Predicting Clinical Deterioration and Mortality at Differing Stages During Hospitalization: A Systematic Review of Risk Prediction Models in Children in Low- and Middle-Income Countries

OBJECTIVE

To determine which risk prediction model best predicts clinical deterioration in children at different stages of hospital admission in low- and middle-income countries.

METHODS

For this systematic review, Embase and MEDLINE databases were searched, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The key search terms were "development or validation study with risk-prediction model" AND "deterioration or mortality" AND "age 0-18 years" AND "hospital-setting: emergency department (ED), pediatric ward (PW), or pediatric intensive care unit (PICU)" AND "low- and middle-income countries." The Prediction Model Risk of Bias Assessment Tool was used by two independent authors. Forest plots were used to plot area under the curve according to hospital setting. Risk prediction models used in two or more studies were included in a meta-analysis.

RESULTS

We screened 9486 articles and selected 78 publications, including 67 unique predictive models comprising 1.5 million children. The best performing models individually were signs of inflammation in children that can kill (SICK) (ED), pediatric early warning signs resource limited settings (PEWS-RL) (PW), and Pediatric Index of Mortality (PIM) 3 as well as pediatric sequential organ failure assessment (pSOFA) (PICU). Best performing models after meta-analysis were SICK (ED), pSOFA and Pediatric Early Death Index for Africa (PEDIA)-immediate score (PW), and pediatric logistic organ dysfunction (PELOD) (PICU). There was a high risk of bias in all studies.

CONCLUSIONS

We identified risk prediction models that best estimate deterioration, although these risk prediction models are not routinely used in low- and middle-income countries. Future studies should focus on large scale external validation with strict methodological criteria of multiple risk prediction models as well as study the barriers in the way of implementation.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews: Prospero ID: CRD42021210489.

Prediction of mortality in severe acute malnutrition in hospitalized children by faecal volatile organic compound analysis: proof of concept

Children with severe acute malnutrition (SAM) display immature, altered gut microbiota and have a high mortality risk. Faecal volatile organic compounds (VOCs) reflect the microbiota composition and may provide insight into metabolic dysfunction that occurs in SAM. Here we determine whether analysis of faecal VOCs could identify children with SAM with increased risk of mortality. VOC profiles from children who died within six days following admission were compared to those who were discharged alive using machine learning algorithms. VOC profiles of children who died could be separated from those who were discharged with fair accuracy (AUC) = 0.71; 95% CI 0.59-0.87; P = 0.004). We present the first study showing differences in faecal VOC profiles between children with SAM who survived and those who died. VOC analysis holds potential to help discover metabolic pathways within the intestinal microbiome with causal association with mortality and target treatments in children with SAM.Trial Registration: The F75 study is registered at clinicaltrials.gov/ct2/show/NCT02246296.

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial

BACKGROUND

Children with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase.

METHODS AND FINDINGS

In a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2-5 days), which was similar between randomized groups (0.23 [95% CI -0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission, age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite.

CONCLUSIONS

Empirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02246296.

Pancreatic Enzyme Replacement Therapy in Children with Severe Acute Malnutrition: A Randomized Controlled Trial

OBJECTIVE

To assess the benefits of pancreatic enzyme replacement therapy (PERT) in children with complicated severe acute malnutrition.

STUDY DESIGN

We conducted a randomized, controlled trial in 90 children aged 6-60 months with complicated severe acute malnutrition at the Queen Elizabeth Central Hospital in Malawi. All children received standard care; the intervention group also received PERT for 28 days.

RESULTS

Children treated with PERT for 28 days did not gain more weight than controls (13.7 ± 9.0% in controls vs 15.3 ± 11.3% in PERT; P = .56). Exocrine pancreatic insufficiency was present in 83.1% of patients on admission and fecal elastase-1 levels increased during hospitalization mostly seen in children with nonedematous severe acute malnutrition (P <.01). Although the study was not powered to detect differences in mortality, mortality was significantly lower in the intervention group treated with pancreatic enzymes (18.6% vs 37.8%; P < .05). Children who died had low fecal fatty acid split ratios at admission. Exocrine pancreatic insufficiency was not improved by PERT, but children receiving PERT were more likely to be discharged with every passing day (P = .02) compared with controls.

CONCLUSIONS

PERT does not improve weight gain in severely malnourished children but does increase the rate of hospital discharge. Mortality was lower in patients on PERT, a finding that needs to be investigated in a larger cohort with stratification for edematous and nonedematous malnutrition. Mortality in severe acute malnutrition is associated with markers of poor digestive function.

TRIAL REGISTRATION

ISRCTN.com: 57423639.