Clinical signs of radiologic pneumonia in under-five hypokalemic diarrheal children admitted to an urban hospital in bangladesh

Navigating a Complex Presentation: Management of Hypernatremic Dehydration, Acute Kidney Injury, Hyperkalemia, and Metabolic Acidosis in a Patient With Down Syndrome: A Case Report

Worldwide, gastroenteritis is a well-known cause of dehydration in pediatric patients and can be life-threatening due to subsequent electrolyte disturbance or dehydration itself. In this case, we present an infant with Down syndrome (karyotype: 21 trisomy) who presented to us with moderate hypernatremic dehydration associated with severe hyperkalemia, moderate metabolic acidosis (pH: 7.1, random blood glucose: 80-110 mg/dL), and elevated kidney function tests secondary to the gastroenteritis caused by Entamoeba histolytica infection. The patient is being followed up by the pediatrics genetics clinic for growth and development, with regular screening for thyroid and celiac diseases, and he has no major heart, gastrointestinal, or renal anomalies. This unique and complex presentation of electrolyte disturbance and dehydration associated with a susceptible condition of Down syndrome deserves special attention with precise management which can be challenging. We managed the patient as a case of hypernatremic dehydration with gradual correction of serum sodium and dehydration, while concurrently managing hyperkalemia by routine methods (beta agonist inhalers, insulin, dextrose 10%) with close laboratory and clinical monitoring at the pediatric intensive care unit. The pediatric nephrology team was also consulted while delineating the management plan. As the patient's condition eventually resolved with normal kidney function and electrolytes, metabolic acidosis also resolved, with good oral intake and urine output, stable vitals, and was discharged after 72 hours. In conclusion, this case showed that pediatric patients with susceptible conditions such as Down syndrome with gastroenteritis can present with a lethal combination of dehydration and/or electrolyte disturbance, making close monitoring and prompt management paramount in such cases.

Clinical Characteristics and Underlying Factors Related to Recovery from Severe Pneumonia in Under-Five Children with or without Malnutrition Treated at Health Care Facilities in Bangladesh

Severe pneumonia with co-morbidity of malnutrition is one of the leading causes of death among children younger than five years of age. We aimed to compare the clinical features related to recovery from severe pneumonia in malnourished and well-nourished under-five children. A significantly lesser proportion of malnourished children compared to well-nourished recovered from rapid breathing (86.5% vs. 90.2%; p = 0.035), chest wall in-drawing (90.5% vs. 93.9%; p = 0.019), and fever (92.2% vs. 95.2%; p = 0.021) on day six after admission to health-care facilities. Malnourished children with severe pneumonia had significantly more rapid breathing (Adjusted Odds Ratio (AOR)) 1.636, 95% Confidence interval (CI) 1.150–2.328 p = 0.006), chest wall in-drawing (AOR 1.698, 95% CI 1.113–2.590, p = 0.014), and fever (AOR 1.700, 95% CI 1.066–2.710, p = 0.026) compared to those in well-nourished children. The study results suggested the lesser disappearance of clinical features among the malnourished children in Bangladesh underscores their vulnerability to severe pneumonia.

The clinical characteristics of Mycoplasma pneumoniae pneumonia and its relationship between hypokalemia in west China

BACKGROUND

Mycoplasma pneumoniae (MP) is one of the most common respiratory pathogens of community acquired pneumonia (CAP) in children. The purpose of this study was to identify epidemics of Mycoplasma pneumoniae pneumonia (MPP) and to determine the relationship between hypokalemia and MPP.

METHODS

This study was retrospectively conducted from 1 August 2016 to 31 July 2018 at Bishan People's Hospital in Chongqing, China. We analyzed the demographic characteristics (age, gender), extra-pulmonary manifestations, fever duration, length of hospital stay, whole blood cell (WBC) count, C-reactive protein (CRP) levels, and lactate dehydrogenase (LDH) levels.

RESULTS

The total number of children with pneumonia was 3,385, including 570 (16.84%) patients in the MP infection group. The male-to-female ratio was 1.34:1. The peak time of MPP incidence was in autumn. The MP infection group had a significantly higher ratio of fever, higher body temperature, and longer fever duration. The number of MP-infected patients with hypokalemia was highest in spring. The length of hospital stay in the mild hypokalemia group was longer than in the normokalemia group. Furthermore, severe hypokalemia cases were all in the severe MP infection group, and the severity of MP infection and hypokalemia were positively correlated.

CONCLUSIONS

In this study, we concluded that children infected with MP were more susceptible to fever, and had a longer duration of fever. The number of MP-infected patients with mild hypokalemia peaked in spring, and affected more boys than girls. Furthermore, patients with severe hypokalemia had longer fever duration, and a correlation was found between the severity of MP infection and hypokalemia.

Cost-effectiveness analysis of a physician deployment program to improve access to healthcare in rural and underserved areas in the Philippines

OBJECTIVES

The objective of this study is to explore the cost-effectiveness of Doctor to the Barrios (DTTB), a physician deployment program in the Philippines.

DESIGN

Cost-effectiveness analysis using decision tree models with a lifetime time horizon and probabilistic sensitivity analysis.

SETTING

Societal and healthcare perspectives.

POPULATION

Hypothetical cohort of children under 5 years in two provinces (Aklan and Nueva Ecija) and in a representative rural municipality.

PARTICIPANTS

None.

INTERVENTIONS

DTTB's impact on paediatric pneumonia and diarrhoea outcomes compared with a scenario without DTTB.

MAIN OUTCOME MEASURES

Costs, effectiveness (in terms of lives saved and quality-adjusted life years (QALYs) gained) and incremental cost-effectiveness ratio (ICER).

RESULTS

DTTB is cost-effective in the two provinces that were included in the study from societal and healthcare perspectives. Looking at a representative rural municipality, base case analysis and probabilistic sensitivity analyses suggest that DTTB has an ICER of 27 192 per QALY gained from a societal perspective. From a healthcare perspective, the base case ICER of DTTB is Philippine pesos (PHP) 71 839 per QALY gained and PHP 2 064 167 per life saved, and 10 000 Monte Carlo simulations produced similar average estimates. The cost per QALY of DTTB from a healthcare perspective is lower than the WHO recommended willingness-to-pay threshold of 100% of the country's per-capita gross domestic product.

CONCLUSIONS

DTTB can be a cost-effective intervention, but its value varies by setting and the conditions of the municipality where it is implemented. By focusing on a narrow set of paediatric outcomes, this study has likely underestimated the health benefits of DTTB. Additional research is needed to understand the full extent of DTTB's impact on the health of communities in rural and remote areas. Future cost-effectiveness analysis should empirically estimate various parameters and include other health conditions in addition to pneumonia and diarrhoea in children.

Determinants and Outcome of Metabolic Acidosis in Diarrheal Children Under 5 Years of Age in an Urban Critical Care Ward in Bangladesh

We evaluated the independent determinants and outcome of metabolic acidosis in diarrheal children. Children under 5 years of age admitted with diarrhea and severe respiratory distress in the critical care ward at Dhaka Hospital of icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) from April 2010 to April 2014 who had their reports of arterial blood gas analyses were enrolled in the study. We compared clinical and laboratory characteristics between the study children with (cases = 74) and without metabolic acidosis (controls = 65). Metabolic acidosis was defined if pH < 7.35 and HCO₃ < 22 mmol/L in ABG. Cases had higher mortality (53% vs 29%, P = .01) compared to controls. After adjustment of potential confounders, for instance, hypokalemia and dehydration, the cases were independently associated with severe sepsis and raised serum creatinine (for both P < .05). Thus, early identification of these features of metabolic acidosis in diarrheal children may help clinicians to have prompt management that may further help reduce mortality in such children especially in resource-limited settings.

Hypoxaemia and septic shock were independent risk factors for mechanical ventilation in Bangladeshi children hospitalised for diarrhoea

AIM

In Bangladesh, approximately 6% of children under five years of age die due to diarrhoea. We evaluated the admission and hospitalisation risk factors for mechanical ventilation and outcomes in children with diarrhoea.

METHODS

This retrospective case-control chart analysis was conducted in the intensive care unit of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. We enrolled 219 children with diarrhoea aged 0-59 months between August 2009 and July 2013. The 73 cases were children who were initially identified as requiring mechanical ventilation during the study period, and the 146 controls were randomly selected from those who did not require mechanical ventilation. We compared the groups to determine the risk factors for mechanical ventilation.

RESULTS

Mortality was significantly higher among the cases than the controls (p < 0.001). In the logistic regression analysis carried out for two separate time points, the independent risk factors for mechanical ventilation on admission were hypoxaemia (p < 0.001) and septic shock (p = 0.004) and during hospitalisation, they were intake of intravenous fluid (p = 0.015), hypokalaemia (p = 0.018), hyperkalaemia (p = 0.005) and septic shock (p = 0.001).

CONCLUSION

Children under five with diarrhoea who required mechanical ventilation frequently had hypoxaemia and septic shock and were more likely to die than unventilated controls.

Clinical Manifestations of Hyponatremia and Hypernatremia in Under-Five Diarrheal Children in a Diarrhea Hospital

OBJECTIVE

To study clinical manifestations and outcome of hyponatremia and hypernatremia in children with diarrhea.

METHOD

We compared children aged 0-59 months hospitalized from 1 January to 31 December 2013 with hyponatremia (serum sodium <130 mmol/l), hypernatremia (serum sodium >150 mmol/l) and normonatremia (serum sodium 135-145 mmol/l).

RESULTS

The case fatality was significantly higher among the children with hypernatremia and hyponatremia than normonatremia. A logistic regression analysis adjusting for potential confounders revealed that children with hyponatremia are more likely to have convulsions, have severe acute malnutrition and be of older age compared with children with normal serum sodium. Children with hypernatremia are more likely to have convulsions and dehydration than normonatremic children (for all p < 0.05).

CONCLUSION

Early diagnosis and prompt management of hypo- and hypernatremia by identifying simple clinical predicting factors of these two conditions in diarrheal children <5 years of age is critically important to prevent deaths in such children, especially in resource-limited settings.

Treatment Failure and Mortality amongst Children with Severe Acute Malnutrition Presenting with Cough or Respiratory Difficulty and Radiological Pneumonia

Background

Appropriate intervention is critical in reducing deaths among under-five, severe acutely malnourished (SAM) children with danger signs of severe pneumonia; however, there is paucity of data on outcome of World Health Organisation (WHO) recommended interventions of SAM children with severe pneumonia. We sought to evaluate outcome of the interventions in such children.

Methods

We prospectively enrolled SAM children aged 0–59 months, admitted to the Intensive Care Unit (ICU) or Acute Respiratory Infection (ARI) ward of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), between April 2011 and June 2012 with cough or respiratory difficulty and radiological pneumonia. All the enrolled children were treated with ampicillin and gentamicin, and micronutrients as recommended by the WHO. Comparison was made among pneumonic children with (n = 111) and without WHO defined danger signs of severe pneumonia (n = 296). The outcomes of interest were treatment failure (if a child required changing of antibiotics) and deaths during hospitalization. Further comparison was also made among those who developed treatment failure and who did not and among the survivors and deaths.

Results

SAM children with danger signs of severe pneumonia more often experienced treatment failure (58% vs. 20%; p<0.001) and fatal outcome (21% vs. 4%; p<0.001) compared to those without danger signs. Only 6/111 (5.4%) SAM children with danger signs of severe pneumonia and 12/296 (4.0%) without danger signs had bacterial isolates from blood. In log-linear binomial regression analysis, after adjusting for potential confounders, danger signs of severe pneumonia, dehydration, hypocalcaemia, and bacteraemia were independently associated both with treatment failure and deaths in SAM children presenting with cough or respiratory difficulty and radiological pneumonia (p<0.01).

Conclusion and Significance

The result suggests that SAM children with cough or respiratory difficulty and radiologic pneumonia who had WHO-defined danger signs of severe pneumonia more often had treatment failure and fatal outcome compared to those without the danger signs. In addition to danger signs of severe pneumonia, other common causes of both treatment failure and deaths were dehydration, hypocalcaemia, and bacteraemia on admission. The result underscores the importance for further research especially a randomized, controlled clinical trial to validate standard WHO therapy in SAM children with pneumonia especially with danger signs of severe pneumonia to reduce treatment failures and deaths.

The radiological diagnosis of pneumonia in children

Despite the importance of paediatric pneumonia as a cause of short and long-term morbidity and mortality worldwide, a reliable gold standard for its diagnosis remains elusive. The utility of clinical, microbiological and radiological diagnostic approaches varies widely within and between populations and is heavily dependent on the expertise and resources available in various settings. Here we review the role of radiology in the diagnosis of paediatric pneumonia. Chest radiographs (CXRs) are the most widely employed test, however, they are not indicated in ambulatory settings, cannot distinguish between viral and bacterial infections and have a limited role in the ongoing management of disease. A standardised definition of alveolar pneumonia on a CXR exists for epidemiological studies targeting bacterial pneumonias but it should not be extrapolated to clinical settings. Radiography, computed tomography and to a lesser extent ultrasonography and magnetic resonance imaging play an important role in complicated pneumonias but there are limitations that preclude their use as routine diagnostic tools. Large population-based studies are needed in different populations to address many of the knowledge gaps in the radiological diagnosis of pneumonia in children, however, the feasibility of such studies is an important barrier.