Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Características clínicas da doença diarréica em lactentes na Zona da Mata Meridional do estado de Pernambuco Clinical characteristics of diarrheal disease in suckling children in the Zona da Mata Meridional in the State of Pernambuco

OBJETIVOS: descrever as características clínicas dos episódios diarréicos apresentados por um grupo de crianças residentes na Zona da Mata Meridional do estado de Pernambuco nos primeiros seis meses de vida. MÉTODOS: o desenho do estudo é uma série de casos dele fazem parte todas as crianças acompanhadas dentro de um estudo de coorte realizado em quatro cidades da Zona da Mata Meridional do estado de Pernambuco e que durante o período de observação apresentaram pelo menos um episódio de doença diarréica. RESULTADOS: foram acompanhados 264 episódios de doença diarréica, que ocorreram em 239 crianças. A duração dos episódios variou entre um e 31 dias, sendo a mediana de dois dias e a moda de um dia. Um total de 93,5% dos episódios se auto-limitou em até sete dias. A maioria das crianças apresentou um episódio de diarréia durante o período de observação. Houve necessidade de hospitalização em 18 episódios (6,8%). Não foi observado nenhum óbito. CONCLUSÕES: a evolução clínica da doença diarréica quando estudada na comunidade é benigna, com episódios diarréicos de curta duração e levando a baixos índices de hospitalização.<br>OBJECTIVES: to describe clinical characteristics of diarrhea episodes in a group of children residing in the Zona da Mata Meridional in the State of Pernambuco during the first six months of life. METHODS: the study's design is a case series comprising all children followed-up within a cohort study accomplished in four cities of the Zona da Mata Meridional of the State of Pernambuco who during observation had at least one episode of diarrheal disease. RESULTS: 264 episodes of diarrhea were followed-up in 239 children. The episodes lasted between one and 31 days, with the median of two days and the mode of one day. 93,5% of the episodes were self-limited to seven days. The majority of the children had one diarrhea episode during observation. Hospitalization was required in 18 episodes (6,8%). No deaths occurred. CONCLUSIONS: the clinical evolution of diarrheal disease when studied in the community is benign with short-lived diarrheic episodes and low hospitalization rates

Fatores de risco para diárreia persistente em lactentes Risk factors to persistent diarrhea in infants

RACIONAL: A diarréia persistente é uma doença multicausal. A análise do risco para o prolongamento do quadro diarréico envolve variáveis ambientais, biológicas e do manejo clínico. OBJETIVO: Identificar fatores de risco para a diarréia persistente em crianças hospitalizadas na fase aguda do quadro diarréico. PACIENTES E MÉTODOS: O estudo foi do tipo caso-controle. A amostra consistiu de 216 crianças menores de 24 meses hospitalizadas por diarréia de início abrupto, no Instituto Materno-Infantil de Pernambuco, Recife, PE. O grupo de casos incluiu as crianças com diarréia persistente e o de controles aquelas com diarréia aguda. Foram analisadas variáveis socioeconômicas, biológicas, de morbidade anterior, clínicas e do manejo terapêutico prévio à admissão. Utilizou-se o odds ratio não ajustado e ajustado, com seus respectivos intervalos de confiança de 95%, observando-se o nível de significância de 5%. A análise multivariada foi feita através de regressão logística. RESULTADOS: O risco de persistência da diarréia foi maior nas crianças com: disenteria, febre no início do quadro, dieta suspensa e uso de antibiótico à admissão hospitalar. O risco de diarréia persistente foi cerca de três vezes maior para crianças sem geladeira no domicílio e que apresentavam hiperemia perianal ao exame físico na admissão hospitalar, sendo estas as variáveis que apresentaram significância estatística após o ajuste para fatores de confusão. CONCLUSÕES: A melhoria das condições ambientais e o manejo adequado e individualizado da criança hospitalizada por diarréia pode contribuir para a redução da morbidade da doença.<br>BACKGROUND: Persistent diarrhea is a multicausal disease. The analysis of risk factors for persistent diarrhea includes environmental and biological variables as well as therapeutical management. AIM: To identify risk factors for persistent diarrhea among children hospitalized with acute diarrhea. PATIENT AND METHODS: This is a case-control study. The sample consisted of 212 infants under 24 months, hospitalized with acute diarrhea, at the "Instituto Materno-Infantil de Pernambuco", Recife, PE, Brazil. Cases were infants with persistent diarrhea and controls those with acute diarrhea. Cases and controls were compared to a series of socio-economic, biological and clinical variables, previous morbidities and therapeutic management prior to hospital admission. Unadjusted and adjusted odds ratio were used with the respective 95% confidence intervals. It was adopted the level of significance of 5%. Logistic regression analysis was conducted to control for potential confounding factors. RESULTS: The risk of persistent diarrhea was higher for infants with: dysentery, fever at the onset of diarrhea, fasting and taking antibiotics prior to hospital admission. The variables that showed the highest adjusted odds ratios for persistent diarrhea were infants living in households without refrigerator and perianal hyperemia at hospital admission. CONCLUSIONS: The improvement of environmental conditions and an adequate clinical management of diarrhea for hospitalized infants may contribute to the reduction of diarrhea morbidity