute, Seoul, Korea.,Research Institute of Basic Science, Seoul National University, Seoul, Korea
| | - Cyprian Ouma
- World Food Programme, Regional Bureau-Nairobi, Nairobi, Kenya
| | - Mesfin Loha
- East Africa Regional Office, World Vision, Nairobi, Kenya
| | - Asrat Dibaba
- East Africa Regional Office, World Vision, Nairobi, Kenya
| | | | - Jaekwang Kim
- Department of Statistics, Iowa State University, Ames, USA
| | | | - Taesung Park
- Department of Statistics, Seoul National University, Seoul, Korea. .,Interdisciplinary program in Bioinofrmatics, Seoul National University, Seoul, Korea.
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16
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Influence of malaria, soil-transmitted helminths and malnutrition on haemoglobin level among school-aged children in Muyuka, Southwest Cameroon: A cross-sectional study on outcomes. PLoS One 2020; 15:e0230882. [PMID: 32226023 PMCID: PMC7105131 DOI: 10.1371/journal.pone.0230882] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/10/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The health of school-aged children (SAC) is often compromised by malaria parasitaemia (MP), soil-transmitted helminths (STH), and malnutrition in the tropics. The aim of this study was to determine the prevalence and influence of MP, STH and malnutrition on haemoglobin (Hb) levels as well as identify its predictors. METHODS This cross-sectional study was carried out in SAC (4-14 years) in Owe, Mpundu and Meanja villages in Muyuka, Southwest Cameroon. Hb concentration was measured using a URIT-12 Hb meter while MP and STH were determined by Giemsa staining of blood films and Kato-Katz technique respectively. Anthropometric measures (weight, height and mid upper arm circumference (MUAC)) of malnutrition (z-scores of <-2 standard deviations below mean) were obtained by standard methods. Categorical and continuous variables were compared appropriately, and multiple linear regression model was used to determine predictors of Hb level. RESULTS The prevalence of MP, STH, anaemia and malnutrition in the 401 SAC examined were 33.9%, 2.2%, 75.3% and 24.4% respectively. The prevalence of MP varied significantly with locality (P = 0.031). Stunting occurred commonly (23.7%) and was significantly higher in males (28.6%), children 11-14 years old (38.3%) and those of Meanja locality (47.4%) than their counterparts. Significantly higher prevalence of anaemia was observed in children of Meanja (89.5%) and those both MP positive and malnourished (86.2%). Moderate anaemia occurred commonly (60.6%) and children ≤6 years old had significantly (P = 0.034) higher prevalence (75.0%). Mean Hb level varied significantly (P = 0.004) with age and those ≤6 years old infected with MP had significantly (P = 0.022) lower values. Significant predictors of Hb levels were the MUAC (P <0.001) and the MP status (P = 0.035). Based on the Hb level (>11g/dL) and the absence of MP, STH and malnutrition, 13.7% of the SAC were considered as healthy. CONCLUSIONS The health of a majority of SAC is compromised by malaria, helminthiasis, malnutrition and other conditions not investigated. Anaemia is of major public health concern hence, intervention programmes that integrate malaria control with improvement of educational levels especially on proper nutrition and health care practices are desirable.
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17
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Grenov B, Lanyero B, Nabukeera-Barungi N, Namusoke H, Ritz C, Friis H, Michaelsen KF, Mølgaard C. Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda. J Pediatr 2019; 210:26-33.e3. [PMID: 30992218 DOI: 10.1016/j.jpeds.2019.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 02/26/2019] [Accepted: 03/12/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition. STUDY DESIGN A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality. RESULTS Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score. CONCLUSIONS Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.
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Affiliation(s)
- Benedikte Grenov
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark.
| | - Betty Lanyero
- Mwanamugimu Nutrition Unit, Department of Pediatrics and Child Health, Mulago National Referral Hospital, Kampala, Uganda
| | | | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Department of Pediatrics and Child Health, Mulago National Referral Hospital, Kampala, Uganda
| | - Christian Ritz
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Friis
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise, and Sports, University of Copenhagen, Copenhagen, Denmark
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18
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Stephens K, Orlick M, Beattie S, Snell A, Munsterman K, Oladitan L, Abdel-Rahman S. Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds. Nutr Clin Pract 2019; 35:344-352. [PMID: 31175704 DOI: 10.1002/ncp.10324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status. METHODS This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification. RESULTS Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S. POPULATION Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement. CONCLUSION The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.
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Affiliation(s)
- Karen Stephens
- Nutrition Services, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Meike Orlick
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Audrey Snell
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Leah Oladitan
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Susan Abdel-Rahman
- UMKC School of Medicine, Kansas City, Missouri, USA.,Innovation in Health Care Delivery, Children's Research Institute, Kansas City, Missouri, USA.,Section of Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri, USA
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19
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Talbert A, Ngari M, Bauni E, Mwangome M, Mturi N, Otiende M, Maitland K, Walson J, Berkley JA. Mortality after inpatient treatment for diarrhea in children: a cohort study. BMC Med 2019; 17:20. [PMID: 30686268 PMCID: PMC6348640 DOI: 10.1186/s12916-019-1258-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 01/10/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND There is an increasing recognition that children remain at elevated risk of death following discharge from health facilities in resource-poor settings. Diarrhea has previously been highlighted as a risk factor for post-discharge mortality. METHODS A retrospective cohort study was conducted to estimate the incidence and demographic, clinical, and biochemical features associated with inpatient and 1-year post-discharge mortality amongst children aged 2-59 months admitted with diarrhea from 2007 to 2015 at Kilifi County Hospital and who were residents of Kilifi Health and Demographic Surveillance System (KHDSS). Log-binomial regression was used to identify risk factors for inpatient mortality. Time at risk was from the date of discharge to the date of death, out-migration, or 365 days later. Post-discharge mortality rate was computed per 1000 child-years of observation, and Cox proportion regression used to identify risk factors for mortality. RESULTS Two thousand six hundred twenty-six child KHDSS residents were admitted with diarrhea, median age 13 (IQR 8-21) months, of which 415 (16%) were severely malnourished and 130 (5.0%) had a positive HIV test. One hundred twenty-one (4.6%) died in the hospital, and of 2505 children discharged alive, 49 (2.1%) died after discharge: 21.4 (95% CI 16.1-28.3) deaths per 1000 child-years. Admission with signs of both diarrhea and severe pneumonia or severe pneumonia alone had a higher risk of both inpatient and post-discharge mortality than admission for diarrhea alone. There was no significant difference in inpatient and post-discharge mortality between children admitted with diarrhea alone and those with other diagnoses excluding severe pneumonia. HIV, low mid-upper arm circumference (MUAC), and bacteremia were associated with both inpatient and post-discharge mortality. Signs of circulatory impairment, sepsis, and abnormal electrolytes were associated with inpatient but not post-discharge mortality. Prior admission and lower chest wall indrawing were associated with post-discharge mortality but not inpatient mortality. Age, stuntedness, and persistent or bloody diarrhea were not associated with mortality before or after discharge. CONCLUSIONS Our results accentuate the need for research to improve the uptake and outcomes of services for malnutrition and HIV as well as to elucidate causal pathways and test interventions to mitigate these risks.
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Affiliation(s)
- Alison Talbert
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya.
| | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Evasius Bauni
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya
| | - Martha Mwangome
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya
| | - Mark Otiende
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya.,Wellcome Trust Centre for Clinical Tropical Medicine, Imperial College, London, UK
| | - Judd Walson
- The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, USA
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research - Coast, PO Box 230, Kilifi, 80108, Kenya.,The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, USA.,Center for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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20
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ESPGHAN/ESPEN/ESPR/CSPEN guidelines on pediatric parenteral nutrition: Organisational aspects. Clin Nutr 2018; 37:2392-2400. [DOI: 10.1016/j.clnu.2018.06.953] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/29/2018] [Indexed: 12/18/2022]
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21
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Ng BK, Liu YE, Wang W, Kelly TL, Wilson KE, Schoeller DA, Heymsfield SB, Shepherd JA. Validation of rapid 4-component body composition assessment with the use of dual-energy X-ray absorptiometry and bioelectrical impedance analysis. Am J Clin Nutr 2018; 108:708-715. [PMID: 30099474 PMCID: PMC7263310 DOI: 10.1093/ajcn/nqy158] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/13/2018] [Indexed: 12/02/2022] Open
Abstract
Background The 4-component (4C) model is a criterion method for human body composition that separates the body into fat, water, mineral, and protein, but requires 4 measurements with significant cost and time requirements that preclude wide clinical use. A simplified model integrating only 2 measurements-dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance analysis (BIA)-and 10 min of patient time has been proposed. Objective We aimed to validate a rapid, simplified 4C DXA + BIA body composition model in a clinical population. Design This was a cross-sectional observational study of 31 healthy adults. Participants underwent whole-body DXA, segmental BIA, air displacement plethysmography (ADP), and total body water (TBW) measurement by deuterium (D2O) dilution. 4C composition was calculated through the use of the Lohman model [DXA mineral mass, D2O TBW, ADP body volume (BV), scale weight] and the simplified model (DXA mineral mass and BV, BIA TBW, scale weight). Accuracy of percentage of fat (%Fat) and protein measurements was assessed via linear regression. Test-retest precision was calculated with the use of duplicate DXA and BIA measurements. Results Of 31 participants, 23 were included in the analysis. TBWBIA showed good test-retest precision (%CV = 5.2 raw; 1.1 after outlier removal) and high accuracy to TBWD2O [TBWD2O = 0.956*TBWBIA, R2= 0.92, root mean squared error (RMSE) = 2.2 kg]. %Fat estimates from DXA, ADP, D2O, and BIA all showed high correlation with the Lohman model. However, only the 4C simplified model provides high accuracy for both %Fat (R2 = 0.96, RMSE = 2.33) and protein mass (R2= 0.76, RMSE = 1.8 kg). %Fat precision from 4C DXA + BIA was comparable with DXA (root mean square-SD = 0.8 and 0.6 percentage units, respectively). Conclusions This work validates a simplified 4C method that measures fat, water, mineral, and protein in a 10-min clinic visit. This model has broad clinical application to monitor many conditions including over/dehydration, malnutrition, obesity, sarcopenia, and cachexia.
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Affiliation(s)
- Bennett K Ng
- University of California, Berkeley and University of California, San Francisco Graduate Program in Bioengineering, CA
| | - Yong E Liu
- Department of Epidemiology, University of Hawaii Cancer Center, Honolulu, HI
| | | | | | | | - Dale A Schoeller
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | - Steven B Heymsfield
- Department of Metabolism and Body Composition, Pennington Biomedical Research Center, Baton Rouge, LA
| | - John A Shepherd
- Department of Epidemiology, University of Hawaii Cancer Center, Honolulu, HI,Address correspondence to JAS (e-mail:)
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22
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Awoke A, Ayana M, Gualu T. Determinants of severe acute malnutrition among under five children in rural Enebsie Sarmidr District, East Gojjam Zone, North West Ethiopia, 2016. BMC Nutr 2018; 4:4. [PMID: 32153868 PMCID: PMC7050716 DOI: 10.1186/s40795-018-0211-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/31/2018] [Indexed: 11/17/2022] Open
Abstract
Background Severe acute malnutrition is one of the major public health problems in developing countries having a devastating effect on the lives of many children under 5 years of age. In Ethiopia, there has been isolated studies conducted on malnutrition with no study attempting to identify the determinants of severe acute malnutrition in the rural district of Enebsie Sarmidr.This study intends to identify the determinants of severe acute malnutrition in rural district located in North West Ethiopia. Methods A Community based un matched case -control study was carried on 311 (64 cases and 247 controls) children aged between birth–59 months with their respective mothers or care takers from March 1–30/ 2016. Odds Ratio along with 95% confidence interval was estimated to identify determinants of severe acute malnutrition using the multivariable logistic regression. Results The response rate was 97.8%. Severe acute malnutrition was significantly associated with age groups birth-24 months (AOR = 2.64, 95% CI 1.17–5.95), late initiation of breast feeding greater than an hour after birth (AOR = 4.26, 95% CI 1.74–10.42), nonexclusive breast feeding (AOR =5.81, 95% CI 1.80–18.79), diarrheal disease in the preceding 2 weeks before SAM (AOR = 7.98, 95% CI 2.57–24.74), febrile illnesses preceding 2 weeks before SAM (AOR = 2.87 95% CI 1.13–7.63), decreased or maintained mealing of the mother compared to the regular during pregnancy or lactation (AOR = 8.15, 95% CI 3.70–17.98) and birth interval less than 2 years (AOR = 3.34, 95% CI 1.55–7.20) after controlling other variables effect. Conclusion A child’s age, late initiation of breast feeding, nonexclusive breast feeding, diarrheal diseases and febrile illnesses preceding 2 weeks before SAM, decreased or maintained mealing compared to the regular during pregnancy and lactating of the mother and narrow birth interval were identified as determinants of SAM. Therefore, collaborative efforts are needed to improve promotion of better child caring practices specifically, child and maternal feeding practices and prevention and treatment of acute illnesses.
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Affiliation(s)
- Abate Awoke
- East Gojjam Zone Health Department, Debre Markos, Ethiopia
| | - Mulatu Ayana
- 2Department of Public Health, College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Tenaw Gualu
- 3Department of Nursing, College of Health Sciences, Debre Markos University, P.O.BOX: 269, Debre Markos, Ethiopia
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23
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Tickell KD, Pavlinac PB, John-Stewart GC, Denno DM, Richardson BA, Naulikha JM, Kirera RK, Swierczewski BE, Singa BO, Walson JL. Impact of Childhood Nutritional Status on Pathogen Prevalence and Severity of Acute Diarrhea. Am J Trop Med Hyg 2017; 97:1337-1344. [PMID: 29140236 PMCID: PMC5817755 DOI: 10.4269/ajtmh.17-0139] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Children with acute and chronic malnutrition are at increased risk of morbidity and mortality following a diarrheal episode. To compare diarrheal disease severity and pathogen prevalence among children with and without acute and chronic malnutrition, we conducted a cross-sectional study of human immunodeficiency virus-uninfected Kenyan children aged 6–59 months, who presented with acute diarrhea. Children underwent clinical and anthropometric assessments and provided stool for bacterial and protozoal pathogen detection. Clinical and microbiological features were compared using log binomial regression among children with and without wasting (mid-upper arm circumference ≤ 125 mm) or stunting (height-for-age z score ≤ −2). Among 1,363 children, 7.0% were wasted and 16.9% were stunted. After adjustment for potential confounders, children with wasting were more likely than nonwasted children to present with at least one Integrated Management of Childhood Illness danger sign (adjusted prevalence ratio [aPR]: 1.3, 95% confidence interval [CI]: 1.0 to 1.5, P = 0.05), severe dehydration (aPR: 2.4, 95% CI: 1.5 to 3.8, P < 0.01), and enteroaggregative Escherichia coli recovered from their stool (aPR: 1.8, 1.1–2.8, P = 0.02). There were no differences in the prevalence of other pathogens by wasting status after confounder adjustment. Stunting was not associated with clinical severity or the presence of specific pathogens. Wasted children with diarrhea presented with more severe disease than children without malnutrition which may be explained by a delay in care-seeking or diminished immune response to infection. Combating social determinants and host risk factors associated with severe disease, rather than specific pathogens, may reduce the disparities in poor diarrhea-associated outcomes experienced by malnourished children.
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Affiliation(s)
- Kirkby D Tickell
- University of Washington, Seattle, Washington.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | | | | | - Donna M Denno
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,University of Washington, Seattle, Washington
| | | | | | - Ronald K Kirera
- United States Army Medical Research Directorate-Kenya (USAMD-K), Nairobi, Kenya
| | | | - Benson O Singa
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Judd L Walson
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,University of Washington, Seattle, Washington
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24
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2:66. [PMID: 29090271 PMCID: PMC5657219 DOI: 10.12688/wellcomeopenres.12357.3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18
th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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Altmann M, Suarez-Bustamante M, Soulier C, Lesavre C, Antoine C. First Wave of the 2016-17 Cholera Outbreak in Hodeidah City, Yemen - ACF Experience and Lessons Learned. PLOS CURRENTS 2017; 9:ecurrents.outbreaks.5c338264469fa046ef013e48a71fb1c5. [PMID: 29188130 PMCID: PMC5693343 DOI: 10.1371/currents.outbreaks.5c338264469fa046ef013e48a71fb1c5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Although cases were reported only in 2010 and 2011, cholera is probably endemic in Yemen. In the context of a civil war, a cholera outbreak was declared in different parts of the country October 6th, 2016. This paper describes the ACF outbreak response in Hodeidah city from October 28th, 2016 to February 28th, 2017 in order to add knowledge to this large outbreak. METHODS The ACF outbreak response in Hodeidah city included a case management component and prevention measures in the community. In partnership with the Ministry of Public Health and Population of Yemen (MoPHP), the case management component included a Cholera Treatment Center (CTC) implemented in the Al Thoraw hospital, 11 Oral Rehydration Therapy Corners (ORTCs) and an active case finding system. In partnership with other stakeholders, prevention measures in the community, including access to safe water and hygiene promotion, were implemented in the most affected communities of the city. RESULTS From October 28th, 2016 until February 28th, 2017, ACF provided care to 8,270 Acute Watery Diarrhea (AWD) cases, of which 5,210 (63%) were suspected cholera cases, in the CTC and the 11 ORTCs implemented in Hodeidah city. The attack rate was higher among people living in Al Hali district, with a peak in November 2016. At the CTC, 8% of children under 5 years-old also presented with Severe Acute Malnutrition (SAM). The Case-Fatality Rate (CFR) was low (0.07%) but 15% of admitted cases defaulted for cultural and security reasons. Environmental management lacked the information to appropriately target affected areas. Financial resources did not allow complete coverage of the city. CONCLUSION Response to the first wave of a large cholera outbreak in Hodeidah city was successful in maintaining a CFR <1% in the CTC. However, considering the actual context of Yemen and its water infrastructure, much more efforts are needed to control the current outbreak resurgence.
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Affiliation(s)
- Mathias Altmann
- Expertise and Advocacy Department, Action Contre la Faim, Paris, France
| | | | - Celine Soulier
- Expertise and Advocacy Department, Action Contre la Faim, Paris, France
| | - Celine Lesavre
- Expertise and Advocacy Department, Action Contre la Faim, Paris, France
| | - Caroline Antoine
- Expertise and Advocacy Department, Action Contre la Faim, Paris, France
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017. [DOI: 10.12688/wellcomeopenres.12357.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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Houston KA, Gibb JG, Maitland K. Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review. Wellcome Open Res 2017; 2:65. [PMID: 28944301 PMCID: PMC5590082 DOI: 10.12688/wellcomeopenres.12346.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 12/11/2022] Open
Abstract
Background: Rehydration strategies in children with severe acute malnutrition (SAM) and severe dehydration are extremely cautious. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Otherwise, guidelines recommend oral or nasogastric rehydration using low sodium oral rehydration solutions. There is limited evidence to support these recommendations. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15
th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, specifically relating to intravenous rehydration, using standard search terms. Two authors assessed papers for inclusion. The primary endpoint was evidence of fluid overload. Results: Four studies were identified, all published in English, including 883 children, all of which were conducted in low resource settings. Two were randomised controlled trials and two observational cohort studies, one incorporated assessment of myocardial and haemodynamic function. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. Mortality was high overall, and particularly in children with shock managed on WHO recommendations (day-28 mortality 82%). There was no difference in safety outcomes when different rates of intravenous rehydration were compared. Conclusions: The current ‘strong recommendations’ for conservative rehydration of children with SAM are not based on emerging evidence. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy. Recent studies have reported no evidence of fluid overload or heart failure with more liberal rehydration regimens. Clinical trials are urgently required to inform guidelines on routes and rates of intravenous rehydration therapy for dehydration in children with SAM.
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017. [DOI: 10.12688/wellcomeopenres.12357.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (20mmols/l) content than standard ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including standard ORS, hypo-osmolar ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines.
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Houston KA, Gibb JG, Mpoya A, Obonyo N, Olupot-Olupot P, Nakuya M, Evans JA, George EC, Gibb DM, Maitland K. Gastroenteritis Aggressive Versus Slow Treatment For Rehydration (GASTRO). A pilot rehydration study for severe dehydration: WHO plan C versus slower rehydration. Wellcome Open Res 2017; 2:62. [PMID: 28905004 PMCID: PMC5571888 DOI: 10.12688/wellcomeopenres.12261.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2017] [Indexed: 11/23/2022] Open
Abstract
Background: The World Health Organization (WHO) rehydration management guidelines (Plan C) for children with acute gastroenteritis (AGE) and severe dehydration are widely practiced in resource-poor settings, yet have never been formally evaluated in a clinical trial. A recent audit of outcome of AGE at Kilifi County Hospital, Kenya noted that 10% of children required high dependency care (20% mortality) and a number developed fluid-related complications. The fluid resuscitation trial, FEAST, conducted in African children with severe febrile illness, demonstrated higher mortality with fluid bolus therapy and raised concerns regarding the safety of rapid intravenous rehydration therapy. Those findings warrant a detailed physiological study of children’s responses to rehydration therapy incorporating quantification of myocardial performance and haemodynamic changes. Methods: GASTRO is a multi-centre, unblinded Phase II randomised controlled trial of 120 children aged 2 months to 12 years admitted to hospital with severe dehydration secondary to AGE. Children with severe malnutrition, chronic diarrhoea and congenital/rheumatic heart disease are excluded. Children will be enrolled over 18 months in 3 centres in Kenya and Uganda and followed until 7 days post-discharge. The trial will randomise children 1:1 to standard rapid rehydration using Ringers Lactate (WHO plan ‘C’ – 100mls/kg over 3-6 hours according to age, plus additional 0.9% saline boluses for children presenting in shock) or to a slower rehydration regimen (100mls/kg given over 8 hours and without the addition of fluid boluses). Enrolment started in November 2016 and is on-going. Primary outcome is frequency of adverse events, particularly related to cardiovascular compromise and neurological sequelae. Secondary outcomes focus on clinical, biochemical, and physiological measures related to assessment of severity of dehydration, and response to treatment by intravenous rehydration. Discussion: Results from this pilot will contribute to generating robust definitions of outcomes (in particular for non-mortality endpoints) for a larger Phase III trial.
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Affiliation(s)
- Kirsty A Houston
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Faculty of Medicine, St Mary's Campus, Norfolk Place, Imperial College London, London, UK
| | - Jack G Gibb
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Faculty of Medicine, St Mary's Campus, Norfolk Place, Imperial College London, London, UK
| | - Ayub Mpoya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Peter Olupot-Olupot
- Mbale Regional Referral Hospital, Mbale, Uganda.,Mbale Clinical Research Institute, Mbale, Uganda
| | | | - Jennifer A Evans
- Department of Paediatrics , University Hospital of Wales, Cardiff, UK
| | - Elizabeth C George
- Medical Research Council (MRC) Clinical Trials Unit, University College London, London, UK
| | - Diana M Gibb
- Medical Research Council (MRC) Clinical Trials Unit, University College London, London, UK
| | - Kathryn Maitland
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Faculty of Medicine, St Mary's Campus, Norfolk Place, Imperial College London, London, UK
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Mramba L, Ngari M, Mwangome M, Muchai L, Bauni E, Walker AS, Gibb DM, Fegan G, Berkley JA. A growth reference for mid upper arm circumference for age among school age children and adolescents, and validation for mortality: growth curve construction and longitudinal cohort study. BMJ 2017; 358:j3423. [PMID: 28774873 PMCID: PMC5541507 DOI: 10.1136/bmj.j3423] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objectives To construct growth curves for mid-upper-arm circumference (MUAC)-for-age z score for 5-19 year olds that accord with the World Health Organization growth standards, and to evaluate their discriminatory performance for subsequent mortality.Design Growth curve construction and longitudinal cohort study.Setting United States and international growth data, and cohorts in Kenya, Uganda, and Zimbabwe.Participants The Health Examination Survey (HES)/National Health and Nutrition Examination Survey (NHANES) US population datasets (age 5-25 years), which were used to construct the 2007 WHO growth reference for body mass index in this age group, were merged with an imputed dataset matching the distribution of the WHO 2006 growth standards age 2-6 years. Validation data were from 685 HIV infected children aged 5-17 years participating in the Antiretroviral Research for Watoto (ARROW) trial in Uganda and Zimbabwe; and 1741 children aged 5-13 years discharged from a rural Kenyan hospital (3.8% HIV infected). Both cohorts were followed-up for survival during one year.Main outcome measures Concordance with WHO 2006 growth standards at age 60 months and survival during one year according to MUAC-for-age and body mass index-for-age z scores.Results The new growth curves transitioned smoothly with WHO growth standards at age 5 years. MUAC-for-age z scores of -2 to -3 and less than-3, compared with -2 or more, was associated with hazard ratios for death within one year of 3.63 (95% confidence interval 0.90 to 14.7; P=0.07) and 11.1 (3.40 to 36.0; P<0.001), respectively, among ARROW trial participants; and 2.22 (1.01 to 4.9; P=0.04) and 5.15 (2.49 to 10.7; P<0.001), respectively, among Kenyan children after discharge from hospital. The AUCs for MUAC-for-age and body mass index-for-age z scores for discriminating subsequent mortality were 0.81 (95% confidence interval 0.70 to 0.92) and 0.75 (0.63 to 0.86) in the ARROW trial (absolute difference 0.06, 95% confidence interval -0.032 to 0.16; P=0.2) and 0.73 (0.65 to 0.80) and 0.58 (0.49 to 0.67), respectively, in Kenya (absolute difference in AUC 0.15, 0.07 to 0.23; P=0.0002).Conclusions The MUAC-for-age z score is at least as effective as the body mass index-for-age z score for assessing mortality risks associated with undernutrition among African school aged children and adolescents. MUAC can provide simplified screening and diagnosis within nutrition and HIV programmes, and in research.
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Affiliation(s)
| | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Martha Mwangome
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
| | - Lilian Muchai
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Evasius Bauni
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
| | - A Sarah Walker
- MRC Clinical Trials Unit, University College London, London, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Diana M Gibb
- MRC Clinical Trials Unit, University College London, London, UK
| | - Gregory Fegan
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
- Swansea Trials Unit, Swansea University Medical School, Swansea, UK
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, PO Box 230-80108, Kilifi, Kenya
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Ngari MM, Fegan G, Mwangome MK, Ngama MJ, Mturi N, Scott JAG, Bauni E, Nokes DJ, Berkley JA. Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study. Paediatr Perinat Epidemiol 2017; 31:233-242. [PMID: 28317139 PMCID: PMC5434848 DOI: 10.1111/ppe.12348] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although pneumonia is a leading cause of inpatient mortality, deaths may also occur after discharge from hospital. However, prior studies have been small, in selected groups or did not fully evaluate risk factors, particularly malnutrition and HIV. We determined 1-year post-discharge mortality and risk factors among children diagnosed with severe pneumonia. METHODS A cohort study of children aged 1-59 months admitted to Kilifi County Hospital with severe pneumonia (2007-12). The primary outcome was death <1 year after discharge, determined through Kilifi Health and Demographic Surveillance System (KHDSS) quarterly census rounds. RESULTS Of 4184 children (median age 9 months) admitted with severe pneumonia, 1041 (25%) had severe acute malnutrition (SAM), 267 (6.4%) had a positive HIV antibody test, and 364 (8.7%) died in hospital. After discharge, 2279 KHDSS-resident children were followed up; 70 (3.1%) died during 2163 child-years: 32 (95% confidence interval (CI) 26, 41) deaths per 1000 child years. Post-discharge mortality was greater after admission for severe pneumonia than for other diagnoses, hazard ratio 2.5 (95% CI 1.2, 5.3). Malnutrition, HIV status, age and prolonged hospitalisation, but not signs of pneumonia severity, were associated with post-discharge mortality. Fifty-two per cent (95% CI 37%, 63%) of post-discharge deaths were attributable to low mid-upper arm circumference and 11% (95% CI 3.3%, 18%) to a positive HIV test. CONCLUSIONS Admission with severe pneumonia is an important marker of vulnerability. Risk stratification and better understanding of the mechanisms underlying post-discharge mortality, especially for undernourished children, are needed to reduce mortality after treatment for pneumonia.
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Affiliation(s)
- Moses M. Ngari
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
| | - Greg Fegan
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,Swansea Trials UnitSwansea University Medical SchoolSwanseaUK
| | - Martha K. Mwangome
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
| | | | - Neema Mturi
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya
| | - John Anthony Gerard Scott
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,London School of Hygiene & Tropical MedicineLondonUK
| | | | - David James Nokes
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,School of Life SciencesUniversity of WarwickCoventryUK
| | - James A. Berkley
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya,Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
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Haque F, Ball RL, Khatun S, Ahmed M, Kache S, Chisti MJ, Sarker SA, Maples SD, Pieri D, Vardhan Korrapati T, Sarnquist C, Federspiel N, Rahman MW, Andrews JR, Rahman M, Nelson EJ. Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting. PLoS Negl Trop Dis 2017; 11:e0005290. [PMID: 28103233 PMCID: PMC5283765 DOI: 10.1371/journal.pntd.0005290] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/31/2017] [Accepted: 12/28/2016] [Indexed: 11/19/2022] Open
Abstract
The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.
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Affiliation(s)
- Farhana Haque
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
- Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Robyn L. Ball
- Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, California, United States of America
| | - Selina Khatun
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Mujaddeed Ahmed
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Saraswati Kache
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stace D. Maples
- Geospatial Center, Stanford University Libraries, Stanford, California, United States of America
| | - Dane Pieri
- Independent Technology Developer, San Francisco, California, United States of America
| | | | - Clea Sarnquist
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
| | - Nancy Federspiel
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Muhammad Waliur Rahman
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
- Infectious Diseases Division (IDD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Jason R. Andrews
- Department of Medicine, Stanford University School of Medicine, Stanford, California, United States of America
| | - Mahmudur Rahman
- Institute of Epidemiology, Disease Control, and Research (IEDCR), Bangladesh Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Eric Jorge Nelson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States of America
- * E-mail:
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Dukhi N, Sartorius B, Taylor M. Mid-upper arm circumference (MUAC) performance versus weight for height in South African children (0–59 months) with acute malnutrition. SOUTH AFRICAN JOURNAL OF CLINICAL NUTRITION 2017. [DOI: 10.1080/16070658.2016.1255483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Natisha Dukhi
- Department of Human Physiology, University of KwaZulu-Natal, Durban, South Africa
| | - Benn Sartorius
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Myra Taylor
- Discipline of Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa
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Frison S, Kerac M, Checchi F, Prudhon C. Anthropometric indices and measures to assess change in the nutritional status of a population: a systematic literature review. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0104-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Howie SRC, Schellenberg J, Chimah O, Ideh RC, Ebruke BE, Oluwalana C, Mackenzie G, Jallow M, Njie M, Donkor S, Dionisio KL, Goldberg G, Fornace K, Bottomley C, Hill PC, Grant CC, Corrah T, Prentice AM, Ezzati M, Greenwood BM, Smith PG, Adegbola RA, Mulholland K. Childhood pneumonia and crowding, bed-sharing and nutrition: a case-control study from The Gambia. Int J Tuberc Lung Dis 2016; 20:1405-1415. [PMID: 27725055 PMCID: PMC5019143 DOI: 10.5588/ijtld.15.0993] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 05/19/2016] [Indexed: 12/03/2022] Open
Abstract
SETTING Greater Banjul and Upper River Regions, The Gambia. OBJECTIVE To investigate tractable social, environmental and nutritional risk factors for childhood pneumonia. DESIGN A case-control study examining the association of crowding, household air pollution (HAP) and nutritional factors with pneumonia was undertaken in children aged 2-59 months: 458 children with severe pneumonia, defined according to the modified WHO criteria, were compared with 322 children with non-severe pneumonia, and these groups were compared to 801 neighbourhood controls. Controls were matched by age, sex, area and season. RESULTS Strong evidence was found of an association between bed-sharing with someone with a cough and severe pneumonia (adjusted OR [aOR] 5.1, 95%CI 3.2-8.2, P < 0.001) and non-severe pneumonia (aOR 7.3, 95%CI 4.1-13.1, P < 0.001), with 18% of severe cases estimated to be attributable to this risk factor. Malnutrition and pneumonia had clear evidence of association, which was strongest between severe malnutrition and severe pneumonia (aOR 8.7, 95%CI 4.2-17.8, P < 0.001). No association was found between pneumonia and individual carbon monoxide exposure as a measure of HAP. CONCLUSION Bed-sharing with someone with a cough is an important risk factor for severe pneumonia, and potentially tractable to intervention, while malnutrition remains an important tractable determinant.
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Affiliation(s)
- S R C Howie
- Medical Research Council Unit, Fajara, The Gambia; Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, Centre for International Health, University of Otago, Dunedin, New Zealand
| | - J Schellenberg
- London School of Hygiene & Tropical Medicine, London, UK
| | - O Chimah
- Medical Research Council Unit, Fajara, The Gambia
| | - R C Ideh
- Medical Research Council Unit, Fajara, The Gambia; Child Health Department, University of Benin, Teaching Hospital, Benin City, Nigeria
| | - B E Ebruke
- Medical Research Council Unit, Fajara, The Gambia
| | - C Oluwalana
- Medical Research Council Unit, Fajara, The Gambia
| | - G Mackenzie
- Medical Research Council Unit, Fajara, The Gambia
| | - M Jallow
- Ministry of Health and Social Welfare, Banjul, The Gambia
| | - M Njie
- Ministry of Health and Social Welfare, Banjul, The Gambia
| | - S Donkor
- Medical Research Council Unit, Fajara, The Gambia
| | - K L Dionisio
- Harvard School of Public Health, Department of Global Health and Population, Boston, and Harvard School of Public Health, Department of Environmental Health, Boston, Massachusetts, USA; National Exposure Research Laboratory, US Environmental Protection Agency, Research Triangle Park, North Carolina, USA
| | - G Goldberg
- MRC-Public Health England Centre for Environment and Health, Imperial College London, London, UK
| | - K Fornace
- Medical Research Council Unit, Fajara, The Gambia, London School of Hygiene & Tropical Medicine, London, UK
| | - C Bottomley
- London School of Hygiene & Tropical Medicine, London, UK
| | - P C Hill
- Centre for International Health, University of Otago, Dunedin, New Zealand
| | - C C Grant
- Department of Paediatrics: Child & Youth Health, University of Auckland, Auckland, New Zealand
| | - T Corrah
- Medical Research Council Unit, Fajara, The Gambia
| | - A M Prentice
- Medical Research Council Unit, Fajara, The Gambia, London School of Hygiene & Tropical Medicine, London, UK
| | - M Ezzati
- Medical Research Council (MRC) Human Nutrition Research, Cambridge, UK
| | - B M Greenwood
- London School of Hygiene & Tropical Medicine, London, UK
| | - P G Smith
- London School of Hygiene & Tropical Medicine, London, UK
| | - R A Adegbola
- Medical Research Council Unit, Fajara, The Gambia, GlaxoSmithKline Vaccines, Wavre, Belgium
| | - K Mulholland
- London School of Hygiene & Tropical Medicine, London, UK, Harvard School of Public Health, Department of Global Health and Population, Boston, and Harvard School of Public Health, Department of Environmental Health, Boston, Massachusetts, USA
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Cichon B, Fabiansen C, Yaméogo CW, Rytter MJH, Ritz C, Briend A, Christensen VB, Michaelsen KF, Oummani R, Filteau S, Ashorn P, Shepherd S, Friis H. Children with moderate acute malnutrition have inflammation not explained by maternal reports of illness and clinical symptoms: a cross-sectional study in Burkina Faso. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0096-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Etiologies, Risk Factors and Impact of Severe Diarrhea in the Under-Fives in Moramanga and Antananarivo, Madagascar. PLoS One 2016; 11:e0158862. [PMID: 27411101 PMCID: PMC4943590 DOI: 10.1371/journal.pone.0158862] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 06/23/2016] [Indexed: 11/21/2022] Open
Abstract
Background Diarrheal disease remains a leading cause of death in children in low-income countries. We investigated the etiology, risk factors and effects on nutritional status of severe diarrhea in children from two districts in Madagascar. Methods We performed a matched case-control study in 2011 to 2014, on children under the age of five years from Moramanga and Antananarivo. The cases were children hospitalized for severe diarrhea and the controls were children without diarrhea selected at random from the community. Stool samples were collected from both groups. Anthropometric measurements were made during follow-up visits about one and two months after enrolment. Results We enrolled 199 cases and 199 controls. Rotavirus infection was the most frequently detected cause of diarrhea. It was strongly associated with severe diarrhea (OR: 58.3; 95% CI: 7.7–439.9), accounting for 42.4% (95% CI: 37.6–43.1) of severe diarrhea cases. At the household level, possession of cattle (OR = 0.3; 95% CI: 0.1–0.6) and living in a house with electricity (OR = 0.4; 95% CI: 0.2–0.8) were protective factors. The presence of garbage around the house was a risk factor for severe diarrhea (OR = 3.2; 95% CI: 1.9–5.4). We found no significant association between severe diarrhea and the nutritional status of the children at follow-up visits, but evident wasting at enrolment was associated with a higher risk of severe diarrhea (OR = 9; 95% CI: 4.5–17.9). Conclusions Severe childhood diarrhea is mostly caused by rotavirus infection. An anti-rotavirus vaccine has already been introduced in Madagascar and should be promoted more widely. However, post-licensing surveillance is required. Interventions to improve the nutritional status of children, preventive measures focused on household and personal hygiene and nutritional rehabilitation during severe diarrheal disease should be reinforced.
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Mid-upper arm circumference v. weight-for-height Z-score for predicting mortality in hospitalized children under 5 years of age. Public Health Nutr 2016; 19:2513-20. [PMID: 27049813 DOI: 10.1017/s1368980016000719] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare the performance of mid-upper arm circumference (MUAC) against weight-for-height Z-score (WHZ) for predicting inpatient deaths in children under 5 years of age. DESIGN Diagnostic test accuracy study. SETTING Paediatric emergency department of a tertiary care hospital catering to semi-urban and rural population in Delhi, India. SUBJECTS Hospitalized children (n 1663) aged 6 months to 5 years, for whom discharge outcome was available, were consecutively recruited over 14 months. MUAC (cm), weight (kg) height (cm), clinical details and the outcome were recorded. MUAC (index test) was compared with WHZ based on the WHO growth standards (reference test) for predicting the outcome. RESULTS One hundred and twenty-four (7 %) children died during hospital stay. Both MUAC < 11·5 cm (adjusted OR (95 % CI): 3·7 (2·43, 5·60), P<0·001) and WHZ<-3 (2·0 (1·37, 2·99), P<0·001) served as independent predictors of inpatient mortality. However, MUAC was a significantly better predictor of mortality compared with WHZ in terms of area under the receiver-operating characteristic curve (MUAC=0·698, WHZ=0·541, P<0·001). MUAC<11·5 cm had the best trade-off of sensitivity and specificity for predicting inpatient mortality. A combination of WHZ<-3 and/or MUAC<11·5 cm did not significantly improve the predictive value over that of MUAC/WHZ, assessed individually. CONCLUSION MUAC<11·5 cm is a better predictor of mortality in hospitalized under-5 children, as compared with WHZ<-3. It should be measured in all emergency settings to identify the children at higher risk of death.
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Batra P, Schlossman N, Balan I, Pruzensky W, Balan A, Brown C, Gamache MG, Schleicher MM, de Sa AB, Saltzman E, Wood L, Roberts SB. A Randomized Controlled Trial Offering Higher- Compared with Lower-Dairy Second Meals Daily in Preschools in Guinea-Bissau Demonstrates an Attendance-Dependent Increase in Weight Gain for Both Meal Types and an Increase in Mid-Upper Arm Circumference for the Higher-Dairy Meal. J Nutr 2016; 146:124-32. [PMID: 26609172 DOI: 10.3945/jn.115.218917] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 10/30/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Controversy remains over the most effective approaches to prevent childhood malnutrition. OBJECTIVES We tested the feasibility and effectiveness of delivering ready-to-use supplementary foods (RUSFs) as a second daily meal in preschool children aged 3-5 y in Guinea-Bissau, and compared RUSFs with different levels of dairy protein. METHODS This study was a 3 mo cluster-randomized controlled pilot trial of 2 RUSFs differing in dairy protein in 533 boys and girls from 9 preschools. Children receiving RUSFs were compared with wait-listed controls, and all students received a daily school lunch. The RUSFs were delivered 5 d/wk for 3 mo and contained 478 kcal and 11.5 g protein per 92-g daily serving. Deliveries included a ready-to-use supplementary food with 15% of protein from dairy sources (RUSF-15%) or one with 33% of protein from dairy sources (RUSF-33%). Intention-to-treat (ITT) and per-protocol analyses (>50 d of RUSF consumption) were conducted. Changes in the weight-for-age z score (WAZ) and height-for-age z score were primary outcomes. Additional outcomes included changes in mid-upper arm circumference (MUAC), hemoglobin, and retinol binding protein. RESULTS Baseline anthropometry was not different between groups (WAZ, -0.48 ± 1.04) and increased significantly over time (P < 0.01) with no effects of the RUSFs in ITT analyses. However, children consuming RUSFs for >50 d had a significantly greater increase in WAZ relative to the increase in controls (+0.40 and +0.32 for RUSF-15% and RUSF-33%, respectively, compared with +0.24 in controls, P < 0.01 and P < 0.05, respectively). RUSF-33%, but not RUSF-15%, also eliminated a decrease in MUAC observed in controls (-0.01 cm in RUSF-33% compared with -0.34 cm in controls, P < 0.05). The only difference between RUSF-15% and RUSF-33% was a mean decrease in hemoglobin in children receiving RUSF-15% (-0.5 compared with -0.002 g/dL, P = 0.05). CONCLUSIONS Implementation of 2-meal preschool feeding programs is feasible in low-income countries, and there are measurable benefits relative to 1-meal programs in children attending preschool regularly. In addition, MUAC and hemoglobin measurements indicate that meals with 33% compared with 15% of protein from dairy may help prevent wasting and anemia.
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Affiliation(s)
- Payal Batra
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Nina Schlossman
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA; Global Food & Nutrition Inc., Washington, DC; and
| | - Ionela Balan
- International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau
| | - William Pruzensky
- International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau
| | - Adrian Balan
- International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau
| | - Carrie Brown
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Madeleine G Gamache
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Molly M Schleicher
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Augusto Braima de Sa
- International Partnership for Human Development, Leesburg, VA and Bissau, Guinea-Bissau
| | - Edward Saltzman
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA
| | - Lauren Wood
- Global Food & Nutrition Inc., Washington, DC; and
| | - Susan B Roberts
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA;
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Binns P, Dale N, Hoq M, Banda C, Myatt M. Relationship between mid upper arm circumference and weight changes in children aged 6-59 months. Arch Public Health 2015; 73:54. [PMID: 26693279 PMCID: PMC4685635 DOI: 10.1186/s13690-015-0103-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/05/2015] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The objectives of this study were to (i) describe the relationship between weight changes and MUAC changes in children aged between 6 and 59 months during treatment for SAM in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC and (ii) describe the sensitivity of both MUAC and weight to episodes of disease experienced during the SAM treatment episodes in CMAM programmes in three country contexts (Malawi, Ethiopia and Bangladesh) admitted using MUAC. METHODS Data collected under research conditions in Malawi were analysed for the correlation between MUAC and weight changes using the Pearson product-moment correlation coefficient (Pearson's r). Further data from other CMAM programmes implemented under field conditions in Ethiopia and Bangladesh were similarly analysed. The association of growth failure following recent episodes of illness were assessed for MUAC and weight change using a two-by-two table, box-plots and Kruskal Wallis non-parametric rank sum test. RESULTS MUAC and weight gain acheived over the entire treatment episode were strongly correlated in all three country contexts, Ethiopia (median Pearson's r = 0.816, 95 % CI = 0.782 - 0.845), Malawi (median Pearson's r = 0.843, 95 % CI = 0.802 - 0.876) and Bangladesh (median Pearson's r = 0.725, 95 % CI = 0.663 - 0.777). MUAC and weight changes at each outpatient visit were closely correlated (median Pearson's r = 0.954, 95 % CI = 0.602 - 0.997) under research conditions. The field data from Ethiopia and Bangladesh showed similar correlation (median Pearson's r = 0.945, 95 % CI = 0.685 - 0.998) and (median Pearson's r = 0.939, 95 % CI = 0.705 - 0.994) respectively. MUAC and weight appear to respond rapidly and similarly to episodes of illness reported during outpatient treatment for SAM for MUAC, diarrhoea RR = 1.88 (95 % CI = 1.64 - 2.15), vomiting RR = 1.89 (95 % CI = 1.58 - 2.26), fever RR = 1.57 (95 % CI = 1.36 - 1.82) and cough1.42 (95 % CI = 1.22 - 1.65). Similar relative risks are seen for weight; diarrhoea RR = 2.03 (95 % CI = 1.77 - 2.31), vomiting RR = 2.09 (95 % CI = 1.77 - 2.47), fever RR = 1.76 (95 % CI = 1.53 - 2.03) and cough RR = 1.25 (95 % CI = 1.06 - 1.48). CONCLUSIONS This study demonstrates a close relationship between MUAC and weight change during recovery from SAM under both research and operational field conditions. Furthermore, changes in both MUAC and weight are observed to occur similarly and rapidly during episodes of illness occurring during treatment with no lag effect on the part of MUAC. This presents the possibility for children undergoing outpatient treatment for SAM to be monitored using MUAC as an alternative to weight. Further research would be required to develop a tool which can be deployed safely and enable MUAC to be used as the sole anthropometric measure for admission, monitoring of recovery and discharge. This development would potentially allow the further decentralisation of the treatment of SAM thus improving programme coverage and child survival.
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Affiliation(s)
| | - Nancy Dale
- />University of Tampere, Tampere, Finland
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Isanaka S, Guesdon B, Labar AS, Hanson K, Langendorf C, Grais RF. Comparison of Clinical Characteristics and Treatment Outcomes of Children Selected for Treatment of Severe Acute Malnutrition Using Mid Upper Arm Circumference and/or Weight-for-Height Z-Score. PLoS One 2015; 10:e0137606. [PMID: 26376281 PMCID: PMC4574398 DOI: 10.1371/journal.pone.0137606] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/20/2015] [Indexed: 11/18/2022] Open
Abstract
Objectives Debate for a greater role of mid-upper arm circumference (MUAC) measures in nutritional programming continues, but a shift from therapeutic feeding programs admitting children using MUAC and/or weight-for-height Z (WHZ) to a new model admitting children using MUAC only remains complicated by limited information regarding the clinical profile and response to treatment of children selected by MUAC vs. WHZ. To broaden our understanding of how children identified for therapeutic feeding by MUAC and/or WHZ may differ, we aimed to investigate differences between children identified for therapeutic feeding by MUAC and/or WHZ in terms of demographic, anthropometric, clinical, and laboratory and treatment response characteristics. Methods Using secondary data from a randomized trial in rural Niger among children with uncomplicated severe acute malnutrition, we compared children that would be admitted to a therapeutic feeding program that used a single anthropometric criterion of MUAC< 115 mm vs. children that are admitted under current admission criteria (WHZ< -3 and/or MUAC< 115 mm) but would be excluded from a program that used a single MUAC< 115 mm admission criterion. We assessed differences between groups using multivariate regression, employing linear regression for continuous outcomes and log-binomial regression for dichotomous outcomes. Results We found no difference in terms of clinical and laboratory characteristics and discharge outcomes evaluated between children that would be included in a MUAC< 115 mm therapeutic feeding program vs. children that are currently eligible for therapeutic feeding but would be excluded from a MUAC-only program. Conclusions A single anthropometric admission criterion of MUAC < 115 mm did not differentiate well between children in terms of clinical or laboratory measures or program outcomes in this context. If nutritional programming is to use a single MUAC-based criterion for admission to treatment, further research and program experience can help to identify the most appropriate criterion in a broad range of contexts to target children in most urgent need of treatment.
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Affiliation(s)
- Sheila Isanaka
- Department of Research, Epicentre, Paris, France
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, United States of America
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, United States of America
- * E-mail:
| | | | - Amy S. Labar
- Department of Research, Epicentre, Paris, France
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de Pee S, Grais R, Fenn B, Brown R, Briend A, Frize J, Shoham J, Kiess L. Prevention of acute malnutrition: distribution of special nutritious foods and cash, and addressing underlying causes--what to recommend when, where, for whom, and how. Food Nutr Bull 2015; 36:S24-9. [PMID: 25902611 DOI: 10.1177/15648265150361s104] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute malnutrition is associated with increased morbidity and mortality risk. When episodes are prolonged or frequent, acute malnutrition is also associated with poor growth and development, which contributes to stunting Nutrition-specific and nutrition-sensitive strategies to prevent undernutrition during the first 1,000 days from conception to 24 months of age can reduce the risks of wasting, stunting, and micronutrient deficiencies. Under circumstances that exacerbate the underlying causes of undernutrition and increase the incidence of wasting, such as food insecurity related to lean seasons or emergencies, or increased incidence of illness, such as diarrhea or measles, additional efforts are required to prevent and treat wasting. Special nutritious foods directly meet the increased nutrient requirements of children at risk for wasting; assistance to vulnerable households, in the form of cash or food, enables households to better meet the food, health, and other needs of household members and may increase resilience; water, sanitation, and hygiene (WASH) and health interventions help prevent and address illness and hence reduce wasting risk. The contributions of specific interventions to reducing the incidence of wasting are difficult to assess under emergency conditions, due to ethical constraints and to the fact that multiple strategies are implemented at the same time. However, pragmatic studies under real-life circumstances, using different designs, e.g., including a group receiving "best possible" treatment, can provide evidence about what works, to what extent, at what cost, and under which circumstances. Programs should address the most important causes in given contexts, be feasible to implement at scale, and assess implementation, coverage, and outcomes.
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Modi P, Nasrin S, Hawes M, Glavis-Bloom J, Alam NH, Hossain MI, Levine AC. Midupper Arm Circumference Outperforms Weight-Based Measures of Nutritional Status in Children with Diarrhea. J Nutr 2015; 145:1582-7. [PMID: 25972523 PMCID: PMC4478950 DOI: 10.3945/jn.114.209718] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 04/21/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Undernutrition contributes to 45% of all deaths in children <5 y of age worldwide, with a large proportion of those deaths caused by diarrhea. However, no validated tools exist for assessing undernutrition in children with diarrhea and possible dehydration. OBJECTIVE This study assessed the validity of different measures of undernutrition in children with diarrhea. METHODS A prospective cohort study was conducted at an urban hospital in Bangladesh. Children <60 mo of age presenting to the hospital rehydration unit with acute diarrhea were eligible for enrollment. Study staff randomly selected 1196 children for screening, of which 1025 were eligible, 850 were enrolled, and 721 had complete data for analysis. Anthropometric measurements, including weight-for-age z score (WAZ), weight-for-length z score (WLZ), midupper arm circumference (MUAC), and midupper arm circumference z score (MUACZ), were calculated pre- and posthydration in all patients. Measurements were evaluated for their ability to correctly identify undernutrition in children with varying degrees of dehydration. RESULTS Of the 721 patients with full data for analysis, the median percent dehydration was 4%. Of the 4 measures evaluated, MUAC and MUACZ demonstrated 92-94% agreement pre- and posthydration compared with 69-76% for WAZ and WLZ. Although each 1% change in hydration status was found to change weight-for-age by 0.0895 z scores and weight-for-length by 0.1304 z scores, MUAC and MUACZ were not significantly affected by dehydration status. Weight-based measures misclassified 12% of children with severe underweight and 14% with severe acute malnutrition (SAM) compared with only 1-2% for MUAC and MUACZ. CONCLUSIONS MUAC and MUACZ were the most accurate predictors of undernutrition in children with diarrhea. WAZ and WLZ were significantly affected by dehydration status, leading to the misdiagnosis of many patients on arrival with severe underweight and SAM. This trial was registered at clinicaltrials.gov as NCT02007733.
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Affiliation(s)
- Payal Modi
- The Warren Alpert Medical School, Brown University, Providence, RI
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - Meagan Hawes
- Whiting School of Engineering, Johns Hopkins University, Baltimore, MD
| | | | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - M Iqbal Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; and
| | - Adam C Levine
- The Warren Alpert Medical School, Brown University, Providence, RI;
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Kerac M, Mwangome M, McGrath M, Haider R, Berkley JA. Management of acute malnutrition in infants aged under 6 months (MAMI): current issues and future directions in policy and research. Food Nutr Bull 2015; 36:S30-4. [PMID: 25993754 PMCID: PMC4817215 DOI: 10.1177/15648265150361s105] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Globally, some 4.7 million infants aged under 6 months are moderately wasted and 3.8 million are severely wasted. Traditionally, they have been over-looked by clinicians, nutritionists, and policy makers. OBJECTIVE To present evidence and arguments for why treating acute malnutrition in infants under 6 months of age is important and outline some of the key debates and research questions needed to advance their care. METHODS Narrative review. RESULTS AND CONCLUSIONS Treating malnourished infants under 6 months of age is important to avoid malnutrition-associated mortality in the short-term and adverse health and development outcomes in the long-term. Physiological and pathological differences demand a different approach from that in older children; key among these is a focus on exclusive breastfeeding wherever possible. New World Health Organization guidelines for the management of severe acute malnutrition (SAM) include this age group for the first time and are also applicable to management of moderate acute malnutrition (MAM). Community-based breastfeeding support is the core, but not the sole, treatment. The mother-infant dyad is at the heart of approaches, but wider family and community relationships are also important. An urgent priority is to develop better case definitions; criteria based on mid-upper-arm circumference (MUAC) are promising but need further research. To effectively move forward, clinical trials of assessment and treatment are needed to bolster the currently sparse evidence base. In the meantime, nutrition surveys and screening at health facilities should routinely include infants under 6 months of age in order to better define the burden and outcomes of acute malnutrition in this age group.
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LaCourse SM, Chester FM, Preidis G, McCrary LM, Maliwichi M, McCollum ED, Hosseinipour MC. Lay-screeners and use of WHO growth standards increase case finding of hospitalized Malawian children with severe acute malnutrition. J Trop Pediatr 2015; 61:44-53. [PMID: 25477308 PMCID: PMC4375387 DOI: 10.1093/tropej/fmu065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES Strategies to effectively identify and refer children with severe acute malnutrition (SAM) to Nutritional Rehabilitation units (NRU) can reduce morbidity and mortality. METHODS From December 2011 to May 2012, we conducted a prospective study task-shifting inpatient malnutrition screening of Malawian children 6-60 months to lay-screeners and evaluated World Health Organization (WHO) criteria vs. the National Center for Health Statistics (NCHS) guidelines for SAM. RESULTS Lay-screeners evaluated 3116 children, identifying 368 (11.8%) with SAM by WHO criteria, including 210 (6.7%) who met NCHS criteria initially missed by standard clinician NRU referrals. Overall case finding increased by 56.7%. Mid-upper arm circumference (MUAC) and bipedal edema captured 86% (181/210) NCHS/NRU-eligible children and 89% of those who died (17/19) meeting WHO criteria. Mortality of NCHS/NRU-eligible children was 10 times greater than those without SAM (odds ratio 10.5, 95% confidence interval 5.4-20.6). CONCLUSIONS Ward-based lay-screeners and WHO guidelines identified high-risk children with SAM missed by standard NRU referral. MUAC and edema detected the majority of NRU-eligible children.
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Affiliation(s)
- Sylvia M. LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA 98195, USA,UNC Project, Lilongwe, Malawi
| | | | - Geoffrey Preidis
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Leah M. McCrary
- UNC Project, Lilongwe, Malawi,University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27516, USA
| | | | - Eric D. McCollum
- UNC Project, Lilongwe, Malawi,Department of Pediatrics, Division of Pulmonology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Mina C. Hosseinipour
- UNC Project, Lilongwe, Malawi,Department of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
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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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Fontes D, Generoso SDV, Toulson Davisson Correia MI. Subjective global assessment: A reliable nutritional assessment tool to predict outcomes in critically ill patients. Clin Nutr 2014; 33:291-5. [DOI: 10.1016/j.clnu.2013.05.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 03/28/2013] [Accepted: 05/03/2013] [Indexed: 01/12/2023]
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Hankard R, Colomb V, Piloquet H, Bocquet A, Bresson JL, Briend A, Chouraqui JP, Darmaun D, Dupont C, Frelut ML, Girardet JP, Goulet O, Rieu D, Simeoni U, Turck D, Vidailhet M. Dépister la dénutrition de l’enfant en pratique courante. NUTR CLIN METAB 2013. [DOI: 10.1016/j.nupar.2012.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Adequacy of child anthropometric indicators for measuring nutritional stress at population level: a study from Niakhar, Senegal. Public Health Nutr 2012; 16:1533-9. [PMID: 23046565 DOI: 10.1017/s136898001200448x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To compare the responsiveness of different anthropometric indicators for measuring nutritional stress among children in developing countries. DESIGN Growth was studied within 6-month intervals in a rural Senegalese community during one dry and two rainy (hungry) seasons. Responsiveness was defined as the change divided by the standard deviation of each anthropometric indicator. Contrast was defined as the difference in responsiveness between dry and rainy seasons. SETTING The study was conducted in Niakhar, a rural area of Senegal under demographic surveillance, with contrasted food and morbidity situations between rainy and dry seasons. SUBJECTS Some 5000 children under 5 years of age were monitored at 6-month intervals in 1983–1984. The present analysis was carried out on a sub-sample of children aged 6–23 months with complete measures, totalling 2803 children-intervals. RESULTS In both univariate and multivariate analysis, mid-upper arm circumference was found to be more responsive to nutritional stress than the commonly used weight-for-height Z-score (contrast = -0.64 for mid-upper arm circumference v. -0.53 for weight-for-height Z-score). Other discriminant indicators were: muscle circumference, weight-for-height, BMI and triceps skinfold. Height, head circumference and subscapular skinfold had no discriminating power for measuring the net effect of nutritional stress during the rainy season. CONCLUSIONS The use of mid-upper arm circumference for assessing nutritional stress in community surveys should be considered and preferred to other nutritional indicators. Strict standardization procedures for measuring mid-upper arm circumference are required for optimal use.
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Dépister la dénutrition de l’enfant en pratique courante. Arch Pediatr 2012; 19:1110-7. [DOI: 10.1016/j.arcped.2012.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 07/04/2012] [Indexed: 11/18/2022]
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