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Afroze F, Khoshnevisan F, Harawa PP, Islam Z, Bourdon C, Khoswe S, Islam M, Sarker SA, Islam F, Sayeem Bin Shahid ASM, Joosten K, Hulst JM, Eneya C, Walson JL, Berkley JA, Potani I, Voskuijl W, Ahmed T, Chisti MJ, Bandsma RHJ. Trajectories of resting energy expenditure and performance of predictive equations in children hospitalized with an acute illness and malnutrition: a longitudinal study. Sci Rep 2024; 14:3613. [PMID: 38351162 PMCID: PMC10864294 DOI: 10.1038/s41598-024-53791-w] [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: 09/27/2023] [Accepted: 02/05/2024] [Indexed: 02/16/2024] Open
Abstract
There is scarce data on energy expenditure in ill children with different degrees of malnutrition. This study aimed to determine resting energy expenditure (REE) trajectories in hospitalized malnourished children during and after hospitalization. We followed a cohort of children in Bangladesh and Malawi (2-23 months) with: no wasting (NW); moderate wasting (MW), severe wasting (SW), or edematous malnutrition (EM). REE was measured by indirect calorimetry at admission, discharge, 14-and-45-days post-discharge. 125 children (NW, n = 23; MW, n = 29; SW, n = 51; EM, n = 22), median age 9 (IQR 6, 14) months, provided 401 REE measurements. At admission, the REE of children with NW and MW was 67 (95% CI [58, 75]) and 70 (95% CI [63, 76]) kcal/kg/day, respectively, while REE in children with SW was higher, 79 kcal/kg/day (95% CI [74, 84], p = 0.018), than NW. REE in these groups was stable over time. In children with EM, REE increased from admission to discharge (65 kcal/kg/day, 95% CI [56, 73]) to 79 (95% CI [72, 86], p = 0.0014) and was stable hereafter. Predictive equations underestimated REE in 92% of participants at all time points. Recommended feeding targets during the acute phase of illness in severely malnourished children exceeded REE. Acutely ill malnourished children are at risk of being overfed when implementing current international guidelines.
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Affiliation(s)
- Farzana Afroze
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farnaz Khoshnevisan
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Philliness Prisca Harawa
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Zahidul Islam
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Celine Bourdon
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Stanley Khoswe
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Munirul Islam
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shafiqul Alam Sarker
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farhana Islam
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Sadat Mohammad Sayeem Bin Shahid
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Koen Joosten
- Department of Neonatal and Paediatric Intensive Care, Division of Paediatric Intensive Care, Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jessie M Hulst
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Chisomo Eneya
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Paediatrics and Child Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Judd L Walson
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - James A Berkley
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Division of Paediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Wieger Voskuijl
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Paediatrics, Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tahmeed Ahmed
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya
- Nutrition Research Division (NRD), International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Robert H J Bandsma
- The Childhood Acute Illness and Nutrition (CHAIN) Network, Nairobi, Kenya.
- Translational Medicine, Hospital for Sick Children, Toronto, Canada.
- Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada.
- Department of Biomedical Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi.
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Dale NM, Ashir GM, Maryah LB, Shepherd S, Tomlinson G, Briend A, Zlotkin S, Parshuram CS. Evaluating the Validity of the Responses to Illness Severity Quantification Score to Discriminate Illness Severity and Level of Care Transitions in Hospitalized Children with Severe Acute Malnutrition. J Pediatr 2023; 262:113609. [PMID: 37419241 DOI: 10.1016/j.jpeds.2023.113609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/25/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE To evaluate the validity of the Responses to Illness Severity Quantification (RISQ) score to discriminate illness severity and transitions between levels of care during hospitalization. STUDY DESIGN A prospective observational study conducted in Maiduguri, Nigeria, enrolled inpatients aged 1-59 months with severe acute malnutrition. The primary outcome was the RISQ score associated with the patient state. Heart and respiratory rate, oxygen saturation, respiratory effort, oxygen use, temperature, and level of consciousness are summed to calculate the RISQ score. Five states were defined by levels of care and hospital discharge outcome. The states were classified hierarchically, reflecting illness severity: hospital mortality was the most severe state, then intensive care unit (ICU), care in the stabilization phase (SP), care in the rehabilitation phase (RP), and lowest severity, survival at hospital discharge. A multistate statistical model examined performance of the RISQ score in predicting clinical states and transitions. RESULTS Of 903 children enrolled (mean age, 14.6 months), 63 (7%) died. Mean RISQ scores during care in each phase were 3.5 (n = 2265) in the ICU, 1.7 (n = 6301) in the SP, and 1.5 (n = 2377) in the RP. Mean scores and HRs for a 3-point change in score at transitions: ICU to death, 6.9 (HR, 1.80); SP to ICU, 2.8 (HR, 2.00); ICU to SP, 2.0 (HR, 0.5); and RP to discharge, 1.4 (HR, 0.91). CONCLUSIONS The RISQ score can discriminate between points of escalation or de-escalation of care and reflects illness severity in hospitalized children with severe acute malnutrition. Evaluation of clinical implementation and demonstration of benefit will be important before widespread adoption.
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Affiliation(s)
- Nancy M Dale
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Garba Mohammed Ashir
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Lawan Bukar Maryah
- Department of Pediatrics, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
| | - Susan Shepherd
- Alliance for International Medical Action, Dakar, Senegal
| | - George Tomlinson
- Department of Medicine, University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - André Briend
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland; Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Christopher S Parshuram
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada; Center for Safety Research, Toronto, ON, Canada; Department of Critical Care Medicine, Hospital for Sick Children, Toronto, ON, Canada.
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Tickell KD, Achieng C, Masheti M, Anyango M, Ndirangu A, Diakhate MM, Yoshioka E, Levin C, Rubin Means A, Choo EM, Ronen K, Unger JA, Richardson BA, Singa BO, McGrath CJ. Family MUAC supported by a two-way SMS platform for identifying children with wasting: the Mama Aweza randomised controlled trial. EClinicalMedicine 2023; 64:102218. [PMID: 37781159 PMCID: PMC10541484 DOI: 10.1016/j.eclinm.2023.102218] [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: 07/14/2023] [Revised: 08/22/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Background Effective methods of preventing and identifying childhood wasting are required to achieve global child health goals. Family mid-upper arm circumference (MUAC) programs train caregivers to screen their child for wasting with MUAC tapes. We assessed the effectiveness of a two-way short message service (SMS) platform (referred to as the Maternally Administered Malnutrition Monitoring System [MAMMS]) in western Kenya. Methods In this individual-level randomised controlled trial in two rural countries in western Kenya, children (aged 5-12 months) were randomly allocated (1:1) to receive either standard care (SOC) or MAMMS. Randomisation method was permuted-block randomisation with a block size of 10. Eligible participants were children attending maternal child health clinics in the two counties whom had a MUAC between 12.5 and 14.0 cm. The MAMMS group received two MUAC tapes and weekly SMS reminders to screen their child's MUAC. The SOC group received routine community health volunteer services and additional quarterly visits from the study team. The primary analysis used a cox proportional hazards model to compare SOC and MAMMS time-to-diagnosis of wasting (MUAC <12.5 cm) confirmed by a health professional during 6-months follow-up. Secondary outcomes were days from enrolment to treatment initiation among children with wasting, proportion of all children with wasting who were identified by the two approaches (treatment coverage), mean MUAC at treatment initiation, and duration of wasting treatment. This trial was registered on ClinicalTrials.gov, NCT03967015. Findings Between August 1, 2019 and January 31, 2022, 1200 children were enrolled, among whom the incidence of confirmed wasting was 37% lower in the MAMMS group (hazard ratio: 0.63, 95% CI: 0.42-0.94, p = 0.022). Among children with wasting, the median number of days-to-diagnosis was similar between study groups (MAMMS: 63 days [interquartile range (IQR): 23-92], SOC: 58 days [IQR: 22-94]). Treatment coverage in the MAMMS group was 83.3% (95% CI: 39.9-100.0) while coverage in the SOC group was 55.6% (95% CI: 22.3-88.9%, p = 0.300). Treatment duration and mean MUAC at treatment initiation were similar between groups. Interpretation Family MUAC supported by SMS was associated with a 37% reduction in wasting among young children. Empowering caregivers to monitor their child's nutritional status at home may prevent a substantial proportion of moderate wasting. Funding Thrasher Research Foundation and Pamela and Evan Fowler.
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Affiliation(s)
| | - Cathering Achieng
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Mary Masheti
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Maureen Anyango
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Agnes Ndirangu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Emily Yoshioka
- Department of Global Health, University of Washington, Seattle, USA
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
| | | | - Esther M. Choo
- Department of Global Health, University of Washington, Seattle, USA
| | - Keshet Ronen
- Department of Global Health, University of Washington, Seattle, USA
| | | | | | - Benson O. Singa
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
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Rees CA, Igunza KA, Madewell ZJ, Akelo V, Onyango D, El Arifeen S, Gurley ES, Hossain MZ, Rahman A, Alam M, Scott JAG, Assefa N, Madrid L, Belachew A, Leulseged H, Kotloff KL, Sow SO, Tapia MD, Keita AM, Sidibe D, Sitoe A, Varo R, Ajanovic S, Bassat Q, Mandomando I, Tippett Barr BA, Ogbuanu I, Cain CJ, Bassey IA, Luke R, Gassama K, Madhi S, Dangor Z, Mahtab S, Velaphi S, du Toit J, Mutevedzi PC, Blau DM, Breiman RF, Whitney CG. Provider adherence to clinical care recommendations for infants and children who died in seven low- and middle-income countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) network. EClinicalMedicine 2023; 63:102198. [PMID: 37692079 PMCID: PMC10484959 DOI: 10.1016/j.eclinm.2023.102198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Background Most childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children. Methods We conducted a retrospective, descriptive study examining clinical data for children aged 1-59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016-June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration. Findings CHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h. Interpretation Provision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Chris A. Rees
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States of America
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | | | - Zachary J. Madewell
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Victor Akelo
- Centers for Disease Control and Prevention-Kenya, Kisumu, Kenya
| | | | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Emily S. Gurley
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Mohammad Zahid Hossain
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Afruna Rahman
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Muntasir Alam
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Nega Assefa
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lola Madrid
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Anteneh Belachew
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Hararghe Health Research, Haramaya University, Ethiopia
| | - Haleluya Leulseged
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Hararghe Health Research, Haramaya University, Ethiopia
| | - Karen L. Kotloff
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Samba O. Sow
- Centre pour le Développement des Vaccins-Mali, Bamako, Mali
| | - Milagritos D. Tapia
- Department of Pediatrics, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | | | | | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
| | - Rosauro Varo
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Sara Ajanovic
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Inácio Mandomando
- Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique
- ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Moçambique
| | | | | | | | | | - Ronita Luke
- Ministry of Health and Sanitation, Freetown, Sierra Leone
| | | | - Shabir Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Sithembiso Velaphi
- Department of Paediatrics and Child Health, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeanie du Toit
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Portia C. Mutevedzi
- Global Health Institute, Emory University, Atlanta, GA, United States of America
| | - Dianna M. Blau
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States of America
| | - Robert F. Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Cynthia G. Whitney
- Global Health Institute, Emory University, Atlanta, GA, United States of America
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Likoswe BH, Chimera-Khombe B, Patson N, Selemani A, Potani I, Phuka J, Maleta K. A Systematic Review on the Optimal Dose and Duration of Ready-to-Use Therapeutic Food (RUTF) for 6-59-Month-Old Children with Severe Wasting or Oedema. Nutrients 2023; 15:nu15071750. [PMID: 37049590 PMCID: PMC10096907 DOI: 10.3390/nu15071750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
The World Health Organisation (WHO) recommends that severe wasting and/or oedema should be treated with ready-to-use therapeutic food (RUTF) at a dose of 150-220 kcal/kg/day for 6-8 weeks. Emerging evidence suggests that variations of RUTF dosing regimens from the WHO recommendation are not inferior. We aimed to assess the comparative efficacy and effectiveness of different RUTF doses and durations in comparison with the current WHO RUTF dose recommendation for treating severe wasting and/or oedema among 6-59-month-old children. A systematic literature search identified three studies for inclusion, and the outcomes of interest included anthropometric recovery, anthropometric measures and indices, non-response, time to recovery, readmission, sustained recovery, and mortality. The study was registered with PROSPERO, CRD 42021276757. Only three studies were eligible for analysis. There was an overall high risk of bias for two of the studies and some concerns for the third study. Overall, there were no differences between the reduced and standard RUTF dose groups in all outcomes of interest. Despite the finding of no differences between reduced and standard-dose RUTF, the studies are too few to conclusively declare that reduced RUTF dose was more efficacious than standard RUTF.
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Affiliation(s)
- Blessings H Likoswe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Bernadette Chimera-Khombe
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Noel Patson
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Apatsa Selemani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Isabel Potani
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - John Phuka
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
| | - Kenneth Maleta
- Department of Nutrition and Dietetics, School of Global and Public Health, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre 312225, Malawi
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Characterising paediatric mortality during and after acute illness in Sub-Saharan Africa and South Asia: a secondary analysis of the CHAIN cohort using a machine learning approach. EClinicalMedicine 2023; 57:101838. [PMID: 36825237 PMCID: PMC9941052 DOI: 10.1016/j.eclinm.2023.101838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND A better understanding of which children are likely to die during acute illness will help clinicians and policy makers target resources at the most vulnerable children. We used machine learning to characterise mortality in the 30-days following admission and the 180-days after discharge from nine hospitals in low and middle-income countries (LMIC). METHODS A cohort of 3101 children aged 2-24 months were recruited at admission to hospital for any acute illness in Bangladesh (Dhaka and Matlab Hospitals), Pakistan (Civil Hospital Karachi), Kenya (Kilifi, Mbagathi, and Migori Hospitals), Uganda (Mulago Hospital), Malawi (Queen Elizabeth Central Hospital), and Burkina Faso (Banfora Hospital) from November 2016 to January 2019. To record mortality, children were observed during their hospitalisation and for 180 days post-discharge. Extreme gradient boosted models of death within 30 days of admission and mortality in the 180 days following discharge were built. Clusters of mortality sharing similar characteristics were identified from the models using Shapley additive values with spectral clustering. FINDINGS Anthropometric and laboratory parameters were the most influential predictors of both 30-day and post-discharge mortality. No WHO/IMCI syndromes were among the 25 most influential mortality predictors of mortality. For 30-day mortality, two lower-risk clusters (N = 1915, 61%) included children with higher-than-average anthropometry (1% died, 95% CI: 0-2), and children without signs of severe illness (3% died, 95% CI: 2-4%). The two highest risk 30-day mortality clusters (N = 118, 4%) were characterised by high urea and creatinine (70% died, 95% CI: 62-82%); and nutritional oedema with low platelets and reduced consciousness (97% died, 95% CI: 92-100%). For post-discharge mortality risk, two low-risk clusters (N = 1753, 61%) were defined by higher-than-average anthropometry (0% died, 95% CI: 0-1%), and gastroenteritis with lower-than-average anthropometry and without major laboratory abnormalities (0% died, 95% CI: 0-1%). Two highest risk post-discharge clusters (N = 267, 9%) included children leaving against medical advice (30% died, 95% CI: 25-37%), and severely-low anthropometry with signs of illness at discharge (46% died, 95% CI: 34-62%). INTERPRETATION WHO clinical syndromes are not sufficient at predicting risk. Integrating basic laboratory features such as urea, creatinine, red blood cell, lymphocyte and platelet counts into guidelines may strengthen efforts to identify high-risk children during paediatric hospitalisations. FUNDING Bill & Melinda Gates FoundationOPP1131320.
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Diagnostic, Management, and Research Considerations for Pediatric Acute Respiratory Distress Syndrome in Resource-Limited Settings: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S148-S159. [PMID: 36661443 DOI: 10.1097/pcc.0000000000003166] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Diagnosis of pediatric acute respiratory distress syndrome (PARDS) in resource-limited settings (RLS) is challenging and remains poorly described. We conducted a review of the literature to optimize recognition of PARDS in RLS and to provide recommendations/statements for clinical practice and future research in these settings as part of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies related to precipitating factors for PARDS, mechanical ventilation (MV), pulmonary and nonpulmonary ancillary treatments, and long-term outcomes in children who survive PARDS in RLS. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Seventy-seven studies were identified for full-text extraction. We were unable to identify any literature on which to base recommendations. We gained consensus on six clinical statements (good practice, definition, and policy) and five research statements. Clinicians should be aware of diseases and comorbidities, uncommon in most high-income settings, that predispose to the development of PARDS in RLS. Because of difficulties in recognizing PARDS and to avoid underdiagnosis, the PALICC-2 possible PARDS definition allows exclusion of imaging criteria when all other criteria are met, including noninvasive metrics of hypoxemia. The availability of MV support, regular MV training and education, as well as accessibility and costs of pulmonary and nonpulmonary ancillary therapies are other concerns related to management of PARDS in RLS. Data on long-term outcomes and feasibility of follow-up in PARDS survivors from RLS are also lacking. CONCLUSIONS To date, PARDS remains poorly described in RLS. Clinicians working in these settings should be aware of common precipitating factors for PARDS in their patients. Future studies utilizing the PALICC-2 definitions are urgently needed to describe the epidemiology, management, and outcomes of PARDS in RLS.
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Islam MR, Fahim SM, Rasul MG, Raihan MJ, Ali NM, Bulbul MMI, Ahmed T. Health Care Providers' Knowledge, Attitude, and Practice Regarding Facility-Based Management of Children With Severe Acute Malnutrition in Bangladesh. Food Nutr Bull 2022; 43:465-478. [PMID: 35982628 DOI: 10.1177/03795721221116710] [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] [Indexed: 01/10/2023]
Abstract
BACKGROUND Severe acute malnutrition (SAM) contributes to a substantial number of child deaths globally per year. The mortality rates can be lowered markedly if guideline-based management protocol is properly followed. However, case-fatality rates in resource-poor centers remain high even after introducing the guidelines. Perhaps, the lack of adequate knowledge leading to inappropriate management by the health care providers is responsible for such burden. OBJECTIVE We aimed to evaluate health care providers' knowledge, attitude, and practice regarding the facility-based management of children with SAM in Bangladesh. METHODS This was a qualitative study where data were collected cross-sectionally from 4 district and 2 tertiary care hospitals. Twenty-six semi-structured in-depth interviews were conducted among the doctors and nurses involved in inpatient care of SAM. Twenty-eight hours of observation were done in each facility to obtain information regarding the management practices. RESULTS The doctors had substantial knowledge in managing children with SAM in the facilities. However, knowledge of nurses was found suboptimal when evaluated based on the national guideline. Both doctors and nurses demonstrated favorable attitude toward management of childhood SAM. Identification of SAM at the facilities was poor due to lack of practice in relation to anthropometric measurements. In addition, improper practices related to blood glucose testing, dehydration monitoring, essential micronutrient administration, and follow-up of children with SAM were observed. CONCLUSION The study results underscore the importance of taking appropriate measures to enhance knowledge and ensure proper practice in relation to inpatient care of children with SAM according to the national guideline in Bangladesh.
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Affiliation(s)
- Md Ridwan Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shah Mohammad Fahim
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Golam Rasul
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Jyoti Raihan
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nafi Mohammad Ali
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Mofijul Islam Bulbul
- National Nutrition Services, Institute of Public Health Nutrition, Ministry of Health and Family Welfare, Government of Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Office of the Executive Director, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Public Health Nutrition, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Hossain MM, Abdulla F, Rahman A. Prevalence and determinants of wasting of under-5 children in Bangladesh: Quantile regression approach. PLoS One 2022; 17:e0278097. [PMID: 36417416 PMCID: PMC9683614 DOI: 10.1371/journal.pone.0278097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Wasting is perhaps one of the signs of malnutrition that has been linked to the deaths of children suffering from malnutrition. As a result, understanding its correlations and drivers is critical. Using quantile regression analysis, this research aims to contribute to the discussion on under-5 malnutrition by analyzing the predictors of wasting in Bangladesh. METHODS AND MATERIALS The dataset was extracted from the 2017-18 Bangladesh demographic and health survey (BDHS) data. The weight-for-height (WHZ) z-score based anthropometric indicator was used in the study as the target variable. The weighted sample constitutes 8,334 children of under-5 years. However, after cleaning the missing values, the analysis is based on 8,321 children. Sequential quantile regression was used for finding the contributing factors. RESULTS The findings of this study depict that the prevalence of wasting in children is about 8 percent and only approximately one percent of children are severely wasted in Bangladesh. Age, mother's BMI, and parental educational qualification, are all major factors of the WHZ score of a child. The coefficient of the female child increased from 0.1 to 0.2 quantiles before dropping to 0.75 quantile. For a child aged up to three years, the coefficients have a declining tendency up to the 0.5 quantile, then an increasing trend. Children who come from the richest households had 16.3%, 3.6%, and 15.7% higher WHZ scores respectively than children come from the poorest households suggesting that the risk of severe wasting in children under the age of five was lower in children from the wealthiest families than in children from the poorest families. The long-term malnutrition indicator (wasting) will be influenced by the presence of various childhood infections and vaccinations. Furthermore, a family's economic position is a key determinant in influencing a child's WHZ score. CONCLUSIONS It is concluded that socioeconomic characteristics are correlated with the wasting status of a child. Maternal characteristics also played an important role to reduce the burden of malnutrition. Thus, maternal nutritional awareness might reduce the risk of malnutrition in children. Moreover, the findings disclose that to enrich the nutritional status of children along with achieving Sustainable Development Goal (SDG)-3 by 2030, a collaborative approach should necessarily be taken by the government of Bangladesh, and non-governmental organizations (NGOs) at the community level in Bangladesh.
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Affiliation(s)
- Md. Moyazzem Hossain
- Department of Statistics, Jahangirnagar University, Savar, Dhaka, Bangladesh
- School of Mathematics, Statistics & Physics, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail: (MMH); (FA)
| | - Faruq Abdulla
- Department of Applied Health and Nutrition, RTM Al Kabir Technical University (RTM-AKTU), Sylhet, Bangladesh
- * E-mail: (MMH); (FA)
| | - Azizur Rahman
- School of Computing, Mathematics and Engineering, Charles Sturt University, Wagga Wagga, New South Wales, Australia
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Saluja K, Reddy KS, Wang Q, Zhu Y, Li Y, Chu X, Li R, Hou L, Horsley T, Carden F, Bartolomeos K, Hatcher Roberts J. Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review. Health Res Policy Syst 2022; 20:98. [PMID: 36071468 PMCID: PMC9449928 DOI: 10.1186/s12961-022-00899-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/16/2022] [Indexed: 11/20/2022] Open
Abstract
Background WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship. Methods We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.
Results The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines. Conclusions The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines. Supplementary Information The online version contains supplementary material available at 10.1186/s12961-022-00899-y.
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Affiliation(s)
- Kiran Saluja
- Bruyere Research Institute, Ottawa, Canada.,Science Division, World Health Organization, Geneva, Switzerland
| | - K Srikanth Reddy
- Bruyere Research Institute, Ottawa, Canada. .,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada. .,Using Evidence Inc., Ottawa, Canada. .,Science Division, World Health Organization, Geneva, Switzerland.
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Ying Zhu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Yanfei Li
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Xiajing Chu
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Rui Li
- Evidence Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
| | - Tanya Horsley
- Royal College of Physicians and Surgeons of Canada, Ottawa, Canada
| | | | | | - Janet Hatcher Roberts
- WHO Collaborating Centre for Knowledge Translation and Health Impact Assessment in Health Equity, Bruyere Research Institute, University of Ottawa, Ottawa, Canada
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Dale NM, Ashir GM, Maryah LB, Shepherd S, Tomlinson G, Briend A, Zlotkin S, Parshuram C. Development and an initial validation of the Responses to Illness Severity Quantification (RISQ) score for severely malnourished children. Acta Paediatr 2022; 111:1752-1763. [PMID: 35582782 PMCID: PMC9545493 DOI: 10.1111/apa.16410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 12/01/2022]
Abstract
Aim To develop and perform an initial validation of a score to measure the severity of illness in hospitalised children with severe acute malnutrition (SAM). Methods A prospective study enrolled SAM children aged 6–59 months hospitalised in Borno State, Nigeria. Candidate items associated with inpatient mortality were combined and evaluated as candidate scores. Clinical and statistical methods were used to identify a preferred score. Results The 513 children enrolled had a mean age of 15.6 months of whom 48 (9%) died. Seven of the 10 evaluated items were significantly associated with mortality. Five different candidate scores were tested. The final score, Responses to Illness Severity Quantification (RISQ), included seven items: heart rate, respiratory rate, respiratory effort, oxygen saturation, oxygen delivery, temperature and level of consciousness. The mean RISQ score on admission was 2.6 in hospital survivors and 7.3 for children dying <48 h. RISQ scores <24 h before death had an area under the receiver operating characteristic curve (AUROC) of 0.93. The RISQ score performed similarly across differing clinical conditions with AUROCs 0.77–0.98 for all conditions except oedema. Conclusion The RISQ score can identify high‐risk malnourished children at and during hospital admission. Clinical application may help prioritise care and potentially improve survival.
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Affiliation(s)
- Nancy M. Dale
- Centre for Global Child Health, Hospital for Sick Children Toronto Canada
- Child Health Evaluative Sciences SickKids Research Institute Toronto Canada
- Center for Safety Research Toronto Ontario Canada
- Tampere Center for Child, Adolescent, and Maternal Health Research: Global Health Group University of Tampere Tampere Finland
| | - Garba Mohammed Ashir
- Department of Pediatrics University of Maiduguri Teaching Hospital Maiduguri Nigeria
| | - Lawan Bukar Maryah
- Department of Pediatrics University of Maiduguri Teaching Hospital Maiduguri Nigeria
| | | | | | - André Briend
- Tampere Center for Child, Adolescent, and Maternal Health Research: Global Health Group University of Tampere Tampere Finland
- Department of Nutrition, Exercise and Sports, Faculty of Science University of Copenhagen Frederiksberg Denmark
| | - Stanley Zlotkin
- Centre for Global Child Health, Hospital for Sick Children Toronto Canada
- Child Health Evaluative Sciences SickKids Research Institute Toronto Canada
- Department of Paediatrics Hospital for Sick Children and University of Toronto Toronto Canada
| | - Christopher Parshuram
- Child Health Evaluative Sciences SickKids Research Institute Toronto Canada
- Center for Safety Research Toronto Ontario Canada
- Department of Critical Care Medicine Hospital for Sick Children Toronto Canada
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Barratt MJ, Nuzhat S, Ahsan K, Frese SA, Arzamasov AA, Sarker SA, Islam MM, Palit P, Islam MR, Hibberd MC, Nakshatri S, Cowardin CA, Guruge JL, Byrne AE, Venkatesh S, Sundaresan V, Henrick B, Duar RM, Mitchell RD, Casaburi G, Prambs J, Flannery R, Mahfuz M, Rodionov DA, Osterman AL, Kyle D, Ahmed T, Gordon JI. Bifidobacterium infantis treatment promotes weight gain in Bangladeshi infants with severe acute malnutrition. Sci Transl Med 2022; 14:eabk1107. [PMID: 35417188 PMCID: PMC9516695 DOI: 10.1126/scitranslmed.abk1107] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Disrupted development of the gut microbiota is a contributing cause of childhood malnutrition. Bifidobacterium longum subspecies infantis is a prominent early colonizer of the infant gut that consumes human milk oligosaccharides (HMOs). We found that the absolute abundance of Bifidobacterium infantis is lower in 3- to 24-month-old Bangladeshi infants with severe acute malnutrition (SAM) compared to their healthy age-matched counterparts. A single-blind, placebo-controlled trial (SYNERGIE) was conducted in 2- to 6-month-old Bangladeshi infants with SAM. A commercial U.S. donor-derived B. infantis strain (EVC001) was administered daily with or without the HMO lacto-N-neotetraose for 28 days. This intervention increased fecal B. infantis abundance in infants with SAM, although to levels still 10- to 100-fold lower than in untreated healthy controls. EVC001 treatment promoted weight gain that was associated with reduced intestinal inflammation markers in infants with SAM. We cultured fecal B. infantis strains from Bangladeshi infants and colonized gnotobiotic mice with these cultured strains. The gnotobiotic mice were fed a diet representative of that consumed by 6-month-old Bangladeshi infants, with or without HMO supplementation. One B. infantis strain, Bg_2D9, expressing two gene clusters involved in uptake and utilization of N-glycans and plant-derived polysaccharides, exhibited superior fitness over EVC001. The fitness advantage of Bg_2D9 was confirmed in a gnotobiotic mouse model of mother-to-infant gut microbiota transmission where dams received a pretreatment fecal community from a SAM infant in the SYNERGIE trial. Whether Bg_2D9 is superior to EVC001 for treating malnourished infants who consume a diet with limited breastmilk requires further clinical testing.
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Affiliation(s)
- Michael J. Barratt
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Sharika Nuzhat
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Kazi Ahsan
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Steven A. Frese
- Evolve BioSystems, Inc., Davis, CA 95618 USA
- Department of Food Science and Technology, University of Nebraska, Lincoln, NE 68588 USA
| | - Aleksandr A. Arzamasov
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
| | - Shafiqul Alam Sarker
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - M. Munirul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Parag Palit
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Md Ridwan Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Matthew C. Hibberd
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Swetha Nakshatri
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Carrie A. Cowardin
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Janaki L. Guruge
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Alexandra E. Byrne
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Siddarth Venkatesh
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Vinaik Sundaresan
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
| | - Bethany Henrick
- Evolve BioSystems, Inc., Davis, CA 95618 USA
- Department of Food Science and Technology, University of Nebraska, Lincoln, NE 68588 USA
| | | | | | | | | | | | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Dmitry A. Rodionov
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
- A.A. Kharkevich Institute for Information Transmission Problems, Russian Academy of Sciences, Moscow 127994 Russia
| | - Andrei L. Osterman
- Infectious and Inflammatory Disease Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037 USA
| | - David Kyle
- Evolve BioSystems, Inc., Davis, CA 95618 USA
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka 1212, Bangladesh
| | - Jeffrey I. Gordon
- Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO 63110 USA
- Center for Gut Microbiome and Nutrition Research, Washington University School of Medicine, St. Louis, MO 63110 USA
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO 63110 USA
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Optimizing prevention and community-based management of severe malnutrition in children. PLoS Med 2022; 19:e1003924. [PMID: 35231022 PMCID: PMC8887723 DOI: 10.1371/journal.pmed.1003924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Zulfiqar A. Bhutta discusses prevention and treatment strategies for optimization of community-based management of severe acute malnutrition in children.
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Wen B, Njunge JM, Bourdon C, Gonzales GB, Gichuki BM, Lee D, Wishart DS, Ngari M, Chimwezi E, Thitiri J, Mwalekwa L, Voskuijl W, Berkley JA, Bandsma RHJ. Systemic inflammation and metabolic disturbances underlie inpatient mortality among ill children with severe malnutrition. SCIENCE ADVANCES 2022; 8:eabj6779. [PMID: 35171682 PMCID: PMC8849276 DOI: 10.1126/sciadv.abj6779] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/23/2021] [Indexed: 06/14/2023]
Abstract
Children admitted to hospital with an acute illness and concurrent severe malnutrition [complicated severe malnutrition (CSM)] have a high risk of dying. The biological processes underlying their mortality are poorly understood. In this case-control study nested within a multicenter randomized controlled trial among children with CSM in Kenya and Malawi, we found that blood metabolomic and proteomic profiles robustly differentiated children who died (n = 92) from those who survived (n = 92). Fatalities were characterized by increased energetic substrates (tricarboxylic acid cycle metabolites), microbial metabolites (e.g., propionate and isobutyrate), acute phase proteins (e.g., calprotectin and C-reactive protein), and inflammatory markers (e.g., interleukin-8 and tumor necrosis factor-α). These perturbations indicated disruptions in mitochondria-related bioenergetic pathways and sepsis-like responses. This study identified specific biomolecular disturbances associated with CSM mortality, revealing that systemic inflammation and bioenergetic deficits are targetable pathophysiological processes for improving survival of this vulnerable population.
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Affiliation(s)
- Bijun Wen
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | - James M. Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Celine Bourdon
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Bonface M. Gichuki
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Dorothy Lee
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
| | | | - Moses Ngari
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Laura Mwalekwa
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, Netherlands
- Department of Pediatrics, the College of Medicine, University of Malawi, Blantyre, Malawi
| | - James A. Berkley
- The Childhood Acute Illness & Nutrition 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
| | - Robert HJ Bandsma
- Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
- Department of Translational medicine, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- Department of Pediatrics, the College of Medicine, University of Malawi, Blantyre, Malawi
- Department of Biomedical Sciences, the College of Medicine, University of Malawi, Blantyre, Malawi
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Bitew ZW, Ayele EG, Worku T, Alebel A, Alemu A, Worku F, Yesuf A. Determinants of mortality among under-five children admitted with severe acute malnutrition in Addis Ababa, Ethiopia. Nutr J 2021; 20:94. [PMID: 34930311 PMCID: PMC8691009 DOI: 10.1186/s12937-021-00750-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Management of severe acute malnutrition (SAM) has been a program priority in Ethiopia, but it remains the leading cause of mortality in under-five children. Hence, this study aimed to identify the incidence density rate of mortality and determinants among under-five children with severe acute malnutrition in St. Paul's Hospital Millennium Medical College, 2012 to 2019. METHODS A retrospective cohort study was conducted and data were collected using a structured checklist from 673 charts, of which 610 charts were included in the final analysis. The Kaplan-Meier survival curve with Log-rank test was used to estimate the survival time. Bi-variable and multi-variable Cox proportional hazard regression models were fitted to identify determinants of death. Schoenfeld residuals test was used to check a proportional hazard assumption. Goodness of fit of the final model was checked using Nelson Aalen cumulative hazard function against Cox-Snell residual. RESULTS In this study, 61 (10%) children died making the incidence density rate of death 5.6 (95% CI: 4.4, 7.2) per 1000 child-days. Shock (Adjusted Hazard Ratio) [AHR] =3.2; 95% CI: 1.6, 6.3)), IV fluid infusion (AHR = 5.2; 95% CI: 2.4, 10.4), supplementing F100 (AHR = 0.12; 95%CI: 0.06, 0.23) and zinc (AHR = 0.45; 95% CI: 0.22, 0.93) were determinants of death. CONCLUSION The overall proportion of deaths was within the range put forth by the Sphere standard and the national SAM management protocol. Shock and IV fluid infusion increased the hazard of death, whereas F100 & zinc were found to decrease the likelihood death. Children with SAM presented with shock should be handled carefully and IV fluids should be given with precautions.
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Affiliation(s)
- Zebenay Workneh Bitew
- St. Paul's Hospital Millennium Medical College, P.O. Box 1271, Addis Ababa, Ethiopia.
| | - Ermias Getaneh Ayele
- St. Paul's Hospital Millennium Medical College, P.O. Box 1271, Addis Ababa, Ethiopia
| | - Teshager Worku
- College of Health and Medical Sciences, School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
| | - Animut Alebel
- College of Health Science, Debre Markos University, Debre Markos, Ethiopia
| | | | - Frehiwot Worku
- Millennium Medical College, Department of Public Health, St. Paul's Hospital, Addis Ababa, Ethiopia
| | - Aman Yesuf
- Millennium Medical College, Department of Public Health, St. Paul's Hospital, Addis Ababa, Ethiopia
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16
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Das K, Das S, Mohapatra S, Swain A, Mohakud NK. Risk and Adverse Outcome Factors of Severe Acute Malnutrition in Children: A Hospital-Based Study in Odisha. Cureus 2021; 13:e18364. [PMID: 34737917 PMCID: PMC8557996 DOI: 10.7759/cureus.18364] [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] [Accepted: 09/28/2021] [Indexed: 11/05/2022] Open
Abstract
Background Malnutrition is prevalent in 41% of children less than five years old in developing countries. Objective To determine the clinical spectrum, identify the risk factors, and find out the factors responsible for the adverse outcomes of severe acute malnutrition (SAM) in children. Methods In this prospective cohort, children aged one month to five years with SAM from October 2016 to September 2018 were enrolled. Clinical profile, contributing factors, treatment, and outcome of cases (n=198) were noted. Results SAM was diagnosed in 323 (1.6%) of admitted cases. The unimmunized children were 123 (62.1%). Common co-morbidities were acute gastroenteritis (n=89, 44.9%), respiratory tract infection (n=88, 44.4%), and septicemia (n=54, 26.7%). Children not on exclusive breastfeeding (n=157, 79.1%), early complementary feeding (<6 months) (n=157, 88.2%), bottle-feeding (n=138, 77.55%), low birth weight (157, 79.1%), living in kutcha houses (115, 58.2%), and unavailability of safe drinking water (131, 66.4%) were the significant risk factors. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes. One hundred and eighty-three (92.4%) children were cured and discharged and 15 (7.6%) children died. Conclusions Wrong feeding practices and unavailability of safe drinking water have an important bearing on the development of SAM children. Pneumonia, diarrhea, nutritional edema, hypothermia, and circulatory shock at the time of admission were responsible for adverse outcomes.
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Affiliation(s)
- Kedarnath Das
- Paediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Swarnalata Das
- Paediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
| | | | - Arakhita Swain
- Paediatrics, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, IND
| | - Nirmal K Mohakud
- Paediatrics, Kalinga Institute of Medical Sciences, Bhubaneswar, IND
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17
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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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Hojsak I, Chourdakis M, Gerasimidis K, Hulst J, Huysentruyt K, Moreno-Villares JM, Joosten K. What are the new guidelines and position papers in pediatric nutrition: A 2015-2020 overview. Clin Nutr ESPEN 2021; 43:49-63. [PMID: 34024560 DOI: 10.1016/j.clnesp.2021.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Nutrition related publications in pediatric population cover wide range of topics and therefore it is usually difficult for clinicians to get an overview of recent nutrition related guidelines or recommendations. METHODS The Special Interest Group (SIG) of Pediatrics of European Society for Clinical Nutrition and Metabolism (ESPEN) performed a literature search to capture publications in the last five years aiming to provide the latest information concerning nutritional issues in children in general and in specific diseases and to discuss progression in the field of pediatric nutrition evidence-based practice. RESULTS Eight major topics were identified as the most frequently reported including allergy, critical illness, neonatal nutrition, parenteral and enteral nutrition, micronutrients, probiotics and malnutrition. Furthermore, it was noted that many reports were disease focused or included micronutrients and were, therefore, represented as tables. CONCLUSION Overall, it has been shown that most reports on nutrition topics in pediatrics were systematic reviews or guidelines/position papers of relevant societies, but many of them basing the conclusion on a limited number of high-quality randomized controlled trials or large observational cohort studies.
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Affiliation(s)
- Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Croatia; University J.J. Strossmayer Medical School, Osijek, Croatia.
| | - Michael Chourdakis
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece.
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, College of Medicine, Veterinary and Life Sciences, Royal Hospital for Sick Children, University of Glasgow, Glasgow, United Kingdom.
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics and Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Koen Huysentruyt
- Department of Pediatric Gastroenterology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | | | - Koen Joosten
- Department of Pediatric Intensive Care, Sophia Children's Hospital - Erasmus Medical Center, Rotterdam, the Netherlands.
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19
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Annan RA, Aduku LNE, Kyei-Boateng S, Yuen HM, Pickup T, Pulman A, Monroy-Valle M, Ashworth A, Jackson AA, Choi S. Implementing effective eLearning for scaling up global capacity building: findings from the malnutrition elearning course evaluation in Ghana. Glob Health Action 2020; 13:1831794. [PMID: 33086945 PMCID: PMC7595220 DOI: 10.1080/16549716.2020.1831794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 09/29/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Global demand for capacity building has increased interest for eLearning. As eLearning resources become more common, effective implementation is required to scale up utilization in Low- and Middle-Income Countries (LMICs). OBJECTIVE This paper describes the process of implementing a malnutrition eLearning course, effectiveness of course delivery models devised, factors affecting course completion, and cost comparison between the models and face-to-face training at healthcare and academic institutions in Ghana. METHODS Four delivery models: Mobile Training Centre (MTC), Online Delivery (OD), Institutional Computer Workstation (ICW) and Mixed Delivery (MD) - a combination of OD and ICW - were determined. Participants were enabled to access the course using one of the four models where contextually appropriate. Pre and post-assessments and questionnaires were administered to compare participants' course completion status and knowledge gain between delivery models. The effect of access to computer and Internet at home and relevance of course to job and academic progression on course completion were further investigated. Comparison of delivery model costs against face-to-face training was also undertaken. RESULTS Of 7 academic and 9 healthcare institutions involving 915 people, 9 used MTC (34.8%), 3 OD (18.8%), 3 ICW (34.2%) and 1 MD (12.2%). Course completion was higher among institutions where the course was relevant to job or implemented as part of required curriculum activities. Knowledge gain was significant among most participants, but higher among those who found the course relevant to job or academic progression. The implementation costs per participant for training with MTC were £51.0, OD £2.2, ICW £1.2 and MD £1.1, compared with a face-to-face training estimate of £105.0 (1 GHS = 0.14 GBP). CONCLUSION The malnutrition eLearning course makes global capacity building in malnutrition management achievable. Adopting contextually appropriate delivery models and ensuring training is relevant to job/academic progression can enhance eLearning effectiveness in LMICs.
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Affiliation(s)
- Reginald Adjetey Annan
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), PMB University Post Office, Kumasi, Ghana
| | - Linda Nana Esi Aduku
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), PMB University Post Office, Kumasi, Ghana
| | - Samuel Kyei-Boateng
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology (KNUST), PMB University Post Office, Kumasi, Ghana
| | - Ho Ming Yuen
- Faculty of Medicine, University of Southampton, Level B, South Academic Block, Southampton General Hospital, Southampton, UK
| | - Trevor Pickup
- Faculty of Medicine, University of Southampton, Level B, South Academic Block, Southampton General Hospital, Southampton, UK
| | - Andy Pulman
- Faculty of Medicine, University of Southampton, Level B, South Academic Block, Southampton General Hospital, Southampton, UK
| | - Michele Monroy-Valle
- Facultad de Ciencias de la Salud, Universidad Rafael Landívar, Ciudad de Guatemala, Guatemala
| | - Ann Ashworth
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Alan A. Jackson
- Faculty of Medicine, University of Southampton, Level B, South Academic Block, Southampton General Hospital, Southampton, UK
| | - Sunhea Choi
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
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20
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Bourdon C, Bartels RH, Chimwezi E, Kool J, Chidzalo K, Perot L, Brals D, Bandsma RHJ, Boele van Hensbroek M, Voskuijl WP. The clinical use of longitudinal bio-electrical impedance vector analysis in assessing stabilization of children with severe acute malnutrition. Clin Nutr 2020; 40:2078-2090. [PMID: 33097306 DOI: 10.1016/j.clnu.2020.09.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Severe Acute Malnutrition (SAM) in children is determined using anthropometry. However, bio-electrical impedance (BI) analysis could improve the estimation of altered body composition linked to edema and/or loss of lean body mass in children with SAM. We aimed to assess: 1) the changes in BI parameters during clinical stabilization and 2) whether BI parameters add prognostic value for clinical outcome beyond the use of anthropometry. METHODS This prospective observational study enrolled children, aged 6-60 months, that were admitted at Queen Elizabeth Central Hospital in Blantyre, Malawi, for complicated SAM (i.e., having either severe wasting or edematous SAM with a complicating illness). Height, weight, mid-upper arm circumference (MUAC), and BI were measured on admission and after clinical stabilization. BI measures were derived from height-adjusted indices of resistance (R/H), reactance (Xc/H), and phase angle (PA) and considered to reflect body fluids and soft tissue in BI vector analysis (BIVA). RESULTS We studied 183 children with SAM (55% edematous; age 23.0 ± 12.0 months; 54% male) and 42 community participants (age 20.1 ± 12.3 months; male 62%). Compared to community participants, the BIVA of children with edematous SAM were short with low PA and positioned low on the hydration axis which reflects severe fluid retention. In contrast, children with severe wasting had elongated vectors with a PA that was higher than children with edematous SAM but lower than community participants. Their BIVA position fell within the top right quadrant linked to leanness and dehydration. BIVA from severely wasted and edematous SAM patients differed between groups and from community children both at admission and after stabilization (p < 0.001). Vector position shifted during treatment only in children with edematous SAM (p < 0.001) and showed a upward translation suggestive of fluid loss. While PA was lower in children with SAM, PA did not contribute more than anthropometry alone towards explaining mortality, length of stay, or time-to-discharge or time-to-mortality. The variability and heterogeneity in BI measures was high and their overall added predictive value for prognosis of individual children was low. CONCLUSIONS BIVA did not add prognostic value over using anthropometry alone to predict clinical outcome. Several implementation challenges need to be optimized. Thus, in low-resource settings, the routine use of BI in the management of pediatric malnutrition is questionable without improved implementation.
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Affiliation(s)
- Céline Bourdon
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
| | - Rosalie H Bartels
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Emmanuel Chimwezi
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Jacintha Kool
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Katherine Chidzalo
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Lyric Perot
- Woodrow Wilson School of Public and International Affairs, Princeton University, NJ, USA
| | - Daniella Brals
- Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | - Robert H J Bandsma
- Translational Medicine Program, The Hospital for Sick Children, Toronto, Canada; The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Michael Boele van Hensbroek
- Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Wieger P Voskuijl
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya; Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherlands; Department of Pediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi; Amsterdam Institute for Global Health and Development, Department of Global Health, Amsterdam University Medical Centres, Amsterdam, the Netherlands
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21
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Gonzales GB, Njunge JM, Gichuki BM, Wen B, Potani I, Voskuijl W, Bandsma RHJ, Berkley JA. Plasma proteomics reveals markers of metabolic stress in HIV infected children with severe acute malnutrition. Sci Rep 2020; 10:11235. [PMID: 32641735 PMCID: PMC7343797 DOI: 10.1038/s41598-020-68143-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 06/17/2020] [Indexed: 01/20/2023] Open
Abstract
HIV infection affects up to 30% of children presenting with severe acute malnutrition (SAM) in Africa and is associated with increased mortality. Children with SAM are treated similarly regardless of HIV status, although mechanisms of nutritional recovery in HIV and/or SAM are not well understood. We performed a secondary analysis of a clinical trial and plasma proteomics data among children with complicated SAM in Kenya and Malawi. Compared to children with SAM without HIV (n = 113), HIV-infected children (n = 54) had evidence (false discovery rate (FDR) corrected p < 0.05) of metabolic stress, including enriched pathways related to inflammation and lipid metabolism. Moreover, we observed reduced plasma levels of zinc-α-2-glycoprotein, butyrylcholinesterase, and increased levels of complement C2 resembling findings in metabolic syndrome, diabetes and other non-communicable diseases. HIV was also associated (FDR corrected p < 0.05) with higher plasma levels of inflammatory chemokines. Considering evidence of biomarkers of metabolic stress, it is of potential concern that our current treatment strategy for SAM regardless of HIV status involves a high-fat therapeutic diet. The results of this study suggest a need for clinical trials of therapeutic foods that meet the specific metabolic needs of children with HIV and SAM.
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Affiliation(s)
- Gerard Bryan Gonzales
- Department of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. .,VIB Inflammation Research Centre, Ghent, Belgium.
| | - James M Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bonface M Gichuki
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bijun Wen
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Isabel Potani
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,Global Child Health Group, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands.,Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Robert H J Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - James A Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya.,Nuffield Department of Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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22
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Gavhi F, Kuonza L, Musekiwa A, Motaze NV. Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study. PLoS One 2020; 15:e0232838. [PMID: 32384106 PMCID: PMC7209205 DOI: 10.1371/journal.pone.0232838] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
Background In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa. Methods We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality. Findings We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9–19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4–3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4–5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9–4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2–2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1–5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1–21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6–3.3, p<0.001). Interpretation Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.
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Affiliation(s)
- Fhatuwani Gavhi
- Division of the National Health Laboratory Service, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- * E-mail:
| | - Lazarus Kuonza
- Division of the National Health Laboratory Service, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
- School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Alfred Musekiwa
- School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Nkengafac Villyen Motaze
- Division of the National Health Laboratory Service, National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Frison S, Angood C, Khara T, Bahwere P, Black RE, Briend A, Connell N, Fenn B, Isanaka S, James P, Kerac M, Mayberry A, Myatt M, Dolan C. Prevention of child wasting: Results of a Child Health & Nutrition Research Initiative (CHNRI) prioritisation exercise. PLoS One 2020; 15:e0228151. [PMID: 32049994 PMCID: PMC7015423 DOI: 10.1371/journal.pone.0228151] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 01/09/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas. METHOD A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions. FINDINGS The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention. DISCUSSION These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting. CONCLUSION This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.
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Affiliation(s)
- Severine Frison
- Emergency Nutrition Network, Oxford, United Kingdom
- Department of Infectious Disease and Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Chloe Angood
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Tanya Khara
- Emergency Nutrition Network, Oxford, United Kingdom
| | | | - Robert E. Black
- Institute for International Programs, Bloomsbury School of Public Health, Johns Hopkins University, Baltimore, United States of America
| | - André Briend
- Center for Child Health Research, Tampere University, Tampere, Finland
| | - Nicki Connell
- Eleanor Crook Foundation, Washington DC, United States of America
| | - Bridget Fenn
- Emergency Nutrition Network, Oxford, United Kingdom
| | - Sheila Isanaka
- Department of Nutrition, Harvard School of Public Health, Boston, United States of America
- Department of Global Health and Population, Harvard School of Public Health, Boston, United States of America
- Department of Research, Epicentre, Paris, France
| | - Philip James
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amy Mayberry
- No Wasted Lives and Action Against Hunger UK, London, United Kingdom
| | - Mark Myatt
- Brixton Health, Llwyngwril Gwynedd, United Kingdom
| | - Carmel Dolan
- Emergency Nutrition Network, Oxford, United Kingdom
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Choi S, Yuen HM, Annan R, Monroy-Valle M, Pickup T, Aduku NEL, Pulman A, Portillo Sermeño CE, Jackson AA, Ashworth A. Improved care and survival in severe malnutrition through eLearning. Arch Dis Child 2020; 105:32-39. [PMID: 31362946 PMCID: PMC6951232 DOI: 10.1136/archdischild-2018-316539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 06/12/2019] [Accepted: 07/13/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Scaling up improved management of severe acute malnutrition (SAM) has been identified as the nutrition intervention with the greatest potential to reduce child mortality but it requires improved operational capacity. OBJECTIVE To investigate whether an eLearning course, which can be used at scale in resource-poor countries, leads to improved diagnosis, clinical management and survival of children with SAM. DESIGN A 2-year preintervention and postintervention study between January 2015 and February 2017. SETTING Eleven healthcare facilities: nine in Ghana, one in Guatemala, and one in El Salvador. INTERVENTION Scenario-based eLearning course 'Caring for infants and young children with severe malnutrition'. MAIN OUTCOME MEASURES Identification of children with SAM, quality of care, case-fatality rate. METHODS Medical record reviews of children aged 0-60 months attending eleven hospitals between August 2014 and July 2016, observations in paediatric wards, and interviews with senior hospital personnel. RESULTS Postintervention there was a significant improvement in the identification of SAM: more children had the requisite anthropometric data (34.9% (1300/3723) vs 15.9% (629/3953)) and more were correctly diagnosed (58.5% (460/786) vs 47.1% (209/444)). Improvements were observed in almost all aspects of the WHO 'Ten Steps' of case-management, and case-fatality fell from 5.8% (26/449) to 1.9% (14/745) (Post-pre difference=-3.9%, 95% CI -6.6 to -1.7, p<0.001). CONCLUSIONS High quality, interactive eLearning can be an effective intervention in scaling up capacity building of health professionals to manage SAM effectively, leading to a reduction in mortality.
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Affiliation(s)
- Sunhea Choi
- Human Development and Health, University of Southampton, Southampton, UK
| | - Ho Ming Yuen
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Reginald Annan
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Michele Monroy-Valle
- Facultad de Ciencias de la Salud, Universidad Rafael Landivar, Guatemala City, Guatemala
| | - Trevor Pickup
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nana Esi Linda Aduku
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Andy Pulman
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Carmen Elisa Portillo Sermeño
- Department of Nutrition and Diets, Hospital Nacional General “Dr. Juan José Fernandez” Zacamil, San Salvador, El Salvador
| | - Alan A Jackson
- National Institutes for Health Research Biomedical Research Centre, University of Southampton, Southampton, UK
| | - Ann Ashworth
- Department of Population Health, London School of Hygiene Tropical Medicine, London, UK
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Zangenberg M, Abdissa A, Johansen ØH, Tesfaw G, Girma T, Kurtzhals JAL. Metronidazole-sensitive organisms in children with severe acute malnutrition: an evaluation of the indication for empiric metronidazole treatment. Clin Microbiol Infect 2019; 26:255.e7-255.e11. [PMID: 31185294 DOI: 10.1016/j.cmi.2019.05.022] [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] [Received: 02/22/2019] [Revised: 05/13/2019] [Accepted: 05/25/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Children with severe acute malnutrition (SAM) are treated with empiric amoxicillin or penicillin and gentamicin because of the high risk of severe infections. Experts have suggested, based on available evidence, adding metronidazole to cover anaerobic bacteraemia and diarrhoea caused by Giardia duodenalis or Clostridium difficile. The objective of this study was to assess the importance of these infections in children with SAM. METHODS Children from 6 months to 15 years with SAM were enrolled and followed clinically. Aerobic and, when patient weight permitted, anaerobic blood cultures were done using Bactec® system, and isolates identified with matrix-assisted laser desorption ionization-time of flight mass spectrometry. Stool samples were tested for C. difficile, G. duodenalis and Entamoeba histolytica by PCR. RESULTS A total of 334 children were enrolled and 174 out of 331 (53%) for which data on this was available had diarrhoea. Of 273 patients tested by blood culture, 11 had bacteraemia (4.0%, 95% CI 2.3-7.1%) but none with strict anaerobic bacteria (0/153, 95% CI 0-2.4%). There was no difference in the prevalence of C. difficile between children with (5/128, 4%) and without (7/87, 8%) diarrhoea (OR 0.47, 95% CI 0.14-1.53), and no difference in the prevalence of Giardia between these groups (78/138, 60% vs. 46/87, 53%; OR 1.34, 95% CI 0.77-2.32). Children with C. difficile had higher mortality than those without this infection (3/11, 27%, vs. 7/186, 4%; OR 43, 95% CI 3.9-483). CONCLUSION Our results do not provide support for empiric metronidazole to cover for anaerobic bacteraemia. Trials evaluating the effect of empiric treatment and its effect on G. duodenalis and C. difficile are warranted.
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Affiliation(s)
- M Zangenberg
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Denmark; Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark.
| | - A Abdissa
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Ethiopia
| | - Ø H Johansen
- Department of Clinical Science, University of Bergen, Norway; Department of Microbiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - G Tesfaw
- Department of Medical Laboratory Sciences and Pathology, Jimma University, Ethiopia
| | - T Girma
- Department of Paediatrics and Child Health, Faculty of Medical Sciences, Jimma University, Ethiopia
| | - J A L Kurtzhals
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen, Denmark; Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
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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: 13] [Impact Index Per Article: 2.6] [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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Bandsma RHJ, Voskuijl W, Chimwezi E, Fegan G, Briend A, Thitiri J, Ngari M, Mwalekwa L, Bandika V, Ali R, Hamid F, Owor B, Mturi N, Potani I, Allubha B, Muller Kobold AC, Bartels RH, Versloot CJ, Feenstra M, van den Brink DA, van Rheenen PF, Kerac M, Bourdon C, Berkley JA. A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial. PLoS Med 2019; 16:e1002747. [PMID: 30807589 PMCID: PMC6390989 DOI: 10.1371/journal.pmed.1002747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 01/18/2019] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Robert H. J. Bandsma
- Division of Gastroenterology, Hepatology and Nutrition, Hospital for Sick Children, Toronto, Canada
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
- Department of Nutrition Sciences, University of Toronto, Toronto, Canada
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - Wieger Voskuijl
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Emmanuel Chimwezi
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Greg Fegan
- Swansea Trials Unit, Swansea University Medical School, Swansea, United Kingdom
| | - André Briend
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
- University of Tampere School of Medicine, Center for Child Health Research, Tampere, Finland
| | | | - Moses Ngari
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | | | - Victor Bandika
- Department of Paediatrics, Coast General Hospital, Mombasa, Kenya
| | - Rehema Ali
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Fauzat Hamid
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Betty Owor
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Neema Mturi
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Benjamin Allubha
- Department of Paediatrics and Child Health College of Medicine, University of Malawi, Blantyre, Malawi
| | - Anneke C. Muller Kobold
- University of Groningen, University Medical Center Groningen, Department of Laboratory Medicine, Groningen, the Netherlands
| | - Rosalie H. Bartels
- Global Child Health Group, Emma Children’s Hospital, Academic Medical Centre, Amsterdam, the Netherlands
| | - Christian J. Versloot
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marjon Feenstra
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Deborah A. van den Brink
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Patrick F. van Rheenen
- University of Groningen, University Medical Center Groningen, Department of Pediatrics, Groningen, the Netherlands
| | - Marko Kerac
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Celine Bourdon
- Translational Medicine Program, Hospital for Sick Children, Toronto, Canada
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
| | - James A. Berkley
- The Childhood Acute Illness and Nutrition Network (CHAIN), Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
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Opoka RO, Ssemata AS, Oyang W, Nambuya H, John CC, Karamagi C, Tumwine JK. Adherence to clinical guidelines is associated with reduced inpatient mortality among children with severe anemia in Ugandan hospitals. PLoS One 2019; 14:e0210982. [PMID: 30682097 PMCID: PMC6347145 DOI: 10.1371/journal.pone.0210982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/04/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In resource limited settings, there is variability in the level of adherence to clinical guidelines in the inpatient management of children with common conditions like severe anemia. However, there is limited data on the effect of adherence to clinical guidelines on inpatient mortality in children managed for severe anemia. METHODS We analyzed data from an uncontrolled before and after in-service training intervention to improve quality of care in Lira and Jinja regional referral hospitals in Uganda. Inpatient records of children aged 0 to 5 years managed as cases of 'severe anemia (SA)' were reviewed to ascertain adherence to clinical guidelines and compare inpatient deaths in SA children managed versus those not managed according to clinical guidelines. Logistic regression analysis was conducted to evaluate the relationship between clinical care factors and inpatient deaths amongst patients managed for SA. RESULTS A total of 1,131 children were assigned a clinical diagnosis of 'severe anemia' in the two hospitals. There was improvement in the level of care after the in-service training intervention with more children being managed according to clinical guidelines compared to the period before, 218/510 (42.7%) vs 158/621 (25.4%) (p < 0.001). Overall, children managed according to clinical guidelines had reduced risk of inpatient mortality compared to those not managed according to clinical guidelines, [OR 0.28, (95%, CI 0.14, 0.55), p = 0.001]. Clinical care factors associated with decreased risk of inpatient death included, having pre-transfusion hemoglobin done to confirm diagnosis [OR 0.5; 95% CI 0.29, 0.87], a co-morbid diagnosis of severe malaria [OR 0.4; 95% CI 0.25, 0.76], and being reviewed after admission by a clinician [OR 0.3; 95% CI 0.18, 0.59], while a co-morbid diagnosis of severe acute malnutrition was associated with increased risk of inpatient death [OR 4.2; 95% CI 2.15, 8.22]. CONCLUSION Children with suspected SA who are managed according to clinical guidelines have lower in-hospital mortality than those not managed according to the guidelines. Efforts to reduce inpatient mortality in SA children in resource-limited settings should focus on training and supporting health workers to adhere to clinical guidelines.
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Affiliation(s)
- Robert O. Opoka
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew S. Ssemata
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Oyang
- Children’s Ward, Lira Regional Referral Hospital, Lira, Uganda
| | - Harriet Nambuya
- Nalufenya Children’s Ward, Jinja Regional Referral Hospital, Jinja, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Charles Karamagi
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - James K. Tumwine
- Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
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29
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Choi S, Yuen HM, Annan R, Pickup T, Pulman A, Monroy-Valle M, Aduku NEL, Kyei-Boateng S, Velásquez Monzón CI, Portillo Sermeño CE, Penn A, Ashworth A, Jackson AA. Effectiveness of the Malnutrition eLearning Course for Global Capacity Building in the Management of Malnutrition: Cross-Country Interrupted Time-Series Study. J Med Internet Res 2018; 20:e10396. [PMID: 30282620 PMCID: PMC6231886 DOI: 10.2196/10396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 01/18/2023] Open
Abstract
Background Scaling up improved management of severe acute malnutrition has been identified as the nutrition intervention with the largest potential to reduce child mortality, but lack of operational capacity at all levels of the health system constrains scale-up. We therefore developed an interactive malnutrition eLearning course that is accessible at scale to build capacity of the health sector workforce to manage severely malnourished children according to the guidelines of the World Health Organization. Objective The aim of this study was to test whether the malnutrition eLearning course improves knowledge and skills of in-service and preservice health professionals in managing children with severe acute malnutrition and enables them to apply the gained knowledge and skills in patient care. Methods This 2-year prospective, longitudinal, cross-country, interrupted time-series study took place in Ghana, Guatemala, El Salvador, and Colombia between January 2015 and February 2017. A subset of 354 in-service health personnel from 12 hospitals and 2 Ministries of Health, 703 preservice trainees from 9 academic institutions, and 204 online users participated. Knowledge gained after training and retention over time was measured through pre- and postassessments comprising questions pertaining to screening, diagnosis, pathophysiology and treatment, and prevention of malnutrition. Comprehension, application, and integration of knowledge were tested. Changes in perception, confidence, and clinical practice were assessed through questionnaires and interviews. Results Before the course, awareness of the World Health Organization guidelines was 36.73% (389/1059) overall, and 26.3% (94/358) among in-service professionals. The mean score gain in knowledge after access to the course in 606 participants who had pre- and postassessment data was 11.8 (95% CI 10.8-12.9; P<.001)—a relative increase of 41.5%. The proportion of participants who achieved a score above the pass mark posttraining was 58.7% (356/606), compared with 18.2% (110/606) in pretraining. Of the in-service professionals, 85.9% (128/149) reported applying their knowledge by changing their clinical practice in screening, assessment, diagnosis, and management. This group demonstrated significantly increased retained knowledge 6 months after training (mean difference [SD] from preassessment of 12.1 [11.8]), retaining 65.8% (12.1/18.4) of gained knowledge from the training. Changes in the management of malnutrition were reported by trained participants, and institutional, operational, and policy changes were also found. Conclusions The malnutrition eLearning course improved knowledge, understanding, and skills of health professionals in the diagnosis and management of children with severe acute malnutrition, and changes in clinical practice and confidence were reported following the completion of the course.
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Affiliation(s)
- Sunhea Choi
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Ho Ming Yuen
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Reginald Annan
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Trevor Pickup
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Andy Pulman
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michele Monroy-Valle
- Facultad de Ciencias de la Salud, Universidad Rafael Landívar, Ciudad de Guatemala, Guatemala
| | - Nana Esi Linda Aduku
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Samuel Kyei-Boateng
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | - Andrew Penn
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Ann Ashworth
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alan A Jackson
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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30
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Trehan I, Bassat Q. The Unbearable Lightness of Being Malnourished: Severe Acute Malnutrition Remains a Neglected Tropical Disease. J Trop Pediatr 2018; 64:169-173. [PMID: 29315432 DOI: 10.1093/tropej/fmx103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Lao PDR.,Department of Pediatrics and Institute for Public Health, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Quique Bassat
- ISGlobal, Barcelona Centre for International Health Research, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,ICREA, Barcelona 08010, Spain.,Pediatric Infectious Diseases Unit, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Universidad Europea de Madrid, Madrid, Spain
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31
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da Silva RE, Amato AA, Sousa TDR, de Carvalho MR, Novaes MRCG. The patient’s safety and access to experimental drugs after the termination of clinical trials: regulations and trends. Eur J Clin Pharmacol 2018; 74:1001-1010. [DOI: 10.1007/s00228-018-2474-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/02/2018] [Indexed: 11/25/2022]
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32
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Tickell KD, Denno DM. Efficacy of World Health Organization Guideline in Facility-Based Reduction of Mortality in Severely Malnourished Children From Low and Middle Income Countries. J Paediatr Child Health 2017; 53:925. [PMID: 28868770 DOI: 10.1111/jpc.13637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/09/2017] [Accepted: 05/23/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Kirkby D Tickell
- Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Donna M Denno
- Department of Global Health, University of Washington, Seattle, Washington, United States.,Department of Pediatrics, University of Washington, Seattle, Washington, United States.,Department of Health Services, University of Washington, Seattle, Washington, United States
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