PLoS One. 2013 Sep 9;8(9):e73728.

Clinical risk factors of death from pneumonia in children with severe acute malnutrition in an urban critical care ward of Bangladesh.

Chisti MJ, Salam MA, Ashraf H, Faruque AS, Bardhan PK, Hossain MI, Shahid AS, Shahunja KM, Das SK, Imran G, Ahmed T.

Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh ; Dhaka Hospital, icddr,b, Dhaka, Bangladesh.

 

 

ABSTRACT:

BACKGROUND: Risks of death are high when children with pneumonia also have severe acute malnutrition (SAM) as a co-morbidity. However, there is limited published information on risk factors of death from pneumonia in SAM children. We evaluated clinically identifiable factors associated with death in under-five children who were hospitalized for the management of pneumonia and SAM.

METHODS: For this unmatched case-control design, SAM children of either sex, aged 0-59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during April 2011 to July 2012 with radiological pneumonia were studied. The SAM children with pneumonia who had fatal outcome constituted the cases (n = 35), and randomly selected SAM children with pneumonia who survived constituted controls (n = 105).

RESULTS: The median (inter-quartile range) age (months) was comparable among the cases and the controls [8.0 (4.9, 11.0) vs. 9.7 (5.0, 18.0); p = 0.210)]. In logistic regression analysis, after adjusting for potential confounders, such as vomiting, abnormal mental status, and systolic hypotension (<70 mm of Hg) in absence of dehydration, fatal cases of severely malnourished under-five children with pneumonia were more often hypoxemic (OR = 23.15, 95% CI = 4.38-122.42), had clinical dehydration (some/severe) (OR = 9.48, 95% CI = 2.42-37.19), abdominal distension at admission (OR = 4.41, 95% CI = 1.12-16.52), and received blood transfusion (OR = 5.50, 95% CI = 1.21-24.99) for the management of crystalloid resistant systolic hypotension.

CONCLUSION AND SIGNIFICANCE: We identified hypoxemia, clinical dehydration, and abdominal distension as the independent predictors of death in SAM children with pneumonia. SAM children with pneumonia who required blood transfusion for the management of crystalloid resistant systolic hypotension were also at risk for death. Thus, early identification and prompt management of these simple clinically recognizable predictors of death and discourage the use of blood transfusion for the management of crystalloid resistant systolic hypotension may help reduce deaths in such population.

PMID: 24040043

 

SUPPLEMENT:

Over view of the novel findings: Children with severe wasting or severe under-nutrition, or nutritional edema were considered as severe acute malnutrition (SAM). The risk of death has been reported to be 15 times higher compared to deaths in children who did not have SAM [1]. Most of these pneumonia related deaths in SAM children occur in the critical care wards of developing countries [2]. However, clinical features of pneumonia in children with SAM often remain subtle [1,3]. Health workers, particularly in resource constrained settings may be less confident in identifying clinical features for the diagnosis of pneumonia in SAM children and as a result they might offer only oral antibiotics following recent WHO recommendations if the SAM children do not have any complications [4]. The bacterial pathogens causing pneumonia in SAM children are often different than those in better-nourished children [1,5,6]. Therefore, the subtle clinical signs and different etiology of pneumonia in SAM children may necessitate first dose of parenteral antibiotics before their referral to tertiary hospitals with the objectives to reduce morbidity and death. However, this management approach might not be feasible at every health care facility in resource limited settings due to lack of funds. From this perspective, identification of simple clinical cues for fatal outcome in SAM children with pneumonia may prove very useful to health professionals, particularly health workers in making referral decisions. However, there is lack of information on factors predictive of death in such children. With these contexts, we planned our study to identify simple clinically recognizable predictors of death in hospitalized, under-five SAM children with pneumonia. According to our study design described in the abstract we found that there were 35 children with pneumonia and SAM who died and in the comparison group there were 105 children with same problem who survived. After evaluation we found that the age of the children who survived and died was almost same. Children who died had anemia compared to those who survived but proportion of children with anemia received blood transfusion was almost same among the survivors and deaths. The most important findings of our study were the independent risk factors for death in children with SAM and pneumonia in our critical care word. These were hypoxemia, clinical dehydration and abdominal distension. Another striking finding of this study was that the SAM children with pneumonia who required blood transfusion for the management of crystalloid resistant systolic hypotension were also at risk for death.

Interpretations: the results of our data suggest that under-five SAM children with pneumonia who had hypoxemia, clinical dehydration, abdominal distension at admission, and those who require blood transfusion for the management of crystalloid resistant systolic hypotension during the course of hospitalized treatment are at higher risk of death.

Significance: Identification of these simple, clinically recognizable features in such children may alert health professionals, especially health workers to administer the first dose of parenteral broad spectrum antibiotics before their referral to the critical care medicine words. The clinicians in the critical care ward should be discouraged in using blood transfusion for the management of crystalloid resistant systolic hypotension in an effort to reduce morbidity and deaths in such population, especially in resource limited settings.

Recommendations: It is almost imperative to conduct a randomized clinical trial with adequate sample size is to evaluate the impact and the role of blood transfusion from patho-physiologic point of view in the management of septic shock in SAM children who also have pneumonia.

 

References

1. Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T (2009) Pneumonia in severely malnourished children in developing countries – mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health 14: 1173-1189.
2. Chisti MJ, Ahmed T, Faruque AS, Abdus Salam M (2010) Clinical and laboratory features of radiologic pneumonia in severely malnourished infants attending an urban diarrhea treatment center in Bangladesh. Pediatr Infect Dis J 29: 174-177.
3. Adegbola RA, Obaro SK (2000) Diagnosis of childhood pneumonia in the tropics. Ann Trop Med Parasitol 94: 197-207.
4. WHO (2006) Pocket book for hospital care of children: guidelines for the management of common illness with limited resources Geneva: World Health Organization. pp. 173-195.
5. Falade AG, Mulholland EK, Adegbola RA, Greenwood BM (1997) Bacterial isolates from blood and lung aspirate cultures in Gambian children with lobar pneumonia. Ann Trop Paediatr 17: 315-319.
6. Adegbola RA, Falade AG, Sam BE, Aidoo M, Baldeh I, et al. (1994) The etiology of pneumonia in malnourished and well-nourished Gambian children. Pediatr Infect Dis J 13: 975-982.

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