Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso

BACKGROUND: Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS: Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS: From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION: The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.     

Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings

Effective case management is an important strategy to reduce pneumonia-related morbidity and mortality in children. Guidelines based on sound evidence are available but are used variably. This review outlines current guidelines for childhood pneumonia management in the setting where most child pneumonia deaths occur and identifies challenges for improved management in a variety of settings and different "at-risk" groups. These include appropriate choice of antibiotic, clinical overlap with other conditions, prompt and appropriate referral for inpatient care, and management of treatment failure. Management of neonates, and of HIV-infected or severely malnourished children is more complicated. The influence of co-morbidities on pneumonia outcome means that pneumonia case management must be integrated within strategies to improve overall paediatric care. The greatest potential for reducing pneumonia-related deaths in health facilities is wider implementation of the current guidelines built around a few core activities: training, antibiotics and oxygen. This requires investment in human resources and in equipment for the optimal management of hypoxaemia. It is important to provide data from a variety of epidemiological settings for formal cost-effectiveness analyses. Improvements in the quality of case management of pneumonia can be a vehicle for overall improvements in child health-care practices.     

Infections associated with severe protein-calorie malnutrition in hospitalized infants and children

One hundred Bangladeshi children admitted to hospital for treatment of severe protein-calorie malnutrition were systematically evaluated for the presence of infections. Ninety percent of children had some evidence of systemic infection at the time of admission and 75% had pneumonia, bacteruria, diarrhea in association with a known enteric pathogen, bacteremia, meningitis, or more than one of these major infections. Forty-nine percent of patients had pneumonia, including 14% of admissions with clinical evidence of pulmonary tuberculosis. Forty-three percent of admissions had diarrhea and 40% had evidence of enteric infections, most commonly shigellae or rotavirus. Bacteruria occurred in 30% of admissions, but bacteremia was identified in only 2% of patients initially. The prevalence of intestinal parasites increased with age, both among inpatients and comparison subjects with less severe grades of malnutrition. There did not appear to be important differences in the parasite loads or prevalences between the 2 groups.Twenty-one inpatients died; deaths were more common in younger children. The cause of death was most frequently related to infections. The identification and appropriate treatment of infections must be considered a major component of the rehabilitation of severely malnourished children.     

Malnutrition as an independent predictor of clinical outcome in critically ill children

ObjectiveTo determine the nutritional status of a cohort of children admitted to a pediatric intensive care unit (ICU) and to assess the effect of malnutrition as an independent risk factor affecting outcome in this patient group.MethodsIn a prospective cohort study, 385 children admitted to the ICU of a teaching hospital over a 2-y period were assessed for nutritional status at admission and clinical outcome. The outcome variables were 30-d mortality, length of ICU stay, and length of mechanical ventilation. Potential exposure variables were gender, age, diagnosis (clinical versus surgical), septic shock, malnutrition, and scores on the Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction. Nutritional status was determined using z scores of weight for age, height for age, and body mass index, based on the World Health Organization child growth standards. Patients with z score < ?2 of anthropometric indexes were considered malnourished.Results175 patients (45.5%) were malnourished on admission. Sixteen patients of the malnourished group (9.14%) and 25 patients (11.9%) of the non-malnourished group died. Malnutrition was associated with greater length of mechanical ventilation and length of ICU stay, but not with mortality on univariate analysis. Malnutrition was associated with greater length of ventilation on the multiple logistic regression model (OR 1.76, 95%; CI 1.08-2.88; P = 0.024).ConclusionMalnutrition is common among children admitted to an ICU. This factor was not a predictor of mortality but showed independent association with length of mechanical ventilation.     

Colonization of the oropharynx with Gram-negative bacilli in children with severe protein-calorie malnutrition

Oral pharyngeal isolation of Gram-negative bacteria was compared in four groups of Bengali children; acutely ill, severely malnourished outpatients swabbed on hospital admission; ill but less severely malnourished outpatients from the same area as the malnourished children; orphans also less severely malnourished but not acutely ill; and well controls drawn from a priviledged socioeconomic group. The expected weight for height percentage (National Center Health Statistics/Center for Disease Control median) of the four groups was respectively 67, 91, 97, and 97%. Isolation of Gram-negative bacteria from 74 of 87 (85%) severely malnourished children was significantly greater (p less than 0.01) compared to 43 of 113 (38%) outpatients, to 20 of 93 (22%) orphans, and to five of 51 (10%) controls. A total of 71 malnourished children under 5 yr of age (90%) had higher rates of Gram-negative throat colonization than did 16 older children (63%) (p less than 0.01). Thus there was an increased rate of Gram-negative colonization in severely malnourished children especially among the younger age group. In the subset of ill children, Gram-negative pharyngeal colonization was significantly associated inversely with nutritional indices and age. The high rate of such carriage may be partly responsible for the increased susceptibility of Gram-negative infection demonstrated in these children.     

Acinetobacter bacteremia in patients with diarrhoeal disease.

In 1994, 171 (27%) of all positive blood cultures in our hospital were due to Acinetobacter species. Of these, 138 cultures were considered significant, 91 (66%) were community-acquired and 47 (34%) were nosocomial. Most acinetobacter bacteraemia in children < or = 1 year old was community-acquired, while nosocomial infection was more common in children > 1 year old (P = 0.01). Most children < or = 5 years old were severely malnourished. The incidence of bacteraemia was lowest during the post-monsoon to early winter months. Acinetobacter bacteraemia associated mortality was twice (16%) that of all other patients (7.7%, P < 0.0005) and accounted for 4.5% of all hospital deaths during the study period. Bacteraemia caused by Acinetobacter species is an important cause of morbidity and mortality among our patient population with diarrhoeal disease.     

Implementation of World Health Organization guidelines for management of severe malnutrition in a hospital in Northeast Brazil

To assess the implementation of WHO guidelines for managing severely malnourished hospitalized children, a case-series study was performed with 117 children from 1 to 60 months of age. A checklist was prepared according to steps in the guidelines and applied to each patient at discharge, thus assessing the procedures adopted during hospitalization. Daily spreadsheets on food and liquid intake, clinical data, prescribed treatment, and laboratory results were also used. 36 steps were evaluated, 24 of which were followed correctly in more than 80% of cases; the proportion was 50 to 80% for seven steps and less than 50% for five steps. Monitoring that required frequent physician and nursing staff bedside presence was associated with difficulties. With some minor adjustments, the guidelines can be followed without great difficulty and without compromising the more important objective of reducing case-fatality.     

Severe malnutrition in children: high case-fatality rates can be reduced

This article offers a protocol for reducing high case fatality rates from malnutrition. Most child deaths from malnutrition occur in the first few days of treatment. Treatment should involve stabilization followed by rehabilitation. The article describes the treatment procedures for hypoglycemia, hypothermia, dehydration, and missed infections and discusses feeding during the stabilization and rehabilitation phases of treatment. All severely malnourished children have excess body sodium but high intracellular and low plasma levels. Malnourished children have deficiencies of potassium and magnesium that may take 2 weeks to correct. Edema is partly due to deficiencies in potassium and magnesium. A high sodium intake can be corrected by rehydrating with a modified oral rehydration solution and the special starter formula. Family food should be prepared without salt. Magnesium and potassium should be added directly to foods. All severely malnourished children have vitamin and mineral deficiencies. Deficiencies may include vitamin A, zinc, copper, selenium, and folic acid. Multivitamin supplements can correct for micronutrient deficiencies. It is advised that zinc should not be ignored, since it is responsible for repair of intestinal mucosa, halting diarrhea, healing of ulcerated skin lesions, restoration of appetite, improved immune function, and lean tissue synthesis. Iron should not be given until growth starts, infections are controlled, and antioxidant status is improved (usually 1 week after admission). Early introduction of iron poses a risk of enhancing pathogen increases and stimulating production of toxic free radicals. Relapses can be reduced by training parents how to feed their child frequently with energy and nutrient dense foods. The regimen was tested in a South African project and found to reduce mortality from 30% to 20%. After greater hospital attention to treatment of sepsis and hypoglycemia, case fatality declined to 6%.     

The impact of HIV on mortality during in-patient rehabilitation of severely malnourished children in Malawi

A prospective cohort study measured mortality during nutritional rehabilitation among HIV-infected and uninfected children, aged 6-59 months, with severe acute malnutrition (SAM). Children were tested for HIV and CD4% on admission to the nutrition rehabilitation unit (NRU). Mortality was assessed by following children to 4 months post discharge from the NRU or death if earlier. Overall mortality was 14.8% (67/454) and HIV prevalence was 17.4% (79/454). HIV-infected children were significantly more likely to die than uninfected children [35.4% (28/79) vs. 10.4% (39/375), P<0.001], and 85.7% of deaths occurred in children with a CD4% less than 20. Forty percent (18/45) of HIV-infected children with a CD4% <20 died, in contrast to 15% (3/20) of HIV-infected children with a CD4% >20 (P=0.05). Routine testing and treatment for HIV among all malnourished children is necessary to improve quality of care and reduce mortality among children with SAM.     

Mortality in a university surgical unit: what is an avoidable death?

Between January 1978 and December 1987 there were 23,557 surgical admissions to the University Surgical Unit in Southampton. During this period there were 543 deaths, an overall death per admission rate of 2.3%. During the 10-year period the number of admissions per year had risen from 1884 in 1978 (death per admission = 3.6%) to 3467 in 1987 (death per admission rate = 1.7%). At the monthly audit meeting an attempt was made to classify each death as 'avoidable' or 'unavoidable'. During this 10-year period it was considered that there were 89 'avoidable' deaths. This represents an avoidable mortality rate (AMR) of 0.38%. These 'avoidable' deaths were due to a wide variety of causes and this paper discusses the lessons learnt from a review of surgical mortality and outlines how units might compare results.     

Long-term morbidity and mortality following hypoxaemic lower respiratory tract infection in Gambian children

Acute lower respiratory infections (ALRI) are the main cause of death in young children worldwide. We report here the results of a study to determine the long-term survival of children admitted to hospital with severe pneumonia. The study was conducted on 190 Gambian children admitted to hospital in 1992-94 for ALRI who survived to discharge. Of these, 83 children were hypoxaemic and were treated with oxygen, and 107 were not. On follow-up in 1996-97, 62% were traced. Of the children with hypoxaemia, 8 had died, compared with 4 of those without. The mortality rates were 4.8 and, 2.2 deaths per 100 child-years of follow-up for hypoxaemic and non-hypoxaemic children, respectively (P = 0.2). Mortality was higher for children who had been malnourished (Z-score < -2) when seen in hospital (rate ratio = 3.2; 95% confidence interval (CI) = 1.03-10.29; P = 0.045). Children with younger siblings experienced less frequent subsequent respiratory infections (rate ratio for further hospitalization with respiratory illness = 0.15; 95% CI = 0.04-0.50; P = 0.002). Children in Gambia who survive hospital admission with hypoxaemic pneumonia have a good prognosis. Survival depends more on nutritional status than on having been hypoxaemic. Investment in oxygen therapy appears justified, and efforts should be made to improve nutrition in malnourished children with pneumonia.     

Hemodynamic findings in servere protein-calorie malnutrition.

This study was undertaken because circulatory distrubances had been advanced as a possible cause of death during initial renourishing of protein-calorie deprived children. Body weight, plasma albumin concentration, intravascular volumes (radiochromium), cardiac index (dye dilution technique), intravascular pressures (flow-guided catheterization), and related hemodynamic parameters were determined at rest in 43 infection-free African children with a form of protein-calorie malnutrition known as marasmic kwashiokor, and were compared with values observed in 24 convalescent children. The malnourished children showed a prolonged circulation time with a tendency to bradycardia and hypotension; cardiac index, stroke index, and heart work were significantly reduced, as were the intravascular volumes. Hemodynamic data correlated with either body weight or plasma albumin and cardiac index bore a direct relation to red cell volume. In the most severely malnourished subjects, ventricle filling pressures were low and vascular resistances were high. It is inferred that most patients were in an adaptive hypocirculatory state comparable to hypothroidism, while the most severely malnourished children showed frank peripheral circulatory failure comparable to hypovolemic shock. Circulatory failure on admission was associated with high death rate during treatment but the relation between cause and effect could not be clearly demonstrated.     

2007 - 2018年云南省某三甲专科医院儿童死因分析

目的 了解云南省某三甲医院住院儿童死因的变化趋势,寻找死亡原因,为制定合理有效的防治措施,降低儿童死亡率提供依据。方法 对云南省某三甲医院2007 - 2018年住院儿童的病历资料进行回顾性分析。 结果 2007 - 2018年12年间,住院儿童数由2007年的16 901例上升到2018年的61 415例,死亡率从0.56%下降到0.12%（P＜0.05）。住院患儿中,男童死亡率为0.20%,女童死亡率为0.22%,差异无统计学意义。各年龄组住院患儿中,新生儿死亡率最高,为0.45%,学龄期组儿童死亡率最低,为0.10%;不同年龄组儿童死亡率不同（P＜0.05）。死亡病例主要集中在入院后24 h～7 d内,占全部死亡病例的57.05%。疾病死因构成中:新生儿的第1位死因是起源于围生期的某些情况;婴儿的第1位死因是呼吸系统疾病;幼儿、学龄前的第1位死因是传染病;学龄期与青春期的第1位死因是肿瘤。结论 随着年份的增加,该院住院儿童人数不断增加,死亡率呈下降趋势;不同年龄组儿童死亡率不同。起源于围生期的某些疾病是儿童的第1位死因。     

New concepts on nutritional management of severe malnutrition: the role of protein

Current guidelines for the management of severe malnutrition are mainly based on new concepts regarding the causes of malnutrition and on advances in our knowledge of the physiological roles of micronutrients. In contrast to the early 'protein dogma', there is a growing body of evidence that severely malnourished children are unable to tolerate large amounts of dietary protein during the initial phase of treatment. Similarly, great caution must be exercised to avoid excessive supply of iron and sodium in the diet, while keeping energy intake at maintenance levels during early treatment. Because severely malnourished children require special micronutrients, a mineral-vitamin mix is added to the milk-based formula diets, which are specially designed for the initial treatment and the rehabilitation phase. To further improve nutritional rehabilitation and reduce cases of relapse, 'ready-to-use therapeutic food' and 'ready-to-eat nutritious supplements' with relatively low protein (10% protein calories) and high fat content (54-59% lipidic calories) have been developed. Although current dietary recommendations do not differentiate between oedematous and nonoedematous forms of malnutrition or between adults and children, there are indications that further clarification is still needed for applying dietary measures for specific target groups.     

The impact of malnutrition on morbidity,mortality, length of hospital stay and costs evaluated through a multivariate model analysis

Malnutrition has been identified as affecting patient outcome. The purpose of this study was to correlate the nutritional status of hospitalized patients with their morbidity, mortality, length of hospital stay and costs. The patients were nutritionally assessed within the first 72 h of hospital admission. The patients' charts were surveyed on the incidence of complications and mortality. Hospital costs were calculated based on economic tables used by insurance companies. Multivariate logistic regression analysis and the Cox regression model were used to identify possible confounding factors. A P<0.05 was considered statistically significant. The mean age was 50.6+/-17.3 years with 50.2% being male. The incidence of complications in the malnourished was 27.0% [Relative risk (RR)=1.60]. Mortality in the malnourished patients was 12.4% vs 4.7% in the well nourished (RR = 2.63). Malnourished patients stayed in the hospital for 16.7+/-24.5 days vs 10.1+/-11.7 days in the nourished. Hospital costs in malnourished patients were increased up to 308.9%. It was concluded that malnutrition, as analyzed by a multivariate logistic regression model, is an independent risk factor impacting on higher complications and increased mortality, length of hospital stay and costs.     

Use of subjective global assessment and clinical outcomes in critically ill geriatric patients receiving nutrition support

The objective of this study is to examine the prevalence of malnutrition and evaluate the nutrition status and clinical outcome in hospitalized patients aged 65 years and older receiving enteral‐parenteral nutrition. This retrospective study was carried out at Ba?kent University Hospital, Adana, Turkey. A total of 119 patients older than 65 years were recruited. Patients were classified into 3 groups: protein‐energy malnutrition (PEM), moderate PEM, and well nourished according to subjective global assessment (SGA) at admission. All patients were fed by enteral or parenteral route. Acute physiological and chronic health evaluation (APACHE‐2) and simplified acute physiology (SAPS 2) scores were recorded in patients followed in the intensive care unit (ICU). Nutrition status was assessed with biochemical (serum albumin, serum prealbumin) parameters. These results were compared with mortality rate and length of hospital stay (LOS). The subjects' mean (±SD) age was 73.1 ± 5.4 years. Using SGA, 5.9% (n = 7) of the patients were classified as severely PEM, 27.7% (n = 33) were classified as moderately PEM, and 66.4% (n = 79) were classified as well nourished. Some 73.1% (n = 87) of the patients were followed in the ICU. Among all patients, 42.9% (n = 51) were fed by a combined enteral‐parenteral route, 31.1% (n = 37) by an enteral route, 18.5% (n = 22) by a parenteral route, and 7.6% (n = 9) by an oral route. The average length of stay for the patients was 18.9 ± 13.7 days. The mortality rate was 44.5% (n = 53). The mortality rate was 43% (n = 34) in well‐nourished patients (n = 79), 48.5% (n = 16) in moderately PEM patients (n = 33), and 42.9% (n = 3) in severely PEM patients (n = 7) (P = .86). The authors observed no difference between well‐nourished and malnourished patients with regard to the serum protein values on admission, LOS, and mortality rate. In this study, malnutrition as defined by SGA did not influence the mortality rate of critically ill geriatric patients receiving enteral or parenteral nutrition. Furthermore, no factor was found to be a good predictor of survival.     

中国部分贫困地区5岁以下儿童死亡情况分析

利用卫—Ⅵ项目地区报告的1997年5岁以下儿童死亡资料,重点围绕死亡水平、死亡儿童年龄构成、死因构成及死亡地点加以分析,并对新生儿死亡率与部分服务利用指标进行了多元回归分析。结果显示,项目地区1997年报告的5岁以下儿童死亡率平均为52.0‰,各省较基线调查时均有不同程度下降,但仍远高于全国农村平均水平。5岁以下儿童死亡中,婴儿死亡占77.3％,婴儿死亡中,新生儿死亡占66.9％;儿童死于家中的构成比居第一位,死于乡卫生院居第二位。感染性疾病(肺炎和腹泻)以及与孕产期保健及产科质量密切相关的死因(新生儿窒息和早产或低出生体重)是婴儿死亡的主要原因,一半以上的1～4岁儿童死亡是由于肺炎和腹泻引起。多元回归分析显示,新生儿死亡率仅与住院分娩率有统计学关联,而与产前检查、新法接生、产后访视无统计学关联。结果提示:项目地区儿童死亡仍有很大降低的余地,在项目开展过程中,应进一步提高产前检查及产后访视的质量,促进住院分娩,增强村民识别儿童危险指征的能力与就医意识,同时加强医疗机构,特别是乡卫生院救治儿童疾病尤其是肺炎、腹泻的能力。     

Refeeding syndrome with enteral nutrition in children: a case report,literature review and clinical guidelines

Refeeding syndrome is a potentially fatal complication of the nutritional management of severely malnourished patients. The syndrome almost always develops during the early stages of refeeding. It can be associated with a severe derangement in electrolyte and fluid balance, and result in significant morbidity and mortality. It is most often reported in adults receiving total parenteral nutrition (TPN), although refeeding with enteral feeds can also precipitate this syndrome.We report what we believe to be the first case of refeeding syndrome in an adolescent with newly diagnosed Crohn's disease. This developed within a few days of starting exclusive polymeric enteral nutrition. A systematic literature review revealed 27 children who developed refeeding syndrome after oral/enteral feeding. Of these, nine died as a direct result of complications of this syndrome. We discuss the implications of this syndrome on clinical practice and propose evidence-based guidelines for its management.     

"CLAPSEN", a global approach to the rehabilitation of severe childhood malnutrition in Bolivia

The "CLAPSEN" approach was developed at the Hospital Materno Infantil German Urquidi in Cochabamba, to provide a global response for the study and treatment of childhood malnutrition. "CLAPSEN" is short for Clinical, Laboratory, Anthropometry, Psychology, Sociology, Nursing (Enfermera in Spanish) and Nutritional care. Most of the malnourished children admitted to Cochabamba Hospital are from poor families, more than three quarters of whom have only recently arrived in the city. Acute malnutrition is just one of the manifestations of a generally unfavorable environment. Malnutrition should not be considered as a simple deficiency in energy, protein or micronutrients, but rather as a multi-deficiency syndrome, also involving a lack of basic health and social care. This study demonstrates that malnourished children display a considerable degree of psychological retardation and of immune system depression. After five weeks of rehabilitation, the children were considered to have recuperated physically, as assessed by anthropometry, but not psychologically, as assessed by the adapted Dewer Score, or immunologically, as shown by the size of the thymus or the extent of maturation of lymphocytes. This strategy was not designed as a long-term approach for treating malnutrition, but rather as a research project to characterize the children arriving at the hospital, to determine the reasons for their malnutrition and to identify strategies that could be implemented earlier by health centers of social services, to prevent deterioration in the condition of these children to severe malnutrition requiring hospital admission. We believe that, in this Latin American context, in which the rate of acute malnutrition is low, the hospital should continue to be involved in the treatment of severely malnourished children with associated diseases. The child's stay in hospital should be short and once the child has recovered clinically, he should be sent home. In light of the observed levels of social deprivation, psychosocial and immune deficits, there appears to be a need for continued support for the family, to ensure the full recovery of the child and to prevent relapses.     

Creating a clinical nutrition registry: prospects, problems, and preliminary results

There is a tremendous gap in the information available to support the practice of hospital-based dietitians and to address the issue of how the risk of developing protein-energy malnutrition can be avoided in the majority of patients. This article describes the rationale and benefits of creating a nutrition registry of within-hospital clinical nutrition care. A nutrition registry is made up of observational data, collected on an ongoing basis, of nutritional interventions provided to hospitalized patients. It is the first step in data gathering to demonstrate the effectiveness of clinical nutrition interventions. The methods and preliminary results of a nutrition registry that was established at The University of Illinois Medical Center, Chicago, III, are presented. Using subjective global assessment, 55% (257 of 467) of patients at admission and 60% (280 of 467) of patients at discharge were moderately or severely malnourished. Patients that were normal nourished at admission and became moderately or severely malnourished had higher hospital charges ($40,329 for moderately malnourished patients, $76,598 for severely malnourished patients) than those that remained normal nourished ($28,368). This pattern held independent of admission nutritional status. Major challenges in implementation of a registry into the responsibilities of the staff dietitian are reviewed. The conclusion of this study is that nutrition registries can be established and will provide the much needed baseline data to document the impact of nutrition interventions on outcomes of medical care.