Choice of fluids for resuscitation in children with severe infection and shock: systematic review

Objective To systemically review the evidence from clinical trials comparing the use of crystalloids and colloids for fluid resuscitation in children with severe infection

Serum Procalcitonin Levels in Children with Clinical Syndromes for Targeting Antibiotic Use at an Emergency Department of a Kenyan Hospital

Serum procalcitonin (PCT) was measured in 228 children aged 1 month to 15 years at an emergency department of a hospital located in an area without local malaria transmission in children with suspected infections; 21% (49) children had a clinical syndrome for suspected bacterial infections (Syndrome+ve). In children with Syndrome+ve criteria, 27/49 (55.1%) had PCT ≥0.5 µg/l but only 59/179 (32.9%) of those Syndrome-ve had abnormal PCT, χ2 = 8.0, p = 0.005; positive likelihood ratio = 2.0 [95% confidence interval (CI) 1.2-3.3]; negative likelihood ratio = 0.8 (95% CI 0.7-1.0). In patients with pneumonia, 9/15 (60%) with severe pneumonia had PCT ≥0.5 µg/l compared to 11/21 (52.4%) with non-severe pneumonia, χ2 = 0.2, p = 0.65. Children with clinical signs of pneumonia or clinical signs suggestive of bacterial infections fulfilling clinical syndromic definitions for suspected bacterial infections commonly have elevated PCT level. PCT levels are associated with disease severity and antibiotic trials guided by PCT levels may be needed where cultures are not available

Hospital-acquired malnutrition in children at a tertiary care hospital

Objectives: This study sought to investigate the incidence and factors associated with hospital-acquired malnutrition in children. Design: A hospital-based longitudinal survey carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: One hundred and seventy children who met the inclusion criteria were included in the study. Outcome measures: Anthropometry was done at admission and discharge. Incidence of hospital-acquired malnutrition was estimated from the total number of children showing a decrease in weight-for-height/length (WFH) or Body Mass Index (BMI) z-scores from the time of admission to discharge. Logistic regression analysis was performed to determine associations between selected variables and weight loss during hospitalisation. Results: Albeit a borderline level of significance, a decrease in calculated z-scores occurred in 60.6% (Confidence Interval (CI) 53.1–67.6%) of children during hospitalisation with a mean weight decrease of 0.5 kg (Standard Deviation (SD) ± 3.37, p = 0.055). Children ≤ 60 months of age demonstrated a mean decrease in weight-for-height/length z-score of 0.145 (SD ± 0.73, p = 0.042); and those \u3e 60 months, a mean decrease in BMI z-score of 0.152 (SD ± 0.39, p = 0.004). The majority with weight loss had been admitted with a diagnosis of gastroenteritis (81.2%), gastritis (64.3%) and pneumonia (55.6%). Weight loss was associated with duration of admission: 3 - 5 days (Odds Ratio (OR) 2.43, CI 1.46–4.03), 5 - 7 days (OR 4.67, CI 1.34–16.24), and \u3e 7 days (OR 2.75, CI 0.88–8.64); score test for trend of odds is OR 1.37 (95% CI 1.11–1.69, p = 0.003). Conclusion: This study found a high incidence of hospital-acquired malnutrition in children. The most affected were those with gastroenteritis, gastritis and pneumonia. Hospital-acquired malnutrition was associated with an increased duration of hospitalisation

Pre-albumin as a marker for predicting weight loss in hospitalised children

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p \u3c 0.001). Using a serum pre-albumin cut off point of \u3c 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation

Pre-albumin as a marker for predicting weight loss in hospitalised children

Objectives: This study sought to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Design: A hospital-based longitudinal survey was carried out between December 2013 and February 2014. Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital. Subjects: A total of 170 children aged 29 days to 15 years who met the inclusion criteria were included in the study. Outcome measures: Serum pre-albumin levels and weight were measured at admission and repeated after 48–96 h. Sensitivity, specificity, and positive and negative predictive values were calculated to determine the diagnostic utility of serum pre-albumin in predicting weight loss in hospitalised children. Results: Of the 170 children studied, 57% and 60% had a drop in serum pre-albumin level and weight within the first four days of hospitalisation respectively. A drop in pre-albumin occurred in 68% of the 103 patients who had weight loss (p < 0.001). Using a serum pre-albumin cut off point of < 0.15 g/l at admission, sensitivity and specificity of serum pre-albumin in predicting weight loss were 76.7% and 29.0% (negative predictive value = 42.9%; positive predictive value = 64.2%). Positive and negative likelihood ratios were low at 1.08 and 0.8. The majority of the patients (72.3%) were already at risk of malnutrition as determined by the pre-albumin risk stratification on admission. Conclusion: Serum pre-albumin is not an accurate surrogate for weight loss during hospitalisation. It is, however, useful in identifying patients at risk of malnutrition on admission and during hospitalisation

Cross-sectional survey on prevalence of attention deficit hyperactivity disorder symptoms at a tertiary care health facility in Nairobi

Background:Attention deficit hyperactivity disorder is the most common childhood neurobehavioral disorder with well documented adverse consequences in adolescence and adulthood, yet 60-80% of cases go undiagnosed. Routine screening is not practiced in most pediatric outpatient services and little information exists on factors associated with the condition in developing countries. Methods:This was a questionnaire based cross-sectional survey whose primary objective was to determine prevalence of attention deficit hyperactivity disorder (ADHD) symptoms in children aged 6-12 years attending a tertiary care hospital Accidents and Emergency unit. Secondary objectives were to: (i) ascertain if physical injury and poor academic performance were associated with ADHD, (ii) compare diagnostic utility of parent-filled Vanderbilt Assessment Scale (VAS) against Statistical Manual of Mental Disorders-IV (DSM-IV) as the gold reference and (iii) establish if there exists an association between ADHD symptoms cluster and co-morbid conditions. Results:Prevalence of cluster of symptoms consistent with ADHD was 6.3% (95% CI; 3.72-10.33) in 240 children studied. Those affected were more likely to repeat classes than the asymptomatic (OR 20.2; 95% CI 4.02-100.43). Additionally, 67% of the symptomatic had previously experienced burns and 37% post-traumatic open wounds. The odds of having an injury in the symptomatic was 2.9 (95% CI; 1.01-8.42) compared to the asymptomatic. Using DSM-IV as reference, VAS had a sensitivity of 66.7% (95%; CI 39.03-87.12) and specificity of 99.0% (95% CI; 96.1-99.2). Positive predictive value was 83.0% (95% CI; 50.4-97.3) and negative predictive value 98.0% (CI 95.1-99.1). Oppositional defiant disorder symptoms, anxiety, depression and conduct problems were not significantly associated with ADHD cluster of symptoms. Conclusion:The study found a relatively high prevalence of symptoms associated with ADHD. Symptomatic children experienced poor school performance. These findings support introduction of a policy on routine screening for ADHD in pediatric outpatient service. Positive history of injury and poor academic performance should trigger further evaluation for ADHD. Vanderbilt assessment scale is easier to administer than DSM-IV but has low sensitivity and high specificity that make it inappropriate for screening. It however provides a suitable alternative confirmatory test to determine who among clinically symptomatic patients requires referral to a psychiatrist

Recalibrating prognostic models to improve predictions of in-hospital child mortality in resource-limited settings

Background In an external validation study, model recalibration is suggested once there is evidence of poor model calibration but with acceptable discriminatory abilities. We identified four models, namely RISC-Malawi (Respiratory Index of Severity in Children) developed in Malawi, and three other predictive models developed in Uganda by Lowlaavar et al. (2016). These prognostic models exhibited poor calibration performance in the recent external validation study, hence the need for recalibration. Objective In this study, we aim to recalibrate these models using regression coefficients updating strategy and determine how much their performances improve. Methods We used data collected by the Clinical Information Network from paediatric wards of 20 public county referral hospitals. Missing data were multiply imputed using chained equations. Model updating entailed adjustment of the model's calibration performance while the discriminatory ability remained unaltered. We used two strategies to adjust the model: intercept-only and the logistic recalibration method. Results Eligibility criteria for the RISC-Malawi model were met in 50,669 patients, split into two sets: a model-recalibrating set (n = 30,343) and a test set (n = 20,326). For the Lowlaavar models, 10,782 patients met the eligibility criteria, of whom 6175 were used to recalibrate the models and 4607 were used to test the performance of the adjusted model. The intercept of the recalibrated RISC-Malawi model was 0.12 (95% CI 0.07, 0.17), while the slope of the same model was 1.08 (95% CI 1.03, 1.13). The performance of the recalibrated models on the test set suggested that no model met the threshold of a perfectly calibrated model, which includes a calibration slope of 1 and a calibration-in-the-large/intercept of 0. Conclusions Even after model adjustment, the calibration performances of the 4 models did not meet the recommended threshold for perfect calibration. This finding is suggestive of models over/underestimating the predicted risk of in-hospital mortality, potentially harmful clinically. Therefore, researchers may consider other alternatives, such as ensemble techniques to combine these models into a meta-model to improve out-of-sample predictive performance

Risk factors for death among children aged 5-14 years hospitalised with pneumonia: a retrospective cohort study in Kenya.

INTRODUCTION: There were almost 1 million deaths in children aged between 5 and 14 years in 2017, and pneumonia accounted for 11%. However, there are no validated guidelines for pneumonia management in older children and data to support their development are limited. We sought to understand risk factors for mortality among children aged 5-14 years hospitalised with pneumonia in district-level health facilities in Kenya. METHODS: We did a retrospective cohort study using data collected from an established clinical information network of 13 hospitals. We reviewed records for children aged 5-14 years admitted with pneumonia between 1 March 2014 and 28 February 2018. Individual clinical signs were examined for association with inpatient mortality using logistic regression. We used existing WHO criteria (intended for under 5s) to define levels of severity and examined their performance in identifying those at increased risk of death. RESULTS: 1832 children were diagnosed with pneumonia and 145 (7.9%) died. Severe pallor was strongly associated with mortality (adjusted OR (aOR) 8.06, 95% CI 4.72 to 13.75) as were reduced consciousness, mild/moderate pallor, central cyanosis and older age (>9 years) (aOR >2). Comorbidities HIV and severe acute malnutrition were also associated with death (aOR 2.31, 95% CI 1.39 to 3.84 and aOR 1.89, 95% CI 1.12 to 3.21, respectively). The presence of clinical characteristics used by WHO to define severe pneumonia was associated with death in univariate analysis (OR 2.69). However, this combination of clinical characteristics was poor in discriminating those at risk of death (sensitivity: 0.56, specificity: 0.68, and area under the curve: 0.62). CONCLUSION: Children >5 years have high inpatient pneumonia mortality. These findings also suggest that the WHO criteria for classification of severity for children under 5 years do not appear to be a valid tool for risk assessment in this older age group, indicating the urgent need for evidence-based clinical guidelines for this neglected population

Survival and haematological recovery of children with severe malaria transfused in accordance to WHO guidelines in Kilifi, Kenya

Background: Severe anaemia requiring emergency blood transfusion is a common complication of malaria in children. To ensure access for urgent blood transfusion, the World Health Organization has developed clear guidelines with haemoglobin thresholds prevent unwarranted transfusion,. Few studies have reported outcome and haematological recovery of children with severe malaria where transfusion practice complies with WHO recommendations. Methods: A prospective observational study of survivors of severe and complicated malaria transfused in accordance with WHO guidelines. Children were invited for review at one month post-discharge. Non-attendees were traced in the community to ascertain survival. Results: Outcome was assessed in 213 survivors. Those transfused were younger, had a higher base deficit, mean lactate levels and a higher prevalence of respiratory distress. As expected mean admission haemoglobin (Hb) was significantly lower amongst transfused [5.0 g/dL SD: 1.9] compared to non-transfused children [8.3 g/dL SD: 1.7] (p < 0.001). At discharge mean Hb was similar 6.4 g/dL [SD: 1.5] and 6.8 g/dL [SD: 1.6] respectively (p = 0.08), most children remained moderately to severely anaemic. At one month follow up 166 children (78%) returned, in whom we found no differences in mean Hb between the transfused (10.2 g/dL [SD: 1.7]) and non-transfused (10.0 g/dL [SD: 1.3]) survivors ( p = 0.25). The major factors affecting haematological recovery were young age (< 24 months) and concomitant malaria parasitaemia; Hb being 8.8 g/dL [SD: 1.5] in parasitaemic individuals compared with 10.5 g/dL [SD: 1.3] in those without (p < 0.001). Conclusion: This data supports the policy of rational use of blood transfusion, as proposed in the WHO guidelines, for children with anaemia in areas where access to emergency transfusion is not guaranteed. We have provided empirical data indicating that transfusion does not influence superior recovery in haemoglobin concentrations and therefore cannot be justified on this basis alone. This may help resolve the disparity between international policy and current clinical practice. Effective anti- malarial treatment at discharge may prevent reoccurrence of anaemia