Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?
With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon...
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| Veröffentlicht in: | PLoS medicine 2006-12, Vol.3 (12), p.e500-e500 |
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| creator | Maitland, Kathryn Berkley, James A Shebbe, Mohammed Peshu, Norbert English, Michael Newton, Charles R J C |
| description | With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early ( |
| doi_str_mv | 10.1371/journal.pmed.0030500 |
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Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%).
Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.</description><identifier>ISSN: 1549-1676</identifier><identifier>ISSN: 1549-1277</identifier><identifier>EISSN: 1549-1676</identifier><identifier>DOI: 10.1371/journal.pmed.0030500</identifier><identifier>PMID: 17194194</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Bacteremia - epidemiology ; Child ; Child, Preschool ; Comorbidity ; Confidence intervals ; Consciousness ; Critical Care and Emergency Medicine ; Dehydration - epidemiology ; Emergency medical care ; Emergency Medicine ; Enteral Nutrition ; Fatalities ; Female ; Health aspects ; Health Policy ; Hospitals ; Humans ; Infant ; Infectious Diseases ; Kenya ; Logistic Models ; Male ; Malnutrition ; Malnutrition - epidemiology ; Malnutrition - mortality ; Malnutrition - therapy ; Malnutrition in children ; Microbiology ; Mortality ; Multivariate Analysis ; Non-Clinical Medicine ; Nutrition ; Nutrition and Metabolism ; Pediatrics ; Pediatrics and Child Health ; Retrospective Studies ; Sensitivity and Specificity ; Surveys ; Triage ; World Health Organization</subject><ispartof>PLoS medicine, 2006-12, Vol.3 (12), p.e500-e500</ispartof><rights>COPYRIGHT 2006 Public Library of Science</rights><rights>2006 Maitland et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited: Maitland K, Berkley JA, Shebbe M, Peshu N, English M, et al. (2006) Children with Severe Malnutrition: Can Those at Highest Risk of Death Be Identified with the WHO Protocol? PLoS Med 3(12): e500. doi:10.1371/journal.pmed.0030500</rights><rights>2006 Maitland et al. 2006</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c734t-4b26b56fff1975e389fc0df5657cf13d0d34346be9994a82e96033649810abaf3</citedby><cites>FETCH-LOGICAL-c734t-4b26b56fff1975e389fc0df5657cf13d0d34346be9994a82e96033649810abaf3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1716191/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1716191/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79342,79343</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/17194194$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Maitland, Kathryn</creatorcontrib><creatorcontrib>Berkley, James A</creatorcontrib><creatorcontrib>Shebbe, Mohammed</creatorcontrib><creatorcontrib>Peshu, Norbert</creatorcontrib><creatorcontrib>English, Michael</creatorcontrib><creatorcontrib>Newton, Charles R J C</creatorcontrib><title>Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?</title><title>PLoS medicine</title><addtitle>PLoS Med</addtitle><description>With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines.
Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%).
Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.</description><subject>Bacteremia - epidemiology</subject><subject>Child</subject><subject>Child, Preschool</subject><subject>Comorbidity</subject><subject>Confidence intervals</subject><subject>Consciousness</subject><subject>Critical Care and Emergency Medicine</subject><subject>Dehydration - epidemiology</subject><subject>Emergency medical care</subject><subject>Emergency Medicine</subject><subject>Enteral Nutrition</subject><subject>Fatalities</subject><subject>Female</subject><subject>Health aspects</subject><subject>Health Policy</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Infant</subject><subject>Infectious Diseases</subject><subject>Kenya</subject><subject>Logistic Models</subject><subject>Male</subject><subject>Malnutrition</subject><subject>Malnutrition - epidemiology</subject><subject>Malnutrition - mortality</subject><subject>Malnutrition - therapy</subject><subject>Malnutrition in children</subject><subject>Microbiology</subject><subject>Mortality</subject><subject>Multivariate Analysis</subject><subject>Non-Clinical Medicine</subject><subject>Nutrition</subject><subject>Nutrition and Metabolism</subject><subject>Pediatrics</subject><subject>Pediatrics and Child Health</subject><subject>Retrospective Studies</subject><subject>Sensitivity and Specificity</subject><subject>Surveys</subject><subject>Triage</subject><subject>World Health Organization</subject><issn>1549-1676</issn><issn>1549-1277</issn><issn>1549-1676</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2006</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><sourceid>DOA</sourceid><recordid>eNqVk92O0zAQhSMEYpeFN0BgCWklLlrsOIntvQCtKmArrajE76XlxOPGJY2L7Szw9rg0QIt6AYqlROPvnIlnPFn2kOApoYw8W7nB96qbbtagpxhTXGJ8KzslZSEmpGLV7b3vk-xeCCuMc4EFvpudEEZEkdZptpq1ttMeevTVxhYFuAEPaK26fojeRuv6C9SoHsXWBUAqotYuWwgReRs-I2eQBpV0NSCroY_WWNA7q9gC-nS1QBvvomtc9-J-dseoLsCD8X2WfXj18v3sanK9eD2fXV5PGkaLOCnqvKrLyhhDBCuBcmEarE1ZlawxhGqsaUGLqgYhRKF4DqLClFaF4ASrWhl6lj3e-W46F-RYpiBJzjlmlDGeiPmO0E6t5MbbtfLfpVNW_gw4v5TKR9t0ILkueUkMow3DRVnyWutKqzrnihOjlE5ez8dsQ5060aQieNUdmB7u9LaVS3cjUw8qIkgyOB8NvPsypNLKtQ0NdJ3qwQ1BVjxnpWBVAp_8BR4_22RHLVX6fdsbl7I2S-ghJXc9GJvClyk1KwkXW9fpET49Gta2OSp4eiBITIRvcamGEOT83dv_YN_8O7v4eMie77EtqC62wXXD9r6GQ7DYgY13IXgwvxtDsNyO0a8ayu0YyXGMkuzRflP_iMa5oT8Ayj0Xpw</recordid><startdate>20061201</startdate><enddate>20061201</enddate><creator>Maitland, Kathryn</creator><creator>Berkley, James A</creator><creator>Shebbe, Mohammed</creator><creator>Peshu, Norbert</creator><creator>English, Michael</creator><creator>Newton, Charles R J C</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>IOV</scope><scope>ISN</scope><scope>ISR</scope><scope>3V.</scope><scope>7TK</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>M0S</scope><scope>M1P</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>5PM</scope><scope>DOA</scope><scope>CZK</scope></search><sort><creationdate>20061201</creationdate><title>Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?</title><author>Maitland, Kathryn ; 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In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines.
Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%).
Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>17194194</pmid><doi>10.1371/journal.pmed.0030500</doi><tpages>9</tpages><oa>free_for_read</oa></addata></record> |
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| subjects | Bacteremia - epidemiology Child Child, Preschool Comorbidity Confidence intervals Consciousness Critical Care and Emergency Medicine Dehydration - epidemiology Emergency medical care Emergency Medicine Enteral Nutrition Fatalities Female Health aspects Health Policy Hospitals Humans Infant Infectious Diseases Kenya Logistic Models Male Malnutrition Malnutrition - epidemiology Malnutrition - mortality Malnutrition - therapy Malnutrition in children Microbiology Mortality Multivariate Analysis Non-Clinical Medicine Nutrition Nutrition and Metabolism Pediatrics Pediatrics and Child Health Retrospective Studies Sensitivity and Specificity Surveys Triage World Health Organization |
| title | Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? |
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