Predictors of death in under-five children with diarrhoea admitted to a critical care ward in an urban hospital in Bangladesh

Aim : To evaluate the clinical and laboratory predictors of death in hospitalized under‐five children with diarrhoea. Methods : This is a prospective cohort study carried out in the Special Care Ward (SCW) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh. All admitted diarrhoeal children of both sexes, aged 0–59 months, from September 2007 through December 2007 were enrolled. We compared and analysed factors among diarrhoeal children who died (n = 29) with those who survived (n = 229). Results : In logistic regression analysis, after adjusting for potential confounders (infusion of intravenous fluid and immature PMN), absent peripheral pulse even after complete rehydration (OR 10.9, 95% CI 2.1–56.8; p < 0.01), severe malnutrition (OR 7.9, 95% CI 1.8–34.8; p < 0.01), hypoxaemia (OR 8.5, 95% CI 1.0‐75.0; p = 0.05), radiological lobar pneumonia (OR 17.8, 95% CI 3.7–84.5; p < 0.01) and hypernatraemia (OR 15.8, 95% CI 3.0–81.8; p < 0.01) were independently associated with deaths among diarrhoeal children admitted to SCW. Conclusions:  Thus, the absence of peripheral pulses even after full rehydration, severe malnutrition, hypoxaemia, lobar pneumonia and hypernatraemia are independent predictors of death among the under‐five children with diarrhoea admitted to critical care ward of a resource‐limited setting in Bangladesh.     

Diagnosis and treatment of severely malnourished children with diarrhoea

Children with severe acute malnutrition complicated by diarrhoea require special care due to their unique physiological vulnerability and increased mortality risks. A systematic literature review (1950–2013) was conducted to identify the most effective diagnostic and therapeutic measures for the community‐based management of severely malnourished children with diarrhoea. No studies directly addressed this question, so the search was broadened to include inpatient care. Of the 129 studies identified, 32 were selected for full review and found to contain varying degrees of indirectness, inconsistency and bias. Evidence from diagnostic studies point to the use of both prolonged and persistent diarrhoea as morbidity markers, rapid hypoglycaemia diagnosis and the frequent aetiological role of Cryptosporidium. Therapeutic studies suggest benefits from routine antiparasitic medication and feeding regimens with ready‐to‐use‐therapeutic foods, lactose‐free diets and zinc supplementation. Existing rehydration treatment guidelines were affirmed, but the utility of glutamine and low osmolarity feeds were inconclusive.     

Impact of zinc supplementation on persistent diarrhoea in malnourished Bangladeshi children

To evaluate the impact of zinc supplementation on the clinical recovery and body weight of children with persistent diarrhoea, a randomized, double-blind, controlled trial was conducted in 190 children with persistent diarrhoea aged between 3 and 24 months. Children were randomly allocated to receive either zinc (20 mg d⁻¹) syrup with multivitamin (2 × RDA) or multivitamin alone in three divided daily doses for 2 weeks. The trial was conducted in a diarrhoeal disease hospital in Dhaka, Bangladesh. Duration until clinical recovery (d), impact on body weight and serum zinc level after 2 weeks of zinc supplementation were recorded. The duration of illness was significantly reduced (33%) with zinc supplementation among children who were underweight (≤70% wt/age, p = 0:03). Supplemented male children also had a significant reduction (27%) in duration for recovery compared with unsupplemented children ( p = 0:05). From baseline to convalescence, zinc-supplemented children maintained their serum zinc concentration (13.4 vs 13.6/ μ mol l⁻¹), whereas unsupplemented children had a decrease in serum zinc after the 2 weeks of diarrhoea (13.6 vs 11.8 μ mol l⁻¹, p < 0:03). The mean body weight of the children in the supplemented group was maintained (5.72 vs 5.70 kg, p = 0:62) during hospitalization, unlike that of the control group, in which there was a reduction in body weight (5.75 vs 5.67 kg, p = 0:05). Five children in the unsupplemented group and one child in the zinc-supplemented group died during the 2 weeks of supplementation ( p = 0:06). Zinc supplementation in persistent diarrhoea significantly reduced the length of the recovery period in malnourished children and prevented a fall in body weight and serum zinc concentration, indicating that zinc is a beneficial therapeutic strategy in this high-risk childhood illness.     

Nutritional status and diarrhoeal pathogen in hospitalized children in Bangladesh

We studied the relationship between nutritional status and infection due to specific enteropathogens in young children with diarrhoea. Overall, 26% of the children were severely underweight, 27% were severely wasted and 19% were severely stunted. Children with Shigellae and V. cholerae O1 were significantly more severely underweight, wasted and stunted than those with rotavirus diarrhoea ( p < 0:0001). Our results indicate that an effective nutrition programme for young children might have greater impact on diarrhoeal illness caused by Shigella and V. cholerae than by rotavirus diarrhoea.     

Mid-upper arm circumference and weight-for-height to identify high-risk malnourished under-five children

The World Health Organization and UNICEF define non-oedematous severe acute malnutrition (SAM) either by a mid-upper arm circumference (MUAC) less than 115 mm or by a weight-for-height z-score (WHZ) less than -3. The objective of this study was to assess whether there was any benefit to identify malnourished children with a high risk of death to combine these two diagnostic criteria. Data of a longitudinal study examining the relationship between anthropometry and mortality in rural Senegal and predating the development of community-based management of SAM were used for this study. First, the receiver operating characteristic (ROC) curves of MUAC and of WHZ to predict mortality were drawn, and then the points corresponding to WHZ less than -3 and/or MUAC less than 115 mm were positioned in relation to these curves. MUAC had the highest ROC curve, which indicates that it identifies high-risk children better than WHZ. Both points representing WHZ less than -3 and/or MUAC less than 115 mm were below the MUAC ROC curve. It is concluded that to identify high-risk malnourished children, there is no benefit in using both WHZ less than -3 and/or MUAC less than 115 mm, and that using MUAC alone is preferable.     

The effect of nutritional support on weight gain of HIV-infected children with prolonged diarrhoea

AIM: To examine the effect on growth and immunity of enhanced calorie and protein provision to HIV-infected children presenting with prolonged diarrhoea. METHODS: A total of 169 HIV-infected children aged 6-36 months with diarrhoea for 7 days or more were randomly assigned to either standard nutrition support for children with prolonged diarrhoea or an enhanced diet started during hospitalisation and continued after discharge. The change in weight between enrolment and 8, 14 and 26 weeks and changes in plasma HIV-RNA and CD4 cell count at 8 and 26 weeks were estimated. RESULTS: Children receiving enhanced nutrition achieved significantly more weight gain (p < 0.001) between enrolment and 8 weeks than children on the standard diet (median increase in weight-for-age standard deviation score +1.02 vs. +0.01). After 8 weeks median weight velocity was normal and similar in both groups. The change in median CD4 count was similar in both groups. The 26-week mortality rate was high in both groups (standard support: 22%, enhanced support: 29%). CONCLUSIONS: Nutrition support of children with advanced HIV infection and prolonged diarrhoea resulted in significant and sustained weight gain, but did not improve CD4 counts or survival. These results support integrated nutrition interventions for HIV-infected children.     

Serum C-reactive protein and C3 complement protein levels in severely malnourished Nigerian children with and without bacterial infections

Bacterial infections are the major determinants of fatality in severe protein-energy malnutrition (PEM). Unfortunately, these infections are difficult to diagnose clinically. C-reactive protein (CRP) levels were determined in 17 infected and 10 non-infected Nigerian children with severe PEM and compared with age/ sex-matched apparently healthy controls. The aim was to study the response of this acute phase protein to bacterial infections as well as to assess its value in the diagnosis of infections in severe PEM. C3 complement protein levels were also determined in the same group of subjects. The major organisms isolated in samples from these subjects were S. aureus and the coliforms. Mean CRP level in the non-infected children with severe PEM was 13.8 ± 6.21 mg/1 and rose to 159.83 ± 124.07 mg/1 in the presence of infection. The mean value in healthy non-infected controls was 2.01 ± 0.96 mg/1. The difference in the mean CRP levels between the infected and non-infected PEM children was statistically significant at p < 0.01. The mean difference between the non-infected and the control subjects was not significant. Using a diagnostic level of 20.00 mg/1 of CRP gave a sensitivity of 85.0% and a specificity of 80.0%. This CRP level is a useful index of bacterial infections in severe PEM. C3 complement protein was low in the non-infected malnourished group, but rose significantly in the presence of infection to values similar to that of the healthy controls. C3 protein thus behaves as an acute phase reactant in the presence of infection in severe PEM, and does not appear to be consumed, probably due to a deficiency in the early components of the complement cascade. This suggests a role for C3 measurement in the monitoring of bacterial infections in severe PEM.     

Lactose intolerance among severely malnourished children with diarrhoea admitted to the nutrition unit,Mulago hospital,Uganda

Background  

Lactose intolerance is a common complication of diarrhoea in infants with malnutrition and a cause of treatment failure. A combination of nutritional injury and infectious insults in severe protein energy malnutrition reduces the capacity of the intestinal mucosa to produce lactase enzyme necessary for the digestion of lactose.     

Aetiology and outcome of pneumonia in human immunodeficiency virus-infected children hospitalized in South Africa

To determine the aetiology and outcome of pneumonia in human immunodeficiency virus (HIV)infected children, we prospectively investigated 250 children hospitalized with pneumonia who were known or clinically suspected to be HIV-positive, or who required intensive care support in Cape Town, South Africa. Blood culture, induced sputum or bronchoalveolar lavage, nasopharyngeal aspirate and gastric lavage were performed. Of the total, 151 children (60.4%) were HIV-infected. Pneumocystis carinii pneumonia (PCP), occurring in 19 (7.6%) children (15 HIVpositive), was the AIDS-defining infection in 20.3%. The incidence and type of bacteraemia (14.3%) were similar in HIV-positive and HIV-negative patients; S. pneumoniae (5%) and S. aureus (2%) were the predominant isolates. Sputum or BAL cultures yielded bacteria in 145 of 243 (60%) specimens; viruses were cultured in 37 (15.2%). Bacterial prevalence (including M. tuberculosis in 8%) and anti-microbial resistance did not differ by HIV status except for S. aureus which was more common in HIV-infected children. Thirty-one (20%) HIV-positive and 8 (8%) HIV-negative children died [RR 1.16 (95% CI 1.05-1.28), p = 0.008]; using multiple logistic regression, PCP was the only risk factor for mortality (p = 0.03). Conclusion: In South Africa, PCP is an important AIDS-defining infection in children; bacterial pathogens occur commonly and with a similar prevalence in HIV-positive and HIV-negative children hospitalized for pneumonia. HIV-infected children with pneumonia have a worse outcome than HIV-negative patients.     

Serum procalcitonin and C-reactive protein in children with diarrhoea of various aetiologies

Aim: Procalcitonin (PCT) and C-reactive protein (CRP) are two acute-phase reactants with different clinical features. The study aimed to compare the diagnostic value of admission serum PCT and CRP concentrations as indicators of aetiology and intensity of inflammation in children hospitalized with diarrhoea. Methods: Serum PCT and CRP concentrations were determined on admission in 129 children hospitalized with diarrhoea. They were divided into four groups: group A: 37 children with diarrhoea as one of symptoms of ongoing systemic bacterial infection (sepsis/meningitis); group B: 36 children with bacterial enterocolitis; group C: 43 children with rotaviral enterocolitis; and group D: 13 children with active inflammatory bowel disease (IBD). For comparison serum PCT and CRP concentrations were determined in 30 healthy controls. Results: PCT concentration was >0.5 ng ml[Formula: See Text] in all 37 (100%) children with diarrhoea and systemic bacterial infection (mean 18.5 ± 3.2 ng ml[Formula: See Text]) and CRP was above 2 mg dl[Formula: See Text] in 33 (89%) of these children (11.7 ± 1.5 mg dl[Formula: See Text]). PCT concentration was ≥0.5 ng ml[Formula: See Text] in 22 of 36 (61%) children with bacterial enterocolitis (2.2 ± 0.6 ng ml[Formula: See Text]), in 3 of 43 (7%) children with rotaviral infection (0.2 ± 0 ng ml[Formula: See Text]) and in 3 of 13 (23%) patients with IBD (0.3 ± 0.1 ng ml[Formula: See Text]). CRP value was ≥2 mg dl[Formula: See Text] in 22 (61%) children from group B (5.4 ± 1.0 mg dl[Formula: See Text]), in 8 (19%) children from group C (1.3 ± 0.3 mg dl[Formula: See Text]) and in 6 (46%) patients from group D (3.3 ± 0.9 mg dl[Formula: See Text]). In the control group the PCT (0.1 ± 0.1 ng ml[Formula: See Text]) and CRP (0.03 ± 0.1 mg dl[Formula: See Text]) levels were low or undetectable.

Conclusion: In this study PCT was a more reliable marker than CRP of systemic bacterial infection in children with diarrhoea. PCT was more specific but less sensitive in the differentiation of bacterial and non-bacterial aetiology of inflammation.     

Management of malnourished children with acute diarrhoea and sugar intolerance

A protocol of nutritional rehabilitation using fermented milk, vegetable oil and caster sugar has been tested on 54 Senegalese children, aged 6-36 months, admitted with acute diarrhoea and malnutrition. At the time of admission, 39 per cent of children were dehydrated and 26 per cent had sugar intolerance. In the course of treatment three went home against medical advice and one died from acute pneumonia with respiratory-heart failure. Among the cases of marasmus there were no differences in mean weight gain between children with sugar intolerance and others despite a longer duration of diarrhoea in the first group. Furthermore, the experimental protocol has never been compromised because of worsening diarrhoea or weight loss. These results indicate that a formula based on fermented milk together with oral rehydration can be used to treat malnourished children with acute diarrhoea and sugar intolerance.     

Management of malnourished children with acute diarrhoea and sugar intolerance

A protocol of nutritional rehabilitation using fermented milk, vegetable oil, and castor sugar has been tested on 54 Senegalese children age 6-36 months admitted with acute diarrhoea and malnutrition. At time of admission, 39 per cent of children were dehydrated and 26 per cent had sugar intolerance. In the course of treatment three absconded and one died from acute pneumonia with respiratory and heart failure. Among those with marasmus there were no differences in mean weight gains between children with sugar intolerance and others, despite a longer duration of diarrhoea in the first group. Furthermore, the treatment protocol has never been compromised because of worsening diarrhoea or weight loss. These results indicate that a formula based on fermented milk together with oral rehydration can be used to treat malnourished children with acute diarrhoea and sugar intolerance.     

Young children non-immunized against measles: characteristics and programmatic implications

AIM: To examine the presenting characteristics, including nutritional status, of young children without measles immunization and to suggest appropriate public health measures to improve immunization status. METHODS: In this retrospective case-control analysis, we studied 4075 children aged 12-23 mo of either sex, who attended ICDDR,B's Dhaka hospital during 1994-2003. Cases included children who reported to this facility without receiving measles vaccine, and the control children were those who received the vaccine. RESULTS: 3181 of 4075 (78%) children, including 1227 (39%) girls and 1954 (61%) boys, received measles immunization. The proportion of vaccinated children increased from 74% in 1997 to 82% in 2001. Some non-specific effects of measles immunization were observed. Fifty-one per cent of the children without measles immunization were stunted, 76% were underweight, and 48% were wasted. The non-immunized children were twice as likely to be stunted, underweight, and wasted than the immunized children; they were more often dehydrated (some or severe dehydration) (28% vs 22%, p<0.001), required longer duration (>72 h) of hospitalization (15% vs 10%, p<0.001), did not receive vitamin A capsule in the previous 6 mo (56% vs 36%, p<0.001), and had more frequent abnormal lung auscultation indicative of acute lower respiratory tract infections (8% vs 5%, p<0.001). Female children, illiterate mother, lack of vitamin A supplementation, and history of measles were significantly associated with non-immunization against measles after controlling for co-variables. Results were similar when different nutritional indicators (underweight, stunting, or wasting) were added separately to logistic regression models. CONCLUSION: Intervention strategies to enhance immunization coverage in infants should target illiterate mothers and their children, particularly the females and malnourished ones, provide them with measles immunization and vitamin A capsule, and encourage their periodic follow-up visits as part of a preventive nutritional programme.     

培养与聚合酶链反应联合进行住院患儿肺炎细菌病原学检测

目的 探讨细菌培养与病原特异性DNA联合检测住院患儿肺炎细菌病原的应用价值.方法对187例肺炎患儿的深部呼吸道吸引物进行肺炎链球菌、流感嗜血杆菌选择性培养和普通培养,并且对同一标本采用靶序列富集多重PCR(Tem-PCB)扩增结合Luminex液态芯片检测平台进行定量测定,检测肺炎链球菌、流感嗜血杆菌、金黄色葡萄球菌、肺炎克雷伯杆菌、大肠杆菌、嗜肺军团菌、绿脓杆菌、鲍曼不动杆菌等14种病原菌的特异性DNA.结果细菌培养的总检出率为40.1%(75/187,含3例检出2种病原菌),病原菌依次为流感嗜血杆菌17.1%、大肠杆菌8.6%、肺炎克雷伯杆菌6.4%、金黄色葡萄球菌4.8%、肺炎链球菌3.7%、绿脓杆菌1.6%、鲍曼不动杆菌1.1%和阴沟肠杆菌1.1%.以细菌培养或Tem-PCR任一阳性为标准,联合检测的总检出率为78.6%(147/187),病原菌依次为流感嗜血杆菌28.9%、肺炎链球菌19.3%、大肠杆菌8.6%、肺炎克雷伯杆菌6.4%、金黄色葡萄球菌5.9%、鲍曼不动杆菌5.9%、绿脓杆菌2.7%和阴沟肠杆菌1.1%.结论 Tem-PCR能提高流感嗜血杆菌、肺炎链球菌、金黄色葡萄球菌、绿脓杆菌和鲍曼不动杆菌的检出例数.细菌培养与病原特异性DNA联合检测应用能显著提高肺炎病原的检出率,可能更真实地反映肺炎的细菌病原学情况.     

Home-based therapy with ready-to-use therapeutic food is of benefit to malnourished, HIV-infected Malawian children

AIM: To determine if home-based nutritional therapy will benefit a significant fraction of malnourished, HIV-infected Malawian children, and to determine if ready-to-use therapeutic food (RUTF) is more effective in home-based nutritional therapy than traditional foods. METHODS: 93 HIV-positive children >1 y old discharged from the nutrition unit in Blantyre, Malawi were systematically allocated to one of three dietary regimens: RUTF, RUTF supplement or blended maize/soy flour. RUTF and maize/soy flour provided 730 kJ x kg(-1) x d(-1), while the RUTF supplement provided a fixed amount of energy, 2100 kJ/d. These children did not receive antiretroviral chemotherapy. Children were followed fortnightly. Children completed the study when they reached 100% weight-for-height, relapsed or died. Outcomes were compared using regression modeling to account for differences in the severity of malnutrition between the dietary groups. RESULTS: 52/93 (56%) of all children reached 100% weight-for-height. Regression modeling found that the children receiving RUTF gained weight more rapidly and were more likely to reach 100% weight-for-height than the other two dietary groups (p < 0.05). CONCLUSION: More than half of malnourished, HIV-infected children not receiving antiretroviral chemotherapy benefit from home-based nutritional rehabilitation. Home-based therapy RUTF is associated with more rapid weight gain and a higher likelihood of reaching 100% weight-for-height.