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Chandwe K, Bwakura-Dangarembizi M, Amadi B, Tawodzera G, Ngosa D, Dzikiti A, Chulu N, Makuyana R, Zyambo K, Mutasa K, Mulenga C, Besa E, Sturgeon JP, Mudzingwa S, Simunyola B, Kazhila L, Zyambo M, Sonkwe H, Mutasa B, Chipunza M, Sauramba V, Langhaug L, Mudenda V, Murch SH, Hill S, Playford RJ, VanBuskirk K, Prendergast AJ, Kelly P. Malnutrition enteropathy in Zambian and Zimbabwean children with severe acute malnutrition: A multi-arm randomized phase II trial. Nat Commun 2024; 15:2910. [PMID: 38632262 PMCID: PMC11024201 DOI: 10.1038/s41467-024-45528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 01/26/2024] [Indexed: 04/19/2024] Open
Abstract
Malnutrition underlies almost half of all child deaths globally. Severe Acute Malnutrition (SAM) carries unacceptable mortality, particularly if accompanied by infection or medical complications, including enteropathy. We evaluated four interventions for malnutrition enteropathy in a multi-centre phase II multi-arm trial in Zambia and Zimbabwe and completed in 2021. The purpose of this trial was to identify therapies which could be taken forward into phase III trials. Children of either sex were eligible for inclusion if aged 6-59 months and hospitalised with SAM (using WHO definitions: WLZ <-3, and/or MUAC <11.5 cm, and/or bilateral pedal oedema), with written, informed consent from the primary caregiver. We randomised 125 children hospitalised with complicated SAM to 14 days treatment with (i) bovine colostrum (n = 25), (ii) N-acetyl glucosamine (n = 24), (iii) subcutaneous teduglutide (n = 26), (iv) budesonide (n = 25) or (v) standard care only (n = 25). The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin, α1-antitrypsin). Laboratory assessments, but not treatments, were blinded. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P < 0.10. Of 143 children screened, 125 were randomised. Teduglutide reduced the primary endpoint of biomarkers of mucosal damage (effect size -0.89 (90% CI: -1.69,-0.10) P = 0.07), while colostrum (-0.58 (-1.4, 0.23) P = 0.24), N-acetyl glucosamine (-0.20 (-1.01, 0.60) P = 0.67), and budesonide (-0.50 (-1.33, 0.33) P = 0.32) had no significant effect. All interventions proved safe. This work suggests that treatment of enteropathy may be beneficial in children with complicated malnutrition. The trial was registered at ClinicalTrials.gov with the identifier NCT03716115.
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Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Faculty of Medicine and Health Sciences, University of Zimbabwe, Parirenyatwa Hospital, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Gertrude Tawodzera
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Anesu Dzikiti
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Nivea Chulu
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Robert Makuyana
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Chola Mulenga
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK
| | - Shepherd Mudzingwa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Bwalya Simunyola
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Lydia Kazhila
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Masuzyo Zyambo
- Department of Anaesthesia, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Hazel Sonkwe
- Department of Anaesthesia, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Miyoba Chipunza
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Virginia Sauramba
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Lisa Langhaug
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
| | - Victor Mudenda
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | | | - Susan Hill
- Great Ormond Street Hospital, London, UK
| | - Raymond J Playford
- University of West London, Ealing, London, UK
- University College Cork, College Road, Cork, Ireland
| | - Kelley VanBuskirk
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia.
- Blizard Institute, Queen Mary University of London, Newark Street, London, UK.
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Abstract
BACKGROUND Environmental enteropathy is an example of a poorly-understood intestinal disorder affecting millions of children worldwide, characterized by malabsorption and stunting. Although there is increasing interest in non-invasive means of assessing intestinal structure and function, the potential value of intestinal biopsy for histology, immunostaining, RNA sequencing and epigenetic work means that endoscopic biopsy remains extremely valuable. We here report our experience in the BEECH (Biomarkers of Environmental Enteropathy in CHildren) study of stunting in Zambia, in the belief that it may help address the knowledge gap regarding the safety of endoscopic biopsy in vulnerable young children. METHODS We report our experience of safety in 119 children undergoing endoscopic biopsy in the BEECH study in Lusaka Children's Hospital, Lusaka, and discuss ethical considerations in this light. RESULTS Upper gastrointestinal endoscopy was performed on children with stunting (length-for-age z score -2 or less) not responsive to nutritional interventions. Conscious sedation was provided by anaesthetists. Of 119 children, 5 (4%) developed transient desaturation, but no serious adverse events were experienced; no clinical, demographic or anaesthetic characteristics were identified as predictive of desaturation. Two children derived clinically useful information from the endoscopy, one life-saving. Of 105 lactase tests, 59 (54%) showed hypolactasia. DISCUSSION Children with stunting underwent endoscopy safely, and some derived clinical benefit. Safety and the possibility of clinical benefit are usually felt to be preconditions for the ethical justification for endoscopy for research in children, and we believe that these conditions were met in this study.
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Affiliation(s)
- Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Correspondence: Kanta Chandwe, MMed. Paeds. Tropical Gastroenterology & Nutrition Group (TROPGAN), University of Zambia, School of Medicine. Lusaka 10101, ZAMBIA. Tel: +260-966-806-816. E-mail:
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Miyoba Chipunza
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Masuzyo Zyambo
- Department of Anaesthesia, University of Zambia School of Medicine, 10101 Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, 10101 Lusaka, Zambia,Barts & The London School of Medicine, Queen Mary University of London, London E1 2AT, UK
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Boyd N, Sharkey E, Nabukenya M, Tumukunde J, Sipuka N, Zyambo M, Walker I, Hart J, Byrne-Davis L. The Safer Anaesthesia from Education (SAFE) ® paediatric anaesthesia course: educational impact in five countries in East and Central Africa. Anaesthesia 2019; 74:1290-1297. [PMID: 31350856 DOI: 10.1111/anae.14778] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2019] [Indexed: 11/28/2022]
Abstract
There is an urgent need to improve access to safe surgical and anaesthetic care for children living in many low- and middle-income countries. Providing quality training for healthcare workers is a key component of achieving this. The 3-day Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course was developed to address the specific skills and knowledge required in this field. We undertook a project to expand this course across five East and Central African countries (Ethiopia, Kenya, Malawi, Uganda and Zambia) and train local faculty. This study reports the outcomes from course evaluation data, exploring the impact on knowledge, skills and behaviour change in participants. Eleven courses were conducted in a 15-month period, with 381 participants attending. Fifty-nine new faculty members were trained. Knowledge scores (0-50 scale) increased significantly from mean (SD) 37.5 (4.7) pre-course to 43.2 (3.5) post-course (p < 0.0001). Skills scores (0-10 scale) increased significantly from 5.7 (2.0) pre-course to 8.0 (1.5) post-course (p < 0.0001). One hundred and twenty-six participants in Malawi, Uganda and Zambia were visited in their workplace 3-6 months later. Knowledge and skills were maintained at follow-up, with scores of 41.5 (5.0) and 8.3 (1.4), respectively (p < 0.0001 compared with pre-course scores). Content analysis from interviews with these participants highlighted positive behaviour changes in the areas of preparation, peri-operative care, resuscitation, management of the sick child, communication and teaching. This study indicates that the SAFE paediatric anaesthesia course is an effective way to deliver training, and could be used to help strengthen emergency and essential surgical care for children as a component of universal health coverage.
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Affiliation(s)
- N Boyd
- Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK
| | - E Sharkey
- Department of Anaesthesia, University College Hospital, London, UK
| | - M Nabukenya
- Department of Anaesthesia, Makerere University College of Health Sciences, Kampala, Uganda
| | - J Tumukunde
- Department of Anaesthesia, Makerere University College of Health Sciences, Kampala, Uganda
| | - N Sipuka
- Department of Anaesthesia and Critical Care, University Teaching Hospital, Lusaka, Zambia
| | - M Zyambo
- Department of Anaesthesia and Critical Care, University Teaching Hospital, Lusaka, Zambia
| | - I Walker
- Department of Anaesthesia, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Department of Anaesthesia, UCL Great Ormond Street Institute of Child Health, London, UK
| | - J Hart
- Department of Education, University of Manchester, Manchester, UK
| | - L Byrne-Davis
- Department of Education, University of Manchester, Manchester, UK
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Bowen L, Zyambo M, Snell D, Kinnear J, Bould MD. Evaluation of the accuracy of common weight estimation formulae in a Zambian paediatric surgical population. Anaesthesia 2016; 72:470-478. [PMID: 28026862 DOI: 10.1111/anae.13780] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2016] [Indexed: 11/29/2022]
Abstract
Limited resources and access to healthcare in sub-Saharan Africa are associated with high rates of malnourished children, although many countries globally are demonstrating increasing childhood obesity. This study evaluated how well current age- or height-based formulae estimate the weight of children undergoing surgery in Zambia. All children under 14 years of age presenting for elective surgery at the University Teaching Hospital, Lusaka, had both height and weight measured. Their actual weight was compared against estimated weight from various formulae. The Broselow tape outperformed all the age-based formulae, demonstrating the lowest median percentage error of -5.8%, with 46.0% of estimates falling within 10% of the actual measured weight (p < 0.001). Of the 1111 children who were eligible for World Health Organization growth standard appraisal, 88 (8%) met the weight criteria for severe acute malnutrition. Our results are consistent with other studies in finding that the Broselow tape is the best estimator of weight in a lower middle-income country, followed by the original Advanced Paediatric Life Support formula if the Broselow tape is unavailable.
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Affiliation(s)
- L Bowen
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - M Zyambo
- Department of Anaesthesia, University Teaching Hospital, Lusaka, Zambia
| | - D Snell
- Department of Anaesthesia and Critical Care Medicine, Northumbria Healthcare NHS Foundation Trust, Wansbeck, UK
| | - J Kinnear
- Department of Anaesthesia and Critical Care Medicine, Southend University Hospital, Southend, UK.,Postgraduate Medical Institute, Anglia Ruskin University, Chelmsford, UK
| | - M D Bould
- Department of Anesthesiology, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
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