Diarrhoea Complicating Severe Acute Malnutrition in Kenyan Children: A Prospective Descriptive Study of Risk Factors and Outcome

BACKGROUND: Severe acute malnutrition (SAM) accounts for two million deaths worldwide annually. In those hospitalised with SAM, concomitant infections and diarrhoea are frequent complications resulting in adverse outcome. We examined the clinical and laboratory features on admission and outcome of children with SAM and diarrhoea at a Kenyan district hospital. METHODS: A 4-year prospective descriptive study involving 1,206 children aged 6 months to 12 years, hospitalized with SAM and managed in accordance with WHO guidelines. Data on clinical features, haematological, biochemical and microbiological findings for children with diarrhoea (≥ 3 watery stools/day) were systematically collected and analyzed to identify risk factors associated with poor outcome. RESULTS: At admission 592 children (49%) had diarrhoea of which 122 (21%) died compared to 72/614 (12%) deaths in those without diarrhoea at admission (Χ(2) = 17.6 p<0.001). A further 187 (16%) children developed diarrhoea after 48 hours of admission and 33 died (18%). Any diarrhoea during admission resulted in a significantly higher mortality 161/852 (19%) than those uncomplicated by diarrhoea 33/351 (9%) (Χ(2) = 16.6 p<0.001). Features associated with a fatal outcome in children presenting with diarrhoea included bacteraemia, hyponatraemia, low mid-upper arm circumference <10 cm, hypoxia, hypokalaemia and oedema. Bacteraemia had the highest risk of death (adjusted OR 6.1; 95% C.I 2.3, 16.3 p<0.001); and complicated 24 (20%) of fatalities. Positive HIV antibody status was more frequent in cases with diarrhoea at admission (23%) than those without (15%, Χ(2) = 12.0 p = 0.001) but did not increase the risk of death in diarrhoea cases. CONCLUSION: Children with SAM complicated by diarrhoea had a higher risk of death than those who did not have diarrhoea during their hospital stay. Further operational and clinical research is needed to reduce mortality in children with SAM in the given setting

An increase in the burden of neonatal admissions to a rural district hospital in Kenya over 19 years

Abstract Background Most of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries. Methods Prospectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1st 1990 up to December 31st 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death. Results The proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45 -1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%. Conclusions There is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death.</p

Frequency of baseline clinical features in 1206 severely malnourished children.

<p> <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038321#pone-0038321-t001" target="_blank"><b>Tables 1</b></a><b> and </b><a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0038321#pone-0038321-t002" target="_blank"><b>2</b></a><b> legend.</b></p>a<p>APLS definition.</p>b<p>Impaired consciousness  =  prostration or coma.</p>c<p>WHO definition of shock  =  impaired consciousness <i>plus</i> weak pulse volume <i>plus</i> CRT>3 seconds.</p>d<p>WHO features of severe dehydration  = 2 or more of (sunken eyes or decreased skin turgour or lethargy or inability to drink).</p>e<p>WHO Danger signs  =  Hypothermia or hypoglycaemia or lethargy.</p

Clinical and laboratory features by mortality of 592 children admitted with diarrhoea.

<p>Clinical and laboratory features by mortality of 592 children admitted with diarrhoea.</p

Kaplan-Meier plot of survival time of children with SAM admitted with and without diarrhoea.

<p>Kaplan-Meier plot of survival time of children with SAM admitted with and without diarrhoea.</p

Blood culture isolates in children admitted with diarrhoea.

<p>Blood culture isolates in children admitted with diarrhoea.</p

Multivariable logistic regression variables associated with death in children with severe malnutrition and diarrhoea at admission.

<p>Different models with and without low MUAC were tested because MUAC has been reported to vary with hydration status.</p