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Li Z, Maimaiti Z, Li ZY, Fu J, Hao LB, Xu C, Chen JY. Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection. Nutrients 2022; 14:nu14204433. [PMID: 36297116 PMCID: PMC9607573 DOI: 10.3390/nu14204433] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022] Open
Abstract
The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.
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Affiliation(s)
- Zhuo Li
- School of Medicine, Nankai University, Tianjin 300071, China
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zulipikaer Maimaiti
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhi-Yuan Li
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jun Fu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Li-Bo Hao
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Chi Xu
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
- Correspondence: (C.X.); (J.-Y.C.)
| | - Ji-Ying Chen
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
- Correspondence: (C.X.); (J.-Y.C.)
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Nigussie J, Girma B, Molla A, Mareg M, Mihretu E. Under-nutrition and associated factors among children infected with human immunodeficiency virus in sub-Saharan Africa: a systematic review and meta-analysis. Arch Public Health 2022; 80:19. [PMID: 34986885 PMCID: PMC8728950 DOI: 10.1186/s13690-021-00785-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/28/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In the developing world, such as the sub-Saharan African region, HIV/AIDS has worsened the impact of under-nutrition in children. HIV infected children are highly vulnerable to under-nutrition. Therefore, the objective of this systematic review and meta-analysis was to estimate the pooled prevalence of under-nutrition, and the pooled effect sizes of associated factors among HIV-infected children in sub-Saharan Africa. METHODS The primary studies for this review were retrieved from PubMed/ MEDLINE online, Science Direct, Hinari, web of science, CINHAL, EMBASE, WHO databases, Google, and Google Scholar databases. The articles selected for this meta-analysis were published between 2010 and 2020. The last search date was 18 October 2021. The data was extracted in Microsoft Excel format and exported to STATA Version 14.0. A random effect meta-analysis model was used. Heterogeneity was evaluated by the I2 test. The Egger weighted regression test was used to assess publication bias. RESULTS We retrieved 847 records from these databases. Of which records, 813 were excluded due to different reasons and 34 studies were included in the final analysis. The pooled prevalence of stunting, underweight and wasting in HIV infected children was 46.7% (95% CI; 40.36-53.07, I2 = 98.7%, p < 0.01), 35.9% (95% CI; 30.79-41.02, I2 = 97.4% p < 0.01), and 23.0% (95% CI; 18.67-27.42, I2 = 96.9%, p < 0.01) respectively. The advanced WHO HIV/AIDS clinical staging (III&IV) [OR = 6.74 (95%: 1.747, 26.021), I2 = 94.7%] and household food insecurity were associated with stunting [OR = 5.92 (95% CI 3.9, 8.87), I2 = 55.7%]. Low family economic status [OR = 4.737 (95% CI: 2.605, 8.614), I2 = 31.2%] and increased feeding frequency [OR = 0.323 (95% CI: 0.172, 0.605), I2 = 69.8%] were significantly associated with under-weight. Anemia [OR = 2.860 (95% CI: 1.636, 5.000), I2 = 74.8%] and diarrhea in the previous month [OR = 4.117 (95% CI: 2.876, 5.894), I2 = 0.0%] were also associated with wasting among HIV infected children in sub-Saharan Africa. CONCLUSIONS The pooled prevalence of under-nutrition among HIV infected children was high. Nutritional assessment and interventions need great attention as a part of HIV care for HIV positive children. The implementation of policies and strategies established by national and international stakeholders in ART care centres should take a maximum emphasis on reducing under-nutrition among HIV infected children.
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Affiliation(s)
- Jemberu Nigussie
- Department of Nursing College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia.
| | - Bekahegn Girma
- Department of Nursing College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
| | - Alemayehu Molla
- Department of Psychiatry College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Moges Mareg
- Department of Reproductive Health School of Public Health, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Esmelealem Mihretu
- Department of Nursing College of Health Sciences and Medicine, Debre Markos University, Debre Markos, Ethiopia
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Wolday D, Ndungu FM, Gómez-Pérez GP, de Wit TFR. Chronic Immune Activation and CD4 + T Cell Lymphopenia in Healthy African Individuals: Perspectives for SARS-CoV-2 Vaccine Efficacy. Front Immunol 2021; 12:693269. [PMID: 34220854 PMCID: PMC8249933 DOI: 10.3389/fimmu.2021.693269] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/04/2021] [Indexed: 12/14/2022] Open
Abstract
Chronic immune activation has been considered as the driving force for CD4+ T cell depletion in people infected with HIV-1. Interestingly, the normal immune profile of adult HIV-negative individuals living in Africa also exhibit chronic immune activation, reminiscent of that observed in HIV-1 infected individuals. It is characterized by increased levels of soluble immune activation markers, such as the cytokines interleukin (IL)-4, IL-10, TNF-α, and cellular activation markers including HLA-DR, CD-38, CCR5, coupled with reduced naïve and increased memory cells in CD4+ and CD8+ subsets. In addition, it is accompanied by low CD4+ T cell counts when compared to Europeans. There is also evidence that mononuclear cells from African infants secrete less innate cytokines than South and North Americans and Europeans in vitro. Chronic immune activation in Africans is linked to environmental factors such as parasitic infections and could be responsible for previously observed immune hypo-responsiveness to infections and vaccines. It is unclear whether the immunogenicity and effectiveness of anti-SARS-CoV-2 vaccines will also be reduced by similar mechanisms. A review of studies investigating this phenomenon is urgently required as they should inform the design and delivery for vaccines to be used in African populations.
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Affiliation(s)
- Dawit Wolday
- Department of Medicine, Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Francis M. Ndungu
- Department of Global Health, Kenyan Medical Research Institute (KEMRI) – Wellcome Research Programme, Nairobi, Kenya
| | - Gloria P. Gómez-Pérez
- Amsterdam Institute of Global Health and Development, Department of Global Health, Amsterdam University, Amsterdam, Netherlands
| | - Tobias F. Rinke de Wit
- Amsterdam Institute of Global Health and Development, Department of Global Health, Amsterdam University, Amsterdam, Netherlands
- Joep-Lange Institute, Amsterdam, Netherlands
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Odwee A, Kasozi KI, Acup CA, Kyamanywa P, Ssebuufu R, Obura R, Agaba JB, Makeri D, Kirimuhuzya C, Sasirabo O, Bamaiyi PH. Malnutrition amongst HIV adult patients in selected hospitals of Bushenyi district in southwestern Uganda. Afr Health Sci 2020; 20:122-131. [PMID: 33402900 PMCID: PMC7750061 DOI: 10.4314/ahs.v20i1.17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Malnutrition is an important clinical outcome amongst HIV patients in developing countries and in Uganda, there is scarcity of information on its prevalence and risk factors amongst HIV adult patients. METHODS A cross-sectional study amongst 253 HIV patients in Bushenyi district assessed their nutritional status using the body mass index (BMI) and mid-upper arm circumference (MUAC), and a questionnaire was used to identify major risk factors. RESULTS The mean age of the study participants was 38.74 ± 0.80 yrs, while females and males were 52.2% and 47.8% respectively. Prevalence of malnutrition was 10.28% (95% CI: 6.82 - 14.69) in the study. Major socio-economic factors associated with malnutrition were being female, unemployed, dependent and with many family members. Patients with opportunistic infections, low adherence to HAART, and stage of HIV/AIDS had a higher risk of malnutrition. DISCUSSION In rural communities, a majority of malnourished patients are elderly and these were identified as priority groups for HIV outreach campaigns. The current policy of prioritizing children and women is outdated due to changing disease dynamics, thus showing a need to revise extension service provision in rural communities. CONCLUSIONS Malnutrition is a threat in HIV adult patients in rural communities of Uganda.
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Affiliation(s)
- Ambrose Odwee
- Department of Public Health, School of Allied Health and Sciences, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Keneth Iceland Kasozi
- Department of Physiology, Faculty of Biomedical Sciences, Kampala International University Western Campus, Box 71, Bushenyi, Uganda
| | - Christine Amongi Acup
- Department of Public Health, School of Allied Health and Sciences, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Patrick Kyamanywa
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Robinson Ssebuufu
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Richard Obura
- School of Business and Management, Mountains of the Moon University, Box 837, Fort Portal, Uganda
| | - Jude B Agaba
- Department of Public Health, School of Allied Health and Sciences, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Danladi Makeri
- Department of Public Health, School of Allied Health and Sciences, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
| | - Claude Kirimuhuzya
- Department of Pharmacology, School of Pharmacy, Kampala International University Western Campus, Box 71 Bushenyi, Uganda
- Department of Pharmacology, School of Medicine, Kabale University, Kabale, Uganda
| | - Olivia Sasirabo
- School of Business and Management, Mountains of the Moon University, Box 837, Fort Portal, Uganda
| | - Pwaveno H Bamaiyi
- Department of Public Health, School of Allied Health and Sciences, Kampala International University Teaching Hospital, Box 71, Bushenyi, Uganda
- Postgraduate School and Research Directorate, Kampala International University Western Campus, Box 71, Bushenyi, Uganda
- Department of Veterinary Public Health and Preventive Medicine, Faculty of Veterinary Medicine, University of Jos, Plateau State, Nigeria
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Baraki AG, Akalu TY, Wolde HF, Takele WW, Mamo WN, Derseh B, Desyibelew HD, Dadi AF. Time to recovery from severe acute malnutrition and its predictors: a multicentre retrospective follow-up study in Amhara region, north-west Ethiopia. BMJ Open 2020; 10:e034583. [PMID: 32060161 PMCID: PMC7045195 DOI: 10.1136/bmjopen-2019-034583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES This study aimed to determine the time to recovery from severe acute malnutrition (SAM) and its predictors in selected public health institutions in Amhara Regional State, Ethiopia. DESIGN An institution-based retrospective follow-up study was conducted using data extracted from 1690 patient cards from September 2012 to November 2016. SETTING Selected government health institutions in the Amhara region, Ethiopia. PARTICIPANTS Children treated in therapeutic feeding units for SAM were included. OUTCOME MEASURES Time to recovery from SAM. RESULTS One thousand and fifty children have recovered from SAM, 62.13% (95% CI 59.8% to 64.5%). The median time to recovery was 16 days (IQR=11-28). Female gender (adjusted HR (AHR)=0.81, 95% CI 0.67 to 0.98), oedematous malnutrition (AHR=0.74 95% CI 0.59 to 0.93), pneumonia (AHR=0.66, 95% CI 0.53 to 0.83), tuberculosis (AHR=0.53, 95% CI 0.36 to 0.77), HIV/AIDS (AHR=0.47, 95% CI 0.28 to 0.79), anaemia (AHR=0.73, 95% CI 0.60 to 0.89) and receiving vitamin A (AHR=1.43, 95% CI 1.12 to 1.82) were notably associated with time to recovery. CONCLUSIONS The time to recovery in this study was acceptable but the proportion of recovery was far below the minimum standard. Special emphasis should be given to the prevention and treatment of comorbidities besides the therapeutic feeding. Supplementing vitamin A would also help to improve the recovery rate.
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Affiliation(s)
- Adhanom Gebreegziabher Baraki
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Temesgen Yihunie Akalu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Haileab Fekadu Wolde
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Wubet Worku Takele
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Worku Nigussu Mamo
- Nutrition, Abrhajira Primary Hospital, West Gondar Zone, Gondar, Ethiopia
| | - Behailu Derseh
- Department of Public Health, College of Health Sciences, Debre Berhan University, Gondar, Ethiopia
| | - Hanna Demelash Desyibelew
- Department of Public Health Nutrition, College of Medicine and Health Sciences, Bahirdar University, Bahir Dar, Ethiopia
| | - Abel Fekadu Dadi
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Co-infection of malaria and HIV infection in severely undernourished children in the Democratic Republic of the Congo: a cross-sectional study. Parasitology 2019; 147:248-253. [PMID: 31727183 PMCID: PMC7050322 DOI: 10.1017/s0031182019001513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose This study aims to determine the prevalence of malaria and HIV seropositivity among children with undernutrition in the Democratic Republic of the Congo. Methods A cross-sectional study of undernourished children aged between 12 and 60 months in Kalembe-Lembe hospital was carried out. Blood samples were collected for the analyses of malaria parasite, haemoglobin and haematocrit levels. HIV serostatus was determined with rapid HIV antibody tests and enzyme-linked immunosorbent assay. Logistic regression analyses were used to identify clinical predictors of HIV seropositivity. Results Of 225 children, 88.9% had malaria; the parasite loads were 16 000 para per μL (38.0%); 24 400 para per μL (56.8%), P < 0.001 and malaria and associated HIV infection accounted for 29.2%. In children aged >12 months, HIV seroprevalence was 29.3%; 86.0% had undernutrition and malaria, 6.8% had undernutrition and HIV and 4.3% had undernutrition, HIV and malaria (P < 0.001). The occurrence of at least three or more symptoms was highly specific (96.4–100.0%) for HIV seropositivity (P < 0.05). The overall mortality rate was 18.4%, higher in children with malaria and HIV (39.6% vs 12.2%, P < 0.001) and those with lower weight gain (4.3 vs 7.5 g kg−1 day−1, P < 0.001). Conclusions There was high prevalence of malaria and HIV and mortality among severely undernourished children with malaria and HIV.
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Islam S, Sarmin M, Ahmed T, Afroze F, Chisti MJ. Factors associated with cerebral edema in children under 5 years of age admitted in an intensive care unit and their outcome. SAGE Open Med 2019; 7:2050312119874622. [PMID: 31523426 PMCID: PMC6727091 DOI: 10.1177/2050312119874622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/13/2019] [Indexed: 11/21/2022] Open
Abstract
Objective: We aimed to evaluate risk factors and outcome of cerebral edema in children with diarrhea. Methods: In this retrospective chart analysis, data of all diarrheal children under 5 years of age having convulsion and admitted in intensive care unit were retrieved from an electronic medical record system of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh, from 1st January 2011 to 31st December 2016. Comparison of clinical and laboratory characteristics was made between children with (cases = 22) and without cerebral edema (controls = 66). Results: Cases more often had a fatal outcome than controls (36% vs 8%, p = 0.003). In logistic regression analysis, after adjusting for potential confounders, the cases were independently associated with respiratory distress (odds ratio = 5.5, confidence interval = 1.55–19.62, p = 0.008), severe sepsis (odds ratio = 4.6, confidence interval = 1.24–16.77, p = 0.022), and severe malnutrition (odds ratio = 0.16, confidence interval = 0.04–0.74, p = 0.019). A rapid drop (>0.5 mmol/L per hour) in serum sodium did not have any impact on developing cerebral edema (p = 0.090). Conclusion: Identification of simple clinical predictors may help in the early treatment of cerebral edema that may further help in reducing deaths in such children especially in resource-poor settings. However, further research with prospective design is needed to consolidate our observation.
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Affiliation(s)
- Shamin Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Monira Sarmin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Farzana Afroze
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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Uwaezuoke SN, Ndu IK, Eze IC. The prevalence and risk of urinary tract infection in malnourished children: a systematic review and meta-analysis. BMC Pediatr 2019; 19:261. [PMID: 31351466 PMCID: PMC6660684 DOI: 10.1186/s12887-019-1628-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 07/16/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There are vast differences in prevalence rates of urinary tract infection (UTI) reported among malnourished children globally. We conducted a systematic review and meta-analysis to provide estimates of pooled prevalence of UTI among these children and combined UTI risk in comparison with their well-nourished counterparts. METHODS We systematically searched electronic databases (MEDLINE, EMBASE, ISI Web of Science and African Journals Online; date of the last search: 22 December 2018) for studies reporting either the prevalence of UTI in malnourished children or parallel healthy controls. Eligible primary studies were observational studies of children in English Language reporting UTI prevalence with background malnutrition or with enough data to compute these estimates, as well as studies which reported at the same time UTI prevalence in healthy controls. We synthesized published prevalence rates or associations (odds ratios [OR]) between malnutrition and UTI and their 95% confidence intervals (CI) using random effects meta-regression and explored potential heterogeneity determinants using meta-regression analysis. This review is registered with PROSPERO, number- CRD42018084765. RESULTS We included 26 cross-sectional and 8 case-control studies reporting on UTI prevalence in malnourished children, and in malnourished children vs. healthy controls, respectively. The pooled prevalence of UTI in 3294 malnourished children was 17% (95% CI, 13, 21%). Heterogeneity was high (I2 = 87.6%; Tau2 = 0.06) as studies varied in their sample size, degree of malnutrition, and study period. Multivariate meta-regression model, including these factors, explained 34.6% of the between-study variance. Pooled OR of UTI in association with malnutrition in 2051 children (1052 malnourished children vs. 999 controls) was 2.34 (95% CI, 1.15, 3.34), with lower between-study heterogeneity (I2 = 53.6%; Tau2 = 0.47). CONCLUSIONS UTI is more prevalent in malnourished children than in their well-nourished counterparts. Screening and treatment for UTI should be incorporated in the management protocol of malnourished children to improve disease outcomes.
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Affiliation(s)
- Samuel N Uwaezuoke
- Department of Pediatrics, College of Medicine, University of Nigeria/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Postal code: 400001, Nigeria.
| | - Ikenna K Ndu
- Department of Pediatrics, Enugu State University Teaching Hospital, Park Lane, Enugu, Nigeria
| | - Ikenna C Eze
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Inflammatory biomarkers in HIV-infected children hospitalized for severe malnutrition in Uganda and Zimbabwe. AIDS 2019; 33:1485-1490. [PMID: 31008797 DOI: 10.1097/qad.0000000000002231] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVES A proportion of HIV-infected children with advanced disease develop severe malnutrition soon after antiretroviral therapy (ART) initiation. We tested the hypothesis that systemic inflammation underlies the pathogenesis of severe malnutrition in HIV-infected children. DESIGN Cross-sectional laboratory substudy in 613 HIV-infected children initiating ART in Uganda and Zimbabwe. METHODS We measured C-reactive protein (CRP), TNFα, IL-6 and soluble CD14 by ELISA in cryopreserved plasma at baseline (pre-ART) and week-4 (children with severe malnutrition only). Independent associations between baseline biomarkers and subsequent hospitalization for severe malnutrition were identified using multivariable fractional polynomial logistic regression. RESULTS Compared with children without severe malnutrition (n = 574, median age 6.3 years, median baseline weight-for-age Z-score -2.2), children hospitalized for severe malnutrition post-ART (n = 39, median age 2.3 years, median baseline weight-for-age Z-score -4.8) had higher baseline CRP [median 13.5 (interquartile range 5.5, 41.1) versus 4.1 (1.4, 14.4) mg/l; P = 0.003] and IL-6 [median 9.2 (6.7, 15.6) versus 5.9 (4.6, 9.3) pg/ml; P < 0.0001], but similar overall TNFα, soluble CD14 and HIV viral load (all P > 0.06). In a multivariable model, higher pre-ART IL-6, lower TNFα and lower weight-for-age were independently associated with subsequent hospitalization for severe malnutrition. Between weeks 0 and 4, there was a significant rise in CRP, IL-6 and soluble CD14, and fall in TNFα and HIV viral load in children hospitalized for severe malnutrition (all P < 0.02). CONCLUSION Pre-ART IL-6 and TNFα were more strongly associated with hospitalization for severe malnutrition than CD4 cell count or viral load, highlighting the importance of inflammation at the time of ART initiation in HIV-infected children.
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Temiye EO, Adeniyi OF, Fajolu IB, Ogbenna AA, Ladapo TA, Esezobor CI, Akinsulie AO, Mabogunje CA. Human immunodeficiency virus status in malnourished children seen at Lagos. PLoS One 2018; 13:e0200435. [PMID: 30286087 PMCID: PMC6171835 DOI: 10.1371/journal.pone.0200435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/14/2018] [Indexed: 12/26/2022] Open
Abstract
Introduction Human immunodeficiency virus and protein energy malnutrition are still prevalent in Nigeria and the occurrence of the two conditions together confers a poor prognosis. The aim of this study was to determine the current categories of malnutrition amongst under-5 children in Lagos, document their HIV status and determine any peculiarities in the clinical features, haematological and some biochemical profile in these children. Methods The study was a cross-sectional study conducted at the Paediatric departments of the Lagos University Teaching Hospital and the Massey Street Children’s Hospital, both in Lagos, over a 6-month period. All the subjects had anthropometry, HIV testing, full blood count and serum proteins done. The factors associated with HIV status were determined with the logistic regression analysis. Results Two hundred and fourteen (214) malnourished children ≤5 years, including 25 (11.7%) with HIV were recruited in the study. Among the study participants, 150 (70.1%) and 54 (29.9%) had moderate and severe malnutrition, respectively. Fever, cough and diarrhea were the most common symptoms in the study participants. The haematological indices were comparable in the two groups, the serum globulin levels though higher in the HIV infected group was not statistically significantly different from the non-infected group.(p = 0.66). None of the factors explored on multivariate analysis was able to predict the occurrence of the infection in this cohort. Conclusion Malnourished children remain a high risk group for HIV infection and the prevalence of the infection obtained in this group of children is still unacceptably high. Discriminatory features between malnutrition and HIV remains difficult. The presence of hyperglobulinaemia on laboratory analysis in a malnourished child may heighten the suspicion of possible underlying associated HIV infection. Screening of malnourished children for HIV infection and further longitudinal studies on malnourished children with HIV is advocated
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Affiliation(s)
- Edamisan Olusoji Temiye
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
| | - Oluwafunmilayo Funke Adeniyi
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
- * E-mail:
| | - Iretiola Bamikeolu Fajolu
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
| | - Ann Abiola Ogbenna
- Department of Haematology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
| | - Taiwo Augustine Ladapo
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
| | - Christopher Imokhuede Esezobor
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
| | - Adebola Olumide Akinsulie
- Department of Paediatrics, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Idi–Araba, Lagos, Nigeria
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Archary M, Mcllleron H, Bobat R, La Russa P, Sibaya T, Wiesner L, Hennig S. Population Pharmacokinetics of Lopinavir in Severely Malnourished HIV-infected Children and the Effect on Treatment Outcomes. Pediatr Infect Dis J 2018; 37:349-355. [PMID: 29227461 PMCID: PMC5849509 DOI: 10.1097/inf.0000000000001867] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In developing countries, malnutrition remains a common clinical syndrome at antiretroviral treatment (ART) initiation. Physiologic changes because of malnutrition and during nutritional recovery could affect the pharmacokinetics of antiretroviral drugs. METHODS HIV-infected children admitted with severe acute malnutrition were randomized to early or delayed initiation of lopinavir (LPV)/ritonavir, abacavir and lamivudine using World Health Organization weight band dosage charts. LPV concentrations were measured on day 1 and day 14. Thereafter, patients were followed-up to week 48. The population pharmacokinetics of LPV was described using NONMEM v7.3. Covariates were screened to assess their influence on the pharmacokinetics of LPV, and the relationship between pharmacokinetic variability and treatment outcomes were assessed. RESULTS Five hundred and two LPV concentrations were collected from 62 pediatric patients 0.1-3.9 years of age (median: 0.9 years). Rifampin-based antituberculosis treatment and "super-boosted" LPV/ritonavir were prescribed in 20 patients. LPV disposition was well described by a one-compartment model with first-order elimination. Neither randomization to early or delayed ART, tuberculosis comedications nor anthropometrical measurements explained the pharmcokinetic variability. Allometrically scaled fat-free mass influenced apparent clearance (CL/F) and volume of distribution (Vd/F). Pharmacokinetic exposure did not correlate with virologic outcomes or death at 12 or 48 weeks. CONCLUSIONS LPV pharmacokinetics was influenced by fat-free mass and not by timing of ART initiation or tuberculosis comedication in severely malnourished HIV-infected children. LPV pharmacokinetics was found to be highly variable and bioavailability greatly reduced, resulting in a high CL estimate in this population. The role of LPV dose adjustment should be further evaluated in severely malnourished children initiating ART.
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Muzigaba M, Van Wyk B, Puoane T. Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals. Afr J Prim Health Care Fam Med 2018; 10:e1-e8. [PMID: 29415550 PMCID: PMC5803520 DOI: 10.4102/phcfm.v10i1.1547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 10/02/2017] [Accepted: 10/10/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas. OBJECTIVE To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa. METHODS An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis. FINDINGS Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians. CONCLUSION Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings.
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Affiliation(s)
- Moise Muzigaba
- Faculty of Community and Health Sciences, School of Public Health, University of the Western Cape.
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Changes in the haematological parameters of HIV-1 infected children at 6 and 12 months of antiretroviral therapy in a large clinic cohort, North-Central Nigeria. J Virus Erad 2017; 3:208-211. [PMID: 29057084 PMCID: PMC5632547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Prior to commencing antiretroviral therapy (ART), haematological abnormalities are a common occurrence in individuals diagnosed with human immunodeficiency virus (HIV). In the course of receiving ART, these abnormalities usually improve. We determined the prevalence of haematological abnormalities in children diagnosed with HIV-1 and the changes in haematological parameters that occur after 6 and 12 months of being on ART. METHODS A cross-sectional study of HIV-1 infected children aged 2 months to 15 years, between July 2005 and March 2013, at the paediatric HIV clinic of the Jos University Teaching Hospital, Jos. Median values of repeated measures were compared using the Wilcoxon signed-rank sum test. RESULTS The prevalence of anaemia, thrombocytopenia and leukopenia among the 941 children studied, prior to ART was 6.4%, 7.0% and 8.6%. Median (IQR) haemoglobin (Hb) levels increased from 10 g/dL (9-11 g/dL) at baseline to 11 g/dL (10-12 g/dL) and 11 g/dL (10-12 g/dL) at 6 and 12 months of ART (P<0.001 and P<0.001), respectively, a 10% increase in both cases. Also, platelet count increased from a median of 327×103/μL (243-426×103/μL) at baseline to 333×103/μL (266-408×103/μL) at 6 months and 339×103/μL (267-420×103/μL) at 12 months, representing a 1.8% and 3.7% increase, respectively. The median total white blood cell count decreased from 7.4×103/μL (5.3-9.9×103/μL) at baseline to 5.9×103/μL (4.6-8.0×103/μL) and 5.8×103/μL (4.5-7.5×103/μL) at 6 and 12 months of ART (P<0.001 and P<0.001), a 20.3% and 21.6% decrease, respectively. CONCLUSION During the 12 months of ART, children in our cohort had significant improvements in haematological parameters such as haemoglobin levels and platelet counts, which would suggest an early positive response to ART.
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Changes in the haematological parameters of HIV-1 infected children at 6 and 12 months of antiretroviral therapy in a large clinic cohort, North-Central Nigeria. J Virus Erad 2017. [DOI: 10.1016/s2055-6640(20)30315-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Chisti MJ, Shahunja KM, Afroze F, Shahid AS, Sharifuzzaman, Ahmed T. Hypoxaemia and septic shock were independent risk factors for mechanical ventilation in Bangladeshi children hospitalised for diarrhoea. Acta Paediatr 2017; 106:1159-1164. [PMID: 28316105 DOI: 10.1111/apa.13836] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 02/24/2017] [Accepted: 03/14/2017] [Indexed: 01/20/2023]
Abstract
AIM In Bangladesh, approximately 6% of children under five years of age die due to diarrhoea. We evaluated the admission and hospitalisation risk factors for mechanical ventilation and outcomes in children with diarrhoea. METHODS This retrospective case-control chart analysis was conducted in the intensive care unit of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. We enrolled 219 children with diarrhoea aged 0-59 months between August 2009 and July 2013. The 73 cases were children who were initially identified as requiring mechanical ventilation during the study period, and the 146 controls were randomly selected from those who did not require mechanical ventilation. We compared the groups to determine the risk factors for mechanical ventilation. RESULTS Mortality was significantly higher among the cases than the controls (p < 0.001). In the logistic regression analysis carried out for two separate time points, the independent risk factors for mechanical ventilation on admission were hypoxaemia (p < 0.001) and septic shock (p = 0.004) and during hospitalisation, they were intake of intravenous fluid (p = 0.015), hypokalaemia (p = 0.018), hyperkalaemia (p = 0.005) and septic shock (p = 0.001). CONCLUSION Children under five with diarrhoea who required mechanical ventilation frequently had hypoxaemia and septic shock and were more likely to die than unventilated controls.
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Affiliation(s)
- Mohammod Jobayer Chisti
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
| | - KM Shahunja
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
| | - Farzana Afroze
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
| | - Abu S.M.S.B. Shahid
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
| | - Sharifuzzaman
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
| | - Tahmeed Ahmed
- Nutrition & Clinical Services Division (NCSD); International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b); Dhaka Bangladesh
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Poda GG, Hsu CY, Chao JCJ. Malnutrition is associated with HIV infection in children less than 5 years in Bobo-Dioulasso City, Burkina Faso: A case-control study. Medicine (Baltimore) 2017; 96:e7019. [PMID: 28538421 PMCID: PMC5457901 DOI: 10.1097/md.0000000000007019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Pediatric human immunodeficiency virus (HIV) infection and malnutrition are still 2 major health issues in sub-Saharan Africa including Burkina Faso where few studies have been conducted on child malnutrition and HIV infection. This study assessed the effects of antiretroviral therapy (ART) in HIV infection and also compared the prevalence of malnutrition in terms of an inadequate diet, underweight, stunting, and wasting among HIV-infected and uninfected children less than 5 years in Bobo-Dioulasso city, Burkina Faso.This was a case-control study matching for age and sex in 164 HIV-infected and 164 HIV-uninfected children. The sociodemographic characteristics of mothers and children, household food security, drinking water source, child feeding and care practices, and child anthropometric data such as body weight, height, and mid-upper arm circumference were collected.The prevalence of food insecurity and inadequate diet was 58% and 92% of children less than 5 years of age, respectively. The prevalence of underweight, stunting, and wasting was 77% versus 35%, 65% versus 61%, and 63% versus 26% in HIV-infected and uninfected children less than 5 years of age, respectively. Out of 164 HIV-infected children, 59% were on ART initiation during data collection and the median of CD4 cell counts was 1078 cells/μL. HIV-infected children on ART had greater CD4 cell counts (P = .04) and higher weight-for-age Z (P = .01) and weight-for-height Z scores (P = .03) than those without ART. HIV infection was a risk factor for those who had inadequate dietary intake [adjusted odds ratio (AOR) = 2.17, 95% confidence interval (CI) 1.17-3.62, P = .04]. In addition, HIV-infected children were more likely of being underweight (AOR = 10.24, 95% CI 4.34-24.17, P < 0.001) and wasting (AOR = 5.57, 95% CI 2.49-12.46, P < 0.001) than HIV-uninfected children less than 5 years of age.High prevalence of malnutrition was observed in HIV-infected children compared with HIV-uninfected children. Except for ART, nutritional assessment and support should be included in pediatric HIV management.
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Affiliation(s)
- Ghislain Gnimbar Poda
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
- Ministry of Health, Ouagadougou, Burkina Faso
| | - Chien-Yeh Hsu
- Department of Information Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Master Program in Global Health and Development
| | - Jane C-J Chao
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
- Master Program in Global Health and Development
- Nutrition Research Center, Taipei Medical University Hospital, Taipei, Taiwan
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Rytter MJH, Namusoke H, Ritz C, Michaelsen KF, Briend A, Friis H, Jeppesen D. Correlates of thymus size and changes during treatment of children with severe acute malnutrition: a cohort study. BMC Pediatr 2017; 17:70. [PMID: 28288591 PMCID: PMC5348758 DOI: 10.1186/s12887-017-0821-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Accepted: 02/24/2017] [Indexed: 12/04/2022] Open
Abstract
Background The impairment of immune functions associated with malnutrition may be one reason for the high mortality in children with severe acute malnutrition (SAM), and thymus atrophy has been proposed as a marker of this immunodeficiency. The aim of this study was to identify nutritional and clinical correlates of thymus size in children with SAM, and predictors of change in thymus size with nutritional rehabilitation. Methods In an observational study among children aged 6–59 months admitted with SAM in Uganda, we measured thymus area by ultrasound on hospital admission to treatment with F75 and F100, on hospital discharge and after 8 weeks of nutritional rehabilitation with ready-to-use therapeutic food, as well as in well-nourished healthy children. We investigated anthropometric, clinical, biochemical and treatment-related correlates of area and growth of the thymus. Results Eighty-five children with SAM with a median age of 16.5 months were included. On admission 27% of the children had a thymus undetectable by ultrasound. Median thymus area was 1.3 cm2 in malnourished children, and 3.5 cm2 in healthy children (p < 0.001). Most anthropometric z-scores, hemoglobin and plasma phosphate correlated positively with thymus area. Thymus area correlated negatively with caretaker-reported severity of illness, plasma α-1 acid glycoprotein, and C-reactive protein >5 mg/L. At follow-up after 8 weeks, median thymus area had increased to 2.5 cm2 (p < 0.001). Increase in thymus area during treatment was associated with simultaneous increase in mid-upper-arm circumference, with 0.29 cm2 higher increase in thymus area per cm larger increment in MUAC (p = 0.03). Children whose F-75 had partially been replaced by rice porridge during their hospital admission had less increase in thymus area after 8 weeks. Conclusion Malnutrition and inflammation are associated with thymus atrophy, and thymus area seems positively associated with plasma phosphate. Substituting therapeutic formula with unfortified rice porridge with the aim of alleviating diarrhea may impair regain of thymus size with nutritional rehabilitation. This calls for research into possible effects of phosphate status on thymus size and other immunological markers. Trial registration The study is based on data from the FeedSAM study, ISRCTN55092738.
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Affiliation(s)
- Maren Johanne Heilskov Rytter
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Mulago Hospital, Kampala, Uganda
| | - Christian Ritz
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.,Tampere Centre for Child Health Research, University of Tampere, Tampere, Finland
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark
| | - Dorthe Jeppesen
- Department of Pediatrics, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
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Tsegay YG, Tadele A, Addis Z, Alemu A, Melku M. Magnitude of cytopenias among HIV-infected children in Bahir Dar, northwest Ethiopia: a comparison of HAART-naïve and HAART-experienced children. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2017; 9:31-42. [PMID: 28260948 PMCID: PMC5325102 DOI: 10.2147/hiv.s125958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background AIDS, caused by HIV, is a multisystem disease that affects hematopoiesis. The aim of this study was to assess cytopenias among HIV-infected children who had a follow-up at Felege Hiwot Referral Hospital, Bahir Dar, northwest Ethiopia. Methods An institution-based cross-sectional study was conducted between April and May 2013. Systematic random sampling method was used to select the study participants. Descriptive statistics, independent t-test as well as chi-square and logistic regression were used for analysis. A p-value <0.05 was considered as statistically significant. Results A total of 224 children (112 highly active antiretroviral therapy [HAART]-naïve and 112 HAART-experienced) participated in the study. The magnitude of anemia, thrombocytopenia, neutropenia, leukopenia and pancytopenia among HAART-naïve HIV-infected children were 30.4%, 9.8%, 8%, 4.5% and 1.8%, respectively. The overall prevalence of anemia, neutropenia, thrombocytopenia, leukopenia and pancytopenia were 29.5%, 8.9%, 8%, 4.5% and 1.4%, respectively. Cluster of differentiation-4 percentage and mean corpuscular volume were significantly different between HAART-experienced and HAART-naïve children. Being of younger age and severely immunosuppressed were risk factors of anemia. Conclusion Anemia was the most common cytopenia, followed by neutropenia. Severe immunosuppression and younger age were significantly associated with anemia. Therefore, emphasis should be given for investigation and management of cytopenias in HIV-infected children, particularly for those who are immunosuppressed and of younger age.
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Affiliation(s)
| | | | | | - Agersew Alemu
- Department of Medical Parasitology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Ampaire L, Muhindo A, Orikiriza P, Mwanga-Amumpaire J, Bebell L, Boum Y. A review of antimicrobial resistance in East Africa. Afr J Lab Med 2016; 5:432. [PMID: 28879114 PMCID: PMC5436405 DOI: 10.4102/ajlm.v5i1.432] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 06/24/2016] [Indexed: 11/11/2022] Open
Abstract
Background and objectives Knowledge of local and regional antimicrobial resistance (AMR) is important for clinical decision making. However, surveillance capacity for AMR is lacking throughout East Africa, and current AMR data are sparse. We sought to address this gap by summarising all available high-quality data on AMR in the East Africa region. Method We searched the PubMed database and African Journals Online archives in April and May 2015 using the search term ‘antimicrobial resistance AND sub-Saharan Africa’ to find articles published from 2005 onwards. Only full-text articles in English were included. Results We included 12 published articles in our analysis. Most articles were on bloodstream infections, hospital-based and cross-sectional in design; a majority described either community- or hospital-acquired infections. High levels of AMR to commonly-used antibiotics were reported, including 50% – 100% resistance to ampicillin and cotrimoxazole infections, emerging resistance to gentamicin (20% – 47%) and relatively high levels of resistance to ceftriaxone (46% – 69%) among Gram-negative infections. Much of the resistance was reported to be in Klebsiella species and Escherichia coli. Among Gram-positive infections, extensive resistance was reported to ampicillin (100%), gentamicin and ceftriaxone (50% – 100%), with methicillin-resistant Staphylococcus aureus prevalence ranging from 2.6% – 4.0%. Conclusion Overall, bacterial resistance was reported among commonly-used antibiotics (ampicillin, gentamicin and ceftriaxone), raising concern that these antibiotics may no longer be useful for treating moderate or severe bacterial infections in East Africa. Thus, empirical treatment of bacterial infections needs to be reconsidered and guided by local assessment of AMR. Improvements in the limited amount of quality data and lack of harmonisation in assessing the burden of AMR are also needed.
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Affiliation(s)
- Lucas Ampaire
- Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Abraham Muhindo
- Department of Medical Laboratory Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Patrick Orikiriza
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Lisa Bebell
- Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Yap Boum
- Epicentre Mbarara Research Centre, Mbarara, Uganda
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Cohn J, Whitehouse K, Tuttle J, Lueck K, Tran T. Paediatric HIV testing beyond the context of prevention of mother-to-child transmission: a systematic review and meta-analysis. Lancet HIV 2016; 3:e473-81. [PMID: 27658876 DOI: 10.1016/s2352-3018(16)30050-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 05/23/2016] [Accepted: 05/24/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Many HIV-positive children in low-income and middle-income countries remain undiagnosed. Although HIV testing in children at health facilities is recommended by WHO, it is not well implemented. This systematic review and meta-analysis examines the case-finding benefit of HIV screening in children aged 0-5 years in low-income and middle-income countries. METHODS We did this systematic review and meta-analysis in accordance with an a-priori protocol. We searched PubMed, MEDLINE, WHO Global Index Medicus, Web of Science, Médecins Sans Frontières, Cochrane, Embase, CABS Abstracts, and LILACS databases for articles published between Jan 1, 2004, and April 30, 2016, that reported the quantitative prevalence of HIV detected through screening in four key contexts (paediatric inpatient settings, paediatric outpatient settings, nutrition centres, and expanded programme on immunisation centres) in paediatric populations in low-income and middle-income countries. Articles were identified and data were extracted in duplicate. The primary outcome was HIV prevalence, for which we used a DerSimonian-Laird random-effects meta-analysis to pool prevalence data and 95% CIs. We did stratified analyses according to geographical context and testing strategy. This study is registered with PROSPERO, number CRD42014014372. FINDINGS Our search found 2996 studies, of which 26 met the inclusion criteria. Paediatric HIV prevalence across all settings was 15·6% (95% CI 11·8-19·5). HIV prevalence by setting was highest in paediatric inpatient settings (21·1%, 95% CI 14·9-27·3), followed by nutrition centres (13·1%, 95% CI 3·4-22·7), expanded programme on immunisation centres (3·3%, 95% CI 0-6·9), and paediatric outpatient settings (2·7%, 95% CI 0·3-5·2). Universal testing and testing triggered by symptoms had similar diagnostic yield in the inpatient setting (21·3%, 95% CI 11·6-31·0 in triggered testing vs 20·9%, 95% CI 13·5-28·3 in universal testing). INTERPRETATION HIV testing in paediatric populations in low-income and middle-income countries outside the context of prevention of mother-to-child transmission programmes provides an important opportunity to identify HIV-positive children. For countries wishing to prioritise interventions, the highest diagnostic yields were obtained from inpatient wards and nutrition centres. Universal testing might be the preferred approach since it did not have a substantially lower diagnostic yield than triggered testing FUNDING None.
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Affiliation(s)
- Jennifer Cohn
- Médecins Sans Frontières, Geneva, Switzerland; Division of Infectious Diseases, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | | | | | | | - Trang Tran
- Médecins Sans Frontières, Geneva, Switzerland
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Abstract
BACKGROUND Information on antiretroviral therapy (ART) use in HIV-infected children with severe malnutrition (SM) is lacking. We investigated long-term ART outcomes in this population. METHODS Children enrolled in the TREAT Asia Pediatric HIV Observational Database who had SM (weight-for-height or body mass index-for-age Z score less than -3) at ART initiation were analyzed. Generalized estimating equations were used to investigate poor weight recovery (weight-for-age Z score less than -3) and poor CD4% recovery (CD4% <25), and competing risk regression was used to analyze mortality and toxicity-associated treatment modification. RESULTS Three hundred fifty-five (11.9%) of 2993 children starting ART had SM. Their median weight-for-age Z score increased from -5.6 at ART initiation to -2.3 after 36 months. Not using trimethoprim-sulfamethoxazole prophylaxis at baseline was associated with poor weight recovery [odds ratio: 2.49 vs. using; 95% confidence interval (CI): 1.66-3.74; P < 0.001]. Median CD4% increased from 3.0 at ART initiation to 27.2 after 36 months, and 56 (15.3%) children died during follow-up. More profound SM was associated with poor CD4% recovery (odds ratio: 1.78 for Z score less than -4.5 vs. -3.5 to less than -3.0; 95% CI: 1.08-2.92; P = 0.023) and mortality (hazard ratio: 2.57 for Z score less than -4.5 vs. -3.5 to less than -3.0; 95% CI: 1.24-5.33; P = 0.011). Twenty-two toxicity-associated ART modifications occurred at a rate of 2.4 per 100 patient-years, and rates did not differ by malnutrition severity. CONCLUSION Trimethoprim-sulfamethoxazole prophylaxis is important for the recovery of weight-for-age in severely malnourished children starting ART. The extent of SM does not impede weight-for-age recovery or antiretroviral tolerability, but CD4% response is compromised in children with a very low weight-for-height/body mass index-for-age Z score, which may contribute to their high rate of mortality.
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Kambale RM, Kasengi JB, Kivukuto JM, Cubaka LM, Mungo BM, Balaluka GB. [Infectious profile and mortality of children aged 0-5 years admitted with severe acute malnutrition: a retrospective cohort study conducted in the Therapeutic Nutritional Center in Bukavu, Republic of Congo]. Pan Afr Med J 2016; 23:139. [PMID: 27279964 PMCID: PMC4885721 DOI: 10.11604/pamj.2016.23.139.8370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/27/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction La malnutrition constitue une toile de fond sur laquelle se greffent plusieurs infections. L'objectif de ce travail est de déterminer les infections les plus létales, la durée médiane de séjour et le gain pondéral médian journalier des enfants malnutris. Méthodes Étude de cohorte rétrospective des enfants malnutris de 0 à 59 mois hospitalisés au Centre Nutritionnel et Thérapeutique de Bukavu du 1er janvier 2011 au 31 décembre 2013. L’évaluation du risque de survenue de décès par complication infectieuse a été faite par la mesure du risque relatif. Nous avons utilisé le test de Mann-Whitney pour comparer les médianes. Les Odd ratio ajustés par régression logistique et leurs intervalles de confiance à 95% du risque de mortalité ont été donnés pour chaque cause infectieuse. Résultats Au total, 574 enfants avaient été inclus. Cinq cent vingt et un (90.8%) enfants étaient sortis guéris, 10 (1.7%) avaient abandonné le traitement et 43 (7.5%) étaient décédés. La durée médiane de séjour était de 19 (13-26) jours et le gain pondéral médian journalier était de 7 (3-13) g/kg/j. Il existait une association statistiquement significative entre la mortalité et le sepsis / choc septique (p = 0,0004), la méningite (p = 0,00001), et l'infection à VIH (p = 0,02). Conclusion Une meilleure prise en charge de la malnutrition aigüe dans notre région devrait se baser sur la mise en place des unités spécialisées et bien équipées pour la prise en charge de la malnutrition associées aux infections sévères.
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Affiliation(s)
- Richard Mbusa Kambale
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | - Joe Bwija Kasengi
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | | | - Liévin Murhula Cubaka
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
| | - Bruno Masumbuko Mungo
- Université Catholique de Bukavu (UCB), Bukavu, République Démocratique du Congo; Hôpital Provincial Général de Référence de Bukavu (HPGRB), Bukavu, République Démocratique du Congo
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Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala. Public Health Nutr 2016; 18:1737-45. [PMID: 26017476 DOI: 10.1017/s136898001400264x] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS Three hundred and six newborns with a median age of 19 d. RESULTS The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.
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Ahmed M, Moremi N, Mirambo MM, Hokororo A, Mushi MF, Seni J, Kamugisha E, Mshana SE. Multi-resistant gram negative enteric bacteria causing urinary tract infection among malnourished underfives admitted at a tertiary hospital, northwestern, Tanzania. Ital J Pediatr 2015; 41:44. [PMID: 26084628 PMCID: PMC4472394 DOI: 10.1186/s13052-015-0151-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/11/2015] [Indexed: 11/28/2022] Open
Abstract
Background Infections are common complications occurring in malnourished childrenas a result of impaired immunity. Urinary tract infections (UTI) have been found to be the commonest cause of fever in normal children in developing countries. However, data regarding UTI among malnourished children is limited because in most of time severe and moderately malnourished children are afebrile despite significant bacteriuria. Methods A total of 402 malnourished underfives were enrolled. Demographic and other clinical characteristics were collected using standardized data collection tool. Urine specimens were cultured and interpreted according to standard operating procedures. Data were analyzed using STATA version 11. Results Out of 402 malnourished underfives, 229 (56.9 %) were male. The median age in months was 17 (IQR; 12–31). Of 402 malnourished underfives, 83 (20.3 %) had significant bacteriuria of gram negative enteric bacteria. Escherichia coli 35/84 and Klebsiella pneumonia 20/84 were predominant bacteria isolated. More than 37 % of isolates were resistant to third generation cephalosporins with all of them exhibiting extended spectrum beta lactamase (ESBL) phenotype. Rates of resistance to ampicillin, amoxillin/clavulanic acid, gentamicin and ciprofloxacin were 82/84 (98.7 %), 47/55 (85.4 %), 45/84 (57.8 %) and 9/84 (10.8 %) respectively. Decrease in age and increase in lymphocytes count were independent factors on multivariate logistic regression analysis found to predict UTI (p < 0.05). Conclusions Multi-resistant gram negative enteric bacteria are common cause of UTI among underfives. A significant number of severe and moderate malnourished children with bacteriuria had no fever. Therefore, routine testing for UTI is emphasized in all malnourished underfives so that appropriate treatment can be initiated.
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Affiliation(s)
- Maimuna Ahmed
- Department of Pediatrics and Child Health, Weill Bugando School of Medicine, Catholic University of health and allied sciences, Mwanza, Tanzania.
| | - Nyambura Moremi
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, P.O.Box 1464, Mwanza, Tanzania.
| | - Mariam M Mirambo
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, P.O.Box 1464, Mwanza, Tanzania.
| | - Adolfine Hokororo
- Department of Pediatrics and Child Health, Weill Bugando School of Medicine, Catholic University of health and allied sciences, Mwanza, Tanzania.
| | - Martha F Mushi
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, P.O.Box 1464, Mwanza, Tanzania.
| | - Jeremiah Seni
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, P.O.Box 1464, Mwanza, Tanzania.
| | - Erasmus Kamugisha
- Department of Biochemistry and Molecular Biology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, Mwanza, Tanzania.
| | - Stephen E Mshana
- Department of Microbiology and Immunology, Weill Bugando School of Medicine, Catholic University of health and allied sciences, P.O.Box 1464, Mwanza, Tanzania.
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Rytter MJH, Namusoke H, Babirekere-Iriso E, Kæstel P, Girma T, Christensen VB, Michaelsen KF, Friis H. Social, dietary and clinical correlates of oedema in children with severe acute malnutrition: a cross-sectional study. BMC Pediatr 2015; 15:25. [PMID: 25885808 PMCID: PMC4383214 DOI: 10.1186/s12887-015-0341-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 03/04/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Severe acute malnutrition is a serious public health problem, and a challenge to clinicians. Why some children with malnutrition develop oedema (kwashiorkor) is not well understood. The objective of this study was to investigate socio-demographic, dietary and clinical correlates of oedema, in children hospitalised with severe acute malnutrition. METHODS We recruited children with severe acute malnutrition admitted to Mulago Hospital, Uganda. Data was collected using questionnaires, clinical examination and measurement of blood haemoglobin, plasma c-reactive protein and α1-acid glycoprotein. Correlates of oedema were identified using multiple logistic regression analysis. RESULTS Of 120 children included, 77 (64%) presented with oedematous malnutrition. Oedematous children were slightly older (17.7 vs. 15.0 months, p = 0.006). After adjustment for age and sex, oedematous children were less likely to be breastfed (odds ratio (OR): 0.19, 95%-confidence interval (CI): 0.06; 0.59), to be HIV-infected (OR: 0.10, CI: 0.03; 0.41), to report cough (OR: 0.33, CI: 0.13; 0.82) and fever (OR: 0.22, CI: 0.09; 0.51), and to have axillary temperature > 37.5 °C (OR: 0.28 CI: 0.11; 0.68). Household dietary diversity score was lower in children with oedema (OR: 0.58, CI: 0.40; 85). No association was found with plasma levels of acute phase proteins, household food insecurity or birth weight. CONCLUSION Children with oedematous malnutrition were less likely to be breastfed, less likely to have HIV infection and had fewer symptoms of other infections. Dietary diversity was lower in households of children who presented with oedema. Future research may confirm whether a causal relationship exists between these factors and nutritional oedema.
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Affiliation(s)
- Maren Johanne Heilskov Rytter
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Hanifa Namusoke
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago Hospital, Kampala, Uganda.
| | - Esther Babirekere-Iriso
- Mwanamugimu Nutrition Unit, Department of Paediatrics, Mulago Hospital, Kampala, Uganda. .,Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Pernille Kæstel
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Tsinuel Girma
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark. .,Department of Paediatrics and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia.
| | - Vibeke Brix Christensen
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Kim F Michaelsen
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 30, 1958, Frederiksberg C, Denmark.
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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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Rytter MJH, Kolte L, Briend A, Friis H, Christensen VB. The immune system in children with malnutrition--a systematic review. PLoS One 2014; 9:e105017. [PMID: 25153531 PMCID: PMC4143239 DOI: 10.1371/journal.pone.0105017] [Citation(s) in RCA: 357] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/16/2014] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed. OBJECTIVES To review the scientific literature about immune function in children with malnutrition. METHODS A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1-60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition. RESULTS The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied. CONCLUSION The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.
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Affiliation(s)
| | - Lilian Kolte
- Department of Infectious Diseases, Copenhagen University Hospital, Hvidovre, Denmark
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
- Department for International Health, University of Tampere, School of Medicine, Tampere, Finland
| | - Henrik Friis
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Vibeke Brix Christensen
- Department of Paediatrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Mody A, Bartz S, Hornik CP, Kiyimba T, Bain J, Muehlbauer M, Kiboneka E, Stevens R, St. Peter JV, Newgard CB, Bartlett J, Freemark M. Effects of HIV infection on the metabolic and hormonal status of children with severe acute malnutrition. PLoS One 2014; 9:e102233. [PMID: 25050734 PMCID: PMC4106836 DOI: 10.1371/journal.pone.0102233] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 06/16/2014] [Indexed: 11/18/2022] Open
Abstract
Background HIV infection occurs in 30% of children with severe acute malnutrition in sub-Saharan Africa. Effects of HIV on the pathophysiology and recovery from malnutrition are poorly understood. Methods We conducted a prospective cohort study of 75 severely malnourished Ugandan children. HIV status/CD4 counts were assessed at baseline; auxologic data and blood samples were obtained at admission and after 14 days of inpatient treatment. We utilized metabolomic profiling to characterize effects of HIV infection on metabolic status and subsequent responses to nutritional therapy. Findings At admission, patients (mean age 16.3 mo) had growth failure (mean W/H z-score −4.27 in non-edematous patients) that improved with formula feeding (mean increase 1.00). 24% (18/75) were HIV-infected. Nine children died within the first 14 days of hospitalization; mortality was higher for HIV-infected patients (33% v. 5%, OR = 8.83). HIV-infected and HIV-negative children presented with elevated NEFA, ketones, and even-numbered acylcarnitines and reductions in albumin and amino acids. Leptin, adiponectin, insulin, and IGF-1 levels were low while growth hormone, cortisol, and ghrelin levels were high. At baseline, HIV-infected patients had higher triglycerides, ketones, and even-chain acylcarnitines and lower leptin and adiponectin levels than HIV-negative patients. Leptin levels rose in all patients following nutritional intervention, but adiponectin levels remained depressed in HIV-infected children. Baseline hypoleptinemia and hypoadiponectinemia were associated with increased mortality. Conclusions Our findings suggest a critical interplay between HIV infection and adipose tissue storage and function in the adaptation to malnutrition. Hypoleptinemia and hypoadiponectinemia may contribute to high mortality rates among malnourished, HIV-infected children.
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Affiliation(s)
- Aaloke Mody
- Division of Pediatric Endocrinology and Diabetes, Pediatric Division of Quantitative Sciences, Duke University Medical Center, Durham, North Carolina, United States of America
- * E-mail:
| | - Sarah Bartz
- Division of Pediatric Endocrinology and Diabetes, Pediatric Division of Quantitative Sciences, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Tonny Kiyimba
- Mwanamugimu Nutrition Unit, Mulago Hospital Complex, Kampala, Uganda
| | - James Bain
- Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Michael Muehlbauer
- Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Robert Stevens
- Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | - John V. St. Peter
- Global Research & Development, Long Term Research, PepsiCo, Inc., Purchase, New York, United States of America
| | - Christopher B. Newgard
- Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina, United States of America
| | - John Bartlett
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Michael Freemark
- Division of Pediatric Endocrinology and Diabetes, Pediatric Division of Quantitative Sciences, Duke University Medical Center, Durham, North Carolina, United States of America
- Sarah W. Stedman Nutrition and Metabolism Center, Duke University Medical Center, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University Medical Center, Durham, North Carolina, United States of America
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Rose AM, Hall CS, Martinez-Alier N. Aetiology and management of malnutrition in HIV-positive children. Arch Dis Child 2014; 99:546-51. [PMID: 24406803 PMCID: PMC4033118 DOI: 10.1136/archdischild-2012-303348] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 12/30/2022]
Abstract
Worldwide, more than 3 million children are infected with HIV and, without treatment, mortality among these children is extremely high. Both acute and chronic malnutrition are major problems for HIV-positive children living in resource-limited settings. Malnutrition on a background of HIV represents a separate clinical entity, with unique medical and social aetiological factors. Children with HIV have a higher daily calorie requirement than HIV-negative peers and also a higher requirement for micronutrients; furthermore, coinfection and chronic diarrhoea due to HIV enteropathy play a major role in HIV-associated malnutrition. Contributory factors include late presentation to medical services, unavailability of antiretroviral therapy, other issues surrounding healthcare provision and food insecurity in HIV-positive households. Treatment protocols for malnutrition have been greatly improved, yet there remains a discrepancy in mortality between HIV-positive and HIV-negative children. In this review, the aetiology, prevention and treatment of malnutrition in HIV-positive children are examined, with particular focus on resource-limited settings where this problem is most prevalent.
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Affiliation(s)
- Anna M Rose
- Department of Genetics, UCL Institute of Ophthalmology, London, UK
- UCL Medical School, London, UK
| | - Charles S Hall
- UCL Medical School, London, UK
- UCL Institute of Global Health, London, UK
| | - Nuria Martinez-Alier
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
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Anyabolu HC, Adejuyigbe EA, Adeodu OO. Undernutrition and anaemia among HAART-naïve HIV infected children in Ile-Ife, Nigeria: a case-controlled, hospital based study. Pan Afr Med J 2014; 18:77. [PMID: 25400844 PMCID: PMC4231248 DOI: 10.11604/pamj.2014.18.77.3746] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 05/06/2014] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Case control studies that assess the burden and factors associated with undernutrition and anaemia among HAART naïve HIV infected children in Nigeria is very sparse. This will help to formulate nutritional programs among these children. METHODS Seventy HAART naive HIV infected children aged 18 months and above were as well as seventy age and sex matched HIV negative children were recruited from August 2007 to January 2009 at Paediatric Clinic of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. Their bio data, WHO clinical stage, anthropometric measurements, haematocrit, serum albumin and CD4 counts were taken with other parameters according to a study proforma. RESULTS The prevalence of stunting, underweight and wasting among the HIV infected subjects were 48. 6%,58. 6% and 31. 4% respectively which as significantly higher than 28. 1%, 7. 1% and 28. 1% among the HIV negative controls. 20. 1% of the HIV infected children were marasmic compared to 2. 3% of the controls. Triple anthropometric failure was found in 7. 1% of the subjects as compared to none among the controls. Anaemia is significantly more prevalent among the subjects than the controls (70. 0% vs 31. 4%; p<0. 001). The prevalence of anaemia was higher in the HIV infected subjects with undernutrition. Low socioeconomic status, hypoalbuminemia and severe immunosuppression are significantly associated with higher undernutrition prevalence. CONCLUSION Several years after availability of HAART, undernutrition and anaemia remain widely prevalent among newly presenting HAART naïve HIV infected Nigerian children. Nutritional supplementation and evaluation for anaemia still need close attention in the management of these children.
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Affiliation(s)
- Henry Chineme Anyabolu
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
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Sunguya BF, Poudel KC, Mlunde LB, Urassa DP, Yasuoka J, Jimba M. Poor nutrition status and associated feeding practices among HIV-positive children in a food secure region in Tanzania: a call for tailored nutrition training. PLoS One 2014; 9:e98308. [PMID: 24846016 PMCID: PMC4028312 DOI: 10.1371/journal.pone.0098308] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 05/01/2014] [Indexed: 11/18/2022] Open
Abstract
Undernutrition among HIV-positive children can be ameliorated if they are given adequate foods in the right frequency and diversity. Food insecurity is known to undermine such efforts, but even in food rich areas, people have undernutrition. As yet no study has examined feeding practices and their associations with nutrition status among as HIV-positive children in regions with high food production. We therefore examined the magnitude of undernutrition and its association with feeding practices among HIV-positive children in a high food production region in Tanzania.
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Affiliation(s)
- Bruno F. Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Krishna C. Poudel
- Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Linda B. Mlunde
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - David P. Urassa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- * E-mail:
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Tylleskär T. Et budsjettkutt som ikke er til å leve med. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:314. [DOI: 10.4045/tidsskr.13.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Girma T, Kæstel P, Mølgaard C, Michaelsen KF, Hother AL, Friis H. Predictors of oedema among children hospitalized with severe acute malnutrition in Jimma University Hospital, Ethiopia: a cross sectional study. BMC Pediatr 2013; 13:204. [PMID: 24314329 PMCID: PMC3866507 DOI: 10.1186/1471-2431-13-204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 11/27/2013] [Indexed: 11/29/2022] Open
Abstract
Background Severe acute malnutrition has two main clinical manifestations, i.e., oedematous and non-oedematous. However, factors associated with oedema are not well established. Methods Children 0.5-14 years of age with SAM (MUAC < 11.0 cm or weight-for-height < 70 % of median and/or nutritional oedema) admitted to the nutrition unit were included. Information on infections before and during admission was collected together with anthropometry. Predictors of oedema was analysed separately for younger (< 60 months) and older children (≥ 60 months). Results 351 children were recruited (median age: 36 months (interquartile range 24 to 60); 43.3% females). Oedema was detected in 61.1%. The prevalence of oedema increased with age, peaked at 37–59 months (75%) and declined thereafter. Infection was more common in the younger group (33% vs. 8.9%, p < 0.001) and in this group children with oedema had less infections (25.2% vs. 45.1%, p = 0.001). In the older group the prevalence of infections was not different between oedematous and non-oedematous children (5.5% v. 14.3%, p = 0.17). In the younger group oedema was less common in children with TB (OR = 0.20, 95% CI: 0.06, 0.70) or diarrhea (OR = 0.40, 95% CI: 0.21, 0.73). Conclusions The proportion of oedema in SAM peaked at three to five years of age and a considerable proportion was above 5 years. Furthermore, the prevalence of infection seemed to be lower among children with oedema. Further studies are needed to better understand the role of infection-immunity interaction.
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Affiliation(s)
- Tsinuel Girma
- Department of Pediatrics and Child Health, Jimma University Specialized Hospital, Jimma, Ethiopia.
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Asafo-Agyei SB, Antwi S, Nguah SB. HIV infection in severely malnourished children in Kumasi, Ghana: a cross-sectional prospective study. BMC Pediatr 2013; 13:181. [PMID: 24206638 PMCID: PMC3828476 DOI: 10.1186/1471-2431-13-181] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 10/31/2013] [Indexed: 12/03/2022] Open
Abstract
Background The Human Immunodeficiency Virus (HIV) epidemic has adversely affected the nutritional status and mortality of children in Africa. This study assessed the disease burden, predictive clinical features and outcomes for children with severe acute malnutrition (SAM) and concomitant HIV infection. Methods This was a cross-sectional prospective study of children with SAM aged between 3 months and 13 years admitted to the nutritional rehabilitation unit (NRU) of Komfo Anokye Teaching Hospital. Socio-demographic, anthropometric and clinical data were documented and HIV serostatus established with 2 rapid HIV antibody tests and Enzyme-linked immunosorbent assay, if indicated. HIV viral polymerase chain reaction testing was not available at the time of the study. Logistic regression analyses were used to identify significant clinical predictors of HIV seropositivity. Results Sixty-seven (27.2%, 95% CI = 21.8-33.3%) of the 246 study children had positive HIV antibody results. Uptake of provider-initiated HIV testing and counselling was 100%. Amongst children aged 18 months and over, the HIV seroprevalence was 28.3% (30/106). HIV seropositivity was strongly associated with prolonged fever, cough and diarrhoea; oral thrush, generalised lymphadenopathy and pulmonary tuberculosis (p value < 0.001 for all parameters). The presence of ≥ 3 of the first 5 aforementioned parameters was highly specific (98.3-100%) for HIV seropositivity in study children. HIV seropositivity was also significantly associated with cough, vomiting, lethargy/altered consciousness, skin rash and hepatomegaly (p value < 0.05 for all parameters). Overall mortality rate was 17.5%, with HIV seropositive children having a significantly higher mortality rate (37.8% versus 10.1%; p value < 0.001) and a lower rate of weight gain (2.4 g/kg/day versus 7.0 g/kg/day; p value < 0.001). Conclusions HIV testing was well accepted by parents/carers and should be offered in all NRUs. There was a high HIV seroprevalence among children with SAM and a significantly poorer outcome in mortality and weight gain. Some clinical features were identified to be predictive of HIV seropositivity and could be useful as indicators to prompt further investigation and/or referral in resource limited settings where HIV test kits are unavailable. This would aid in the early detection and comprehensive management of the HIV seropositive child with SAM.
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Sunguya BF, Poudel KC, Mlunde LB, Urassa DP, Jimba M, Yasuoka J. Efficacy of in-service nutrition training for mid-level providers to improve feeding practices among HIV-positive children in Tanga, Tanzania: study protocol for a cluster randomized controlled trial. Trials 2013; 14:352. [PMID: 24156500 PMCID: PMC4015912 DOI: 10.1186/1745-6215-14-352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/15/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Feeding practices and child undernutrition can be improved when trained health workers provide proper nutrition counseling to caregivers. However, this important management component is difficult to achieve in countries where trained health workers are limited; Tanzania is no exception. In rural and semi-urban areas, mid-level providers (MLPs) are left to manage diseases such as HIV/AIDS.Training health workers in nutrition has been shown to be an effective intervention among HIV-negative children elsewhere, but no studies have been conducted among HIV-positive children. Furthermore, in Tanzania and other countries with MLPs, no evidence currently exists demonstrating an improvement in nutrition among children who receive health services given by MLPs. This study thus aims to examine the efficacy of nutrition training of MLPs on feeding practices and the nutrition status of HIV-positive children in Tanga, Tanzania. METHODS/DESIGN We will conduct a cluster randomized controlled trial in care and treatment centers (CTCs) in Tanga, Tanzania. The CTCs will be the unit of randomization. We will select 16 CTCs out of 32 for this study, of which we will randomly assign 8 to the intervention arm and 8 to the control arm by coin flipping. From the selected CTCs we will attempt to recruit a total of 800 HIV-positive children aged 6 months to 14 years, half of whom will be receiving care and/or treatment in the CTCs of the intervention arm, and the other half of whom will be receiving care and/or treatment in the CTCs of the control arm (400 children in each condition).We will provide nutrition training to MLPs of the CTCs selected for the intervention arm. In this intervention, we will use the World Health Organization guidelines on nutrition training of health workers for HIV-positive children aged 6 months to 14 years. The trained MLPs will then provide tailored nutrition counseling to caregivers of children being treated at the 8 CTCs of the intervention arm. We will measure nutrition status and child feeding practices monthly for a total of six months. CONCLUSIONS Results of this trial will help expanding undernutrition interventions among HIV-positive children in Tanzania and other countries. TRIAL REGISTRATION Current Controlled Trials: ISRCTN65346364.
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Affiliation(s)
- Bruno F Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Krishna C Poudel
- Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts Amherst, Arnold House, 715 North Pleasant St, Amherst, MA 01003-9304, USA
| | - Linda B Mlunde
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - David P Urassa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O. Box 65489, Dar es Salaam, Tanzania
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Fergusson P, Tomkins A, Kerac M. Improving survival of children with severe acute malnutrition in HIV-prevalent settings. Int Health 2013; 1:10-6. [PMID: 24036290 DOI: 10.1016/j.inhe.2009.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The care of severely malnourished children in sub-Saharan Africa is challenging, especially in HIV-prevalent settings. Recent improvements to facility-based individual case management, and increased community-based management focusing on early identification and high programme coverage have led to reductions in mortality. Further interventions are urgently needed to address resistant mortality, mostly attributable to HIV. This paper explores strategies in three main areas to improve survival for children with severe acute malnutrition (SAM): identifying HIV and improving case management for HIV-infected children; strengthening existing strategies to improve outcomes for all children with SAM, regardless of HIV status; and improving early identification and increasing programme coverage. Although interventions to further improve survival among children with SAM in sub-Saharan Africa must firstly ensure best care for all children, HIV-infected children are at particular risks for mortality. Integration of specific interventions for HIV testing and treatment into SAM care is essential. International guidelines should reflect best evidence, and are in urgent need of updating and adapting to local country context. Effective interventions already exist that can improve survival in children with SAM in HIV-prevalent settings. The challenge is to implement what we know and to research what we do not.
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Affiliation(s)
- Pamela Fergusson
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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Fredrick F, Valentine G. Improvised peritoneal dialysis in an 18-month-old child with severe acute malnutrition (kwashiorkor) and acute kidney injury: a case report. J Med Case Rep 2013; 7:168. [PMID: 23809461 PMCID: PMC3700773 DOI: 10.1186/1752-1947-7-168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 05/31/2013] [Indexed: 05/27/2023] Open
Abstract
Introduction Severe acute malnutrition is common in developing countries. Children with severe acute malnutrition are prone to complications, including electrolyte imbalance and infections. Our patient was an 18-month-old boy who had severe acute malnutrition (kwashiorkor) and developed acute kidney injury, which was managed with peritoneal dialysis using improvised equipment. This case report illustrates the importance of improvisation in resource-limited settings in providing lifesaving treatment. To the best of our knowledge, this is the first case report on peritoneal dialysis in a child with severe acute malnutrition (kwashiorkor). Case presentation We report a case of an 18-month-old Bantu-African Tanzanian boy who had severe malnutrition and developed anuric acute kidney injury. He had severe renal dysfunction and was managed with peritoneal dialysis using an improvised catheter and bedside constituted fluids (from intravenous fluids) and was diuretic after 7 days of peritoneal dialysis, with complete recovery of renal functions after 2 weeks. Conclusion Children with severe acute malnutrition who develop acute kidney injury should be offered peritoneal dialysis, which may be provided using improvised equipment in resource-limited settings, as illustrated in this case report.
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Affiliation(s)
- Francis Fredrick
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania.
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Alcoba G, Kerac M, Breysse S, Salpeteur C, Galetto-Lacour A, Briend A, Gervaix A. Do children with uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis. PLoS One 2013; 8:e53184. [PMID: 23326395 PMCID: PMC3541371 DOI: 10.1371/journal.pone.0053184] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 11/26/2012] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Current (1999) World Health Organization guidelines recommend giving routine antibiotics (AB) for all children with severe acute malnutrition (SAM), even if they have uncomplicated disease with no clinically obvious infections. We examined the evidence behind this recommendation. METHODS AND FINDINGS OVID-MEDLINE, EMBASE, COCHRANE, GLOBAL-HEALTH, CINAHL, POPLINE, AFRICA-WIDE-NiPAD, and LILACS were searched for AB efficacy, bacterial resistance, and infection rates in SAM. Following PRISMA guidelines, a systematic review and meta-analysis were performed. Three randomised controlled trials (RCT), five Cochrane reviews, and 37 observational studies were identified. One cohort-study showed no increase in nutritional-cure and mortality in uncomplicated SAM where no AB were used. (p>0.05). However, an unpublished RCT in this setting did show mortality benefits. Another RCT did not show superiority of ceftriaxone over amoxicilllin for these same outcomes, but adressed SAM children with and without complications (p = 0.27). Another RCT showed no difference between amoxicillin and cotrimoxazole efficacies for pneumonia in underweight, but not SAM. Our meta-analysis of 12 pooled susceptibility-studies for all types of bacterial isolates, including 2767 stricly SAM children, favoured amoxicillin over cotrimoxazole for susceptibility medians: 42% (IQR 27-55%) vs 22% (IQR 17-23%) and population-weighted-means 52.9% (range 23-57%) vs 35.4% (range 6.7-42%). Susceptibilities to second-line AB were better, above 80%. Prevalence of serious infections in SAM, pooled from 24 studies, ranged from 17% to 35.2%. No study infered any association of infection prevalence with AB regimens in SAM. CONCLUSIONS The evidence underlying current antibiotic recommendations for uncomplicated SAM is weak. Susceptibility-studies favour amoxicillin over cotrimoxazole. However, given that these antibiotics have side-effects, costs, and risks as well as benefits, their routine use needs urgent testing. With reliable monitoring, we believe that there is sufficient equipoise for placebo controlled RCTs, the only robust way to demonstrate true efficacy.
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Affiliation(s)
- Gabriel Alcoba
- Geneva University Hospitals, Child & Adolescent Department, Paediatric Emergency Division, Geneva, Switzerland.
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Sunguya BF, Poudel KC, Mlunde LB, Otsuka K, Yasuoka J, Urassa DP, Mkopi NP, Jimba M. Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania. Nutr J 2012; 11:60. [PMID: 22931107 PMCID: PMC3478224 DOI: 10.1186/1475-2891-11-60] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 08/24/2012] [Indexed: 11/10/2022] Open
Abstract
Background HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naïve HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania. Methods This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses. Results Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001). Conclusions Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.
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Affiliation(s)
- Bruno F Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
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Prompt initiation of ART With therapeutic food is associated with improved outcomes in HIV-infected Malawian children with malnutrition. J Acquir Immune Defic Syndr 2012; 59:173-6. [PMID: 22107819 DOI: 10.1097/qai.0b013e3182405f8f] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This retrospective observational study of 140 HIV-infected children with uncomplicated malnutrition in urban Malawi tested the hypothesis that initiation of antiretroviral therapy (ART) within 21 days of outpatient therapeutic feeding (prompt ART) improved clinical outcomes. Children receiving prompt ART were more likely to recover nutritionally (86% vs. 60%, P < 0.01) and had higher rates of weight gain (3.6 vs. 1.6 g/k/day; P = 0.02). Logistic regression modeling found prompt ART was associated with increased likelihood of nutritional recovery (odds ratio: 5.4, 95% confidence interval: 2.0 to 14.5). This suggests that prompt ART is associated with improved outcomes in HIV-infected Malawian children with uncomplicated malnutrition.
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Musoke PM, Fergusson P. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings. Am J Clin Nutr 2011; 94:1716S-1720S. [PMID: 22089437 PMCID: PMC3226024 DOI: 10.3945/ajcn.111.018374] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
More than 2 million children globally are living with HIV infection and >90% of these reside in sub-Saharan Africa. Severe acute malnutrition (SAM) remains a major problem for HIV-infected children who live in resource-limited settings (RLS), and SAM is an important risk factor for mortality. SAM in HIV-infected children is associated with complications including electrolyte disorders, micronutrient deficiencies, and severe infections, which contribute to the high mortality. Access to antiretroviral therapy (ART) has significantly improved the survival of HIV-infected children, although the response to ART of children with SAM remains undocumented in the literature. Immune and virologic responses to ART in RLS are similar to those of infected children in resource-rich settings, but delays in initiation of therapy have led to a high early mortality. Antiretroviral drug toxicities have been described in children who receive therapy and may affect their quality of life and long-term survival. Metabolic complications of ART include lipodystrophy, dyslipidemia, lactic acidosis, insulin resistance, and osteopenia. These complications have been well described in adults and children from developed countries, but data from RLS are limited, and these complications may be compounded by SAM. In this article we review the epidemiology, clinical presentation, and complications of SAM in HIV-infected children and the metabolic complications of HIV-infected children in the era of ART, and discuss future research priorities for RLS.
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Affiliation(s)
- Philippa M Musoke
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda.
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Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough. BMC Public Health 2011; 11:869. [PMID: 22087543 PMCID: PMC3226559 DOI: 10.1186/1471-2458-11-869] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 11/16/2011] [Indexed: 12/01/2022] Open
Abstract
Background The prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania. Methods From September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children's anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods. Results ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children. In the multivariate analysis, child's HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p < 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p < 0.001). Conclusion HIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea.
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Lazzerini M, Tickell D. Antibiotics in severely malnourished children: systematic review of efficacy, safety and pharmacokinetics. Bull World Health Organ 2011; 89:594-607. [PMID: 21836758 DOI: 10.2471/blt.10.084715] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2010] [Revised: 03/31/2011] [Accepted: 04/08/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To systemically review the evidence in support of World Health Organization guidelines recommending broad-spectrum antibiotics for children with severe acute malnutrition (SAM). METHODS CENTRAL, MEDLINE, EMBASE, LILACS, POPLINE, CAB Abstracts and ongoing trials registers were searched. Experts were contacted. Conference proceedings and reference lists were manually searched. All study types, except single case reports, were included. FINDINGS Two randomized controlled trials (RCTs), one before-and-after study and two retrospective reports on clinical efficacy and safety were retrieved, together with 18 pharmacokinetic studies. Trial quality was generally poor and results could not be pooled due to heterogeneity. Oral amoxicillin for 5 days was as effective as intramuscular ceftriaxone for 2 days (1 RCT). For uncomplicated SAM, amoxicillin showed no benefit over placebo (1 retrospective study). The introduction of a standardized regimen using ampicillin and gentamicin significantly reduced mortality in hospitalized children (odds ratio, OR: 4.0; 95% confidence interval, CI: 1.7-9.8; 1 before-and-after study). Oral chloramphenicol was as effective as trimethoprim-sulfamethoxazole in children with pneumonia (1 RCT). Pharmacokinetic data suggest that normal doses of penicillins, cotrimoxazole and gentamicin are safe in malnourished children, while the dose or frequency of chloramphenicol requires adjustment. Existing evidence is not strong enough to further clarify recommendations for antibiotic treatment in children with SAM. CONCLUSION Large RCTs are needed to define optimal antibiotic treatment in children with SAM with and without complications. Further research into gentamicin and chloramphenicol toxicity and into the pharmacokinetics of ceftriaxone and ciprofloxacin is also required.
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Affiliation(s)
- Marzia Lazzerini
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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Hospitalization for severe malnutrition among HIV-infected children starting antiretroviral therapy. AIDS 2011; 25:951-6. [PMID: 21487251 DOI: 10.1097/qad.0b013e328345e56b] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe early hospitalization for severe malnutrition in HIV-infected children initiating antiretroviral therapy (ART). DESIGN Randomized trial of induction-maintenance and monitoring strategies in HIV-infected children. SETTING Three tertiary hospitals in Uganda and one in Zimbabwe. PARTICIPANTS 1207 HIV-infected children, median age 6 years (range, 3 months to 17 years). INTERVENTION Abacavir, lamivudine and nevirapine or efavirenz were given; children in induction-maintenance arms also received zidovudine to week 36. Pre-ART inpatient/outpatient nutritional rehabilitation for children with baseline severe malnutrition. MAIN OUTCOME MEASURES : Hospitalization for severe malnutrition and change in CD4 cell percentage by week 12 after ART. Mortality and change in weight-for-age Z-score (WAZ) by week 24 after ART. RESULTS Thirty-nine of 1207 (3.2%) children were hospitalized for severe malnutrition (20 with oedema), median 28 days [interquartile range (IQR) 14, 36] after ART for marasmus and 26 days (IQR 14, 56) after ART for kwashiorkor. Hospitalized children had lower baseline and greater 24-week rise in WAZ than nonhospitalized children (P < 0.001). Twenty-nine of 39 (74%) children admitted for severe malnutrition had underlying infections. Of 220 children with advanced disease (baseline WAZ and CD4 cell Z-scores both <-3), 7.3% [95% confidence interval (CI) 3.8, 10.7] developed kwashiorkor and 3.6% (95% CI 1.2, 6.1) developed marasmus by week 12. CD4 cell percentage rise was similar among groups (P = 0.37). Twenty-four-week mortality was 32, 20 and 1.7% among children hospitalized with marasmus, kwashiorkor and not hospitalized, respectively, (P < 0.001). CONCLUSION One in nine children with advanced HIV required early hospitalization for severe malnutrition after ART, with a 15-fold increase in 6-month mortality compared with nonhospitalized children. Integration of HIV/malnutrition services and further research to determine optimal ART timing, role of supplementary feeding and antimicrobial prophylaxis are urgently required.
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Bunn J, Thindwa M, Kerac M. Features associated with underlying HIV infection in severe acute childhood malnutrition: a cross sectional study. Malawi Med J 2010; 21:108-12. [PMID: 20345019 DOI: 10.4314/mmj.v21i3.45645] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Up to half of all children presenting to Nutrition Rehabilitation Units (NRUs) in Malawi with severe acute malnutrition (SAM) are infected with HIV. There are many similarities in the clinical presentation of SAM and HIV. It is important to identify HIV infected children, in order to improve case management. This study aims to identify features suggestive of HIV in children with SAM. METHODS All 1024 children admitted to the Blantyre NRU between July 2006 and March 2007 had demographic, anthropometric and clinical characteristics documented on admission. HIV status was known for 904 children, with 445 (43%) seropositive and 459 (45%) seronegative. Features associated with HIV were determined. RESULTS Associations were found for the following signs: chronic ear discharge (OR 14.6, 95%CI 5.8-36.7), lymphadenopathy (6.4, 3.5-11.7), clubbing (4.9, 2.6-9.4), marasmus (4.9, 3.5-6.8), hepato-splenomegally (3.2, 1.8-5.6), and oral candida (2.4, 1.8-3.27). Any one of these signs was present in 74% of the HIV seropositive, and 38% of HIV uninfected children. A history of recurrent respiratory infection (OR 9.6, 4.8-18.6), persistent fever, recent outpatient attendance, or hospital admission were also associated with HIV. Persistent diarrhoea was no more frequent in HIV (OR 1.1). Orphaning (OR 2.1, 1.4-3.3) or a household contact with TB (OR 1.7, 1.1-2.6), were more common in HIV. Each of these features were present in >10% of seropositive children. HIV infected children were more stunted, wasted, and anaemic than uninfected children. CONCLUSIONS Features commonly associated with HIV were often present in uninfected children with SAM, and HIV could neither be diagnosed, nor excluded using these. We recommend HIV testing be offered to all children with SAM where HIV is prevalent.
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Rowe JS, Shah SS, Motlhagodi S, Bafana M, Tawanana E, Truong HT, Wood SM, Zetola NM, Steenhoff AP. An epidemiologic review of enteropathogens in Gaborone, Botswana: shifting patterns of resistance in an HIV endemic region. PLoS One 2010; 5:e10924. [PMID: 20543877 PMCID: PMC2881529 DOI: 10.1371/journal.pone.0010924] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 04/23/2010] [Indexed: 11/19/2022] Open
Abstract
Background The epidemiology of diarrheal disease in Botswana, an HIV endemic region, is
largely unknown. Our primary objective was to characterize the prevalent
bacterial and parasitic enteropathogens in Gaborone, Botswana. Secondary
objectives included determining corresponding antimicrobial resistance
patterns and the value of stool white and red blood cells for predicting
bacterial and parasitic enteropathogens. Methodology/Principal Findings A retrospective cross-sectional study examined laboratory records of stool
specimens analyzed by the Botswana National Health Laboratory in Gaborone,
Botswana from February 2003 through July 2008. In 4485 specimens the median
subject age was 23 [interquartile range 1.6–34]
years. Overall, 14.4% (644 of 4485) of samples yielded a
pathogen. Bacteria alone were isolated in 8.2% (367 of 4485),
parasites alone in 5.6% (253 of 4485) and both in 0.5%
(24 of 4485) of samples. The most common bacterial pathogens were
Shigella spp. and Salmonella spp.,
isolated from 4.0% (180 of 4485) and 3.9% (175 of
4485) of specimens, respectively. Escherichia coli (22 of
4485) and Campylobacter spp. (22 of 4485) each accounted
for 0.5% of pathogens. Comparing antimicrobial resistance among
Shigella spp. and Salmonella spp.
between two periods, February 2003 to February 2004 and July 2006 to July
2008, revealed an increase in ampicillin resistance among
Shigella spp. from 43% to 83%
(p<0.001). Among Salmonella spp., resistance to
chloramphenicol decreased from 56% to 6%
(p<0.001). The absence of stool white and red blood cells correlated
with a high specificity and negative predictive value. Conclusions/Significance Most gastroenteritis stools were culture and microscopy negative suggesting
that viral pathogens were the majority etiologic agents in this Botswana
cohort. Shigella spp. and Salmonella spp.
were the most common bacteria; Isospora spp. and
Cryptosporidium spp. were the most common parasites.
Resistance to commonly used antimicrobials is high and should be closely
monitored.
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Affiliation(s)
- Jack S. Rowe
- Botswana-UPenn Partnership, Gaborone, Botswana
- University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania, United States of America
| | - Samir S. Shah
- University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania, United States of America
- The Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania, United States of America
| | - Stephen Motlhagodi
- Botswana National Health Laboratory, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
| | - Margaret Bafana
- Botswana National Health Laboratory, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
| | - Ephraim Tawanana
- Botswana National Health Laboratory, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
| | | | - Sarah M. Wood
- The Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania, United States of America
| | - Nicola M. Zetola
- Botswana-UPenn Partnership, Gaborone, Botswana
- Princess Marina Hospital, Gaborone, Botswana
| | - Andrew P. Steenhoff
- Botswana-UPenn Partnership, Gaborone, Botswana
- University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania, United States of America
- Princess Marina Hospital, Gaborone, Botswana
- The Children's Hospital of Philadelphia, Philadelphia,
Pennsylvania, United States of America
- * E-mail:
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47
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Sztam KA, Fawzi WW, Duggan C. Macronutrient supplementation and food prices in HIV treatment. J Nutr 2010; 140:213S-23S. [PMID: 19939991 PMCID: PMC3361012 DOI: 10.3945/jn.109.110569] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Infection caused by HIV and malnutrition have a complex interaction and often coexist geographically. Malnutrition has synergistic immune effects and HIV affects nutritional status. HIV care and treatment programs are compelled to confront this dual burden to optimize HIV outcomes. In this article, we review the published literature concerning intervention studies in adults and children and the effect of food prices on HIV treatment programs. While the evidence base is relatively incomplete for specific macronutrient interventions in the context of HIV treatment, it is clear that a new standard of care is needed, guided by experience, rationale, and existing data, in which malnourished patients may easily access nutritional therapies within HIV treatment. From this clinical foundation, we may both treat patients and evaluate novel therapies. Some HIV care and treatment programs provide food-based supplements; however, rising food costs and economic instability may jeopardize the success of these programs. HIV treatment programs may struggle to meet the needs of patients with potential increased rates of malnutrition and food insecurity in the setting of high food prices.
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Affiliation(s)
- Kevin A. Sztam
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115,To whom correspondence should be addressed. E-mail:
| | - Wafaie W. Fawzi
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
| | - Christopher Duggan
- Children's Hospital Boston, Division of Pediatric Gastroenterology and Nutrition, Boston, MA 02115 and; Harvard School of Public Health, Department of Nutrition, Boston, MA 02115
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48
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Malnutrition associated with increased risk of peripheral neuropathy in Peruvian children with HIV infection. J Acquir Immune Defic Syndr 2009; 52:656-8. [PMID: 19935209 DOI: 10.1097/qai.0b013e3181bb268d] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T. Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health 2009; 14:1173-89. [PMID: 19772545 DOI: 10.1111/j.1365-3156.2009.02364.x] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To quantify the degree by which moderate and severe degrees of malnutrition increase the mortality risk in pneumonia, to identify potential differences in the aetiology of pneumonia between children with and without severe malnutrition, and to evaluate the validity of WHO-recommended clinical signs (age-specific fast breathing and chest wall indrawing) for the diagnosis of pneumonia in severely malnourished children. METHODS Systematic search of the existing literature using a variety of databases (Medline, EMBASE, the Web of Science, Scopus and CINAHL). RESULTS Mortality risk: Sixteen relevant studies were identified, which universally showed that children with pneumonia and moderate or severe malnutrition are at higher risk of death. For severe malnutrition, reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For moderate malnutrition, relative risks ranged from 1.2 to 36.5. Aetiology: Eleven studies evaluated the aetiology of pneumonia in severely malnourished children. Commonly isolated bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency of organisms differed from those reported in children without severe malnutrition. There are very few data on the role of respiratory viruses and tuberculosis. Clinical signs: Four studies investigating the validity of clinical signs showed that WHO-recommended clinical signs were less sensitive as predictors of radiographic pneumonia in severely malnourished children. CONCLUSIONS Pneumonia and malnutrition are two of the biggest killers in childhood. Guidelines for the care of children with pneumonia and malnutrition need to take into account this strong and often lethal association if they are to contribute to the UN Millennium Development Goal 4, aiming for substantial reductions in childhood mortality. Additional data regarding the optimal diagnostic approach to and management of pneumonia and malnutrition are required from regions where death from these two diseases is common.
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Affiliation(s)
- Mohammod Jobayer Chisti
- Clinical Science Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
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50
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Validation of 2006 WHO prediction scores for true HIV infection in children less than 18 months with a positive serological HIV test. PLoS One 2009; 4:e5312. [PMID: 19390690 PMCID: PMC2669178 DOI: 10.1371/journal.pone.0005312] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 02/20/2009] [Indexed: 11/19/2022] Open
Abstract
Introduction All infants born to HIV-positive mothers have maternal HIV antibodies, sometimes persistent for 18 months. When Polymerase Chain Reaction (PCR) is not available, August 2006 World Health Organization (WHO) recommendations suggest that clinical criteria may be used for starting antiretroviral treatment (ART) in HIV seropositive children <18 months. Predictors are at least two out of sepsis, severe pneumonia and thrush, or any stage 4 defining clinical finding according to the WHO staging system. Methods and Results From January 2005 to October 2006, we conducted a prospective study on 236 hospitalized children <18 months old with a positive HIV serological test at the national reference hospital in Kigali. The following data were collected: PCR, clinical signs and CD4 cell count. Current proposed clinical criteria were present in 148 of 236 children (62.7%) and in 95 of 124 infected children, resulting in 76.6% sensitivity and 52.7% specificity. For 87 children (59.0%), clinical diagnosis was made based on severe unexplained malnutrition (stage 4 clinical WHO classification), of whom only 44 (50.5%) were PCR positive. Low CD4 count had a sensitivity of 55.6% and a specificity of 78.5%. Conclusion As PCR is not yet widely available, clinical diagnosis is often necessary, but these criteria have poor specificity and therefore have limited use for HIV diagnosis. Unexplained malnutrition is not clearly enough defined in WHO recommendations. Extra pulmonary tuberculosis (TB), almost impossible to prove in young children, may often be the cause of malnutrition, especially in HIV-affected families more often exposed to TB. Food supplementation and TB treatment should be initiated before starting ART in children who are staged based only on severe malnutrition.
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