and postdischarge child deaths Tickell KD Walson JL Denno DM I npatient management of malnutrition Food systems N utrient deficiency Malnutrition amp complications Infection ID: 603882
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Slide1
Malnutrition-associated inpatient and post-discharge child deaths
Tickell
KD,
Walson
JL,
Denno
DMSlide2
Inpatient management of malnutrition
Food systems
N
utrient deficiency
Malnutrition
& complications
Infection
WASH
Prevention
TreatmentSlide3
Severe acute malnutrition
with complications (SAM-C)Slide4
SAM-C
case fatality
WHO indicates <10%
1
Sub-Saharan
centers of
excellence:
15 - 25%
2,3,4
Blantyre
, Malawi: 42% at 1 year 5Slide5
Importance of SAM-C
g
uidelines
Opportunity
We estimate that 100,000/year
child deaths
averted if 10
%
target reached
Highly accessible population
–
rapid impact is possible
Directly attributable to SAM-C
6
12.2% of diarrhea deaths
12.3% of measles deaths
8.7% of pneumonia deathsSlide6
Ancestry tracing guideline
2013 WHO update
20
03 & 1999 WHO SAM guideline1981 WHO PEM guideline
Text books:
F. Savage-King (1992) “Nutrition in Developing C
ountries”M. King (1969) “Medical Care in Developing
Countries”
MethodsSlide7
Results
:
Only
1
/4 based on RCT
evidenceSlide8
Areas of guidance
Feeding &
f
luids
Infection management
Discharge & follow-up careSlide9
Feeding & fluids
ReSoMal
, unless cholera
High dose
vit
A: measles, eye signs
RUTF for diarrhea
Shock/Severe dehydration: IV HS Darrow’s or Ringer’s + 5% Dextrose
No Fe until rehabilitation
F
olic acid,
Zn, Cu
RCT
Observational
Indirect
<6 mo: breastfeed or
relactate
F75 -> RUTF: stabilized
F100->rapid
wgt
gain
King
(1969)
WHO
(2013)
WHO (
1999)
WHO (2003)
WHO PEM
(1981)
Savage King
(1992)
Low dose
vit
A
Cholera
: standard ORS
Monitor every 5-10
mins
if on IV
Transfusion: unimproved shock/anemia
No transfusions after 24
hrsSlide10
Feeding & fluids
ReSoMal
, unless cholera
High dose
vit
A: measles, eye signs
RUTF for diarrhea
Shock/Severe dehydration: IV HS Darrow’s or Ringer’s + 5% Dextrose
No Fe until rehabilitation
F
olic acid,
Zn, Cu
RCT
Observational
Indirect
<6 mo: breastfeed or
relactate
F75 -> RUTF: stabilized
F100->rapid
wgt
gain
King
(1969)
WHO
(2013)
WHO (
1999)
WHO (2003)
WHO PEM
(1981)
Savage King
(1992)
Low dose
vit
A
Cholera
: standard ORS
Monitor every 5-10
mins
if on IV
Transfusion: unimproved shock/anemia
No transfusions after 24
hrsSlide11
Infection
Ampicillin & gentamicin on admission
ART
when
stable if HIV+
Measles vaccine if not immunized
Conscious & hypoglycemic: IV + oral dose glucose
Unconcious
&
hypoglycemic: IV + oral dose
HIV+ & >24 months: ART based on CD4
HIV+ & <24 months: ART for life
RCT
Observational
Indirect
Zn for diarrhea
HIV+ no difference for
zn
&
vit
A
HIV+ no difference for feeding
< 6mo same ABX as older
King
(1969)
WHO
(2013)
WHO (
1999)
WHO (2003)
WHO PEM
(1981)
Savage King
(1992)Slide12
Infection
Ampicillin & gentamicin on admission
ART
when
stable if HIV+
Measles vaccine if not immunized
Conscious & hypoglycemic: IV + oral dose glucose
Unconcious
&
hypoglycemic: IV + oral dose
HIV+ & >24 months: ART based on CD4
HIV+ & <24 months: ART for life
RCT
Observational
Indirect
Zn for diarrhea
HIV+ no difference for
zn
&
vit
A
HIV+ no difference for feeding
< 6mo same ABX as older
King
(1969)
WHO
(2013)
WHO (
1999)
WHO (2003)
WHO PEM
(1981)
Savage King
(1992)Slide13
Discharge & follow-up care
Do not use %weight gain
Follow-up care d/c: WHZ >-2 & no edema x 2 weeks
Provide emotional and sensory support
Hospital d/c: no complications, alert, appetite not anthropometry
< 6mo: hospital d/c W gain > 5g/kg/day
RCT
Observational
Indirect
Assess progress using the anthropometric measure which qualified the child
for admission
If edema only complication normal
anthropmetirc
used for F/U
King
(1969)
WHO
(2013)
WHO (
1999)
WHO (2003)
WHO PEM
(1981)
Savage King
(1992)Slide14
WHO 2013 update:
“Major research gaps were identified in each of the sections
covered.”
Two key populations:
7
“No randomized controlled trials i
n
HIV-infected children
with
SAM were identified that directly addressed any of the prioritized questions
.”
“No studies were found in the peer-reviewed literature that reported outcomes when WHO therapeutic feeding
recommendations…are applied to
SAM infants who are
less than 6 months of age.”Slide15
Weak evidence
&
h
igh mortality42% of SAM inpatients die within 1 year
62% of HIV+ children died
67% of infants died
Post-discharge mortality
44% of
deaths
Queen Elizabeth hospital: “the biggest and one of the best” (
T
he Guardian 2005)
Data from
Kerac
, et al 2014
5Slide16
Timing of deaths
No data on causes of deathSlide17
Guidelines
Useful clinical tool & synthesis of evidence/opinion
Evidence
W
eak or non-existent for most elements
Systematic search of trials registries
Limited potential for impact
SAM-C
Underlying cause: We don’t know why these children dieSlide18
Beyond SAM-C
No guidelines for
MAM
34% of diarrhea deaths attributable to MAM
32% of pneumonia deaths attributable
to
MAM
6
No guidelines for stunting
45% of diarrhea
deaths attributable to stunting
43% of pneumonia deaths attributable to stunting
6Slide19
Judd
Walson
Co-director
Donna
Denno
Investigator
Kirk
Tickell
Coordinator
Bangladesh
Pakistan
Kenya
Malawi
Uganda
Next steps: The CHAIN network
Jay Berkley
DirectorSlide20
Opportunities for intervention
Hospital & post-discharge
Intervene on modifiable pathways to deathSlide21
References
1: WHO.
Guidelines for the Inpatient Management of Severely Malnourished Children.
Geneva: WHO, 2003. 2: Personal communication between Kirk Tickell and Jay Berkley (12/8/14)
3: Fergusson, P. "HIV Prevalence and Mortality Among Children Undergoing Treatment for Severe Acute Malnutrition in Sub-Saharan Africa: a Systematic Review and Meta-analysis.” R
Soc
Tropl Med (2009) 103
, 541—548 4:
Personal communication between Donna Denno and Maurice Kelly (6/6/14)5: Kerac, MH. Et al. "Follow-Up of Post-Discharge Growth and Mortality After Treatment for Severe Acute Malnutrition (FuSAM Study): a Prospective Cohort Study."
PLOS One 9.6 (2014): E96030.7: Black RE, et al. (2013) Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet, Aug 3; 382: 427-51
.7: WHO. Updates on the Management of Severe Acute Malnutrition in Infants and Children. Geneva: WHO, 2013.