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Kisenge R, Ideh RC, Kamara J, Coleman-Nekar YJG, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Duggan CP, Manji KP, Rees CA. Morbidity and unplanned healthcare encounters after hospital discharge among young children in Dar es Salaam, Tanzania and Monrovia, Liberia. BMJ Paediatr Open 2024; 8:e002613. [PMID: 38906561 PMCID: PMC11191828 DOI: 10.1136/bmjpo-2024-002613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/08/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Researchers and healthcare providers have paid little attention to morbidity and unplanned healthcare encounters for children following hospital discharge in low- and middle-income countries. Our objective was to compare symptoms and unplanned healthcare encounters among children aged <5 years who survived with those who died within 60 days of hospital discharge through follow-up phone calls. METHODS We conducted a secondary analysis of a prospective observational cohort of children aged <5 years discharged from neonatal and paediatric wards of two national referral hospitals in Dar es Salaam, Tanzania and Monrovia, Liberia. Caregivers of enrolled participants received phone calls 7, 14, 30, 45, and 60 days after hospital discharge to record symptoms, unplanned healthcare encounters, and vital status. We used logistic regression to determine the association between reported symptoms and unplanned healthcare encounters with 60-day post-discharge mortality. RESULTS A total of 4243 participants were enrolled and had 60-day vital status available; 138 (3.3%) died. For every additional symptom ever reported following discharge, there was a 35% greater likelihood of post-discharge mortality (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.10 to 1.66; p=0.004). The greatest survival difference was noted for children who had difficulty breathing (2.1% among those who survived vs 36.0% among those who died, p<0.001). Caregivers who took their child home from the hospital against medical advice during the initial hospitalisation had over eight times greater odds of post-discharge mortality (aOR 8.06, 95% CI 3.87 to 16.3; p<0.001) and those who were readmitted to a hospital had 3.42 greater odds (95% CI 1.55 to 8.47; p=0.004) of post-discharge mortality than those who did not seek care when adjusting for site, sociodemographic factors, and clinical variables. CONCLUSION Surveillance for symptoms and repeated admissions following hospital discharge by healthcare providers is crucial to identify children at risk for post-discharge mortality.
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Affiliation(s)
- Rodrick Kisenge
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | | | - Abraham Samma
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Accident and Emergency Department, Aga Khan Health Services, Dar es Salaam, United Republic of Tanzania
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Infectious Diseases and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Paediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
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Islam MA, Hassan MZ, Aleem MA, Akhtar Z, Chowdhury S, Ahmmed MK, Rahman M, Rahman MZ, Mah-E-Muneer S, Uzzaman MS, Shirin T, Flora MS, Rahman M, Davis WW, Azziz-Baumgartner E, Iuliano AD, Chowdhury F. Post-discharge mortality among patients hospitalised with severe acute respiratory infection, Bangladesh, 2012-2019: a prospective observational study. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 25:100363. [PMID: 39021479 PMCID: PMC467067 DOI: 10.1016/j.lansea.2024.100363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 11/09/2023] [Accepted: 01/31/2024] [Indexed: 07/20/2024]
Abstract
Background Enhancing outcomes post-hospitalisation requires an understanding of predictive factors for adverse events. This study aimed to estimate post-discharge mortality rates among patients with severe acute respiratory infection (SARI) in Bangladesh, identify associated factors, and document reported causes of death. Methods From January 2012 to December 2019, we conducted follow-up calls to patients or their families 30 days after discharge to assess the status of patients with SARI. Proportions of deaths within 30 days of discharge were estimated, and a comparative analysis of demographics, clinical characteristics, and influenza illness between decedents and survivors was performed using multivariable Cox regression models. Findings Among 23,360 patients with SARI (median age: 20 years, IQR: 1.5-48, 65% male), 351 (1.5%) died during hospitalisation. Of 23,009 patients alive at discharge, 20,044 (87%) were followed, with 633 (3.2%) deaths within 30 days of discharge. In children (<18 years), difficulty breathing (adjusted hazard ratio [aHR] 1.8; 95% CI 1.1-3.0), longer hospital stay (aHR 1.1; 95% CI 1.1-1.1), and heart diseases (aHR 8.5; 95% CI 3.2-23.1) were associated with higher post-discharge death risk. Among adults (≥18 years), difficulty breathing (aHR 2.3; 95% CI 1.7-3.0), chronic obstructive pulmonary disease (aHR 1.7; 95% CI 1.4-2.2), and intensive care unit admission (aHR 5.2; 95% CI 1.9-14.0) were linked to elevated post-discharge death risk. Influenza virus was detected in 13% (46/351) of in-hospital SARI deaths and 10% (65/633) of post-discharge SARI deaths. Interpretation Nearly one in twenty patients with SARI died during hospitalisation or within 1 month of discharge, with two-thirds of deaths occurring post-discharge. Seasonal influenza vaccination is recommended to mitigate influenza-associated mortality. To enhance post-discharge outcomes, hospitals should consider developing safe-discharge algorithms, reinforcing post-discharge care plans, and establishing outpatient monitoring for recently discharged patients. Funding Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA [U01GH002259].
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Affiliation(s)
- Md Ariful Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Zakiul Hassan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Abdul Aleem
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Zubair Akhtar
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sukanta Chowdhury
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Kaousar Ahmmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafizur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammed Ziaur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Syeda Mah-E-Muneer
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - M Salim Uzzaman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Tahmina Shirin
- Institute of Epidemiology, Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | | | - Mahmudur Rahman
- Global Health Development (GHD), The Eastern Mediterranean Public Health Network (EMPHNET), Dhaka, Bangladesh
| | - William W. Davis
- Influenza Division, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | | | - A. Danielle Iuliano
- Influenza Division, Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Fahmida Chowdhury
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Marangu-Boore D, Mwaniki P, Isaaka L, Njoroge T, Mumelo L, Kimego D, Adem A, Jowi E, Ithondeka A, Wanyama C, Agweyu A. Characteristics of children readmitted with severe pneumonia in Kenyan hospitals. BMC Public Health 2024; 24:1324. [PMID: 38755590 PMCID: PMC11097591 DOI: 10.1186/s12889-024-18651-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Pneumonia is a leading cause of childhood morbidity and mortality. Hospital re-admission may signify missed opportunities for care or undiagnosed comorbidities. METHODS We conducted a retrospective cohort study including children aged ≥ 2 months-14 years hospitalised with severe pneumonia between 2013 and 2021 in a network of 20 primary referral hospitals in Kenya. Severe pneumonia was defined using the 2013 World Health Organization criteria, and re-admission was based on clinical documentation from individual patient case notes. We estimated the prevalence of re-admission, described clinical management practices, and modelled risk factors for re-admission and inpatient mortality. RESULTS Among 20,603 children diagnosed with severe pneumonia, 2,274 (11.0%, 95% CI 10.6-11.5) were readmitted. Re-admission was independently associated with age (12-59 months vs. 2-11 months: adjusted odds ratio (aOR) 1.70, 1.54-1.87; >5 years vs. 2-11 months: aOR 1.85, 1.55-2.22), malnutrition (weight-for-age-z-score (WAZ) <-3SD vs. WAZ> -2SD: aOR 2.05, 1.84-2.29); WAZ - 2 to -3 SD vs. WAZ> -2SD: aOR 1.37, 1.20-1.57), wheeze (aOR 1.17, 1.03-1.33) and presence of a concurrent neurological disorder (aOR 4.42, 1.70-11.48). Chest radiography was ordered more frequently among those readmitted (540/2,274 [23.7%] vs. 3,102/18,329 [16.9%], p < 0.001). Readmitted patients more frequently received second-line antibiotics (808/2,256 [35.8%] vs. 5,538/18,173 [30.5%], p < 0.001), TB medication (69/2,256 [3.1%] vs. 298/18,173 [1.6%], p < 0.001), salbutamol (530/2,256 [23.5%] vs. 3,707/18,173 [20.4%], p = 0.003), and prednisolone (157/2,256 [7.0%] vs. 764/18,173 [4.2%], p < 0.001). Inpatient mortality was 2,354/18,329 (12.8%) among children admitted with a first episode of severe pneumonia and 269/2,274 (11.8%) among those who were readmitted (adjusted hazard ratio (aHR) 0.93, 95% CI 0.82-1.07). Age (12-59 months vs. 2-11 months: aHR 0.62, 0.57-0.67), male sex (aHR 0.81, 0.75-0.88), malnutrition (WAZ <-3SD vs. WAZ >-2SD: aHR 1.87, 1.71-2.05); WAZ - 2 to -3 SD vs. WAZ >-2SD: aHR 1.46, 1.31-1.63), complete vaccination (aHR 0.74, 0.60-0.91), wheeze (aHR 0.87, 0.78-0.98) and anaemia (aHR 2.14, 1.89-2.43) were independently associated with mortality. CONCLUSIONS Children readmitted with severe pneumonia account for a substantial proportion of pneumonia hospitalisations and deaths. Further research is required to develop evidence-based approaches to screening, case management, and follow-up of children with severe pneumonia, prioritising those with underlying risk factors for readmission and mortality.
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Affiliation(s)
- Diana Marangu-Boore
- Paediatric Pulmonology Division, Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya.
| | - Paul Mwaniki
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lynda Isaaka
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Teresiah Njoroge
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Livingstone Mumelo
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Dennis Kimego
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | | | - Conrad Wanyama
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ambrose Agweyu
- Epidemiology and Demography Department, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, Great Britain
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Srivastava AD, Awasthi S, Jauhari S. Prevalence of persistent pneumonia among severe pneumonia and nutritional status as its associated risk factor: A prospective observational study among under-five children. J Family Med Prim Care 2024; 13:1911-1916. [PMID: 38948562 PMCID: PMC11213408 DOI: 10.4103/jfmpc.jfmpc_1480_23] [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: 09/06/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 07/02/2024] Open
Abstract
Background Malnourishment is a risk factor for persistent pneumonia among under-five children with severe pneumonia. This study aims to determine the prevalence of persistent pneumonia and the association between nutritional status and pneumonia severity in children under 5 years of age. Methodology A prospective observational hospital-based study was conducted in the Department of Paediatrics, King George's Medical University (KGMU) from May 2019 to April 2020 among children aged 1 month to 5 years admitted with a diagnosis of severe pneumonia. An anthropometric assessment along with general and systemic examination was conducted. Weight for age, height for age and weight for height were calculated to assess the nutritional status. Children with severe pneumonia were followed for 4-6 weeks to assess the prevalence of persistent pneumonia. Results The prevalence of persistent pneumonia was 6.8%, while 32 (31.1%) and 64 (62.1%) patients had recurrent and severe pneumonia, respectively. No statistically significant distribution was observed in age, sex, residential area, parent's education or occupation of the child. The statistically significant distribution was seen on assessing nutritional status based on weight for age, height for age and weight for height (P value- 0.001, 0.001, 0.0001). Those with weight for age ≤ 3SD were anaemics and up to 1 year of age had 5.21, 3.52 and 2.83 times more odds of having persistent pneumonia, respectively. Conclusion The prevalence of persistent pneumonia among children less than 5 years of age was 6.8%. Malnutrition can be considered a major determinant of persistent pneumonia among children under 5 years of age.
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Affiliation(s)
- Akanksha D Srivastava
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Shally Awasthi
- Department of Pediatrics, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Sugandha Jauhari
- Department of Community Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
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Alam J, Fahim SM, Islam MR, Alam MA, Gazi MA, Ahmed T. Effects of L-Carnitine Supplementation on the Rate of Weight Gain and Biomarkers of Environmental Enteric Dysfunction in Children with Severe Acute Malnutrition: A Double-Blind Randomized Controlled Clinical Trial. J Nutr 2024; 154:949-961. [PMID: 38331348 DOI: 10.1016/j.tjnut.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/20/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) is a major public health concern among low- and middle-income countries, where the majority of the children encountering this acute form of malnutrition suffer from environmental enteric dysfunction (EED). However, evidence regarding the effects of L-carnitine supplementation on the rate of weight gain and EED biomarkers in malnourished children is limited. OBJECTIVES We aimed to investigate the role of L-carnitine supplementation on the rate of weight gain, duration of hospital stays, and EED biomarkers among children with SAM. METHODS A prospective, double-blind, placebo-controlled, randomized clinical trial was conducted at the Nutritional Rehabilitation Unit (NRU) of Dhaka Hospital, International Centre for Diarrheal Disease Research, Bangladesh. Children with SAM aged 9-24 mo were randomly assigned to receive commercial L-carnitine syrup (100 mg/kg/d) or placebo for 15 d in addition to standard of care. A total of 98 children with Weight-for-Length-z-score (WLZ) < -3 Standard deviation were enrolled between October 2021 and March 2023. Analyses were conducted on an intention-to-treat basis. RESULTS The primary outcome variable, "rate of weight gain," was comparable between L-carnitine and placebo groups (2.09 ± 2.23 compared with 2.07 ± 2.70; P = 0.973), which was consistent even after adjusting for potential covariates (age, sex, Weight-for-Age z-score, asset index, and WASH practices) through linear regression [ß: 0.37; 95% confidence interval (CI): -0.63,1.37; P = 0.465]. The average hospital stay was ∼4 d. The results of adjusted median regression showed that following intervention, there was no significant difference in the EED biomarkers among the treatment arms; Myeloperoxidase (ng/mL) [ß: -1342.29; 95% CI: -2817.35, 132.77; P = 0.074], Neopterin (nmol/L) [ß: -153.33; 95% CI: -556.58, 249.91; P = 0.452], alpha-1-antitrypsin (mg/mL) [ß: 0.05; 95% CI: -0.15, 0.25; P = 0.627]. Initial L-carnitine (μmol/L) levels (median, interquartile range) for L-carnitine compared with placebo were 54.84 (36.0, 112.9) and 59.74 (45.7, 96.0), whereas levels after intervention were 102.05 (60.9, 182.1) and 105.02 (73.1, 203.7). CONCLUSIONS Although our study findings suggest that L-carnitine bears no additional effect on SAM, we recommend clinical trials with a longer duration of supplementation, possibly with other combinations of interventions, to investigate further into this topic of interest. This trial was registered at clinicaltrials.gov as NCT05083637.
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Affiliation(s)
- Jinat Alam
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
| | - Shah Mohammad Fahim
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ridwan Islam
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Ashraful Alam
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Poche Centre for Indigenous Health, University of Queensland, Brisbane Qld, Australia
| | - Md Amran Gazi
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of Global Health, University of Washington, Seattle, WA, United States; Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Knappett M, Nguyen V, Chaudhry M, Trawin J, Kabakyenga J, Kumbakumba E, Jacob ST, Ansermino JM, Kissoon N, Mugisha NK, Wiens MO. Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis. EClinicalMedicine 2024; 67:102380. [PMID: 38204490 PMCID: PMC10776442 DOI: 10.1016/j.eclinm.2023.102380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
Background Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding No specific funding was received.
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Affiliation(s)
- Martina Knappett
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Vuong Nguyen
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Maryum Chaudhry
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jessica Trawin
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
| | - Jerome Kabakyenga
- Maternal Newborn & Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
- Faculty of Medicine, Dept of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elias Kumbakumba
- Dept of Paediatrics and Child Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Shevin T. Jacob
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - J. Mark Ansermino
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
| | - Niranjan Kissoon
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
- Dept of Pediatrics, BC Children’s Hospital, University of British Columbia, Rm 2D19, 4480 Oak Street, Vancouver, BC V6H 3V4, Canada
| | | | - Matthew O. Wiens
- Institute for Global Health, BC Children’s Hospital and BC Women’s Hospital + Health Centre, 305-4088 Cambie Street, Vancouver, BC V5Z 2X8, Canada
- Walimu, Plot 5-7, Coral Crescent, Kololo, P.O. Box 9924, Kampala, Uganda
- Dept of Anesthesia, Pharmacology & Therapeutics, University of British Columbia, 217-2176 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
- BC Children’s Hospital Research Institute, 938 West 28th Ave, Vancouver, BC V5Z 4H4, Canada
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7
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Argent AC. Pediatric Intensive Care Development When Resources Are Scarce and Demand Is Potentially Very High. Pediatr Crit Care Med 2023; 24:525-527. [PMID: 37260338 DOI: 10.1097/pcc.0000000000003260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Andrew C Argent
- Department of Pediatrics and Child Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Belyaeva IA, Bombardirova EP, Prihodko EA, Kruglyakov AY, Mikheeva AA, Larina AR. Clinical Phenotypes of Malnutrition in Young Children: Differential Nutritional Correction. CURRENT PEDIATRICS 2023. [DOI: 10.15690/vsp.v21i6.2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This review article summarizes current data on malnutrition etiology and pathogenesis in infants. Topical requirements for revealing this condition, its diagnosis and severity assessment via centile metrics are presented. The characteristics of the most common clinical phenotypes of postnatal growth insufficiency in infants (premature infants with different degree of maturation, including patients with bronchopulmonary dysplasia) are described. Differential approaches for malnutrition nutritional correction in these children are presented. The final section of the article describes special nutritional needs for children with congenital heart defects in terms of hemodynamic disorders nature and severity. Modern nutritional strategies for preparation of these patients to surgery and for their postoperative period are presented. The use of high-calorie/high-protein product for malnutrition correction in the most vulnerable patients with described in this review phenotypes is worth noticing.
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Affiliation(s)
- I. A. Belyaeva
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery; Pirogov Russian National Research Medical University; Morozovskaya Children’s City Hospital
| | - E. P. Bombardirova
- Research Institute of Pediatrics and Children’s Health in Petrovsky National Research Centre of Surgery
| | | | | | - A. A. Mikheeva
- Research Institute for Healthcare Organization and Medical Management
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Enteric Permeability, Systemic Inflammation, and Post-Discharge Growth Among a Cohort of Hospitalized Children in Kenya and Pakistan. J Pediatr Gastroenterol Nutr 2022; 75:768-774. [PMID: 36123771 PMCID: PMC9645542 DOI: 10.1097/mpg.0000000000003619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To determine whether gut permeability is associated with post-discharge growth and systemic inflammation among hospitalized children in low- and middle-income countries. METHODS Children aged 2-23 months being discharged from Civil Hospital Karachi (Pakistan) and Migori County Referral Hospital (Kenya) underwent lactulose-rhamnose ratio (LRR) permeability testing and were compared to age-matched children from their home communities. Linear mixed effect models estimated the associations between LRR among discharged children with change in length-for-age (LAZ) and weight-for-age z score (WAZ) at 45, 90, and 180 days after discharge. Linear regression tested if relationships between LRR, systemic inflammation [C-reative protein (CRP), Cluster of Differentiation 14 (CD14), Tumour Necrosis Factor Alpha (TNFα), Interleukin-6 (IL-6)], and enterocyte damage [Intestinal Fatty-Acid Binding protein (I-FABP)] differed between the hospitalized and community groups. RESULTS One hundred thirty-seven hospitalized and 84 community participants were included. The hospitalized group had higher log-LRR [0.43, 95% confidence interval (CI): 0.15-0.71, P = 0.003] than the community children. Adjustment for weight-for-length z score at discharge attenuated this association (0.31, 95% CI: 0.00-0.62, P = 0.049). LRR was not associated with changes in WAZ or LAZ in the post-discharge period. Associations between LRR and CRP (interaction P = 0.036), TNFα ( P = 0.017), CD14 ( P = 0.078), and IL-6 ( P = 0.243) differed between community and hospitalized groups. LRR was associated with TNFα ( P = 0.004) and approached significance with CD14 ( P = 0.078) and IL-6 ( P = 0.062) in community children, but there was no evidence of these associations among hospitalized children. CONCLUSIONS Although increased enteric permeability is more prevalent among children being discharged from hospital compared to children in the community, it does not appear to be an important determinant of systemic inflammation or post-discharge growth among hospitalized children.
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10
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Njunge JM, Tickell K, Diallo AH, Sayeem Bin Shahid ASM, Gazi MA, Saleem A, Kazi Z, Ali S, Tigoi C, Mupere E, Lancioni CL, Yoshioka E, Chisti MJ, Mburu M, Ngari M, Ngao N, Gichuki B, Omer E, Gumbi W, Singa B, Bandsma R, Ahmed T, Voskuijl W, Williams TN, Macharia A, Makale J, Mitchel A, Williams J, Gogain J, Janjic N, Mandal R, Wishart DS, Wu H, Xia L, Routledge M, Gong YY, Espinosa C, Aghaeepour N, Liu J, Houpt E, Lawley TD, Browne H, Shao Y, Rwigi D, Kariuki K, Kaburu T, Uhlig HH, Gartner L, Jones K, Koulman A, Walson J, Berkley J. The Childhood Acute Illness and Nutrition (CHAIN) network nested case-cohort study protocol: a multi-omics approach to understanding mortality among children in sub-Saharan Africa and South Asia. Gates Open Res 2022; 6:77. [PMID: 36415883 PMCID: PMC9646488 DOI: 10.12688/gatesopenres.13635.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 08/10/2023] Open
Abstract
Introduction: Many acutely ill children in low- and middle-income settings have a high risk of mortality both during and after hospitalisation despite guideline-based care. Understanding the biological mechanisms underpinning mortality may suggest optimal pathways to target for interventions to further reduce mortality. The Childhood Acute Illness and Nutrition (CHAIN) Network ( www.chainnnetwork.org) Nested Case-Cohort Study (CNCC) aims to investigate biological mechanisms leading to inpatient and post-discharge mortality through an integrated multi-omic approach. Methods and analysis; The CNCC comprises a subset of participants from the CHAIN cohort (1278/3101 hospitalised participants, including 350 children who died and 658 survivors, and 270/1140 well community children of similar age and household location) from nine sites in six countries across sub-Saharan Africa and South Asia. Systemic proteome, metabolome, lipidome, lipopolysaccharides, haemoglobin variants, toxins, pathogens, intestinal microbiome and biomarkers of enteropathy will be determined. Computational systems biology analysis will include machine learning and multivariate predictive modelling with stacked generalization approaches accounting for the different characteristics of each biological modality. This systems approach is anticipated to yield mechanistic insights, show interactions and behaviours of the components of biological entities, and help develop interventions to reduce mortality among acutely ill children. Ethics and dissemination. The CHAIN Network cohort and CNCC was approved by institutional review boards of all partner sites. Results will be published in open access, peer reviewed scientific journals and presented to academic and policy stakeholders. Data will be made publicly available, including uploading to recognised omics databases. Trial registration NCT03208725.
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Affiliation(s)
- James M. Njunge
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kirkby Tickell
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - Abdoulaye Hama Diallo
- Department of Public Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | | | - Md. Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ali Saleem
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Syed Ali
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Caroline Tigoi
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Emily Yoshioka
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Moses Mburu
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses Ngari
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Narshion Ngao
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bonface Gichuki
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elisha Omer
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Wilson Gumbi
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Benson Singa
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Robert Bandsma
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Biomedical Sciences, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Wieger Voskuijl
- Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Centre for Global Child Health & Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Thomas N. Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alex Macharia
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | | | - Rupasri Mandal
- Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - David S. Wishart
- Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Hang Wu
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Lei Xia
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Michael Routledge
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
| | - Yun Yun Gong
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Camilo Espinosa
- Departments of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Nima Aghaeepour
- Departments of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Eric Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Yan Shao
- Wellcome Sanger Institute, Hinxton, UK
| | - Doreen Rwigi
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Kariuki
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Timothy Kaburu
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Holm H. Uhlig
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
- Department of Paediatrics and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lisa Gartner
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kelsey Jones
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Albert Koulman
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- NIHR BRC Nutritional Biomarker Laboratory, University of Cambridge, Cambridge, UK
| | - Judd Walson
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James Berkley
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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11
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Uddin MF, Molyneux S, Muraya K, Jemutai J, Berkley JA, Walson JL, Hossain MA, Islam MA, Zakayo SM, Njeru RW, Ahmed T, Chisti MJ, Sarma H. Treatment-seeking and recovery among young undernourished children post-hospital discharge in Bangladesh: A qualitative study. PLoS One 2022; 17:e0274996. [PMID: 36149880 PMCID: PMC9506605 DOI: 10.1371/journal.pone.0274996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Post-hospital discharge mortality is high among undernourished children in many low and middle-income countries. Although a number of quantitative studies have highlighted a range of potential socio-cultural, economic and health system factors influencing paediatric post-discharge treatment-seeking and recovery, few studies have explored family and provider perspectives of the post-discharge period in-depth. METHODS This work was part of a large, multi-country prospective cohort study, the Childhood Acute Illness and Nutrition (CHAIN) Network. We conducted a qualitative sub-study to understand the post-discharge treatment-seeking and recovery experiences of families of undernourished children aged 2-23 months admitted in a rural and urban icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) hospital. Methods included repeat in-depth interviews (73 interviews in total) with 29 family members of 17 purposively selected children. These data were supplemented by interviews with 33 health workers, and by observations in hospitals and homes. RESULTS Important drivers of treatment-seeking perceived to support recovery included advice provided to family members while in hospital, media campaigns on hygiene practice, availability of free treatment, and social and financial support from family members, relatives and neighbours. Key perceived challenges included low household incomes, mothers having to juggle multiple responsibilities in addition to caring for the sick child, lack of support (sometimes violence) from the child's father, and family members' preference for relatively accessible drug shops, physicians or healers over hospital admission. CONCLUSION Development of interventions that address the challenges that families face is essential to support post-discharge adherence to medical advice and recovery. Potential interventions include strengthening information giving during hospitalization on what post-discharge care is needed and why, reducing direct and indirect costs associated with hospital visits, engaging fathers and other 'significant others' in post-discharge advice, and building mobile phone-based support for follow-up care.
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Affiliation(s)
- Md. Fakhar Uddin
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sassy Molyneux
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Kui Muraya
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Julie Jemutai
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Judd L. Walson
- Department of Global Health, Medicine, Pediatrics and Epidemiology, University of Washington, Seattle, WA, United States of America
| | - Md. Alamgir Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Aminul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Haribondhu Sarma
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
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12
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Inoue A, Dhoubhadel BG, Shrestha D, Raya GB, Hayashi Y, Shrestha S, Edwards T, Parry CM, Ariyoshi K, Cox SE. Risk factors for wasting among hospitalised children in Nepal. Trop Med Health 2022; 50:68. [PMID: 36114587 PMCID: PMC9479416 DOI: 10.1186/s41182-022-00461-0] [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: 05/16/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022] Open
Abstract
Background Malnutrition has various adverse effects in children. This study aimed to determine risk factors for malnutrition among hospitalised children, changes in nutritional status at admission and discharge and effects of use of systematic anthropometric measurement in identification of malnutrition. Methods We enrolled 426 children, aged between 6 months and 15 years, admitted to Siddhi Memorial Hospital, Bhaktapur, Nepal, from November 2016 to June 2017. Anthropometric measurements were performed at the time of admission and discharge. Risk factors were assessed by multivariable logistic regression models. Results Median age of children was 26 months (IQR: 13–49), and males were 58.7%. The prevalence of wasting was 9.2% (39/426) at admission and 8.5% (36/426) at discharge. Risk factors associated with wasting at admission were ethnic minority (aOR: 3.6, 95% CI 1.2–10.8), diarrhoeal diseases (aOR = 4.0; 95% CI 1.3–11.8), respiratory diseases (aOR: 3.4, 95% CI 1.4–8.1) and earthquake damage to house (aOR = 2.6; 95% CI 1.1–6.3). Clinical observation by care providers identified only 2 out of 112 malnutrition cases at admission and 4 out of 119 cases at discharge that were detected by the systematic anthropometric measurement. Conclusions Ethnic minority, diarrhoeal diseases, respiratory infections and house damage due to the earthquake were risk factors associated with wasting. Systematic anthropometric examination can identify significantly more malnourished children than simple observation of care providers.
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13
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Tsegaye AT, Pavlinac PB, Turyagyenda L, Diallo AH, Gnoumou BS, Bamouni RM, Voskuijl WP, van den Heuvel M, Mbale E, Lancioni CL, Mupere E, Mukisa J, Lwanga C, Atuhairwe M, Chisti MJ, Ahmed T, Shahid AS, Saleem AF, Kazi Z, Singa BO, Amam P, Masheti M, Berkley JA, Walson JL, Tickell KD. The Role of Food Insecurity and Dietary Diversity on Recovery from Wasting among Hospitalized Children Aged 6-23 Months in Sub-Saharan Africa and South Asia. Nutrients 2022; 14:3481. [PMID: 36079736 PMCID: PMC9460249 DOI: 10.3390/nu14173481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/08/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Current guidelines for the management of childhood wasting primarily focus on the provision of therapeutic foods and the treatment of medical complications. However, many children with wasting live in food-secure households, and multiple studies have demonstrated that the etiology of wasting is complex, including social, nutritional, and biological causes. We evaluated the contribution of household food insecurity, dietary diversity, and the consumption of specific food groups to the time to recovery from wasting after hospital discharge. Methods: We conducted a secondary analysis of the Childhood Acute Illness Network (CHAIN) cohort, a multicenter prospective study conducted in six low- or lower-middle-income countries. We included children aged 6−23 months with wasting (mid-upper arm circumference [MUAC] ≤ 12.5 cm) or kwashiorkor (bipedal edema) at the time of hospital discharge. The primary outcome was time to nutritional recovery, defined as a MUAC > 12.5 cm without edema. Using Cox proportional hazards models adjusted for age, sex, study site, HIV status, duration of hospitalization, enrollment MUAC, referral to a nutritional program, caregiver education, caregiver depression, the season of enrollment, residence, and household wealth status, we evaluated the role of reported food insecurity, dietary diversity, and specific food groups prior to hospitalization on time to recovery from wasting during the 6 months of posthospital discharge. Findings: Of 1286 included children, most participants (806, 63%) came from food-insecure households, including 170 (13%) with severe food insecurity, and 664 (52%) participants had insufficient dietary diversity. The median time to recovery was 96 days (18/100 child-months (95% CI: 17.0, 19.0)). Moderate (aHR 1.17 [0.96, 1.43]) and severe food insecurity (aHR 1.14 [0.88, 1.48]), and insufficient dietary diversity (aHR 1.07 [0.91, 1.25]) were not significantly associated with time to recovery. Children who had consumed legumes and nuts prior to diagnosis had a quicker recovery than those who did not (adjusted hazard ratio (aHR): 1.21 [1.01,1.44]). Consumption of dairy products (aHR 1.13 [0.96, 1.34], p = 0.14) and meat (aHR 1.11 [0.93, 1.33]), p = 0.23) were not statistically significantly associated with time to recovery. Consumption of fruits and vegetables (aHR 0.78 [0.65,0.94]) and breastfeeding (aHR 0.84 [0.71, 0.99]) before diagnosis were associated with longer time to recovery. Conclusion: Among wasted children discharged from hospital and managed in compliance with wasting guidelines, food insecurity and dietary diversity were not major determinants of recovery.
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Affiliation(s)
| | | | | | - Abdoulaye H. Diallo
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Blaise S. Gnoumou
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Roseline M. Bamouni
- Department of Public Health, University Joseph Ki-Zerbo, Ouagadougou 03BP7021, Burkina Faso
| | - Wieger P. Voskuijl
- Amsterdam UMC, University of Amsterdam, Amsterdam Centre for Global Child Health & Emma Children’s Hospital, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Meta van den Heuvel
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| | - Emmie Mbale
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 265, Malawi
| | - Christina L. Lancioni
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Ezekiel Mupere
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala P.O. Box 7072, Uganda
| | - John Mukisa
- Uganda-CWRU Research Collaboration, Kampala P.O. Box 663, Uganda
| | | | | | - Mohammod J. Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Abu S.M.S.B. Shahid
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka 1212, Bangladesh
| | - Ali F. Saleem
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University, Karachi 74800, Pakistan
| | | | - Pholona Amam
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - Mary Masheti
- Kenya Medical Research Institute, Nairobi 54840, Kenya
| | - James A. Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi 80108, Kenya
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7LG, UK
| | - Judd L. Walson
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi 184742, Kenya
| | - Kirkby D. Tickell
- Departments of Global Health, University of Washington, Seattle, WA 98195, USA
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14
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Njunge JM, Tickell K, Diallo AH, Sayeem Bin Shahid ASM, Gazi MA, Saleem A, Kazi Z, Ali S, Tigoi C, Mupere E, Lancioni CL, Yoshioka E, Chisti MJ, Mburu M, Ngari M, Ngao N, Gichuki B, Omer E, Gumbi W, Singa B, Bandsma R, Ahmed T, Voskuijl W, Williams TN, Macharia A, Makale J, Mitchel A, Williams J, Gogain J, Janjic N, Mandal R, Wishart DS, Wu H, Xia L, Routledge M, Gong YY, Espinosa C, Aghaeepour N, Liu J, Houpt E, Lawley TD, Browne H, Shao Y, Rwigi D, Kariuki K, Kaburu T, Uhlig HH, Gartner L, Jones K, Koulman A, Walson J, Berkley J. The Childhood Acute Illness and Nutrition (CHAIN) network nested case-cohort study protocol: a multi-omics approach to understanding mortality among children in sub-Saharan Africa and South Asia. Gates Open Res 2022; 6:77. [PMID: 36415883 PMCID: PMC9646488 DOI: 10.12688/gatesopenres.13635.1] [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: 06/01/2022] [Indexed: 02/15/2024] Open
Abstract
Introduction: Many acutely ill children in low- and middle-income settings have a high risk of mortality both during and after hospitalisation despite guideline-based care. Understanding the biological mechanisms underpinning mortality may suggest optimal pathways to target for interventions to further reduce mortality. The Childhood Acute Illness and Nutrition (CHAIN) Network ( www.chainnnetwork.org) Nested Case-Cohort Study (CNCC) aims to investigate biological mechanisms leading to inpatient and post-discharge mortality through an integrated multi-omic approach. Methods and analysis; The CNCC comprises a subset of participants from the CHAIN cohort (1278/3101 hospitalised participants, including 350 children who died and 658 survivors, and 270/1140 well community children of similar age and household location) from nine sites in six countries across sub-Saharan Africa and South Asia. Systemic proteome, metabolome, lipidome, lipopolysaccharides, haemoglobin variants, toxins, pathogens, intestinal microbiome and biomarkers of enteropathy will be determined. Computational systems biology analysis will include machine learning and multivariate predictive modelling with stacked generalization approaches accounting for the different characteristics of each biological modality. This systems approach is anticipated to yield mechanistic insights, show interactions and behaviours of the components of biological entities, and help develop interventions to reduce mortality among acutely ill children. Ethics and dissemination. The CHAIN Network cohort and CNCC was approved by institutional review boards of all partner sites. Results will be published in open access, peer reviewed scientific journals and presented to academic and policy stakeholders. Data will be made publicly available, including uploading to recognised omics databases. Trial registration NCT03208725.
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Affiliation(s)
- James M. Njunge
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Kirkby Tickell
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - Abdoulaye Hama Diallo
- Department of Public Health, Faculty of Health Sciences, University of Ouagadougou, Ouagadougou, Burkina Faso
| | | | - Md. Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ali Saleem
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Zaubina Kazi
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Syed Ali
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Karachi, Pakistan
| | - Caroline Tigoi
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Emily Yoshioka
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Moses Mburu
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Moses Ngari
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Narshion Ngao
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bonface Gichuki
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elisha Omer
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Wilson Gumbi
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Benson Singa
- Kenya Medical Research Institute, Nairobi, Kenya
| | - Robert Bandsma
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Biomedical Sciences, University of Malawi College of Medicine, Blantyre, Malawi
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Wieger Voskuijl
- Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Centre for Global Child Health & Emma Children’s Hospital, Amsterdam, The Netherlands
| | - Thomas N. Williams
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Institute of Global Health Innovation, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alex Macharia
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | | | | | | | | | - Rupasri Mandal
- Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - David S. Wishart
- Department of Biological Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Hang Wu
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Lei Xia
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Michael Routledge
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
- School of Food and Biological Engineering, Jiangsu University, Zhenjiang, China
| | - Yun Yun Gong
- School of Food Science and Nutrition, University of Leeds, Leeds, UK
| | - Camilo Espinosa
- Departments of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Nima Aghaeepour
- Departments of Anesthesiology, Pain, and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | - Eric Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Yan Shao
- Wellcome Sanger Institute, Hinxton, UK
| | - Doreen Rwigi
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kevin Kariuki
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Timothy Kaburu
- The Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Holm H. Uhlig
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
- Department of Paediatrics and Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Lisa Gartner
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Kelsey Jones
- Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
- Gastroenterology Department, Great Ormond Street Hospital for Children, London, UK
| | - Albert Koulman
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
- NIHR BRC Nutritional Biomarker Laboratory, University of Cambridge, Cambridge, UK
| | - Judd Walson
- Global Health and Epidemiology, University of Washington, Seattle, Seattle, USA
| | - James Berkley
- The Childhood Acute Illness and Nutrition Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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15
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Grimbeek A, Saloojee H. Clinical and growth outcomes of severely malnourished children following hospital discharge in a South African setting. PLoS One 2022; 17:e0262700. [PMID: 35061836 PMCID: PMC8782382 DOI: 10.1371/journal.pone.0262700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/03/2022] [Indexed: 11/25/2022] Open
Abstract
Background Data on outcomes of children with severe acute malnutrition (SAM) following treatment are scarce with none described from any upper-middle-income country. This study established mortality, clinical outcomes and anthropometric recovery of children with SAM six months following hospital discharge. Methods A prospective cohort study was conducted in children aged 3–59 months enrolled on discharge from two hospitals in the Tshwane district of South Africa between April 2019 and January 2020. The primary outcome was mortality at six months. Secondary outcomes included relapse rates, type(s) and frequency of morbidities experienced and the anthropometric changes in children with SAM following hospital discharge. Standard programmatic support included nutritional supplements. Results Forty-three children were enrolled with 86% of participants followed up to six months. Only a third of the participants had normal anthropometry at hospital discharge–a quarter still had ongoing SAM. There were no deaths, although four children (9%) were re-hospitalised including two for complicated SAM. Mean weight-for-length z-scores (WLZ) and wasting rates improved at one month but deteriorated by three months. At three months, six children (14%) either had ongoing or relapsed SAM–a SAM incidence rate of 20 per 1000 person-months despite more than half of the participants still receiving nutritional supplements at the time. Risk factors associated with persistent malnutrition at three months included a low WLZ on admission (relative risk [RR] 3.3, 95% confidence interval [95%CI] 1.2–9.2), being discharged from hospital before meeting WHO SAM treatment discharge criteria (RR 5.3, 95%CI 1.3–14.8) or having any illness by three months (RR 8.6, 95%CI 1.3–55.7). Conclusion Post-discharge mortality and morbidity was lower than in other less resourced settings. However, anthropometric recovery was poorer than expected. Modifying discharge criteria, optimising the use of available nutritional supplements and better integration with community-based health and social services may improve outcomes for children with SAM post-hospitalisation.
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Affiliation(s)
- Angelika Grimbeek
- Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Haroon Saloojee
- Division of Community Paediatrics, Department of Paediatrics and Child Health, University of the Witwatersrand, Johannesburg, South Africa
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16
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Rees CA, Kisenge R, Ideh RC, Kamara J, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook A, Niescierenko M, Manji KP, Duggan CP. A Prospective, observational cohort study to identify neonates and children at risk of postdischarge mortality in Dar es Salaam, Tanzania and Monrovia, Liberia: the PPDM study protocol. BMJ Paediatr Open 2022; 6:10.1136/bmjpo-2021-001379. [PMID: 35404835 PMCID: PMC8756287 DOI: 10.1136/bmjpo-2021-001379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Over half of the 5 million annual deaths among children aged 0-59 months occur in sub-Saharan Africa. The period immediately after hospitalisation is a vulnerable time in the life of a child in sub-Saharan Africa as postdischarge mortality rates are as high as 1%-18%. Identification of neonates and children who are at highest risk for postdischarge mortality may allow for the direction of interventions to target patients at highest risk. METHODS AND ANALYSIS The Predicting Post-Discharge Mortality study is a prospective, observational study being conducted at Muhimbili National Hospital (Dar es Salaam, Tanzania) and John F. Kennedy Medical Center (Monrovia, Liberia). The aim is to derive and validate two, age population specific, clinical prediction rules for the identification of neonates (n=2000) and children aged 1-59 months (n=2000) at risk for all-cause mortality within 60 days of discharge from the neonatal intensive care unit or paediatric ward. Caregivers of participants will receive phone calls 7, 14, 30, 45 and 60 days after discharge to assess vital status. Candidate predictor variables will include demographic, anthropometric and clinical factors. Elastic net regression will be used to derive the clinical prediction rules. Bootstrapped selection with repetitions will be used for internal validation. Planned secondary analyses include the external validation of existing clinical prediction models, determination of clinicians' ability to identify neonates and children at risk of postdischarge mortality at discharge, analysis of factors associated with hospital readmission and unplanned clinic visits and description of health-seeking behaviours in the postdischarge period. ETHICS AND DISSEMINATION This study received ethical clearance from the Tanzania National Institute of Medical Research, Muhimbili University of Health and Allied Sciences, the John F. Kennedy Medical Center Institutional Review Board, and the Boston Children's Hospital Institutional Review Board. Findings will be disseminated at scientific conferences and as peer-reviewed publications.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA .,Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adrianna Westbrook
- Pediatric Biostatistics Core, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher P Duggan
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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17
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Kirolos A, Blacow RM, Parajuli A, Welton NJ, Khanna A, Allen SJ, McAllister DA, Campbell H, Nair H. The impact of childhood malnutrition on mortality from pneumonia: a systematic review and network meta-analysis. BMJ Glob Health 2021; 6:bmjgh-2021-007411. [PMID: 34848440 PMCID: PMC8634228 DOI: 10.1136/bmjgh-2021-007411] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/09/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Childhood malnutrition is widespread in low-income and middle-income countries (LMICs) and increases the frequency and severity of infections such as pneumonia. We aimed to identify studies investigating pneumonia deaths in malnourished children and estimate mortality risk by malnutrition severity. METHODS We conducted a systematic review of MEDLINE, EMBASE and Global Health databases to identify relevant studies. We used a network meta-analysis to derive ORs of death from pneumonia for moderately and severely underweight children using low weight-for-age, the most reported measure of malnutrition. We compared meta-estimates of studies conducted before and after 2000 to assess changes in mortality risk over time. We estimated the prevalence of underweight hospitalised children from hospital-based cohort studies and calculated the population attributable fraction of in-hospital pneumonia deaths from being underweight using our results. RESULTS Our network meta-analysis included 33 544 underweight children from 23 studies. The estimated OR of death from pneumonia was 2.0 (95% CI 1.6 to 2.6) and 4.6 (95% CI 3.7 to 5.9) for children moderately and severely underweight, respectively. The OR of death from pneumonia for those severely underweight was 5.3 (95% CI 3.9 to 7.4) pre-2000 and remained high post-2000 at 4.1 (95% CI 3.0 to 6.0). Prevalence of underweight children hospitalised with pneumonia varied (median 40.2%, range 19.6-66.3) but was high across many LMIC settings. We estimated a median 18.3% (range 10.8-34.6) and 40.9% (range 14.7-69.9) of in-hospital pneumonia deaths were attributable to being moderately and severely underweight, respectively. CONCLUSIONS The risk of death from childhood pneumonia dramatically increases with malnutrition severity. This risk has remained high in recent years with an estimated over half of in-hospital pneumonia deaths attributable to child malnutrition. Prevention and treatment of all child malnutrition must be prioritised to maintain progress on reducing pneumonia deaths.
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Affiliation(s)
- Amir Kirolos
- University of Liverpool Department of Women's and Children's Health, Liverpool, UK .,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi.,The University of Edinburgh Usher Institute, Edinburgh, UK
| | | | - Arun Parajuli
- The University of Edinburgh Usher Institute, Edinburgh, UK
| | - Nicky J Welton
- University of Bristol Bristol Population Health Science Institute, Bristol, UK
| | - Alisha Khanna
- The University of Edinburgh Usher Institute, Edinburgh, UK
| | - Stephen J Allen
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.,Alder Hey Children's Hospital, Liverpool, Merseyside, UK
| | | | - Harry Campbell
- The University of Edinburgh Usher Institute, Edinburgh, UK
| | - Harish Nair
- The University of Edinburgh Usher Institute, Edinburgh, UK
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18
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Managing the Critically Ill Child-What Resources Do You Really Need (and What Do You Have)? Crit Care Med 2021; 49:712-714. [PMID: 33731612 DOI: 10.1097/ccm.0000000000004841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Vonasek BJ, Mhango S, Crouse HL, Nyangulu T, Gaven W, Ciccone E, Kondwani A, Patel B, Fitzgerald E. Improving recognition and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi: a quality improvement initiative. Paediatr Int Child Health 2021; 41:177-187. [PMID: 34494509 PMCID: PMC8671256 DOI: 10.1080/20469047.2021.1967627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Severe acute malnutrition (SAM) is common in low-income countries and is associated with high mortality in young children. OBJECTIVE To improve recognition and management of SAM in a tertiary hospital in Malawi. METHODS The impact of multifaceted quality improvement interventions in process measures pertaining to the identification and management of SAM was assessed. Interventions included focused training for clinical staff, reporting process measures to staff, and mobile phone-based group messaging for enhanced communication. This initiative focused on children aged 6-36 months admitted to Kamuzu Central Hospital in Malawi from September 2019 to March 2020. Before-after comparisons were made with baseline data from the year before, and process measures within this intervention period which included three plan-do-study-act (PDSA) cycles were compared. RESULTS During the intervention period, 418 children had SAM and in-hospital mortality was 10.8%, which was not significantly different from the baseline period. Compared with the baseline period, there was significant improvement in the documentation of full anthropometrics on admission, blood glucose test within 24 hours of admission and HIV testing results by discharge. During the intervention period, amidst increasing patient census with each PDSA cycle, three process measures were maintained (documentation of full anthropometrics, determination of nutritional status and HIV testing results), and there was significant improvement in blood glucose documentation. CONCLUSION Significant improvement in key quality measures represents early progress towards the larger goal of improving patient outcomes, most notably mortality, in children admitted with SAM.
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Affiliation(s)
- Bryan J. Vonasek
- Department of Pediatrics, Baylor College of Medicine, Houston, USA
| | - Susan Mhango
- Baylor College of Medicine Children’s Foundation Malawi, Lilongwe, Malawi
| | | | - Temwachi Nyangulu
- Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi
| | | | - Emily Ciccone
- Department of Medicine, University of North Carolina at Chapel Hill, USA
| | - Alexander Kondwani
- Centre of Excellence for Nutrition, North West University, Potchefstroom, South Africa
| | - Binita Patel
- Department of Pediatrics, Baylor College of Medicine, Houston, USA
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20
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Hossain MI, Huq S, Ahmed T. Changes in Nutritional Status and Morbidities Among Children Having Severe Acute Malnutrition Attending a Nutrition Follow-Up Unit in Bangladesh Who Did Not Receive Any Food Supplementation. Food Nutr Bull 2021; 42:399-405. [PMID: 34212780 DOI: 10.1177/03795721211028545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The problem of severe acute malnutrition (SAM) among <5 years old (U-5) children in Bangladesh is awful with higher risk of death or morbidities. However, there is no nationwide program where these children are managed with take-home therapeutic/supplementary food as recommended by World Health Organization. OBJECTIVE This study aimed to identify the changes in nutritional status and morbidities over 3 months of U-5 children having severe wasting (ie, SAM) whose parents refused to admit their children in the residential nutrition rehabilitation unit of the Dhaka Hospital of icddr, b, instead attended the nutrition follow-up unit (NFU), and thus did not receive any food supplementation during nutritional rehabilitation. METHODS At the NFU, these SAM children on every visit (fortnightly to monthly) received health and nutrition education, multivitamins, zinc and iron supplements, and treatment of illnesses if any. RESULTS During the study period, a total 180 U-5 SAM children came regularly for NFU visit for at least 3 months, and they comprised our study sample. Their age at first NFU visit (baseline) was 13.4 ± 7.8 months and 46% were female. Over these 3 month follow-up period, the rate of weight gain was 2.2 ± 1.9 g/kg/d, change in mid upper arm circumference was from 105 to 115 mm, and change in weight-for-length or weight-for-height z-score was from -2.70 ± 0.94 to -1.95 ± 1.00. During the prior 14 days to the 4 NFU follow-up visit, 13.6% to 22.8% had common cold and/or cough, and 12.2% to 15.1% had pneumonia. CONCLUSION Because the rate of weight gain was far below the expected ∼5 g/kg/d, the NFU visits without food supplementation are insufficient in terms of catchup growth. Thus, additional efforts are required to improve the management of these SAM children for their catchup growth.
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Affiliation(s)
- Md Iqbal Hossain
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh.,Faculty, James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
| | - Sayeeda Huq
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Mohakhali, Dhaka, Bangladesh.,Faculty, James P. Grant School of Public Health, BRAC University, Mohakhali, Dhaka, Bangladesh
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21
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Vessière A, Font H, Gabillard D, Adonis-Koffi L, Borand L, Chabala C, Khosa C, Mavale S, Moh R, Mulenga V, Mwanga-Amumpere J, Taguebue JV, Eang MT, Delacourt C, Seddon JA, Lounnas M, Godreuil S, Wobudeya E, Bonnet M, Marcy O. Impact of systematic early tuberculosis detection using Xpert MTB/RIF Ultra in children with severe pneumonia in high tuberculosis burden countries (TB-Speed pneumonia): a stepped wedge cluster randomized trial. BMC Pediatr 2021; 21:136. [PMID: 33743621 PMCID: PMC7980598 DOI: 10.1186/s12887-021-02576-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Background In high tuberculosis (TB) burden settings, there is growing evidence that TB is common in children with pneumonia, the leading cause of death in children under 5 years worldwide. The current WHO standard of care (SOC) for young children with pneumonia considers a diagnosis of TB only if the child has a history of prolonged symptoms or fails to respond to antibiotic treatments. As a result, many children with TB-associated severe pneumonia are currently missed or diagnosed too late. We therefore propose a diagnostic trial to assess the impact on mortality of adding the systematic early detection of TB using Xpert MTB/RIF Ultra (Ultra) performed on nasopharyngeal aspirates (NPA) and stool samples to the WHO SOC for children with severe pneumonia, followed by immediate initiation of anti-TB treatment in children testing positive on any of the samples. Methods TB-Speed Pneumonia is a pragmatic stepped-wedge cluster randomized controlled trial conducted in six countries with high TB incidence rate (Côte d’Ivoire, Cameroon, Uganda, Mozambique, Zambia and Cambodia). We will enrol 3780 children under 5 years presenting with WHO-defined severe pneumonia across 15 hospitals over 18 months. All hospitals will start managing children using the WHO SOC for severe pneumonia; one hospital will be randomly selected to switch to the intervention every 5 weeks. The intervention consists of the WHO SOC plus rapid TB detection on the day of admission using Ultra performed on 1 nasopharyngeal aspirate and 1 stool sample. All children will be followed for 3 months, with systematic trial visits at day 3, discharge, 2 weeks post-discharge, and week 12. The primary endpoint is all-cause mortality 12 weeks after inclusion. Qualitative and health economic evaluations are embedded in the trial. Discussion In addition to testing the main hypothesis that molecular detection and early treatment will reduce TB mortality in children, the strength of such pragmatic research is that it provides some evidence regarding the feasibility of the intervention as part of routine care. Should this intervention be successful, safe and well tolerated, it could be systematically implemented at district hospital level where children with severe pneumonia are referred. Trial registration ClinicalTrials.gov, NCT03831906. Registered 6 February 2019.
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Affiliation(s)
- Aurélia Vessière
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France.
| | - Hélène Font
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | - Delphine Gabillard
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
| | | | - Laurence Borand
- Epidemiology and Public Health Unit, Pasteur Institute in Cambodia, Phnom Penh, Cambodia
| | - Chishala Chabala
- University of Zambia School of Medicine, University Teaching Hospital, Lusaka, Zambia
| | - Celso Khosa
- Instituto Nacional de Saúde, Maputo, Mozambique
| | - Sandra Mavale
- Paediatrics Department, Maputo Central Hospital, Maputo, Mozambique
| | - Raoul Moh
- Programme PAC-CI, CHU de Treichville, Abidjan, Ivory Coast
| | - Veronica Mulenga
- Children's Hospital, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Mao Tan Eang
- National Center for Tuberculosis and Leprosy (CENAT/NTP), Ministry of Health, Phnom Penh, Cambodia
| | - Christophe Delacourt
- Department of Paediatric Pulmonology, Necker University Teaching Hospital, Paris, France
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa.,Department of Infectious Diseases, Imperial College London, London, UK
| | | | | | - Eric Wobudeya
- Makerere University-Johns Hopkins University Research Collaboration (MU-JHU) Care Ltd, Kampala, Uganda
| | - Maryline Bonnet
- IRD UMI233/Inserm U1175, University of Montpellier, Montpellier, France
| | - Olivier Marcy
- University of Bordeaux, Inserm, Institut de Recherche pour le Développement (IRD), UMR 1219, Bordeaux, France
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22
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Simen-Kapeu A, Reserva ME, Ekpini RE. Galvanizing Action on Primary Health Care: Analyzing Bottlenecks and Strategies to Strengthen Community Health Systems in West and Central Africa. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:S47-S64. [PMID: 33727320 PMCID: PMC7971379 DOI: 10.9745/ghsp-d-20-00377] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/01/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The renewed commitment to primary health care (PHC) presents an opportunity to strengthen health systems in West and Central Africa (WCA). Though evidence-based cost-effective interventions that are predicted to prevent up to one-third of maternal, newborn, and child health complications and deaths with universal coverage have been identified, more than 50% of people living in rural areas or from poor families still do not have access to these interventions in resource-constrained settings. METHODS We conducted a multicountry systematic analysis of bottlenecks and proposed solutions to strengthen community health systems through a series of collaborative workshops in 22 countries in WCA. Countries were categorized by their under-5 mortality rate (U5MR) to assess specificities related to reported challenges. We also reviewed existing data on selected health system tracer interventions to analyze country profiles. RESULTS The bottlenecks identified as severe or very severe were related to health financing (19 countries, 86%), essential medical technology and products (16 countries, 73%), integrated health service delivery (14 countries, 64%), and community ownership and partnerships (self-reported by 14 countries, 64%). Only the integrated service delivery was self-reported as a severe challenge by countries with high U5MR. The issue of human resources for community health was one of the least reported challenges. CONCLUSION In WCA, strengthening community health systems as part of PHC revitalization efforts should focus on increasing health financing and innovative investments, strengthening the logistics management system, and fostering community ownership and partnerships. Countries with high U5MR should also reinforce integrated service delivery approaches through innovation. Government actions galvanized by global and regional ongoing initiatives should be sustained to ensure that no one is left behind.
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Affiliation(s)
- Aline Simen-Kapeu
- United Nations Children's Fund, West and Central Regional Office, Dakar, Senegal.
| | | | - Rene Ehounou Ekpini
- United Nations Children's Fund, West and Central Regional Office, Dakar, Senegal
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23
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Bwakura-Dangarembizi M, Dumbura C, Amadi B, Ngosa D, Majo FD, Nathoo KJ, Mwakamui S, Mutasa K, Chasekwa B, Ntozini R, Kelly P, Prendergast AJ. Risk factors for postdischarge mortality following hospitalization for severe acute malnutrition in Zimbabwe and Zambia. Am J Clin Nutr 2021; 113:665-674. [PMID: 33471057 PMCID: PMC7948837 DOI: 10.1093/ajcn/nqaa346] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Children discharged from hospital following management of complicated severe acute malnutrition (SAM) have a high risk of mortality, especially HIV-positive children. Few studies have examined mortality in the antiretroviral therapy (ART) era. OBJECTIVES Our objectives were to ascertain 52-wk mortality in children discharged from hospital for management of complicated SAM, and to identify independent predictors of mortality. METHODS A prospective cohort study was conducted in children enrolled from 3 hospitals in Zambia and Zimbabwe between July 2016 and March 2018. The primary outcome was mortality at 52 wk. Univariable and multivariable Cox regression models were used to identify independent risk factors for death, and to investigate whether HIV modifies these associations. RESULTS Of 745 children, median age at enrolment was 17.4 mo (IQR: 12.8, 22.1 mo), 21.7% were HIV-positive, and 64.4% had edema. Seventy children (9.4%; 95% CI: 7.4, 11.7%) died and 26 exited during hospitalization; 649 were followed postdischarge. At discharge, 43.9% had ongoing SAM and only 50.8% of HIV-positive children were receiving ART. Vital status was ascertained for 604 (93.1%), of whom 55 (9.1%; 95% CI: 6.9, 11.7%) died at median 16.6 wk (IQR: 9.4, 21.9 wk). Overall, 20.0% (95% CI: 13.5, 27.9%) and 5.6% (95% CI: 3.8, 7.9%) of HIV-positive and HIV-negative children, respectively, died [adjusted hazard ratio (aHR): 3.83; 95% CI: 2.15, 6.82]. Additional independent risk factors for mortality were ongoing SAM (aHR: 2.28; 95% CI: 1.22, 4.25), cerebral palsy (aHR: 5.60; 95% CI: 2.72, 11.50) and nonedematous SAM (aHR: 2.23; 95% CI: 1.24, 4.01), with no evidence of interaction with HIV status. CONCLUSIONS HIV-positive children have an almost 4-fold higher mortality than HIV-negative children in the year following hospitalization for complicated SAM. A better understanding of causes of death, an improved continuum of care for HIV and SAM, and targeted interventions to improve convalescence are needed.
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Affiliation(s)
- Mutsa Bwakura-Dangarembizi
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kusum J Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Simutanyi Mwakamui
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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24
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Uddin MF, Molyneux S, Muraya K, Hossain MA, Islam MA, Shahid ASMSB, Zakayo SM, Njeru RW, Jemutai J, Berkley JA, Walson JL, Ahmed T, Sarma H, Chisti MJ. Gender-related influences on adherence to advice and treatment-seeking guidance for infants and young children post-hospital discharge in Bangladesh. Int J Equity Health 2021; 20:64. [PMID: 33627119 PMCID: PMC7903601 DOI: 10.1186/s12939-021-01404-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 02/09/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Post-hospital discharge mortality risk is high among young children in many low and middle-income countries (LMICs). The available literature suggests that child, caregiver and health care provider gender all play important roles in post-discharge adherence to medical advice, treatment-seeking and recovery for ill children in LMICs, including those with undernutrition. METHODS A qualitative study was embedded within a larger multi-country multi-disciplinary observational cohort study involving children aged less than 2 years conducted by the Childhood Acute Illness and Nutrition (CHAIN) Network. Primary data were collected from family members of 22 purposively selected cohort children. Family members were interviewed several times in their homes over the 6 months following hospital discharge (total n = 78 visits to homes). These in-depth interviews were complemented by semi-structured individual interviews with 6 community representatives, 11 community health workers and 12 facility-based health workers, and three group discussions with a total of 24 community representatives. Data were analysed using NVivo11 software, using both narrative and thematic approaches. RESULTS We identified gender-related influences at health service/system and household/community levels. These influences interplayed to family members' adherence to medical advice and treatment-seeking after hospital discharge, with potentially important implications for children's recovery. Health service/system level influences included: fewer female medical practitioners in healthcare facilities, which influenced mothers' interest and ability to consult them promptly for their child's illnesses; gender-related challenges for community health workers in supporting mothers with counselling and advice; and male caregivers' being largely absent from the paediatric wards where information sessions to support post-discharge care are offered. Gendered household/community level influences included: women's role as primary caretakers for children and available levels of support; male family members having a dominant role in decision-making related to food and treatment-seeking behaviour; and greater reluctance among parents to invest money and time in the treatment of female children, as compared to male children. CONCLUSIONS A complex web of gender related influences at health systems/services and household/community levels have important implications for young children's recovery post-discharge. Immediate interventions with potential for positive impact include awareness-raising among all stakeholders - including male family members - on how gender influences child health and recovery, and how to reduce adverse consequences of gender-based discrimination. Specific interventions could include communication interventions in facilities and homes, and changes in routine practices such as who is present in facility interactions. To maximise and sustain the impact of immediate actions and interventions, the structural drivers of women's position in society and gender inequity must also be tackled. This requires interventions to ensure equal equitable opportunities for men and women in all aspects of life, including access to education and income generation activities. Given patriarchal norms locally and globally, men will likely need special targeting and support in achieving these objectives.
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Affiliation(s)
- Md Fakhar Uddin
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh.
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya.
| | - Sassy Molyneux
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Kui Muraya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
| | - Md Alamgir Hossain
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | - Md Aminul Islam
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
| | - Abu Sadat Mohammad Sayeem Bin Shahid
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | | | - Rita Wanjuki Njeru
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - Julie Jemutai
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
| | - James A Berkley
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- KEMRI-Wellcome Trust Research Programme, P.O. Box 230-80108, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Old Road Campus, Headington, Oxford, OX3 7BN, UK
| | - Judd L Walson
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Global Health, Medicine, Paediatrics and Epidemiology, University of Washington, Seattle, USA
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Haribondhu Sarma
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Research School of Population Health, Australian National University, Acton, ACT, Canberra, 2601, Australia
| | - Mohammod Jobayer Chisti
- Nutrition and Clinical Services Division, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
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25
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Giri S, Halvas-Svendsen T, Rogne T, Shrestha SK, Døllner H, Solligård E, Risnes K. Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality. Glob Pediatr Health 2020; 7:2333794X20947926. [PMID: 32995370 PMCID: PMC7502999 DOI: 10.1177/2333794x20947926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 12/29/2022] Open
Abstract
Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.
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Affiliation(s)
- Samita Giri
- Norwegian University of Science and Technology, Trondheim, Norway.,Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Tormod Rogne
- Norwegian University of Science and Technology, Trondheim, Norway
| | | | - Henrik Døllner
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Solligård
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kari Risnes
- Norwegian University of Science and Technology, Trondheim, Norway.,St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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26
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Shahrin L, Chisti MJ, Brintz B, Islam Z, Shahid ASMSB, Hassan MZ, Leung DT, Chowdhury F. Clinical and laboratory predictors of 30-day mortality in severe acute malnourished children with severe pneumonia. Trop Med Int Health 2020; 25:1422-1430. [PMID: 32985047 DOI: 10.1111/tmi.13484] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the predictors of mortality within 30 days of hospital admission in a diarrhoeal disease hospital in Bangladesh. METHODS Cohort study of hospitalised children aged 0-59 months with severe acute malnutrition (SAM) and severe pneumonia in Dhaka Hospital, icddr,b, Bangladesh from April 2015 to March 2017. Those discharged were followed up, and survival status at 30 days from admission was determined. Children who died were compared with the survivors in terms of clinical and laboratory biomarkers. Multivariable logistic regression analysis was used for calculating adjusted odds ratio for death within 30 days of hospital admission. RESULTS We enrolled 191 children. Mortality within 30 days of admission was 6% (14/191). After adjusting for potential confounders (hypoxia, CRP and haematocrit) in logistic regression analysis, independent factors associated with death were female sex (aOR = 5.80, 95% CI: 1.34-25.19), LAZ <-4 (aOR = 6.51, 95% CI: 1.49-28.44) and Polymorphonuclear Leucocytes (PMNL) (>6.0 × 109 /L) (aOR = 1.06, 95% CI: 1.01-1.11). Using sex, Z-score for length for age (LAZ), and PMNL percentage, we used random forest and linear regression models to achieve a cross-validated AUC of 0.83 (95% CI: 0.82, 0.84) for prediction of 30-day mortality. CONCLUSIONS The results of our data suggest that female sex, severe malnutrition (<-4 LAZ) and higher PMNL percentage were prone to be associated with 30-day mortality in children with severe pneumonia. Association of these factors may be used in clinical decision support for prompt identification and appropriate management for prevention of mortality in this population.
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Affiliation(s)
- Lubaba Shahrin
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mohammod J Chisti
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Benjamin Brintz
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Zahidul Islam
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Abu S M S B Shahid
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Md Zakiul Hassan
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Daniel T Leung
- Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Fahmida Chowdhury
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
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27
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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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28
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Ghazawy ER, Bebars GM, Eshak ES. Survival status and mortality predictors among severely malnourished under 5 years of age children admitted to Minia University maternity and children hospital. BMC Pediatr 2020; 20:233. [PMID: 32429871 PMCID: PMC7236451 DOI: 10.1186/s12887-020-02146-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 05/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Though effective treatment programs for severely malnourished children are available, mortality rate among children with acute malnutrition continue to rise and little is known about its long-term outcomes and potential predictors of its in-hospital and post-discharge mortality. The aim of this study was to assess the survival status and predictors for mortality in severely malnourished children admitted to Minia University Maternity and Children Hospital. METHODS A retrospective cohort study which included 135 children under 5 years of age who were admitted to the nutrition rehabilitation ward with severe acute malnutrition (SAM) during the period from January to December 2018. Data were collected from the inpatient's hospital records and the children's parents/guardians were interviewed using a detailed structured questionnaire that inquired about demographic and socioeconomic variables. The logistic and Cox regressions were used to assess the factors associated with the SAM's mortality. RESULTS A total of 135 children were enrolled into the study. Death rate during hospitalization was 9.6%. The survival rate at the end of the fourth week of admission was 82.4%. There were 6.7% post-discharge deaths among 104 alive discharged children which occurred within 8 weeks after discharge. The adjusted HRs (95% CIs) for total SAM deaths were 1.57 (1.10-2.99) in children < 12 vs ≥ 12 months old; 4.79 (2.23-6.10) in those with WAZ < -3SD, 2.99 (1.16-4.66) in those with edema at admission and 3.44 (1.07-9.86) in children with complications. The respective ORs (95%CIs) for in-hospital SAM deaths in the same groups of children were 2.64 (1.22-6.43), 8.10 (2.16-11.67), 3.04 (1.70-6.06) and 3.71 (1.59-6.78). The main predictor for the SAM's post-discharge mortality was illiteracy of mothers; the adjusted HR (95%CI) was 7.10 (1.58-31.93; p = 0.01). CONCLUSIONS Age, WAZ, edema and complications at admission were predictors for both in-hospital and total SAM mortality, while mother's education contributed to the early post-discharge mortality. The identification of predictors for mortality is an important preliminary step for interventions aiming to reduce morbidity and mortality.
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Affiliation(s)
- Eman Ramadan Ghazawy
- Public Health and Preventive Medicine department, Faculty of medicine, El-Minia University. University St, El-Minia, 1666 Egypt
| | | | - Ehab Salah Eshak
- Public Health and Preventive Medicine department, Faculty of medicine, El-Minia University. University St, El-Minia, 1666 Egypt
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29
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López-Ejeda N, Charle-Cuellar P, G. B. Alé F, Álvarez JL, Vargas A, Guerrero S. Bringing severe acute malnutrition treatment close to households through community health workers can lead to early admissions and improved discharge outcomes. PLoS One 2020; 15:e0227939. [PMID: 32023265 PMCID: PMC7001926 DOI: 10.1371/journal.pone.0227939] [Citation(s) in RCA: 8] [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: 07/09/2019] [Accepted: 01/01/2020] [Indexed: 11/18/2022] Open
Abstract
Severe acute malnutrition (SAM) affects over 16.6 million children worldwide. The integrated Community Case Management (iCCM) strategy seeks to improve essential health by means of nonmedical community health workers (CHWs) who treat the deadliest infectious diseases in remote rural areas where there is no nearby health center. The objective of this study was to assess whether SAM treatment delivered by CHWs close to families' locations may improve the early identification of cases compared to outpatient treatment at health facilities (HFs), with a decreased number complicated cases referred to stabilization centers, increased anthropometric measurements at admission (closer to the admission threshold) and similarity in clinical outcomes (cure, death, and default). The study included 930 children aged 6 to 59 months suffering from SAM in the Kita district of the Kayes Region in Mali; 552 children were treated by trained CHWs. Anthropometric measurements, the presence of edema, and other medical signs were recorded at admission, and the length of stay and clinical outcomes were recorded at discharge. The results showed fewer children with edema at admission in the CHW group than in the HF group (0.4% vs. 3.7%; OR = 10.585 [2.222-50.416], p = 0.003). Anthropometric measurements at admission were higher in the CHW group, with fewer children falling into the lowest quartiles of both weight-for-height z-scores (20.2% vs. 31.5%; p = 0.002) and mid-upper arm circumference (18.0% vs. 32.4%; p<0.001), than in the HF group. There was no difference in the length of stay. More children in the CHW group were cured (95.9% vs. 88.7%; RR = 3.311 [1.772-6.185]; p<0.001), and there were fewer defaulters (3.7% vs. 9.8%; RR = 3.345 [1.702-6.577]; p<0.001) than in the HF group. Regression analyses demonstrated that less severe anthropometric measurements at admission resulted in an increased probability of cure at discharge. The study results also showed that CHWs provided more integrated care, as they diagnosed and treated significantly more cases of infectious diseases than HFs (diarrhea: 36.0% vs. 18.3%, p<0.001; malaria: 41.7% vs. 19.8%, p<0.001; acute respiratory infection: 34.8% vs. 25.2%, p = 0.007). The addition of SAM treatment in the curative tasks that the CHWs provided to the families resulted in earlier admission and more integrated care for children than those associated with HFs. CHW treatment also achieved better discharge outcomes than standard community treatment.
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Affiliation(s)
- Noemí López-Ejeda
- Action Against Hunger, Madrid, Spain
- EPINUT Research Group (ref. 920325), Complutense University of Madrid, Madrid, Spain
- * E-mail: ,
| | | | | | | | | | - Saul Guerrero
- Action Against Hunger, New York, New York, United States of America
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30
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Gonzales GB, Ngari MM, Njunge JM, Thitiri J, Mwalekwa L, Mturi N, Mwangome MK, Ogwang C, Nyaguara A, Berkley JA. Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study. MATERNAL AND CHILD NUTRITION 2019; 16:e12913. [PMID: 31756291 PMCID: PMC7083470 DOI: 10.1111/mcn.12913] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/19/2019] [Accepted: 10/23/2019] [Indexed: 11/11/2022]
Abstract
Hospital readmission is common among children with complicated severe acute malnutrition (cSAM) but not well‐characterised. Two distinct cSAM phenotypes, marasmus and kwashiorkor, exist, but their pathophysiology and whether the same phenotype persists at relapse are unclear. We aimed to test the association between cSAM phenotype at index admission and readmission following recovery. We performed secondary data analysis from a multicentre randomised trial in Kenya with 1‐year active follow‐up. The main outcome was cSAM phenotype upon hospital readmission. Among 1,704 HIV‐negative children with cSAM discharged in the trial, 177 children contributed a total of 246 readmissions with cSAM. cSAM readmission was associated with age<12 months (p = .005), but not site, sex, season, nor cSAM phenotype. Of these, 42 children contributed 44 readmissions with cSAM that occurred after a monthly visit when SAM was confirmed absent (cSAM relapse). cSAM phenotype was sustained during cSAM relapse. The adjusted odds ratio for presenting with kwashiorkor during readmission after kwashiorkor at index admission was 39.3 [95% confidence interval (95% CI) [2.69, 1,326]; p = .01); and for presenting with marasmus during readmission after kwashiorkor at index admission was 0.02 (95% CI [0.001, 0.037]; p = .01). To validate this finding, we examined readmissions to Kilifi County Hospital, Kenya occurring at least 2 months after an admission with cSAM. Among 2,412 children with cSAM discharged alive, there were 206 readmissions with cSAM. Their phenotype at readmission was significantly influenced by their phenotype at index admission (p < .001). This is the first report describing the phenotype and rate of cSAM recurrence.
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Affiliation(s)
- Gerard Bryan Gonzales
- Laboratory of Gastroenterology, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,VIB Inflammation Research Centre, Ghent, Belgium.,Department of Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Moses M Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James M Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Neema Mturi
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Martha K Mwangome
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Caroline Ogwang
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Amek Nyaguara
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - James A Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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31
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Bebars GM, Askalany HT. Assessment of left ventricular systolic and diastolic functions in severely malnourished children. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2019. [DOI: 10.1186/s43054-019-0004-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Malnourished children endure many changes in body composition and lose heart and skeletal muscle mass. Diastolic dysfunction is one of the major causes of heart failure with preserved ejection fraction.
Aim
To assess left ventricular systolic and diastolic functions in children with severe acute malnutrition using tissue Doppler imaging technique and to evaluate the effect of nutritional rehabilitation.
Patients and Methods
A follow-up case-control study conducted on 60 severely malnourished children (WHZ < -3SD) and 120 age and sex-matched healthy children as a control group. Tissue Doppler imaging (TDI) was done for all included malnourished children at admission and for control to measure left ventricular systolic and diastolic functions. Nutritional rehabilitation was done according to WHO protocol and tissue doppler was repeated after rehabilitation when (WHZ > -2SD) to detect any changes in systolic or diastolic functions.
Results
Systolic function was normal in malnourished children and control. Grade I diastolic dysfunction was detected in 40% and grade II in 30% of severely malnourished children in comparison to 100% normal diastolic function in control group. No correlations between diastolic dysfunction and either anthropometric measurements, electrolyte disturbances or Hb% in malnourished children before nutritional rehabilitation. Mortality from sepsis with associated ventricular dysfunction grade II documented in 3.3% of malnourished children. After nutritional rehabilitation diastolic function improved significantly as 65.6% of children attained normal diastolic function, 31% grade1 and 3.4% grade II. Positive correlations between diastolic function and WAZ, HAZ, WHZ and MUAC after rehabilitation.
Conclusion
Severe acute malnutrition affects diastolic function in children which is reversible in most of these cases with rehabilitation. TDI is an easy and practical method for detection and follow-up of ventricular function in malnourished children.
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32
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Tüshaus L, Moreo M, Zhang J, Hartinger SM, Mäusezahl D, Karlen W. Physiologically driven, altitude-adaptive model for the interpretation of pediatric oxygen saturation at altitudes above 2,000 m a.s.l. J Appl Physiol (1985) 2019; 127:847-857. [PMID: 31525318 DOI: 10.1152/japplphysiol.00478.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Measuring peripheral oxygen saturation (SpO2) with pulse oximeters at the point of care is widely established. However, since SpO2 is dependent on ambient atmospheric pressure, the distribution of SpO2 values in populations living above 2000 m a.s.l. is largely unknown. Here, we propose and evaluate a computer model to predict SpO2 values for pediatric permanent residents living between 0 and 4,000 m a.s.l. Based on a sensitivity analysis of oxygen transport parameters, we created an altitude-adaptive SpO2 model that takes physiological adaptation of permanent residents into account. From this model, we derived an altitude-adaptive abnormal SpO2 threshold using patient parameters from literature. We compared the obtained model and threshold against a previously proposed threshold derived statistically from data and two empirical data sets independently recorded from Peruvian children living at altitudes up to 4,100 m a.s.l. Our model followed the trends of empirical data, with the empirical data having a narrower healthy SpO2 range below 2,000 m a.s.l. but the medians never differed more than 2.3% across all altitudes. Our threshold estimated abnormal SpO2 in only 17 out of 5,981 (0.3%) healthy recordings, whereas the statistical threshold returned 95 (1.6%) recordings outside the healthy range. The strength of our parametrized model is that it is rooted in physiology-derived equations and enables customization. Furthermore, as it provides a reference SpO2, it could assist practitioners in interpreting SpO2 values for diagnosis, prognosis, and oxygen administration at higher altitudes.NEW & NOTEWORTHY Our model describes the altitude-dependent decrease of SpO2 in healthy pediatric residents based on physiological equations and can be adapted based on measureable clinical parameters. The proposed altitude-specific abnormal SpO2 threshold might be more appropriate than rigid guidelines for administering oxygen that currently are only available for patients at sea level. We see this as a starting point to discuss and adapt oxygen administration guidelines.
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Affiliation(s)
- Laura Tüshaus
- Mobile Health Systems Lab, Institute for Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Monica Moreo
- Mobile Health Systems Lab, Institute for Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Jia Zhang
- Mobile Health Systems Lab, Institute for Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Switzerland
| | - Stella Maria Hartinger
- Universidad Peruana Cayetano Heredia, Lima, Peru.,Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Daniel Mäusezahl
- Department of Epidemiology & Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Walter Karlen
- Mobile Health Systems Lab, Institute for Robotics and Intelligent Systems, Department of Health Sciences and Technology, ETH Zurich, Switzerland
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Childhood Acute Illness and Nutrition (CHAIN) Network: a protocol for a multi-site prospective cohort study to identify modifiable risk factors for mortality among acutely ill children in Africa and Asia. BMJ Open 2019; 9:e028454. [PMID: 31061058 PMCID: PMC6502050 DOI: 10.1136/bmjopen-2018-028454] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Children admitted to hospitals in resource-poor settings remain at risk of both inpatient and post-discharge mortality. While known risk factors such as young age and nutritional status can identify children at risk, they do not provide clear mechanistic targets for intervention. The Childhood Acute Illness and Nutrition (CHAIN) cohort study aims to characterise the biomedical and social risk factors for mortality in acutely ill children in hospitals and after discharge to identify targeted interventions to reduce mortality. METHODS AND ANALYSIS The CHAIN network is currently undertaking a multi-site, prospective, observational cohort study, enrolling children aged 1 week to 2 years at admission to hospitals at nine sites located in four African and two South Asian countries. The CHAIN Network supports the sites to provide care according to national and international guidelines. Enrolment is stratified by anthropometric status and children are followed throughout hospitalisation and for 6 months after discharge. Detailed clinical, demographic, anthropometric, laboratory and social exposures are assessed. Scheduled visits are conducted at 45, 90 and 180 days after discharge. Blood, stool and rectal swabs are collected at enrolment, hospital discharge and follow-up. The primary outcome is inpatient or post-discharge death. Secondary outcomes include readmission to hospital and nutritional status after discharge. Cohort analysis will identify modifiable risks, children with distinct phenotypes, relationships between factors and mechanisms underlying poor outcomes that may be targets for intervention. A nested case-control study examining infectious, immunological, metabolic, nutritional and other biological factors will be undertaken. ETHICS AND DISSEMINATION This study protocol was reviewed and approved primarily by the Oxford Tropical Research Ethics Committee, and the institutional review boards of all partner sites. The study is being externally monitored. Results will be published in open access peer-reviewed scientific journals and presented to academic and policy stakeholders. TRIAL REGISTRATION NUMBER NCT03208725.
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Tickell KD, Mangale DI, Tornberg-Belanger SN, Bourdon C, Thitiri J, Timbwa M, Njirammadzi J, Voskuijl W, Chisti MJ, Ahmed T, Shahid ASMSB, Diallo AH, Ouédrago I, Khan AF, Saleem AF, Arif F, Kazi Z, Mupere E, Mukisa J, Sukhtankar P, Berkley JA, Walson JL, Denno DM. A mixed method multi-country assessment of barriers to implementing pediatric inpatient care guidelines. PLoS One 2019; 14:e0212395. [PMID: 30908499 PMCID: PMC6433255 DOI: 10.1371/journal.pone.0212395] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/27/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction Accelerating progress in reducing child deaths is needed in order to achieve the Sustainable Development Goal child mortality target. This will require a focus on vulnerable children–including young children, those who are undernourished or with acute illnesses requiring hospitalization. Improving adherence to inpatient guidelines may be an important strategy to reduce child mortality, including among the most vulnerable. The aim of our assessment of nine sub-Saharan African and South Asian hospitals was to determine adherence to pediatric inpatient care recommendations, in addition to capacity for and barriers to implementation of guideline-adherent care prior to commencing the Childhood Acute Illness and Nutrition (CHAIN) Cohort study. The CHAIN Cohort study aims to identify modifiable risk factors for poor inpatient and post discharge outcomes above and beyond implementation of guidelines. Methods Hospital infrastructure, staffing, durable equipment, and consumable supplies such as medicines and laboratory reagents, were evaluated through observation and key informant interviews. Inpatient medical records of 2–23 month old children were assessed for adherence to national and international guidelines. The records of children with severe acute malnutrition (SAM) were oversampled to reflect the CHAIN study population. Seven core adherence indicators were examined: oximetry and oxygen therapy, fluids, anemia diagnosis and transfusion, antibiotics, malaria testing and antimalarials, nutritional assessment and management, and HIV testing. Results All sites had facilities and equipment necessary to implement care consistent with World Health Organization and national guidelines. However, stockouts of essential medicines and laboratory reagents were reported to be common at some sites, even though they were mostly present during the assessment visits. Doctor and nurse to patient ratios varied widely. We reviewed the notes of 261 children with admission diagnoses of sepsis (17), malaria (47), pneumonia (70), diarrhea (106), and SAM (119); 115 had multiple diagnoses. Adherence to oxygen therapy, antimalarial, and malnutrition refeeding guidelines was >75%. Appropriate antimicrobials were prescribed for 75% of antibiotic-indicative conditions. However, 20/23 (87%) diarrhea and 20/27 (74%) malaria cases without a documented indication were prescribed antibiotics. Only 23/122 (19%) with hemoglobin levels meeting anemia criteria had recorded anemia diagnoses. HIV test results were infrequently documented even at hospitals with universal screening policies (66/173, 38%). Informants at all sites attributed inconsistent guideline implementation to inadequate staffing. Conclusion Assessed hospitals had the infrastructure and equipment to implement guideline-consistent care. While fluids, appropriate antimalarials and antibiotics, and malnutrition refeeding adherence was comparable to published estimates from low- and high-resource settings, there were inconsistencies in implementation of some other recommendations. Stockouts of essential therapeutics and laboratory reagents were a noted barrier, but facility staff perceived inadequate human resources as the primary constraint to consistent guideline implementation.
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Affiliation(s)
- Kirkby D. Tickell
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Dorothy I. Mangale
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Stephanie N. Tornberg-Belanger
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Celine Bourdon
- Program in Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Jenala Njirammadzi
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Mohammod J. Chisti
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | | | - Abdoulaye H. Diallo
- Department of Public Health, Centre MURAZ Research Institute, Ministry of Health, Bobo-Dioulasso, Burkina Faso
- Department of Public Health, University of Ouagadougou, Ouagadougou, Burkina Faso
| | - Issaka Ouédrago
- Department of Paediatrics, Banfora Regional Referral Hospital, Banfora, Burkina Faso
| | - Al Fazal Khan
- Centre for Nutrition & Food Security (CNFS), icddr, b, Dhaka, Bangladesh
| | - Ali F. Saleem
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Fehmina Arif
- Department of Paediatrics, Civil Hospital Karachi, Karachi, Pakistan
| | - Zaubina Kazi
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Ezekiel Mupere
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John Mukisa
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | - Judd L. Walson
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Donna M. Denno
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Department of Health Services, University of Washington, Seattle, Washington, United States of America
- * E-mail:
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High burden of co-morbidity and mortality among severely malnourished children admitted to outpatient therapeutic programme facilities in the conflict setting of Borno, Nigeria: a retrospective review. Public Health Nutr 2019; 22:1786-1793. [PMID: 30741140 DOI: 10.1017/s1368980018003968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To present evidence on the burden and outcomes of co-morbidities among severely malnourished (SAM) children admitted to outpatient therapeutic programme (OTP) facilities in the conflict setting of Borno, Nigeria. DESIGN Retrospective medical chart review. SETTING Facility-based study.ParticipantsChildren aged 6-59 months with SAM enrolled in OTP between June and November 2016 whose medical records were analysed. Only pneumonia and diarrhoea were examined due to data limitations. Stata software was used for descriptive, multivariate and survival analyses. RESULTS Records of 396 children with median age of 15 months were identified and analysed from the date of enrolment to exit from OTP. Mean length of stay in OTP was 61d, with co-infected SAM children having shorter stay (P=0·006). Of the total, 148 (37·4 %) had at least one co-morbidity (pneumonia or diarrhoea), of which thirty-nine (26·4 %) had both. Cumulative rate of mortality during follow-up time was 9·5 (95 % CI 6·0, 15·1) per 10 000 child-days; SAM children with co-morbidities were ten times more likely to die than those without (hazard ratio=10·2; 95 % CI 3·4, 31·0). In multivariable analysis, co-morbidity (P=0·01), oedema (P=0·003), dehydration (P=0·02) and weight on admission (P=0·01) were associated with mortality. Both recovery and defaulter rates (57·8 and 36·1 %, respectively) did not meet SPHERE standards. CONCLUSIONS Children with SAM and co-morbidities are less likely to survive, presenting a significant barrier in improving child survival. The findings call for integrated OTP models that incorporate clinical algorithms and ensure prompt referral for SAM children with co-morbidity.
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Bebars GM, Afifi MF, Mahrous DM, Okaily NE, Mounir SM, Mohammed EA. Assessment of some micronutrients serum levels in children with severe acute malnutrition with and without cerebral palsy- A follow up case control study. CLINICAL NUTRITION EXPERIMENTAL 2019. [DOI: 10.1016/j.yclnex.2018.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Madrid L, Casellas A, Sacoor C, Quintó L, Sitoe A, Varo R, Acácio S, Nhampossa T, Massora S, Sigaúque B, Mandomando I, Cousens S, Menéndez C, Alonso P, Macete E, Bassat Q. Postdischarge Mortality Prediction in Sub-Saharan Africa. Pediatrics 2019; 143:peds.2018-0606. [PMID: 30552144 DOI: 10.1542/peds.2018-0606] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although the burden of postdischarge mortality (PDM) in low-income settings appears to be significant, no clear recommendations have been proposed in relation to follow-up care after hospitalization. We aimed to determine the burden of pediatric PDM and develop predictive models to identify children who are at risk for dying after discharge. METHODS Deaths after hospital discharge among children aged <15 years in the last 17 years were reviewed in an area under demographic and morbidity surveillance in Southern Mozambique. We determined PDM over time (up to 90 days) and derived predictive models of PDM using easily collected variables on admission. RESULTS Overall PDM was high (3.6%), with half of the deaths occurring in the first 30 days. One primary predictive model for all ages included young age, moderate or severe malnutrition, a history of diarrhea, clinical pneumonia symptoms, prostration, bacteremia, having a positive HIV status, the rainy season, and transfer or absconding, with an area under the curve of 0.79 (0.75-0.82) at day 90 after discharge. Alternative models for all ages including simplified clinical predictors had a similar performance. A model specific to infants <3 months old was used to identify as predictors being a neonate, having a low weight-for-age z score, having breathing difficulties, having hypothermia or fever, having oral candidiasis, and having a history of absconding or transfer to another hospital, with an area under the curve of 0.76 (0.72-0.91) at day 90 of follow-up. CONCLUSIONS Death after discharge is an important although poorly recognized contributor to child mortality. A simple predictive algorithm based on easily recognizable variables could readily be used to identify most infants and children who are at a high risk of dying after discharge.
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Affiliation(s)
- Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain
| | - Aina Casellas
- Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain
| | | | - Llorenç Quintó
- Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain
| | - Sozinho Acácio
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Sergio Massora
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Betuel Sigaúque
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | | | - Simon Cousens
- Faculty of Epidemiology and Population Health, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clara Menéndez
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain.,Centro de Investigacion Biomedica en Red (CIBER) de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Pedro Alonso
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain
| | - Eusebio Macete
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique; .,Hospital Clínic de Barcelona, Barcelona Institute for Global Health and Universitat de Barcelona, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats, Passeig Lluís Companys 23, Barcelona, Spain; and.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu and University of Barcelona, Barcelona, Spain
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Nemetchek B, English L, Kissoon N, Ansermino JM, Moschovis PP, Kabakyenga J, Fowler-Kerry S, Kumbakumba E, Wiens MO. Paediatric postdischarge mortality in developing countries: a systematic review. BMJ Open 2018; 8:e023445. [PMID: 30593550 PMCID: PMC6318528 DOI: 10.1136/bmjopen-2018-023445] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To update the current evidence base on paediatric postdischarge mortality (PDM) in developing countries. Secondary objectives included an evaluation of risk factors, timing and location of PDM. DESIGN Systematic literature review without meta-analysis. DATA SOURCES Searches of Medline and EMBASE were conducted from October 2012 to July 2017. ELIGIBILITY CRITERIA Studies were included if they were conducted in developing countries and examined paediatric PDM. 1238 articles were screened, yielding 11 eligible studies. These were added to 13 studies identified in a previous systematic review including studies prior to October 2012. In total, 24 studies were included for analysis. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted and synthesised data using Microsoft Excel. RESULTS Studies were conducted mostly within African countries (19 of 24) and looked at all admissions or specific subsets of admissions. The primary subpopulations included malnutrition, respiratory infections, diarrhoeal diseases, malaria and anaemia. The anaemia and malaria subpopulations had the lowest PDM rates (typically 1%-2%), while those with malnutrition and respiratory infections had the highest (typically 3%-20%). Although there was significant heterogeneity between study populations and follow-up periods, studies consistently found rates of PDM to be similar, or to exceed, in-hospital mortality. Furthermore, over two-thirds of deaths after discharge occurred at home. Highly significant risk factors for PDM across all infectious admissions included HIV status, young age, pneumonia, malnutrition, anthropometric variables, hypoxia, anaemia, leaving hospital against medical advice and previous hospitalisations. CONCLUSIONS Postdischarge mortality rates are often as high as in-hospital mortality, yet remain largely unaddressed. Most children who die following discharge do so at home, suggesting that interventions applied prior to discharge are ideal to addressing this neglected cause of mortality. The development, therefore, of evidence-based, risk-guided, interventions must be a focus to achieve the sustainable development goals.
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Affiliation(s)
- Brooklyn Nemetchek
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Lacey English
- Department of Medicine, University of North Carolina, Raleigh, North Carolina, USA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - John Mark Ansermino
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Peter P Moschovis
- Division of Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jerome Kabakyenga
- Maternal, Newborn and Child Health Institute, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Susan Fowler-Kerry
- College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Elias Kumbakumba
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Matthew O Wiens
- Center for International Child Health, BC Children's Hospital, Vancouver, British Columbia, Canada
- Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
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John C, Diala U, Adah R, Lar L, Envuladu EA, Adedeji I, Lasisi K, Olusunde O, James F, Abdu H. Survival and nutritional status of children with severe acute malnutrition, six months post-discharge from outpatient treatment in Jigawa state, Nigeria. PLoS One 2018; 13:e0196971. [PMID: 29924797 PMCID: PMC6010258 DOI: 10.1371/journal.pone.0196971] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 04/24/2018] [Indexed: 01/10/2023] Open
Abstract
Background The Outpatient Therapeutic Program (OTP) for treatment brings the management of Severe Acute Malnutrition (SAM) closer to the community. Many lives have been saved through this approach, but little data exists on the outcome of the children after discharge from such programmes. This study was aimed to determine the survival and nutritional status of children at six months after discharge from OTP for SAM. Methodology This was a prospective study of children with SAM admitted into 10 OTPs in two local government areas of Jigawa state from June 2016 to July 2016. Home visits at six months after discharge enabled the collection of data on survival and nutritional status. The primary outcome measures were survival and nutritional status (Mid upper arm circumference and weight-for-height z-score). Result Of 494 children with SAM, 410 were discharged and 379 were followed up. Of these, 354, (93.4%) were found alive while 25 (6.6%) died. Among the survivors 333 (94.1%) had MUAC ≥12.5cm and 64 (18.1%) had WHZ<-3. Mortality rates were higher 10 (8.4%) among the 6-11months old. Most deaths 16 (64%) occurred within the first 3months post-discharge. Those who died were significantly more stunted, p = 0.016 and had a smaller head circumference, p = 0.005 on entry to OTP programme. There was improvement from admission to six months follow up in the number of children with complete immunization (27.4% to 35.6%), and a decrease in the number of unimmunized children (34.8% vs 20.6%) at follow-up. Conclusion The study demonstrates good post discharge survival rate and improved nutritional status for SAM patients managed in OTPs. There were, however considerable post discharge mortality, especially in the first three months and lower immunization uptake post discharge. A follow-up programme will improve these indices further.
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Affiliation(s)
- Collins John
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
- * E-mail:
| | - Udochukwu Diala
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | - Ruth Adah
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
| | - Luret Lar
- Department of Community Medicine, Jos University Teaching Hospital, Jos, Nigeria
| | | | - Idris Adedeji
- Department of Paediatrics, Abubakar Tafawa Balewa University Teaching Hospital Bauchi, Bauchi, Nigeria
| | - Kazeem Lasisi
- Department of Mathematical Sciences, Abubakar Tafewa Balewa University Bauchi, Bauchi, Nigeria
| | - Oluseyi Olusunde
- National Primary Health Care Development Agency, North Central Zonal Office, Abuja, Nigeria
| | - Femi James
- Federal Ministry of Health, Maternal, Newborn and Child Health Unit, Abuja, Nigeria
| | - Halima Abdu
- Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
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Metabolic phenotyping of malnutrition during the first 1000 days of life. Eur J Nutr 2018; 58:909-930. [PMID: 29644395 PMCID: PMC6499750 DOI: 10.1007/s00394-018-1679-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023]
Abstract
Nutritional restrictions during the first 1000 days of life can impair or delay the physical and cognitive development of the individual and have long-term consequences for their health. Metabolic phenotyping (metabolomics/metabonomics) simultaneously measures a diverse range of low molecular weight metabolites in a sample providing a comprehensive assessment of the individual's biochemical status. There are a growing number of studies applying such approaches to characterize the metabolic derangements induced by various forms of early-life malnutrition. This includes acute and chronic undernutrition and specific micronutrient deficiencies. Collectively, these studies highlight the diverse and dynamic metabolic disruptions resulting from various forms of nutritional deficiencies. Perturbations were observed in many pathways including those involved in energy, amino acid, and bile acid metabolism, the metabolic interactions between the gut microbiota and the host, and changes in metabolites associated with gut health. The information gleaned from such studies provides novel insights into the mechanisms linking malnutrition with developmental impairments and assists in the elucidation of candidate biomarkers to identify individuals at risk of developmental shortfalls. As the metabolic profile represents a snapshot of the biochemical status of an individual at a given time, there is great potential to use this information to tailor interventional strategies specifically to the metabolic needs of the individual.
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Ngari MM, Mwalekwa L, Timbwa M, Hamid F, Ali R, Iversen PO, Fegan GW, Berkley JA. Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya. Am J Clin Nutr 2018; 107:626-634. [PMID: 29635501 PMCID: PMC6134064 DOI: 10.1093/ajcn/nqy007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/08/2018] [Indexed: 12/15/2022] Open
Abstract
Background Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions. Objective The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM. Design This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2-59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points. Results Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥-2, respectively, which, compared with a WHZ <-3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥-2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs. Conclusions Anthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.
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Affiliation(s)
- Moses M Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | | | - Molline Timbwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Per Ole Iversen
- Department of Nutrition, IBM, University of Oslo, Norway
- Department of Hematology, Oslo University Hospital, Oslo, Norway
| | - Greg W Fegan
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - James A Berkley
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Joshi R, Faruqui N, Nagarajan SR, Rampatige R, Martiniuk A, Gouda H. Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review. Int J Epidemiol 2018; 47:255-279. [PMID: 29092034 DOI: 10.1093/ije/dyx216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2017] [Indexed: 11/14/2022] Open
Abstract
Introduction Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies. Methods A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest. Results The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time. Conclusions The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.
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Affiliation(s)
- Rohina Joshi
- George Institute for Global Health
- University of New South Wales
- University of Sydney, Sydney, NSW, Australia
| | - Neha Faruqui
- George Institute for Global Health
- University of Sydney, Sydney, NSW, Australia
| | | | | | - Alex Martiniuk
- George Institute for Global Health
- University of Sydney, Sydney, NSW, Australia
| | - Hebe Gouda
- School of Public Health
- Queensland Centre for Mental Health Research, University of Queensland, Brisbane, QLD, Australia
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Argent AC. Considerations for Assessing the Appropriateness of High-Cost Pediatric Care in Low-Income Regions. Front Pediatr 2018; 6:68. [PMID: 29637061 PMCID: PMC5880905 DOI: 10.3389/fped.2018.00068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/08/2018] [Indexed: 12/24/2022] Open
Abstract
It may be difficult to predict the consequences of provision of high-cost pediatric care (HCC) in low- and middle-income countries (LMICs), and these consequences may be different to those experienced in high-income countries. An evaluation of the implications of HCC in LMICs must incorporate considerations of the specific context in that country (population age profile, profile of disease, resources available), likely costs of the HCC, likely benefits that can be gained versus the costs that will be incurred. Ideally, the process that is followed in decision making around HCC should be transparent and should involve the communities that will be most affected by those decisions. It is essential that the impacts of provision of HCC are carefully monitored so that informed decisions can be made about future provision medical interventions.
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Affiliation(s)
- Andrew C Argent
- Paediatric Critical Care, Paediatrics and Child Health, University of Cape Town, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Abstract
The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.
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Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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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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Mwangome M, Ngari M, Fegan G, Mturi N, Shebe M, Bauni E, Berkley JA. Diagnostic criteria for severe acute malnutrition among infants aged under 6 mo. Am J Clin Nutr 2017; 105:1415-1423. [PMID: 28424189 PMCID: PMC5445677 DOI: 10.3945/ajcn.116.149815] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/15/2017] [Indexed: 11/14/2022] Open
Abstract
Background: There is an increasing recognition of malnutrition among infants under 6 mo of age (U6M). Current diagnosis criteria use weight-for-length z scores (WLZs), but the 2006 WHO standards exclude infants shorter than 45 cm. In older children, midupper arm circumference (MUAC) predicts mortality better than does WLZ. Outcomes may also be influenced by exposure to HIV and size or gestational age at birth. Diagnostic thresholds for WLZ, MUAC, and other indexes have not been fully evaluated against mortality risk among U6M infants.Objective: The aim was to determine the association of anthropometric indexes with risks of inpatient and postdischarge mortality among U6M infants recruited at the time of hospitalization.Design: We analyzed data from a cohort of U6M infants admitted to Kilifi County Hospital (2007-2013), Kenya. The primary outcomes were inpatient death and death during follow-up over 1 y after discharge. We calculated adjusted RRs for inpatient mortality and HRs for postdischarge mortality for different anthropometric measures and thresholds. Discriminatory value was assessed by using receiver operating characteristic curves.Results: A total of 2882 infants were admitted: 140 (4.9%) died in the hospital and 1405 infants were followed up after discharge. Of these, 75 (5.3%) died within 1 y during 1318 child-years of observation. MUAC and weight-for-age z score (WAZ) predicted inpatient and postdischarge mortality better than did WLZ (P < 0.0001). A single MUAC threshold of <11.0 cm performed similarly to MUAC thresholds that varied with age (all P > 0.05) and performed better than WLZ <-3 for both inpatient and postdischarge mortality (both P < 0.001). Reported small size at birth did not reduce the risk of death associated with anthropometric indexes.Conclusions: U6M infants at the highest risk of death are best targeted by using MUAC or WAZ. Further research into the effectiveness of potential interventions is required.
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Affiliation(s)
- Martha Mwangome
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya; .,Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Moses Ngari
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya;,Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Greg Fegan
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya;,Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom; and
| | - Neema Mturi
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya
| | - Mohammed Shebe
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya
| | - Evasius Bauni
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya
| | - James A Berkley
- Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Program, Kilifi, Kenya;,Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya;,Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Oxford, United Kingdom
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Ngari MM, Fegan G, Mwangome MK, Ngama MJ, Mturi N, Scott JAG, Bauni E, Nokes DJ, Berkley JA. Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study. Paediatr Perinat Epidemiol 2017; 31:233-242. [PMID: 28317139 PMCID: PMC5434848 DOI: 10.1111/ppe.12348] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although pneumonia is a leading cause of inpatient mortality, deaths may also occur after discharge from hospital. However, prior studies have been small, in selected groups or did not fully evaluate risk factors, particularly malnutrition and HIV. We determined 1-year post-discharge mortality and risk factors among children diagnosed with severe pneumonia. METHODS A cohort study of children aged 1-59 months admitted to Kilifi County Hospital with severe pneumonia (2007-12). The primary outcome was death <1 year after discharge, determined through Kilifi Health and Demographic Surveillance System (KHDSS) quarterly census rounds. RESULTS Of 4184 children (median age 9 months) admitted with severe pneumonia, 1041 (25%) had severe acute malnutrition (SAM), 267 (6.4%) had a positive HIV antibody test, and 364 (8.7%) died in hospital. After discharge, 2279 KHDSS-resident children were followed up; 70 (3.1%) died during 2163 child-years: 32 (95% confidence interval (CI) 26, 41) deaths per 1000 child years. Post-discharge mortality was greater after admission for severe pneumonia than for other diagnoses, hazard ratio 2.5 (95% CI 1.2, 5.3). Malnutrition, HIV status, age and prolonged hospitalisation, but not signs of pneumonia severity, were associated with post-discharge mortality. Fifty-two per cent (95% CI 37%, 63%) of post-discharge deaths were attributable to low mid-upper arm circumference and 11% (95% CI 3.3%, 18%) to a positive HIV test. CONCLUSIONS Admission with severe pneumonia is an important marker of vulnerability. Risk stratification and better understanding of the mechanisms underlying post-discharge mortality, especially for undernourished children, are needed to reduce mortality after treatment for pneumonia.
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Affiliation(s)
- Moses M. Ngari
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
| | - Greg Fegan
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,Swansea Trials UnitSwansea University Medical SchoolSwanseaUK
| | - Martha K. Mwangome
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya
| | | | - Neema Mturi
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya
| | - John Anthony Gerard Scott
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,London School of Hygiene & Tropical MedicineLondonUK
| | | | - David James Nokes
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,School of Life SciencesUniversity of WarwickCoventryUK
| | - James A. Berkley
- KEMRI/Wellcome Trust Research ProgrammeKilifiKenya,The Childhood Acute Illness & Nutrition (CHAIN) NetworkNairobiKenya,Centre for Tropical Medicine & Global HealthUniversity of OxfordOxfordUK
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49
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Grellety E, Babakazo P, Bangana A, Mwamba G, Lezama I, Zagre NM, Ategbo EA. Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo. BMC Med 2017; 15:87. [PMID: 28441944 PMCID: PMC5405483 DOI: 10.1186/s12916-017-0848-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/30/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months. METHODS We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat. RESULTS The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group. CONCLUSIONS CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs. TRIAL REGISTRATION ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.
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Affiliation(s)
| | - Pélagie Babakazo
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Amina Bangana
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
| | - Gustave Mwamba
- Save the Children United Kingdom, Kinshasa, Democratic Republic of the Congo
| | - Ines Lezama
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
| | - Noël Marie Zagre
- United Nations International Children Emergency Fund West and Central Africa Regional Office, Dakar, Senegal
| | - Eric-Alain Ategbo
- United Nations International Children Emergency Fund, Kinshasa, Democratic Republic of the Congo
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50
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Phuong NTK, Hoang TT, Van PH, Tu L, Graham SM, Marais BJ. Encouraging rational antibiotic use in childhood pneumonia: a focus on Vietnam and the Western Pacific Region. Pneumonia (Nathan) 2017; 9:7. [PMID: 28702309 PMCID: PMC5471677 DOI: 10.1186/s41479-017-0031-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 04/03/2017] [Indexed: 01/21/2023] Open
Abstract
Globally, pneumonia is considered to be the biggest killer of infants and young children (aged <5 years) outside the neonatal period, with the greatest disease burden in low- and middle-income countries. Optimal management of childhood pneumonia is challenging in settings where clinicians have limited information regarding the local pathogen and drug resistance profiles. This frequently results in unnecessary and poorly targeted antibiotic use. Restricting antibiotic use is a global priority, particularly in Asia and the Western Pacific Region where excessive use is driving high rates of antimicrobial resistance. The authors conducted a comprehensive literature review to explore the antibiotic resistance profile of bacteria associated with pneumonia in the Western Pacific Region, with a focus on Vietnam. Current management practices were also considered, along with the diagnostic dilemmas faced by doctors and other factors that increase unnecessary antibiotic use. This review offers some suggestions on how these issues may be addressed.
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Affiliation(s)
- Nguyen T. K. Phuong
- Respiratory Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
- Infectious Disease Team, The Children’s Hospital at Westmead and Discipline of Paediatrics and Adolescent Medicine, University of Sydney, Sydney, NSW Australia
| | - Tran T. Hoang
- Neonatal Department, Da Nang Hospital for Women and Children, Da Nang, Vietnam
| | - Pham H. Van
- Microbiology Department, The University of Medicine and Pharmacy, Ho Chi Minh, Vietnam
| | - Lolyta Tu
- Antimicrobial Stewardship Team, The Children’s Hospital at Westmead, Sydney, Australia
| | - Stephen M. Graham
- Centre for International Child Health, University of Melbourne and Murdoch Children’s Research Institute, Melbourne, Australia
| | - Ben J. Marais
- Infectious Disease Team, The Children’s Hospital at Westmead and Discipline of Paediatrics and Adolescent Medicine, University of Sydney, Sydney, NSW Australia
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