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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2024; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/19/2024] Open
Abstract
Background Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial will reappraise current recommendations with mortality as the primary outcome. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling children in Uganda, Kenya, Nigeria and Niger aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration (IV) given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is mortality to 96 hours and for oral rehydration a change in sodium levels at 24 hours post-randomisation. Secondary outcomes include measures assessing safety (evidence of pulmonary oedema or heart failure); change in sodium from post-iv levels for those in Stratum A; perturbations of electrolyte abnormalities (severe hyponatraemia <125 mmols/L or hypokalaemia. Discussion If the trial shows that rehydration strategies for non-malnourished children are safe and improve mortality in SAM this could prompt revisions to the current treatment recommendations or may prompt future Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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Kumar C, Manwatkar S, Saroj AK, Singh TB, Rao SK. Effectiveness of the WHO Protocol for the Management of Shock in Children With Severe Acute Malnutrition. Cureus 2023; 15:e46252. [PMID: 37908954 PMCID: PMC10614509 DOI: 10.7759/cureus.46252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
Background The WHO protocol for the management of shock in children with severe acute malnutrition (SAM) is not supported by physiological evidence. In this study, we aimed to assess the effectiveness of the WHO treatment protocol in the management of shock in children with SAM. Methodology This cohort study included children aged 2-60 months with WHO-defined SAM and fulfilling the WHO criteria for identification of shock. The exclusion criteria included severe anemia (hemoglobin <4 g/dL), congenital anomalies, congenital heart defects, and chronic diseases. The WHO treatment protocol for the management of shock was used, and features of resolution of shock were assessed at eight and 24 hours. Oliguria was recorded at eight and 24 hours along with in-hospital mortality. Multiple logistic regression was used to determine predictors of mortality. Results Of 53 children, 40 (75.4%) were discharged and 13 (24.5%) expired. We observed significant resolution of features of shock at 24 hours compared to eight hours (35 (71.4%) vs. 10 (18.8%), p < 0.0001). Further analysis revealed a significant resolution of features of shock (p = 0.03) at 24 hours in both fluid-responsive (24 vs. 10) and fluid-refractory children (11 vs. 27) compared to eight hours. Multivariate analysis revealed that mechanical ventilation was positively related to death (odds ratio (OR) = 85, 95% confidence interval (CI) = 8.49, 860, p < 0.0001), and inotrope scores <20 (OR = 0.053, 95% CI = 0.004, 0.64, p = 0.021) and blood transfusion (OR = 0.025, 95% CI = 0.001, 0.61, p = 0.024) had favorable outcomes. Conclusions The WHO protocol for the management of shock in children with SAM is effective in fluid-responsive shock whereas evidence was inconclusive in fluid-refractory shock.
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Affiliation(s)
- Chandan Kumar
- Division of Pediatric Intensive Care and Pulmonology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Shiva Manwatkar
- Division of Pediatric Intensive Care and Pulmonology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Anil K Saroj
- Division of Pediatric Intensive Care and Pulmonology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Tej Bali Singh
- Department of Preventive Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
| | - Sunil Kumar Rao
- Division of Pediatric Intensive Care and Pulmonology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, IND
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Fustiñana A, Yock-Corrales A, Casson N, Galvis L, Iramain R, Lago P, Da Silva APP, Paredes F, Zamarbide MP, Aprea V, Kohn-Loncarica G. Adherence to Pediatric Sepsis Treatment Recommendations at Emergency Departments: A Multicenter Study in Latin America. Pediatr Emerg Care 2022; 38:e1496-e1502. [PMID: 35802481 DOI: 10.1097/pec.0000000000002801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Sepsis is one of the most urgent health care issues worldwide. Guidelines for early identification and treatment are essential to decrease sepsis-related mortality. Our aim was to collect data on the epidemiology of pediatric septic shock (PSS) from the emergency department (PED) and to assess adherence to recommendations for its management in the first hour. METHODS A multicenter, prospective, cross-sectional study was conducted evaluating children with PSS seen at the PED of 10 tertiary-care centers in Latin America. Adherence to guidelines was evaluated. RESULTS We included 219 patients (median age, 3.7 years); 43% had comorbidities, 31% risk factors for developing sepsis, 74% clinical signs of "cold shock," and 13% of "warm shock," 22% had hypotension on admission. Consciousness was impaired in 55%. A peripheral line was used as initial access in 78% (median placement time, 10 minutes). Fluid and antibiotics infusion was achieved within a median time of 30 minutes (interquartile range [IQR], 20-60 minutes) and 40 minutes (IQR, 20-60 minutes), respectively; 40% responded inadequately to fluids requiring vasoactive drugs (median time at initiation, 60 minutes; IQR, 30-135 minutes). Delay to vasoactive drug infusion was significantly longer when a central line was placed compared to a peripheral line (median time, 133 minutes [59-278 minutes] vs 42 minutes [30-70 minutes], respectively [ P < 0.001]). Adherence to all treatment goals was achieved in 13%. Mortality was 10%. An association between mortality and hypotension on admission was found (26.1% with hypotension vs 4.9% without; P < 0.001). CONCLUSIONS We found poor adherence to the international recommendations for the treatment of PSS in the first hour at the PED in third-level hospitals in Latin America.
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Abstract
OBJECTIVES Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.
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Abstract
OBJECTIVES To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels. DESIGN Prospective observational study. SETTING Pediatric ward of a tertiary government referral hospital in Malawi. PATIENTS Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018. INTERVENTIONS Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes. MEASUREMENTS AND MAIN RESULTS Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate. CONCLUSIONS Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.
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Özer I. Refeeding Syndrome Developed in a Patient With Kwashiorkor Can Mimic Findings of Mitochondrial Disorder. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221093287. [PMID: 35519509 PMCID: PMC9067038 DOI: 10.1177/11795476221093287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 03/16/2022] [Indexed: 11/17/2022]
Abstract
Kwashiorkor is a serious nutritional disease. The 7-month-old male patient presented with severe metabolic acidosis and elevated liver enzymes. His condition was similar to fatty acid oxidation defect. He was taken to the hospital on the previous day with complaints of poor sucking and difficulty breathing. Treatment of upper respiratory tract infection was provided and then he returned to his home. He was cyanotic in bed after 12 hours. The patient, who was taken to the hospital unconscious and not fed for 12 hours, was not given any food orally in the first health center. Until laboratory tests are done, only iv electrolyte and a fluid containing dextrose were given. When the laboratory results were found to be significantly pathological, he was urgently referred to our hospital 4 hours after the admission. The content of the iv treatment applied at the time of referral was not clearly written. Low electrolytes, uric acid, liver enzymes, urea and creatinine elevation were detected at an outer center. Ketosis, lactic acidosis and dibasic aciduria were detected in urine organic acid analysis. He was diagnosed with Kwashiorkor and refeeding syndrome according to the clinical and laboratory findings. His complaints improved with appropriate treatment.
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Affiliation(s)
- Işil Özer
- Işıl Özer, Ondokuz Mayıs University, Medical Faculty, Child Metabolism Division, Kurupelit Campus 55139 Atakum Samsun, Turkey.
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Olupot-Olupot P, Aloroker F, Mpoya A, Mnjalla H, Paasi G, Nakuya M, Houston K, Obonyo N, Hamaluba M, Evans JA, Dewez M, Atti S, Guindo O, Ouattara SM, Chara A, Sainna HA, Amos OO, Ogundipe O, Sunyoto T, Coldiron M, LANGENDORF C, SCHERRER MF, PETRUCCI R, Connon R, George EC, Gibb DM, Maitland K. Gastroenteritis Rehydration Of children with Severe Acute Malnutrition (GASTROSAM): A Phase II Randomised Controlled trial: Trial Protocol. Wellcome Open Res 2021; 6:160. [PMID: 34286105 PMCID: PMC8276193 DOI: 10.12688/wellcomeopenres.16885.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Children hospitalised with severe acute malnutrition (SAM) are frequently complicated (>50%) by diarrhoea ( ≥3 watery stools/day) which is accompanied by poor outcomes. Rehydration guidelines for SAM are exceptionally conservative and controversial, based upon expert opinion. The guidelines only permit use of intravenous fluids for cases with advanced shock and exclusive use of low sodium intravenous and oral rehydration solutions (ORS) for fear of fluid and/or sodium overload. Children managed in accordance to these guidelines have a very high mortality. The proposed GASTROSAM trial is the first step in reappraising current recommendations. We hypothesize that liberal rehydration strategies for both intravenous and oral rehydration in SAM children with diarrhoea may reduce adverse outcomes. Methods An open Phase II trial, with a partial factorial design, enrolling Ugandan and Kenyan children aged 6 months to 12 years with SAM hospitalised with gastroenteritis (>3 loose stools/day) and signs of moderate and severe dehydration. In Stratum A (severe dehydration) children will be randomised (1:1:2) to WHO plan C (100mls/kg Ringers Lactate (RL) with intravenous rehydration given over 3-6 hours according to age including boluses for shock), slow rehydration (100 mls/kg RL over 8 hours (no boluses)) or WHO SAM rehydration regime (ORS only (boluses for shock (standard of care)). Stratum B incorporates all children with moderate dehydration and severe dehydration post-intravenous rehydration and compares (1:1 ratio) standard WHO ORS given for non-SAM (experimental) versus WHO SAM-recommended low-sodium ReSoMal. The primary outcome for intravenous rehydration is urine output (mls/kg/hour at 8 hours post-randomisation), and for oral rehydration a change in sodium levels at 24 hours post-randomisation. This trial will also generate feasibility, safety and preliminary data on survival to 28 days. Discussion. If current rehydration strategies for non-malnourished children are safe in SAM this could prompt future evaluation in Phase III trials.
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Affiliation(s)
- Peter Olupot-Olupot
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Florence Aloroker
- Department of Paediatrics, Soroti Regional Referral Hospital, Soroti, PO Box 289, Uganda
| | - Ayub Mpoya
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Hellen Mnjalla
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - George Paasi
- Department of Paediatrics, Mbale Clinical Research Institute, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Margaret Nakuya
- Mbale Regional Referral Hospital, Pallisa Road, Mbale, PO Box 291, Uganda
| | - Kirsty Houston
- Department of Medicine, Imperial College London, London, W2 1PG, UK
| | - Nchafatso Obonyo
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Mainga Hamaluba
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
| | - Jennifer A Evans
- Department of Paediatrics, University Hospital of Wales, Cardiff, Wales, CF14 4XW, UK
| | | | | | | | | | | | | | - Omokore Oluseyi Amos
- Child Health Division, Family Health Dept., Federal Ministry of Health, Maiduguri, Nigeria
| | | | - Temmy Sunyoto
- MSF Operational Research Unit, LuxOR, Luxembourg City, Luxembourg
| | | | | | | | | | - Roisin Connon
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Elizabeth C. George
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Diana M. Gibb
- MRC Clinical Trials Unit at University College London, University College London, London, WC1V 6LJ, UK
| | - Kathryn Maitland
- Clinical Trials Facility, KEMRI-Wellcome Trust Research Programme, Kilifi, PO Box 230, Kenya
- Department of Medicine, Imperial College London, London, W2 1PG, UK
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8
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Vonasek BJ, Chiume M, Crouse HL, Mhango S, Kondwani A, Ciccone EJ, Kazembe PN, Gaven W, Fitzgerald E. Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi. Paediatr Int Child Health 2020; 40:148-157. [PMID: 32242509 DOI: 10.1080/20469047.2020.1747003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood. METHODS Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression. RESULTS Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44). CONCLUSION HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.
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Affiliation(s)
- Bryan J Vonasek
- Department of Pediatrics, Baylor College of Medicine , Houston, USA
| | - Msandeni Chiume
- Department of Paediatrics, Kamuzu Central Hospital , Lilongwe, Malawi.,College of Medicine, University of Malawi , Lilongwe, Malawi
| | - Heather L Crouse
- Department of Pediatrics, Baylor College of Medicine , Houston, USA
| | - Susan Mhango
- Baylor College of Medicine Children's Foundation Malawi , Lilongwe, Malawi
| | | | - Emily J Ciccone
- Department of Medicine, University of North Carolina at Chapel Hill , Chapel Hill, USA
| | | | - Wilfred Gaven
- Malawi College of Health Sciences , Lilongwe, Malawi
| | - Elizabeth Fitzgerald
- Department of Pediatrics, University of North Carolina at Chapel Hill , Chapel Hill, USA
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9
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B-type Natriuretic peptide Levels and Outcome in Children With Severe Acute Malnutrition With Co-morbidity. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1792-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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10
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Brent B, Obonyo N, Akech S, Shebbe M, Mpoya A, Mturi N, Berkley JA, Tulloh RMR, Maitland K. Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study. JAMA Netw Open 2019; 2:e191054. [PMID: 30901050 PMCID: PMC6583281 DOI: 10.1001/jamanetworkopen.2019.1054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/04/2019] [Indexed: 01/14/2023] Open
Abstract
Importance Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited. Objective To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM). Design, Setting, and Participants A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016. Exposures Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28. Main Outcomes and Measures Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared. Results Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities. Conclusions and Relevance There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.
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Affiliation(s)
- Bernadette Brent
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Imperial College, London, United Kingdom
| | - Nchafatso Obonyo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Samuel Akech
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Mohammed Shebbe
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Ayub Mpoya
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - Neema Mturi
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
| | - James A. Berkley
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Kathryn Maitland
- Kenya Medical Research Institute Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya
- Department of Paediatrics, Faculty of Medicine, St Mary’s Campus, Imperial College, London, United Kingdom
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Nwankwor OC, McKelvie B, Frizzola M, Hunter K, Kabara HS, Oduwole A, Oguonu T, Kissoon N. A National Survey of Resources to Address Sepsis in Children in Tertiary Care Centers in Nigeria. Front Pediatr 2019; 7:234. [PMID: 31245338 PMCID: PMC6579914 DOI: 10.3389/fped.2019.00234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/22/2019] [Indexed: 01/11/2023] Open
Abstract
Background: Infections leading to sepsis are major contributors to mortality and morbidity in children world-wide. Determining the capacity of pediatric hospitals in Nigeria to manage sepsis establishes an important baseline for quality-improvement interventions and resource allocations. Objectives: To assess the availability and functionality of resources and manpower for early detection and prompt management of sepsis in children at tertiary pediatric centers in Nigeria. Methods: This was an online survey of tertiary pediatric hospitals in Nigeria using a modified survey tool designed by the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS). The survey addressed all aspects of pediatric sepsis identification, management, barriers and readiness. Results: While majority of the hospitals 97% (28/29) reported having adequate triage systems, only 60% (16/27) follow some form of guideline for sepsis management. There was no consensus national guideline for management of pediatric sepsis. Over 50% of the respondents identified deficit in parental education, poor access to healthcare services, failure to diagnose sepsis at referring institutions, lack of medical equipment and lack of a definitive protocol for managing pediatric sepsis, as significant barriers. Conclusions: Certain sepsis-related interventions were reportedly widespread, however, there is no standardized sepsis protocol, and majority of the hospitals do not have pediatric intensive care units (PICU). These findings could guide quality improvement measures at institutional level, and healthcare policy/spending at the national level.
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Affiliation(s)
- Odiraa C Nwankwor
- Division of Critical Care Medicine, Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE, United States.,Division of Critical Care Medicine, Department of Pediatrics, Cooper University Hospital, Camden, NJ, United States
| | - Brianna McKelvie
- Department of Pediatrics, Children's Hospital, Western University, London, ON, Canada
| | - Meg Frizzola
- Division of Critical Care Medicine, Department of Pediatrics, Alfred I. DuPont Hospital for Children, Wilmington, DE, United States
| | - Krystal Hunter
- Cooper University Hospital, Cooper Research Institute, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Halima S Kabara
- Department of Anaesthesia/Intensive Care Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Abiola Oduwole
- Department of Paediatrics, Lagos University Teaching Hospital/College of Medicine, University of Lagos, Lagos, Nigeria
| | - Tagbo Oguonu
- Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, Nigeria
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, University of British Columbia and BC Children's Hospital, Vancouver, BC, Canada
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12
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Gelbart B. Fluid Bolus Therapy in Pediatric Sepsis: Current Knowledge and Future Direction. Front Pediatr 2018; 6:308. [PMID: 30410875 PMCID: PMC6209667 DOI: 10.3389/fped.2018.00308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 10/01/2018] [Indexed: 12/21/2022] Open
Abstract
Sepsis is a leading cause of morbidity and mortality in children with a worldwide prevalence in pediatric intensive care units of approximately 8%. Fluid bolus therapy (FBT) is a first line therapy for resuscitation of septic shock and has been a recommendation of international guidelines for nearly two decades. The evidence base supporting these guidelines are based on limited data including animal studies and case control studies. In recent times, evidence suggesting harm from fluid in terms of morbidity and mortality have generated interest in evaluating FBT. In view of this, studies of fluid restrictive strategies in adults and children have emerged. The complexity of studying FBT relates to several points. Firstly, the physiological and haemodynamic response to FBT including magnitude and duration is not well described in children. Secondly, assessment of the circulation is based on non-specific clinical signs and limited haemodynamic monitoring with limited physiological targets. Thirdly, FBT exists in a complex myriad of pathophysiological responses to sepsis and other confounding therapies. Despite this, a greater understanding of the role of FBT in terms of the physiological response and possible harm is warranted. This review outlines current knowledge and future direction for FBT in sepsis.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit Royal Children's Hospital, Melbourne, VIC, Australia.,Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,The University of Melbourne, Melbourne, VIC, Australia
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13
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Muggleton ER. Variability of response to the fluid bolus is again demonstrated. Crit Care 2017; 21:224. [PMID: 28841889 PMCID: PMC5574114 DOI: 10.1186/s13054-017-1793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2:66. [PMID: 29090271 PMCID: PMC5657219 DOI: 10.12688/wellcomeopenres.12357.3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18
th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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15
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017; 2:66. [PMID: 29090271 PMCID: PMC5657219 DOI: 10.12688/wellcomeopenres.12357.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2017] [Indexed: 07/13/2024] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines.
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Affiliation(s)
- Kirsty A. Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G. Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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16
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Houston KA, Gibb JG, Maitland K. Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review. Wellcome Open Res 2017. [DOI: 10.12688/wellcomeopenres.12357.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines
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17
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Argent AC, Chisti MJ, Ranjit S. What's new in PICU in resource limited settings? Intensive Care Med 2017; 44:467-469. [PMID: 28913544 DOI: 10.1007/s00134-017-4905-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/09/2017] [Indexed: 01/25/2023]
Affiliation(s)
- Andrew C Argent
- School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa. .,Paediatric Intensive Care, Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, South Africa.
| | - Mohammod J Chisti
- Clinical Research, Hospitals, Nutrition and Clinical Services Division (NCSD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.,ICU, Dhaka Hospital, NCSD, icddr,b, Dhaka, Bangladesh
| | - Suchitra Ranjit
- Pediatric Intensive Care, Apollo Children's Hospital, Chennai, India
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18
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Houston KA, Gibb JG, Maitland K. Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review. Wellcome Open Res 2017; 2:65. [PMID: 28944301 PMCID: PMC5590082 DOI: 10.12688/wellcomeopenres.12346.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2017] [Indexed: 12/11/2022] Open
Abstract
Background: Rehydration strategies in children with severe acute malnutrition (SAM) and severe dehydration are extremely cautious. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Otherwise, guidelines recommend oral or nasogastric rehydration using low sodium oral rehydration solutions. There is limited evidence to support these recommendations. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15
th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, specifically relating to intravenous rehydration, using standard search terms. Two authors assessed papers for inclusion. The primary endpoint was evidence of fluid overload. Results: Four studies were identified, all published in English, including 883 children, all of which were conducted in low resource settings. Two were randomised controlled trials and two observational cohort studies, one incorporated assessment of myocardial and haemodynamic function. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. Mortality was high overall, and particularly in children with shock managed on WHO recommendations (day-28 mortality 82%). There was no difference in safety outcomes when different rates of intravenous rehydration were compared. Conclusions: The current ‘strong recommendations’ for conservative rehydration of children with SAM are not based on emerging evidence. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy. Recent studies have reported no evidence of fluid overload or heart failure with more liberal rehydration regimens. Clinical trials are urgently required to inform guidelines on routes and rates of intravenous rehydration therapy for dehydration in children with SAM.
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Affiliation(s)
- Kirsty A Houston
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Jack G Gibb
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
| | - Kathryn Maitland
- Department of Paediatrics, Faculty of Medicine, Imperial College, London, W2 1PG, UK.,KEMRI-Wellcome Trust Research Programme, Kilifi, 80108, Kenya
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19
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Kissoon N. Understanding fluid administration approaches in children with co-morbidities and septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:204. [PMID: 28774323 PMCID: PMC5543432 DOI: 10.1186/s13054-017-1741-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Niranjan Kissoon
- Department of Pediatrics, BC Children's Hospital, University of British Columbia, B245, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada. .,Child & Family Research Institute (CFRI), Vancouver, British Columbia, Canada. .,Division of Critical Care, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
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