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Abstract
OBJECTIVES Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC. METHODS We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month-18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected. RESULTS We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC. CONCLUSIONS Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.
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Wen B, Brals D, Bourdon C, Erdman L, Ngari M, Chimwezi E, Potani I, Thitiri J, Mwalekwa L, Berkley JA, Bandsma RHJ, Voskuijl W. Predicting the risk of mortality during hospitalization in sick severely malnourished children using daily evaluation of key clinical warning signs. BMC Med 2021; 19:222. [PMID: 34538239 PMCID: PMC8451091 DOI: 10.1186/s12916-021-02074-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 07/27/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Despite adherence to WHO guidelines, inpatient mortality among sick children admitted to hospital with complicated severe acute malnutrition (SAM) remains unacceptably high. Several studies have examined risk factors present at admission for mortality. However, risks may evolve during admission with medical and nutritional treatment or deterioration. Currently, no specific guidance exists for assessing daily treatment response. This study aimed to determine the prognostic value of monitoring clinical signs on a daily basis for assessing mortality risk during hospitalization in children with SAM. METHODS This is a secondary analysis of data from a randomized trial (NCT02246296) among 843 hospitalized children with SAM. Daily clinical signs were prospectively collected during ward rounds. Multivariable extended Cox regression using backward feature selection was performed to identify daily clinical warning signs (CWS) associated with time to death within the first 21 days of hospitalization. Predictive models were subsequently developed, and their prognostic performance evaluated using Harrell's concordance index (C-index) and time-dependent area under the curve (tAUC). RESULTS Inpatient case fatality ratio was 16.3% (n=127). The presence of the following CWS during daily assessment were found to be independent predictors of inpatient mortality: symptomatic hypoglycemia, reduced consciousness, chest indrawing, not able to complete feeds, nutritional edema, diarrhea, and fever. Daily risk scores computed using these 7 CWS together with MUAC<10.5cm at admission as additional CWS predict survival outcome of children with SAM with a C-index of 0.81 (95% CI 0.77-0.86). Moreover, counting signs among the top 5 CWS (reduced consciousness, symptomatic hypoglycemia, chest indrawing, not able to complete foods, and MUAC<10.5cm) provided a simpler tool with similar prognostic performance (C-index of 0.79; 95% CI 0.74-0.84). Having 1 or 2 of these CWS on any day during hospitalization was associated with a 3 or 11-fold increased mortality risk compared with no signs, respectively. CONCLUSIONS This study provides evidence for structured monitoring of daily CWS as recommended clinical practice as it improves prediction of inpatient mortality among sick children with complicated SAM. We propose a simple counting-tool to guide healthcare workers to assess treatment response for these children. TRIAL REGISTRATION NCT02246296.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Celine Bourdon
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Lauren Erdman
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Isabel Potani
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Department of Paediatrics, Coast General Hospital, Mombasa, Kenya.,Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada.,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya.,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Biomedical Sciences, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wieger Voskuijl
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, The Netherlands. .,The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya. .,Department of Paediatrics, Kamuzu University of Health Sciences, formerly College of Medicine, University of Malawi, Blantyre, Malawi. .,Amsterdam Center for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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