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Mambulu-Chikankheni FN. Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002277. [PMID: 37594922 PMCID: PMC10437970 DOI: 10.1371/journal.pgph.0002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 07/18/2023] [Indexed: 08/20/2023]
Abstract
Severe acute malnutrition (SAM) is associated with 30.9% of South Africa's audited under-five children deaths regardless of available guidelines to reduce SAM at each level of a three tyre referral system. Existing research has explored and offered solutions for SAM guidelines implementation at each referral system level, but their connectedness in continuation of care is under-explored. Therefore, I examined implementation of SAM guidelines and factors influencing implementation within subdistrict referral systems. An explanatory qualitative case study design was used. The study was conducted in two subdistricts involving two district hospitals; three community health centres, four clinics, and two emergency service stations. Between February to July 2016 and 2018, data were collected using 39 in-depth interviews with clinical, emergency service and administrative personnel; 40 reviews of records of children younger than five years; appraisals of nine facilities involved in referrals and observations. Thematic content analysis was used to analyse all data except records which were aggregated to elicit whether required SAM guidelines' steps were administered per case reviewed. Record reviews revealed SAM diagnosis discrepancies demonstrated by incomplete anthropometric assessments; non-compliance to SAM management guidelines was noted through skipping some critical steps including therapeutic feeding at clinic level. Record reviews further revealed variations of referral mechanisms across subdistricts, contradictory documentation within records, and restricted continuation of care. Interviews, observations and facility appraisals revealed that factors influencing these practices included inadequate clinical skills; inconsistent supervision and monitoring; unavailability of subdistrict specific referral policies and operational structures; and suboptimal national policies on therapeutic food. SAM diagnosis, management, and referrals within subdistrict health systems need to be strengthened to curb preventable child deaths. Implementation of SAM guidelines needs to be accompanied by job aids and supervision with standardised tools; subdistrict-specific referral policies and suboptimal national policies to ensure availability and accessibility of therapeutic foods.
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Affiliation(s)
- Faith Nankasa Mambulu-Chikankheni
- Department of Curriculum and Teaching Studies (Human Ecology), Nalikule College of Education, Lilongwe, Malawi
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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2
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Palit P, Nuzhat S, Khan SS, Gazi MA, Islam MR, Islam MO, Mahfuz M, Liu J, Houpt ER, Haque R, Ahmed T. Use of TaqMan Array Cards to investigate the aetiological agents of diarrhoea among young infants with severe acute malnutrition. Trop Med Int Health 2021; 26:1659-1667. [PMID: 34498343 DOI: 10.1111/tmi.13677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Studies involving less sensitive conventional microscopy and culture-based approaches have identified distinct differences in diarrhoeal aetiology in childhood malnutrition. Our study involved the use of an advanced molecular biology technique, the TaqMan Array Cards (TAC), to elucidate the diarrhoeal aetiology among young infants with severe acute malnutrition (SAM). METHOD A total of 113 faecal samples was collected from SAM infants, aged 2-6 months, upon admission to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) with complications of diarrhoea and related comorbidities. We used TAC for the detection of 29 different diarrhoeal enteropathogens from a single faecal sample. For comparison, we also analysed 25 diarrhoeal samples from well-nourished infants of similar age. RESULTS Higher odds of detection of all bacterial enteropathogens were associated with diarrhoea among SAM infants. In particular, the detection of Aeromonas sp (aOR: 25.7, p = 0.011), Campylobacter sp (aOR: 9.6, p < 0.01) and ETEC (aOR: 5.2, p = 0.022) was significantly associated with diarrhoea among SAM infants in comparison to well-nourished infants. 80% higher odds of detection of rotavirus and norovirus GII were associated with diarrhoea among well-nourished infants in comparison to SAM infants (aOR: 0.2, p < 0.05). CONCLUSION Our study findings demonstrate a difference in diarrhoeal aetiology among SAM and well-nourished young infants, which may be useful in providing an evidence-based logic for possible revision of treatment guidelines for treatment of young diarrhoeal infants with SAM in the early management of the menace of antimicrobial resistance.
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Affiliation(s)
- Parag Palit
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sharika Nuzhat
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Shaila Sharmeen Khan
- Emerging Infections and Parasitology Laboratory, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Amran Gazi
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Ridwan Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Md Ohedul Islam
- Emerging Infections and Parasitology Laboratory, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.,Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Rashidul Haque
- Emerging Infections and Parasitology Laboratory, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.,James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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3
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Trehan I. The past informs the future: inpatient mortality in severe childhood malnutrition. Am J Clin Nutr 2020; 112:911-912. [PMID: 32885811 DOI: 10.1093/ajcn/nqaa231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Indi Trehan
- Department of Pediatrics, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, Seattle, WA, USA
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Risk Factors of Mortality in Hospitalized Children with Severe Acute Malnutrition. Indian J Pediatr 2019; 86:1069. [PMID: 31280409 PMCID: PMC6815279 DOI: 10.1007/s12098-019-03016-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/11/2019] [Indexed: 11/02/2022]
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Bashaka PJ, Sawe HR, Mwafongo V, Mfinanga JA, Runyon MS, Murray BL. Undernourished children presenting to an urban emergency department of a tertiary hospital in Tanzania: a prospective descriptive study. BMC Pediatr 2019; 19:327. [PMID: 31510970 PMCID: PMC6737698 DOI: 10.1186/s12887-019-1706-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 09/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Childhood undernutrition causes significant morbidity and mortality in low- and middle-income countries (LMICs). In Tanzania, the in-hospital prevalence of undernutrition in children under five years of age is approximated to be 30% with a case fatality rate of 8.8%. In Tanzania, the burden of undernourished children under five years of age presenting to emergency departments (EDs) and their outcomes are unknown. This study describes the clinical profiles and outcomes of this population presenting to the emergency department of Muhimbili National Hospital (ED-MNH), a large, urban hospital in Dar es Salaam, Tanzania. METHODS This was a prospective descriptive study of children aged 1-59 months presenting to the ED-MNH over eight weeks in July and August 2016. Enrolment occurred through consecutive sampling. Children less than minus one standard deviation below World Health Organization mean values for Weight for Height/Length, Height for Age, or Weight for Age were recruited. Structured questionnaires were used to document primary outcomes of patient demographics and clinical presentations, and secondary outcomes of 24-h and 30-day mortality. Data was summarised using descriptive statistics and relative risks (RR). RESULTS A total of 449 children were screened, of whom 34.1% (n = 153) met criteria for undernutrition and 95.4% (n = 146) of those children were enrolled. The majority of these children, 56.2% (n = 82), were male and the median age was 19 months (IQR 10-31 months). They presented most frequently with fever 24.7% (n = 36) and cough 24.0% (n = 35). Only 6.7% (n = 9) were diagnosed with acute undernutrition by ED-MNH physicians. Mortality at 24 h and 30 days were 2.9% (n = 4) and 12.3% (n = 18) respectively. A decreased level of consciousness with Glasgow Coma Scale below fifteen on arrival to the ED and tachycardia from initial vital signs were found to be associated with a statistically significant increased risk of death in undernourished children, with mortality rates of 16.1% (n = 23), and 24.6% (n = 35), respectively. CONCLUSIONS In an urban ED of a tertiary referral hospital in Tanzania, undernutrition remains under-recognized and is associated with a high rate of in-hospital mortality.
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Affiliation(s)
- Prosper J Bashaka
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania.
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Victor Mwafongo
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania
| | - Juma A Mfinanga
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania.,Emergency Medicine Department, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Michael S Runyon
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania.,Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Brittany L Murray
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, P.O Box 65001, Dar es Salaam, Dar es salaam, Tanzania.,Division of Paediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Predictors of mortality among hospitalized children with severe acute malnutrition: a prospective study from Uganda. Pediatr Res 2018; 84:92-98. [PMID: 29795207 DOI: 10.1038/s41390-018-0016-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 09/11/2017] [Accepted: 09/12/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND We determined the predictors of mortality among children admitted with severe acute malnutrition (SAM). METHODS This was a prospective study nested in a randomized trial among 6-59-month-old children admitted with SAM. Socio-demographic and medical history data were collected using questionnaires and clinical examination, anthropometry and laboratory tests were performed. They were monitored daily until discharge or death during hospitalization while receiving care according to national guidelines. Predictors of death were assessed using Cox regression. RESULTS Of 400 children, 9.8% (n = 39) died during hospitalization. Predictors of mortality included diarrhoea at admission [hazard ratio [HR] 2.19, 95% confidence interval (CI): 1.06; 4.51], lack of appetite [HR 4.50, 95% CI: 1.76; 11.50], suspected sepsis [HR 2.23, 95% CI: 1.18; 4.24] and skin ulcers [HR 4.23, 95% CI: 1.26; 4.17]. Chest indrawing [HR 5.0, 95% CI: 1.53; 16.3], oxygen saturation below 94% [HR 3.92, 95% CI: 1.42; 10.83] and confirmed HIV infection [HR 3.62, 95% CI: 1.69; 7.77] also predicted higher mortality. CONCLUSION Infections were major contributors to mortality. This underscores the need for improved prevention and management of these infections among children with severe malnutrition.
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Versloot CJ, Voskuijl W, van Vliet SJ, van den Heuvel M, Carter JC, Phiri A, Kerac M, Heikens GT, van Rheenen PF, Bandsma RHJ. Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi. BMC Pediatr 2017; 17:112. [PMID: 28446221 PMCID: PMC5406940 DOI: 10.1186/s12887-017-0860-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). Methods In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. Results The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes. Conclusions This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings. Trial registration ISRCTN13916953 Registered: 14 January 2013.
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Affiliation(s)
- Christian J Versloot
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Wieger Voskuijl
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Sara J van Vliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Meta van den Heuvel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Jane C Carter
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Public Health, University College London, London, UK
| | - Geert Tom Heikens
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Robert H J Bandsma
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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8
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van Zutphen T, Ciapaite J, Bloks VW, Ackereley C, Gerding A, Jurdzinski A, de Moraes RA, Zhang L, Wolters JC, Bischoff R, Wanders RJ, Houten SM, Bronte-Tinkew D, Shatseva T, Lewis GF, Groen AK, Reijngoud DJ, Bakker BM, Jonker JW, Kim PK, Bandsma RHJ. Malnutrition-associated liver steatosis and ATP depletion is caused by peroxisomal and mitochondrial dysfunction. J Hepatol 2016; 65:1198-1208. [PMID: 27312946 DOI: 10.1016/j.jhep.2016.05.046] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 04/15/2016] [Accepted: 05/30/2016] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Severe malnutrition in young children is associated with signs of hepatic dysfunction such as steatosis and hypoalbuminemia, but its etiology is unknown. Peroxisomes and mitochondria play key roles in various hepatic metabolic functions including lipid metabolism and energy production. To investigate the involvement of these organelles in the mechanisms underlying malnutrition-induced hepatic dysfunction we developed a rat model of malnutrition. METHODS Weanling rats were placed on a low protein or control diet (5% or 20% of calories from protein, respectively) for four weeks. Peroxisomal and mitochondrial structural features were characterized using immunofluorescence and electron microscopy. Mitochondrial function was assessed using high-resolution respirometry. A novel targeted quantitative proteomics method was applied to analyze 47 mitochondrial proteins involved in oxidative phosphorylation, tricarboxylic acid cycle and fatty acid β-oxidation pathways. RESULTS Low protein diet-fed rats developed hypoalbuminemia and hepatic steatosis, consistent with the human phenotype. Hepatic peroxisome content was decreased and metabolomic analysis indicated peroxisomal dysfunction. This was followed by changes in mitochondrial ultrastructure and increased mitochondrial content. Mitochondrial function was impaired due to multiple defects affecting respiratory chain complex I and IV, pyruvate uptake and several β-oxidation enzymes, leading to strongly reduced hepatic ATP levels. Fenofibrate supplementation restored hepatic peroxisome abundance and increased mitochondrial β-oxidation capacity, resulting in reduced steatosis and normalization of ATP and plasma albumin levels. CONCLUSIONS Malnutrition leads to severe impairments in hepatic peroxisomal and mitochondrial function, and hepatic metabolic dysfunction. We discuss the potential future implications of our findings for the clinical management of malnourished children. LAY SUMMARY Severe malnutrition in children is associated with metabolic disturbances that are poorly understood. In order to study this further, we developed a malnutrition animal model and found that severe malnutrition leads to an impaired function of liver mitochondria which are essential for energy production and a loss of peroxisomes, which are important for normal liver metabolic function.
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Affiliation(s)
- Tim van Zutphen
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jolita Ciapaite
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Systems Biology Centre for Energy Metabolism and Ageing, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Vincent W Bloks
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Cameron Ackereley
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Albert Gerding
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Angelika Jurdzinski
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Roberta Allgayer de Moraes
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ling Zhang
- Physiology and Experimental Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Justina C Wolters
- Systems Biology Centre for Energy Metabolism and Ageing, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; Department of Pharmacy, Analytical Biochemistry, University of Groningen, Groningen, The Netherlands
| | - Rainer Bischoff
- Systems Biology Centre for Energy Metabolism and Ageing, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands; Department of Pharmacy, Analytical Biochemistry, University of Groningen, Groningen, The Netherlands
| | - Ronald J Wanders
- Laboratory Genetic Metabolic Diseases, Departments of Pediatrics and Clinical Chemistry, Academic Medical Center, Amsterdam, The Netherlands (current address: Icahn Institute for Genomics and Multiscale Biology, New York, USA)
| | - Sander M Houten
- Laboratory Genetic Metabolic Diseases, Departments of Pediatrics and Clinical Chemistry, Academic Medical Center, Amsterdam, The Netherlands (current address: Icahn Institute for Genomics and Multiscale Biology, New York, USA)
| | | | - Tatiana Shatseva
- Program in Cell Biology, Hospital for Sick Children, Toronto, Canada
| | - Gary F Lewis
- The Division of Endocrinology and Metabolism, Department of Medicine and the Banting and Best Diabetes Centre, University of Toronto, Toronto, Canada
| | - Albert K Groen
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk-Jan Reijngoud
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Barbara M Bakker
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Systems Biology Centre for Energy Metabolism and Ageing, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Johan W Jonker
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter K Kim
- Program in Cell Biology, Hospital for Sick Children, Toronto, Canada; Department of Biochemistry, University of Toronto, Toronto, Canada.
| | - Robert H J Bandsma
- Department of Pediatrics, Center for Liver, Digestive and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Physiology and Experimental Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Canada; Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Canada; Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.
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Dave P, Nimbalkar S, Phatak A, Desai R, Srivastava S. Missed Opportunities for Nutritional Rehabilitation in Children Admitted to Surgical Wards. SCIENTIFICA 2016; 2016:3470621. [PMID: 27429836 PMCID: PMC4939328 DOI: 10.1155/2016/3470621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 06/06/2023]
Abstract
Background. Malnutrition in children has serious health and economic consequences. We studied documentation of malnutrition, actual prevalence, and treatment given in children admitted to surgical wards. Methods. Retrospective study of 154 patients aged <5 yrs admitted to general surgical, orthopedic, and otorhinolaryngology wards. Records were evaluated for completeness of data, way of documentation, and data quality. Descriptive analysis was done. If malnutrition was not identified and/or proper action was not taken, it was defined as a "missed opportunity." Results. Of 154 records audited, 100 (64.94%) were males, 108 (70.13%) were from general surgery ward, and 78 (50.65%) were residing in suburban area. The mean (SD) age of the study population was 2.32 (1.16) years whereas mean (SD) duration of stay was 5.84 (6.29) days. Weight and height were mentioned in 116 (75.32%) and 8 (5.19%) records, respectively, mostly by nonsurgical personnel. Documentation and treatment of malnutrition were poor. Out of 106 apparently correct weight records, 19 (17.93%) children were severely undernourished and 30 (28.30%) were moderately undernourished whereas 20 (18.87%) children were not undernourished but required nutritional attention. Conclusion. There is poor documentation of nutritional indicators of children admitted to surgical wards. From data that was available, it is apparent that malnutrition is at high levels. "Identification" and hence management of malnutrition need more attention.
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Affiliation(s)
- Pooja Dave
- Department of Surgery, Pramukhswami Medical College, Charutar Arogya Mandal, Karamsad, Gujarat 388325, India
- Department of Pediatrics, Pramukhswami Medical College, Charutar Arogya Mandal, Karamsad, Gujarat 388325, India
| | - Somashekhar Nimbalkar
- Department of Pediatrics, Pramukhswami Medical College, Charutar Arogya Mandal, Karamsad, Gujarat 388325, India
| | - Ajay Phatak
- Central Research Services, Chautar Arogya Mandal, Karamsad, Gujarat 388325, India
| | - Rajendra Desai
- Central Research Services, Chautar Arogya Mandal, Karamsad, Gujarat 388325, India
| | - Shirish Srivastava
- Department of Surgery, Pramukhswami Medical College, Charutar Arogya Mandal, Karamsad, Gujarat 388325, India
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Gebremichael DY. Predictors of nutritional recovery time and survival status among children with severe acute malnutrition who have been managed in therapeutic feeding centers, Southern Ethiopia: retrospective cohort study. BMC Public Health 2015; 15:1267. [PMID: 26689192 PMCID: PMC4687080 DOI: 10.1186/s12889-015-2593-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/10/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Malnutrition remains to be one of the most common causes of morbidity and mortality among children in developing countries. The prevalence of wasting in Ethiopia remained about 10 % for the past ten years. Mortality rate of children with severe acute malnutrition treated in inpatient set ups has remained unacceptably high. METHODS A retrospective cohort study was conducted in Southern Ethiopia. The study population were children with severe acute malnutrition aged from 6 to 59 months who have been managed at Karat and Fasha stabilization centers between September 30, 2013, and Sep. 29, 2014. The total sample size was 420 and pretested questionnaire was used. Kaplan Meier analysis was used to estimate time to nutritional recovery and Cox proportional-hazard regression analysis was carried out to determine independent predictors. RESULTS Nutritional recovery rate was 3.61 per 100 person day observations. Median nutritional recovery time was 22 and 29 days for edematous malnourished and severely wasted children respectively. The independent predictors of nutritional recovery rate were: stabilization center (AHR = 1.4, 95 % CI: 1.1-1.7), malnutrition status (AHR = 1.8, 95 % CI: 1.3-2.4), weight (AHR = 1.5, 95 % CI: 1.2-1.9), mid- upper arm circumference (AHR = 1.4, 95 % CI: 1.1-1.9), inpatient complications (AHR = 2.2, 95 % CI: 1.4-3.5) and did not lose edema within four days of inpatient treatment (AHR = 2.3, 95 % CI: 1.1-4.8). CONCLUSIONS The findings of this study confirm the probability of surviving gets slimmer with inpatient complications and staying longer in stabilization centers. So, to prevent complications and enhance recovery rate due emphasis should be given in improving early detection and treatment of severely malnourished children in Ethiopia.
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Affiliation(s)
- Delelegn Yilma Gebremichael
- Department of Public Health, Ambo University, College of Medicine and Health Sciences, P.O. Box 19, Ambo, Ethiopia.
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11
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Bandsma RHJ, Ackerley C, Koulajian K, Zhang L, van Zutphen T, van Dijk TH, Xiao C, Giacca A, Lewis GF. A low-protein diet combined with low-dose endotoxin leads to changes in glucose homeostasis in weanling rats. Am J Physiol Endocrinol Metab 2015; 309:E466-73. [PMID: 26152763 DOI: 10.1152/ajpendo.00090.2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 07/01/2015] [Indexed: 12/23/2022]
Abstract
Severe malnutrition is a leading cause of global childhood mortality, and infection and hypoglycemia or hyperglycemia are commonly present. The etiology behind the changes in glucose homeostasis is poorly understood. Here, we generated an animal model of severe malnutrition with and without low-grade inflammation to investigate the effects on glucose homeostasis. Immediately after weaning, rats were fed diets containing 5 [low-protein diet (LP)] or 20% protein [control diet (CTRL)], with or without repeated low-dose intraperitoneal lipopolysaccharide (LPS; 2 mg/kg), to mimic inflammation resulting from infections. After 4 wk on the diets, hyperglycemic clamps or euglycemic hyperinsulinemic clamps were performed with infusion of [U-(13)C6]glucose and [2-(13)C]glycerol to assess insulin secretion, action, and hepatic glucose metabolism. In separate studies, pancreatic islets were isolated for further analyses of insulin secretion and islet morphometry. Glucose clearance was reduced significantly by LP feeding alone (16%) and by LP feeding with LPS administration (43.8%) compared with control during the hyperglycemic clamps. This was associated with a strongly reduced insulin secretion in LP-fed rats in vivo as well as ex vivo in islets but signficantly enhanced whole body insulin sensitivity. Gluconeogenesis rates were unaffected by LP feeding, but glycogenolysis was higher after LP feeding. A protein-deficient diet in young rats leads to a susceptibility to low-dose endotoxin-induced impairment in glucose clearance with a decrease in the islet insulin secretory pathway. A protein-deficient diet is associated with enhanced peripheral insulin sensitivity but impaired insulin-mediated suppression of hepatic glycogenolysis.
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Affiliation(s)
- Robert H J Bandsma
- Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; Physiology and Experimental Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands;
| | - Cameron Ackerley
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Khajag Koulajian
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Ling Zhang
- Physiology and Experimental Medicine Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tim van Zutphen
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Theo H van Dijk
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Changting Xiao
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adria Giacca
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
| | - Gary F Lewis
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and Banting and Best Diabetes Centre, University of Toronto, Toronto, Ontario, Canada
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Munthali T, Jacobs C, Sitali L, Dambe R, Michelo C. Mortality and morbidity patterns in under-five children with severe acute malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based records (2009-2013). ACTA ACUST UNITED AC 2015; 73:23. [PMID: 25937927 PMCID: PMC4416273 DOI: 10.1186/s13690-015-0072-1] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/05/2015] [Indexed: 11/16/2022]
Abstract
Background Severe acute malnutrition has continued to be growing problem in Sub Saharan Africa. We investigated the factors associated with morbidity and mortality of under-five children admitted and managed in hospital for severe acute malnutrition. Methods It was a retrospective quantitative review of hospital based records using patient files, ward death and discharge registers. It was conducted focussing on demographic, clinical and mortality data which was extracted on all children aged 0–60 months admitted to the University Teaching Hospital in Zambia from 2009 to 2013. Cox proportional Hazards regression was used to identify predictors of mortality and Kaplan Meier curves where used to predict the length of stay on the ward. Results Overall (n = 9540) under-five children with severe acute malnutrition were admitted during the period under review, comprising 5148 (54%) males and 4386 (46%) females. Kwashiorkor was the most common type of severe acute malnutrition (62%) while diarrhoea and pneumonia were the most common co-morbidities. Overall mortality was at 46% with children with marasmus having the lowest survival rates on Kaplan Meier graphs. HIV infected children were 80% more likely to die compared to HIV uninfected children (HR = 1.8; 95%CI: 1.6-1.2). However, over time (2009–2013), admissions and mortality rates declined significantly (mortality 51% vs. 35%, P < 0.0001). Conclusions We find evidence of declining mortality among the core morbid nutritional conditions, namely kwashiorkor, marasmus and marasmic-kwashiorkor among under-five children admitted at this hospital. The reasons for this are unclear or could be beyond the scope of this study. This decline in numbers could be either be associated with declining admissions or due to the interventions that have been implemented at community level to combat malnutrition such as provision of “Ready to Use therapeutic food” and prevention of mother to child transmission of HIV at health centre level. Strategies that enhance and expand growth monitoring interventions at community level to detect malnutrition early to reduce incidence of severe cases and mortality need to be strengthened.
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Affiliation(s)
- Tendai Munthali
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia.,Ministry of Ministry of Community Development Mother and Child health, Private Bag W252 Sadzu Road, Lusaka, Zambia
| | - Choolwe Jacobs
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Lungowe Sitali
- Department of Biomedical Sciences, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Rosalia Dambe
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia
| | - Charles Michelo
- Department of Public Health, School of Medicine, University of Zambia, PO Box 50110, Lusaka, Zambia
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13
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Co-morbidities in hospitalized children with severe acute malnutrition. Indian Pediatr 2013; 51:125-7. [PMID: 23999679 DOI: 10.1007/s13312-014-0343-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 07/19/2013] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To study the co morbidities in hospitalized children with severe acute malnourishment. METHODS 104 severe acute malnourished children were included. RESULTS 54% had diarrhea and 27.8% had acute respiratory tract infections. Tuberculosis was diagnosed in 22% of cases (60.8% cases in children 6-12 mo old). Malaria and Measles were diagnosed in 3.8% each, and HIV infection was seen in 2.9% cases. Signs of vitamin B and vitamin A deficiency were seen in 14.4% and 5.8% cases, respectively. Malaria and HIV were not found to be major co morbid conditions. CONCLUSIONS Timely identification and treatment of various co-morbidities is likely to break undernutrition-disease cycle, and to decrease mortality and improve outcome.
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Lelijveld N, Mahebere-Chirambo C, Kerac M. Carer and staff perspectives on supplementary suckling for treating infant malnutrition: qualitative findings from Malawi. MATERNAL & CHILD NUTRITION 2013; 10:593-603. [PMID: 23795949 PMCID: PMC6860316 DOI: 10.1111/mcn.12064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Severe acute malnutrition (SAM) in infants aged <6 months is a major global health problem. Supplementary suckling (SS) is widely recommended as an inpatient treatment technique for infant <6 months SAM. Its aim is to re-establish effective exclusive breastfeeding. Despite widespread support in guidelines, research suggests that field use of SS is limited in many settings. In this study, we aimed therefore to describe and understand the barriers and facilitating factors to SS as a treatment technique for infant SAM. We conducted qualitative interviews and focus group discussions in a hospital setting in Blantyre, Malawi, with ward staff and caregivers of infants <2 years. We created a conceptual framework based on five major themes identified from the data: (1) motivation; (2) breastfeeding views; (3) practicalities; (4) understanding; and (5) perceptions of hospital-based medicine. Within each major theme, more setting-specific subthemes can also be developed. Other health facilities considering SS roll-out could consider their own barriers and facilitators using our framework; this will facilitate the implementation of SS, improve staff confidence and therefore give SS a better chance of success. Used to shape and guide discussions and inform action plans for implementing SS, the framework has the potential to facilitate SS roll-out in settings other than Malawi, where this study was conducted. We hope that it will help pave the way to more widespread SS, more research into its use and effectiveness, and a stronger evidence-base on malnutrition in infants aged <6 months.
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Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One 2012; 7:e38321. [PMID: 22675542 PMCID: PMC3366921 DOI: 10.1371/journal.pone.0038321] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Accepted: 05/03/2012] [Indexed: 01/27/2023] Open
Abstract
Background Severe acute malnutrition (SAM) accounts for two million deaths worldwide annually. In those hospitalised with SAM, concomitant infections and diarrhoea are frequent complications resulting in adverse outcome. We examined the clinical and laboratory features on admission and outcome of children with SAM and diarrhoea at a Kenyan district hospital. Methods A 4-year prospective descriptive study involving 1,206 children aged 6 months to 12 years, hospitalized with SAM and managed in accordance with WHO guidelines. Data on clinical features, haematological, biochemical and microbiological findings for children with diarrhoea (≥3 watery stools/day) were systematically collected and analyzed to identify risk factors associated with poor outcome. Results At admission 592 children (49%) had diarrhoea of which 122 (21%) died compared to 72/614 (12%) deaths in those without diarrhoea at admission (Χ2 = 17.6 p<0.001). A further 187 (16%) children developed diarrhoea after 48 hours of admission and 33 died (18%). Any diarrhoea during admission resulted in a significantly higher mortality 161/852 (19%) than those uncomplicated by diarrhoea 33/351 (9%) (Χ2 = 16.6 p<0.001). Features associated with a fatal outcome in children presenting with diarrhoea included bacteraemia, hyponatraemia, low mid-upper arm circumference <10 cm, hypoxia, hypokalaemia and oedema. Bacteraemia had the highest risk of death (adjusted OR 6.1; 95% C.I 2.3, 16.3 p<0.001); and complicated 24 (20%) of fatalities. Positive HIV antibody status was more frequent in cases with diarrhoea at admission (23%) than those without (15%, Χ2 = 12.0 p = 0.001) but did not increase the risk of death in diarrhoea cases. Conclusion Children with SAM complicated by diarrhoea had a higher risk of death than those who did not have diarrhoea during their hospital stay. Further operational and clinical research is needed to reduce mortality in children with SAM in the given setting.
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Affiliation(s)
- Alison Talbert
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Nahashon Thuo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Japhet Karisa
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Charles Chesaro
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Eric Ohuma
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - James Ignas
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher Toromo
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sarah Atkinson
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Kathryn Maitland
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- Wellcome Trust Centre for Clinical Tropical Medicine, Faculty of Medicine, Imperial College, Norfolk Place, London, United Kingdom
- * E-mail:
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Unresolved antiretroviral treatment management issues in HIV-infected children. J Acquir Immune Defic Syndr 2012; 59:161-9. [PMID: 22138766 DOI: 10.1097/qai.0b013e3182427029] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Antiretroviral therapy in children has expanded dramatically in low-income and middle-income countries. The World Health Organization revised its pediatric HIV guidelines to recommend initiation of antiretroviral therapy in all HIV-infected children younger than 2 years, regardless of CD4 count or clinical stage. The number of children starting life-long antiretroviral therapy should therefore expand dramatically over time. The early initiation of antiretroviral therapy has indisputable benefits for children, but there is a paucity of definitive information on the potential adverse effects. In this review, a comprehensive literature search was conducted to provide an overview of our knowledge about the complications of treating pediatric HIV. Antiretroviral therapy in children, as in adults, is associated with enhanced survival, reduction in opportunistic infections, improved growth and neurocognitive function, and better quality of life. Despite antiretroviral therapy, HIV-infected children may continue to lag behind their uninfected peers in growth and development. In addition, epidemic concurrent conditions, such as tuberculosis, malaria, and malnutrition, can combine with HIV to yield more rapid disease progression and poor treatment outcomes. Additional studies are required to evaluate the long-term effects of antiretroviral therapy in HIV-infected infants, children, and adolescents, particularly in resource-limited countries where concomitant infections and conditions may enhance the risk of adverse effects. There is an urgent need to evaluate drug-drug interactions in children to determine optimal treatment regimens for both HIV and coinfections.
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Challenges in the Management of HIV-Infected Malnourished Children in Sub-Saharan Africa. AIDS Res Treat 2012; 2012:790786. [PMID: 22606378 PMCID: PMC3353143 DOI: 10.1155/2012/790786] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Revised: 11/16/2011] [Accepted: 11/17/2011] [Indexed: 12/20/2022] Open
Abstract
Infection with HIV, and oftentimes coinfection with TB, complicates the care of severely malnourished children in sub-Saharan Africa. These superimposed infections challenge clinicians faced with a population of malnourished children for whose care evidence-based guidelines have not kept up. Even as the care of HIV-uninfected malnourished children has improved dramatically with the advent of community-based care and even as there are hopeful signs that the HIV epidemic may be stabilizing or ameliorating, significant gaps remain in the care of malnourished children with HIV. Here we summarize what is currently known, what remains unknown, and what remains challenging about how to treat severely malnourished children with HIV and TB.
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Irena AH, Mwambazi M, Mulenga V. Diarrhea is a major killer of children with severe acute malnutrition admitted to inpatient set-up in Lusaka, Zambia. Nutr J 2011; 10:110. [PMID: 21989455 PMCID: PMC3214843 DOI: 10.1186/1475-2891-10-110] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 10/11/2011] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Mortality of children with Severe Acute Malnutrition (SAM) in inpatient set-ups in sub-Saharan Africa still remains unacceptably high. We investigated the prevalence and effect of diarrhea and HIV infection on inpatient treatment outcome of children with complicated SAM receiving treatment in inpatient units. METHOD A cohort of 430 children aged 6-59 months old with complicated SAM admitted to Zambia University Teaching Hospital's stabilization centre from August to December 2009 were followed. Data on nutritional status, socio-demographic factors, and admission medical conditions were collected up on enrollment. T-test and chi-square tests were used to compare difference in mean or percentage values. Logistic regression was used to assess risk of mortality by admission characteristics. RESULTS Majority, 55.3% (238/430) were boys. The median age of the cohort was 17 months (inter-quartile range, IQR 12-22). Among the children, 68.9% (295/428) had edema at admission. The majority of the children, 67.3% (261/388), presented with diarrhea; 38.9% (162/420) tested HIV positive; and 40.5% (174/430) of the children died. The median Length of stay of the cohort was 9 days (IQR, 5-14 days); 30.6% (53/173) of the death occurred within 48 hours of admission. Children with diarrhea on admission had two and half times higher odds of mortality than those without diarrhea; Adjusted OR = 2.5 (95% CI 1.50-4.09, P < 0.001). The odds of mortality for children with HIV infection was higher than children without HIV infection; Adjusted OR = 1.6 (95% CI 0.99-2.48 P = 0.5). CONCLUSION Diarrhea is a major cause of complication in children with severe acute malnutrition. Under the current standard management approach, diarrhea in children with SAM was found to increase their odds of death substantially irrespective of other factors.
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Affiliation(s)
| | - Mwate Mwambazi
- Department of Pediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Veronica Mulenga
- Department of Pediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
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Bandsma RHJ, Mendel M, Spoelstra MN, Reijngoud DJ, Boer T, Stellaard F, Brabin B, Schellekens R, Senga E, Heikens GT. Mechanisms behind decreased endogenous glucose production in malnourished children. Pediatr Res 2010; 68:423-8. [PMID: 20657348 DOI: 10.1203/pdr.0b013e3181f2b959] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Severe malnutrition is a major health problem in developing countries and can present itself as kwashiorkor or marasmus. Although marasmus is characterized by clinical wasting, kwashiorkor is associated with peripheral edema, oxidative stress, hypoalbuminemia, and hypoglycemia. The etiology of the hypoglycemia is poorly understood. We determined endogenous glucose production (EGP) in children with severe malnutrition. Children with kwashiorkor, marasmus, and controls received a primed constant infusion of [6,6H2]glucose for 2 h. An i.v. bolus of 13C-ketoisocaproic acid (KIC) was given, and breath samples were obtained during 2 h. Isotope dilution was used to calculate EGP, and 13CO2/12CO2 production was determined. Mean EGP ± SEM was 5.5 ± 0.3 mg/kg/min in the kwashiorkor group and 6.9 ± 0.4 mg/kg/min and 7.6 ± 0.7 mg/kg/min in the marasmic and control group, respectively, (p < 0.05 kwashiorkor versus marasmus and controls). EGP correlated with serum albumin concentration (r = 0.67; p < 0.001) and urinary 8-hydroxydeoxyguanosine as a marker of oxidative stress (r = -0.62; p < 0.005). 13CO2 secretion as a marker of hepatic mitochondrial function was significantly higher in the marasmic group compared with kwashiorkor and controls. We conclude that decreased EGP in severely malnourished children is related to the degree of hypoalbuminemia and oxidative stress but is not associated with a clear defect in hepatic mitochondrial function.
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Heikens GT, Manary M. Wasting disease in African children: the challenges ahead. Malawi Med J 2010; 21:101-5. [PMID: 20345017 DOI: 10.4314/mmj.v21i3.45628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Joint BAPEN and Nutrition Society Symposium on 'Feeding size 0: the science of starvation'. Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock. Proc Nutr Soc 2009; 68:274-80. [PMID: 19490738 DOI: 10.1017/s0029665109001359] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The systematic failure to recognise and appropriately treat children with severe malnutrition has been attributed to the elevated case-fatality rates, often as high as 50%, that still prevail in many hospitals in Africa. Children admitted to Kilifi District Hospital, on the coast of Kenya, with severe malnutrition frequently have life-threatening features and complications, many of which are not adequately identified or treated by WHO guidelines. Four main areas have been identified for research: early identification and better supportive care of sepsis; evidence-based fluid management strategies; improved antimicrobial treatment; rational use of nutritional strategies. The present paper focuses on the identification of children with sepsis and on fluid management strategies.
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Lapidus N, Minetti A, Djibo A, Guerin PJ, Hustache S, Gaboulaud V, Grais RF. Mortality risk among children admitted in a large-scale nutritional program in Niger, 2006. PLoS One 2009; 4:e4313. [PMID: 19177169 PMCID: PMC2629565 DOI: 10.1371/journal.pone.0004313] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 12/23/2008] [Indexed: 11/18/2022] Open
Abstract
Background In 2006, the Médecins sans Frontières nutritional program in the region of Maradi (Niger) included 68,001 children 6–59 months of age with either moderate or severe malnutrition, according to the NCHS reference (weight-for-height<80% of the NCHS median, and/or mid-upper arm circumference<110 mm for children taller than 65 cm and/or presence of bipedal edema). Our objective was to identify baseline risk factors for death among children diagnosed with severe malnutrition using the newly introduced WHO growth standards. As the release of WHO growth standards changed the definition of severe malnutrition, which now includes many children formerly identified as moderately malnourished with the NCHS reference, studying this new category of children is crucial. Methodology Program monitoring data were collected from the medical records of all children admitted in the program. Data included age, sex, height, weight, MUAC, clinical signs on admission including edema, and type of discharge (recovery, death, and default/loss to follow up). Additional data included results of a malaria rapid diagnostic test due to Plasmodium falciparum (Paracheck®) and whether the child was a resident of the region of Maradi or came from bordering Nigeria to seek treatment. Multivariate logistic regression was performed on a subset of 27,687 children meeting the new WHO growth standards criteria for severe malnutrition (weight-for-height<−3 Z score, mid-upper arm circumference<110 mm for children taller than 65 cm or presence of bipedal edema). We explored two different models: one with only basic anthropometric data and a second model that included perfunctory clinical signs. Principal Findings In the first model including only weight, height, sex and presence of edema, the risk factors retained were the weight/height1.84 ratio (OR: 5,774; 95% CI: [2,284; 14,594]) and presence of edema (7.51 [5.12; 11.0]). A second model, taking into account supplementary data from perfunctory clinical examination, identified other risk factors for death: apathy (9.71 [6.92; 13.6]), pallor (2.25 [1.25; 4.05]), anorexia (1.89 [1.35; 2.66]), fever>38.5°C (1.83 [1.25; 2.69]), and age below 1 year (1.42 [1.01; 1.99]). Conclusions Although clinicians will continue to perform screening using clinical signs and anthropometry, these risk indicators may provide additional criteria for the assessment of absolute and relative risk of death. Better appraisal of the child's risk of death may help orientate the child towards either hospitalization or ambulatory care. As the transition from the NCHS growth reference to the WHO standards will increase the number of children classified as severely malnourished, further studies should explore means to identify children at highest risk of death within this group using simple and standardized indicators.
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Fergusson P, Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis. Trans R Soc Trop Med Hyg 2008; 103:541-8. [PMID: 19058824 DOI: 10.1016/j.trstmh.2008.10.029] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2008] [Revised: 10/23/2008] [Accepted: 10/23/2008] [Indexed: 11/25/2022] Open
Abstract
This systematic review and meta-analysis explored HIV prevalence and mortality in children undergoing treatment for severe acute malnutrition (SAM) in sub-Saharan Africa. It included all studies reporting on HIV infection within a sample of children with SAM where HIV status was assessed using a blood test and SAM was defined using the WHO, Gomez, Wellcome or Waterlow definitions. Children from 17 studies were included in the analysis (n=4891), of whom 29.2% were HIV-infected. HIV-infected children were significantly more likely to die than HIV-uninfected children (30.4% vs. 8.4%; P<0.001; relative risk=2.81, 95% CI 2.04-3.87). HIV-negative children treated within community-based therapeutic care (CTC) programmes had lower mortality (4.3%) than those treated within an inpatient nutrition rehabilitation unit (NRU) (15.1%). There was no significant difference in mortality for HIV-infected children with SAM treated in the CTC (30.0%) or NRU (31.3%) settings. HIV prevalence is high in children with SAM in sub-Saharan Africa, and HIV-infected children are at significantly increased risk of mortality. There is an urgent need to integrate HIV testing and treatment into care for children with SAM in regions of high HIV prevalence.
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Huang LC, Myer L, Jaspan HB. The role of polyclonal intravenous immunoglobulin in treating HIV-infected children with severe bacterial infections: a retrospective cohort study. BMC Infect Dis 2008; 8:127. [PMID: 18811982 PMCID: PMC2570677 DOI: 10.1186/1471-2334-8-127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Accepted: 09/24/2008] [Indexed: 01/18/2023] Open
Abstract
Background Mortality among HIV-infected children in developing countries remains high after serious bacterial infections despite the use of antibiotics. Intravenous immunoglobulin (IVIG) has been used as an adjuvant therapy to treat these infections, but little data exists regarding its efficacy, and previous studies have focused on IVIG as a prophylactic agent. We examined the impact of IVIG as an adjuvant therapy in reducing mortality and length of hospital stay in HIV-infected children with serious bacterial infections. Methods This retrospective study focused on pediatric admissions at a large urban hospital between 2002 and 2006. Children between the ages of one month and nine years of age with laboratory confirmed HIV-status, serious bacterial infection, no prior exposure to IVIG, and a hospital length of stay of 5 days or more, were eligible for inclusion. Results A total of 140 children (median age 1.2 years) met inclusion criteria; lower respiratory tract infection was diagnosed in 94 (67%) of the children, while 74 (53%) had bacterial sepsis. Fifty-four (39%) children were receiving antiretroviral therapy and 39 (28%) were receiving tuberculosis treatment. Overall 73 (52%) were treated with IVIG, with the majority (74%) of children receiving a single dose. Thirteen (9%) died during their hospital admission. In crude analysis IVIG was significantly associated with increased mortality was (Odds Ratio (OR): 5.8; 95% Confidence Interval (CI): 1.2–27.1) and this association was weakened by adjustment for other predictors of mortality (OR 4.3, 95% CI 0.7–27.9, p = 0.123). IVIG use was also associated with longer hospital stays. Conclusion Administration of one to three doses of IVIG during the acute phase of illness does not appear to reduce mortality or the length of hospital stays in HIV-infected children with serious bacterial infections. However, the retrospective nature of this study makes confounding by indication difficult to control and further studies regarding the timing, dosing, and method of administration are required. Nonetheless the routine use of IVIG in resource-limited settings should be carefully considered given its high cost.
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Affiliation(s)
- Lyen C Huang
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
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Berti A, Bregani ER, Manenti F, Pizzi C. Outcome of severely malnourished children treated according to UNICEF 2004 guidelines: a one-year experience in a zone hospital in rural Ethiopia. Trans R Soc Trop Med Hyg 2008; 102:939-44. [PMID: 18597802 DOI: 10.1016/j.trstmh.2008.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Revised: 05/19/2008] [Accepted: 05/20/2008] [Indexed: 10/21/2022] Open
Abstract
Malnutrition still has a dramatic impact on childhood mortality in sub-Saharan African countries. Very few studies have tried to evaluate the outcome of severely malnourished children treated according to the UNICEF 2004 guidelines and reported fatality rates are still very high. During 2006, 1635 children were admitted to the paediatric ward of St. Luke Catholic Hospital in Wolisso, South West Shewa, Ethiopia. Four hundred and ninety-three (30.15%) were severely malnourished and were enrolled in the study. We reviewed the registration books and inpatient charts to analyze their outcome. A mortality rate of 7.1% was found, which is significantly lower than reported in the literature. 28.6% of deaths occurred within 48 h of admission; the recovery rate was 88.4%; the drop-out rate was 4.5%. Early deaths were due to the poor condition of the children on admission, leading to failure of treatment. Late mortality was considered to be related to electrolyte imbalances, which we were unable to measure. The clinical skills of nursing and medical staff were considered an important factor in improving the outcome of malnourished patients. We found that proper implementation of WHO guidelines for the hospital treatment of severely malnourished children can lead to a relatively low mortality rate, especially when good clinical monitoring is assured.
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Affiliation(s)
- Anna Berti
- St. Luke Hospital, Wolisso, South West Shewa, Ethiopia.
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Heikens GT, Bunn J, Amadi B, Manary M, Chhagan M, Berkley JA, Rollins N, Kelly P, Adamczick C, Maitland K, Tomkins A. Case management of HIV-infected severely malnourished children: challenges in the area of highest prevalence. Lancet 2008; 371:1305-7. [PMID: 18406865 DOI: 10.1016/s0140-6736(08)60565-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre 3, Malawi.
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Heikens GT, Molyneux E, Broadhead R, Rollins N, Adhikari M. Research challenges to improve maternal and child survival. Lancet 2007; 369:2159-2160. [PMID: 17604796 DOI: 10.1016/s0140-6736(07)61010-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Robin Broadhead
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nigel Rollins
- Department of Paediatrics and Child Health, Nelson R Mandela Medical School University of Kwa Zulu-Natal, Durban, South Africa
| | - Miriam Adhikari
- Department of Paediatrics and Child Health, Nelson R Mandela Medical School University of Kwa Zulu-Natal, Durban, South Africa
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