Predictors of Hospitalization During the First Year of Life among 31999 Tanzanian Infants

Identifying Infants and Young Children at Risk of Unplanned Hospital Admissions and Clinic Visits in Dar es Salaam, Tanzania

BACKGROUND

Pediatric inpatient mortality rates are as high as 11% in parts of sub-Saharan Africa. Unscheduled clinic visits also burden children in sub-Saharan Africa. Our objective was to identify factors associated with hospital admissions and unscheduled clinic visits among Tanzanian children < 24 months of age.

METHODS

We conducted a secondary analysis of 2 trials conducted in Dar es Salaam, Tanzania. We performed univariate and Poisson multivariable regression analyses to identify factors associated with hospital admissions and unscheduled clinic visits.

RESULTS

Of 4784 children < 24 months of age, 293 (6.1%) were hospitalized at least once and 1308 (27.3%) had ≥ 1 unscheduled clinic visit. Infants and children who were exposed to but HIV-negative had increased risk of hospital admission [adjusted risk ratios (aRR): 3.67; 95% CI: 2.45-5.50; P < 0.001] compared with HIV-unexposed children. Those who were HIV-positive had even higher risk of hospital admission compared with those not exposed to HIV (aRR: 10.87; 95% CI: 7.01-16.89; P < 0.001). Birth weight and breast-feeding status were not associated with increased risk of hospital admission. Children with Apgar scores < 7 (aRR: 1.32; 95% CI: 1.03-1.69; P = 0.001), not exclusively breast-fed up to 6 months of age (aRR: 1.34; 95% CI: 1.12-1.60; P = 0.001), and who were HIV-exposed and HIV-negative (aRR: 2.35; 95% CI: 2.08-2.66; P < 0.001) or HIV-positive (aRR: 3.02; 95% CI: 2.52-3.61; P < 0.001) had higher risk of unscheduled clinic visits.

CONCLUSIONS

Exposure to HIV and being HIV-positive were associated with the greatest risk for hospital admission and unplanned clinic visits among infants and children in Tanzania. Targeting these vulnerable populations in interventional studies may reduce morbidity.

Hospital admissions in the first year of life: inequalities over three decades in a southern Brazilian city

BACKGROUND

Hospital admissions in infancy are declining in several countries. We describe admissions to neonatal intensive care units (NICU) and other hospitalizations over a 33-year period in the Brazilian city of Pelotas.

METHODS

We analysed data from four population-based birth cohorts launched in 1982, 1993, 2004 and 2015, each including all hospital births in the calendar year. NICU and other hospital admissions during infancy were reported by the mothers in the perinatal interview and at the 12-month visit, respectively. We describe these outcomes by sex of the child, family income and maternal skin colour.

RESULTS

In 1982, NICUs did not exist in the city; admissions into NICUs increased from 2.7% of all newborns in 1993 to 6.7% in 2015, and admission rates were similar in all income groups. Hospitalizations during the first year of life fell by 29%, from 23.7% in 1982 to 16.8% in 2015, and diarrhoea admissions fell by 95.2%. Pneumonia admissions fell by 46.3% from 1993 to 2015 (no data available for 1982). Admissions due to perinatal causes increased during the period. In the poorest income quintile, total admissions fell by 33% (from 35.7% to 23.9%), but in the richest quintile these remained stable at around 10%, leading to a reduction in inequalities. Over the whole period, children born to women with black or brown skin were 30% more likely to be admitted than those of white-skinned mothers.

CONCLUSIONS

Whereas NICU admissions increased, total admissions in the first year of life declined by nearly one-third. Socioeconomic disparities were reduced, but important gaps remain.

Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya

Background

Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions.

Objective

The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM.

Design

This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2-59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points.

Results

Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥-2, respectively, which, compared with a WHZ <-3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥-2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs.

Conclusions

Anthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.

A cohort study of low birth weight and health outcomes in the first year of life, Ghana

Objective

To investigate the effect of birth weight on infant mortality, illness and care seeking in rural Ghana.

Methods

Using randomized controlled trial data, we compared infants weighing 2.00–2.49, 1.50–1.99 and < 1.50 kg with non-low-birth-weight infants. We generated adjusted mortality hazard ratios (aHR), adjusted illness rate ratios (aRR) and adjusted odds ratios (aOR) for health-facility admissions and absence of care seeking for four time periods: infancy, the neonatal period, early infancy and late infancy – represented by ages of 0–364, 0–27, 28–182 and 183–364 days, respectively.

Findings

Among 22 906 infants, compared with non-low-birth-weight infants: (i) infants weighing 2.00–2.49, 1.50–1.99 and < 1.50 kg were about two (aHR: 2.13; 95% confidence interval, CI: 1.76–2.59), eight (aHR: 8.21; 95% CI: 6.26–10.76) and 25 (aHR: 25.38; 95% CI: 18.36–35.10) times more likely to die in infancy, respectively; (ii) those born weighing < 1.50 kg were about 48 (aHR: 48.45; 95% CI: 32.81–71.55) and eight (aHR: 8.42; 95% CI: 3.09–22.92) times more likely to die in the neonatal period and late infancy, respectively; (iii) those born weighing 1.50–1.99 kg (aRR: 1.57; 95% CI: 1.27–1.95) or < 1.50 kg (aRR: 1.58; 95% CI: 1.13–2.21) had higher neonatal illness rates; and (iv) for those born weighing 1.50–1.99 kg, care was less likely to be sought in the neonatal period (aOR: 3.30; 95% CI: 1.98–5.48) and early infancy (aOR : 1.74; 95% CI: 1.26–2.39).

Conclusion

For low-birth-weight infants in Ghana, strategies to minimize mortality and improve care seeking are needed.