Community-Based Management of Acute Malnutrition in Infants Under 6 Months of Age

Abstract Objectives To examine the outcomes of acutely malnourished infants under 6 months (u6m) who could not be hospitalized or exclusively breastfed and were instead treated under the community management of acute malnutrition (CMAM) model using ready to use therapeutic food (RUTF) or a supplemental food. Methods The study was a retrospective chart review of 323 infants u6m with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) seen across 20 CMAM clinics in rural southern Malawi who could not be admitted to inpatient care, which is the established standard of care for acute malnutrition in infants u6m. Infants with SAM were given 175 kcal/kg/day of RUTF and those with MAM were given 75 kcal/kg/day RUTF or supplemental food, based on availability. Nutritional counseling was provided to the caregivers of all participants, and mothers were counseled about improved breastfeeding practices. Infants were reassessed every two weeks. Outcomes included successful nutritional recovery (achieving WHZ of ≥−2 without edema), failure to achieve recovery after 12 weeks, hospitalization, death, and loss to follow up. Demographic information was also collected. Continuous variables were compared using Student's t test. Categorical variables were compared using Fisher's exact test. Results 130 infants u6m with SAM and 193 with MAM were treated using the same CMAM model used in 6–59 month-old children. About 90% of children in both groups were breastfeeding. Mean duration of therapy was 31.5 days for SAM and 20.8 days for MAM. Recovery rates were high in both groups (SAM 75%; MAM 81%). Recovery rates and other outcomes were similar to older children who were being treated contemporaneously at the same sites in the context of randomized clinical trials. Conclusions When inpatient care is not possible, therapeutic and supplementary foods provided to infants u6m with acute malnutrition is a viable treatment option. Making this option available has the potential to massively scale up the number of infants treated, with acceptable recovery rates, and at a relatively low cost to the health care system. Funding Sources None.

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P047: Emergency department practice patterns of UTI investigation among the delirious elderly: a retrospective chart review

CJEM ◽

10.1017/cem.2020.253 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S81-S81

Author(s):

R. Pinnell ◽

P. Joo

Keyword(s):

Emergency Department ◽

Elderly Patients ◽

Chart Review ◽

Retrospective Chart Review ◽

Patient Characteristics ◽

Urinary Symptoms ◽

Categorical Variables ◽

Continuous Variables ◽

Indwelling Catheter ◽

Exact Test

Introduction: Delirium is a common emergency department (ED) presentation in elderly patients. Urinary tract infection (UTI) investigation and treatment are often initiated in delirious patients in the absence of specific urinary symptoms, despite a paucity of evidence to support this practice. The purpose of this study is to describe the prevalence of UTI investigation, diagnosis and treatment in delirious elderly patients in the ED. Methods: We performed a retrospective chart review of elderly patients presenting to the ED at The Ottawa Hospital between January 15-July 30, 2018 with a chief complaint of confusion or similar. Exclusion criteria were pre-existing and current UTI diagnosis, Glasgow Coma Scale <13, current indwelling catheter or nephrostomy tube, transfers between hospitals, and leaving without being seen. The primary outcome was the proportion of patients for whom urine tests (urinalysis or culture) or antibiotic treatment were ordered. Secondary outcomes were associations between patient characteristics, rates of UTI investigation, and patient outcomes. Descriptive values were reported as proportions with exact binomial confidence intervals for categorical variables and means with standard deviations for continuous variables. Comparisons were conducted with Fischer's exact test for categorical variables and t-tests for continuous variables. Results: After analysis of 1039 encounters with 961 distinct patients, 499 encounters were included. Urine tests were conducted in 324 patients (64.9% [60.6-69.1]) and antibiotics were prescribed to 176 (35.2% [31.1-39.6]). Overall 57 patients (11.4% [8.8-14.5]) were diagnosed with UTI, of which only 12 (21.1% [11.4-33.9]) had any specific urinary symptom. For those patients who had no urinary symptoms or other obvious indication for antibiotics (n = 342), 199 (58.2% [52.8-63.5]) received urine tests and 62 (18.1% [14.2-22.6]) received antibiotics. Patients who received urine tests were older (82.4 ± 8.8 vs. 78.3 ± 8.4 years, p < 0.001) but did not differ in sex distribution from those than those who did not. Additionally, patients who received antibiotics were more likely to be admitted (OR = 2.6 [1.48-4.73]) and had higher mortality at 30 days (OR = 4.2 [1.35-12.91]) and 6 months (OR = 3.2 [1.33-7.84]) than those who did not. Conclusion: Delirious patient without urinary symptoms in the ED were frequently investigated and treated for UTI despite a lack of evidence regarding whether this practice is beneficial.

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Integrated program achieves good survival but moderate recovery rates among children with severe acute malnutrition in India

American Journal of Clinical Nutrition ◽

10.3945/ajcn.112.054080 ◽

2013 ◽

Vol 98 (5) ◽

pp. 1335-1342 ◽

Cited By ~ 15

Author(s):

Víctor M Aguayo ◽

Vandana Agarwal ◽

Manohar Agnani ◽

Dwarka Das Agrawal ◽

Sheela Bhambhal ◽

...

Keyword(s):

Severe Acute Malnutrition ◽

Acute Malnutrition ◽

Good Survival ◽

Recovery Rates ◽

Integrated Program

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The Effectiveness of the Malnutrition eLearning Course for Global Capacity Building in the Management of Malnutrition: A Prospective Empirical Study (Preprint)

10.2196/preprints.10396 ◽

2018 ◽

Author(s):

Sunhea Choi ◽

Ho Ming Yuen ◽

Reginald Annan ◽

Trevor Pickup ◽

Andrew Pulman ◽

...

Keyword(s):

Clinical Practice ◽

Health Professionals ◽

Severe Acute Malnutrition ◽

Scale Up ◽

Health Sector ◽

Nutrition Intervention ◽

Acute Malnutrition ◽

World Health ◽

Knowledge Gain ◽

Prospective Longitudinal

BACKGROUND Scaling-up improved management of severe acute malnutrition has been identified as the nutrition intervention with the largest potential to reduce child mortality but lack of operational capacity at all levels of the health system constrains scale-up. We therefore developed an interactive Malnutrition eLearning course that is accessible at scale to build capacity of the health sector workforce to manage severely malnourished children according to guidelines of the World Health Organization (WHO). OBJECTIVE The study aim was to test whether the Malnutrition eLearning course improves knowledge and skills of in-service and pre-service health professionals in managing children with severe acute malnutrition. METHODS This 2-year prospective, longitudinal, empirical research study took place in Ghana, Guatemala, El Salvador and Colombia between January 2015 and February 2017. A subset of 354 in-service health personnel from 12 hospitals and 2 Ministries of Health, 703 pre-service trainees from 9 academic institutions, and 204 online users participated. Knowledge gain after training and retention over time were measured through pre- and post-assessments, comprising questions pertaining to screening, diagnosis, pathophysiology, and treatment and prevention of malnutrition. Comprehension, application and integration of knowledge were tested. Changes in perception, confidence, and clinical practice were assessed through questionnaires and interviews. RESULTS Before the course, awareness of the WHO guidelines was 36.7% (389/1059) overall and 26.3% (94/358) among in-service professionals. The mean score gain in knowledge after access to the course of 606 participants who had pre-and post-assessment data was 11.8 (95% CI 10.8, 12.9 P<.001) – a relative increase of 41.5%. The proportion who achieved above the pass mark post-training was 58.7% (356/606), compared with 18.2% (110/606) pre-training. Of the in-service professionals, 86% (128/149) reported applying their knowledge by changing their clinical practice in screening, assessment, diagnosis and/or management. This group demonstrated significantly increased, retained knowledge 6-months after training (mean difference (SD) from pre-assessment:12.1 (11.8)), retaining 65.8% (12.1/18.4) of gained knowledge from the training. Changes in the management of malnutrition were reported by trained participants, and institutional operational and policy changes were also found. CONCLUSIONS The Malnutrition eLearning course improved knowledge, understanding and skills of health professionals in the diagnosis and management of children with severe acute malnutrition, and changes in clinical practice and confidence were reported following completion of the course.

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Reoperation Rates of Percutaneous and Paddle Leads in Spinal Cord Stimulator Systems: A Single-Center Retrospective Analysis

Pain Medicine ◽

10.1093/pm/pnaa215 ◽

2020 ◽

Author(s):

Devin D Antonovich ◽

Willy Gama ◽

Alexandra Ritter ◽

Bethany Jacobs Wolf ◽

Ryan H Nobles ◽

...

Keyword(s):

Spinal Cord ◽

South Carolina ◽

Cox Regression ◽

Retrospective Chart Review ◽

Patient Characteristics ◽

Categorical Variables ◽

Continuous Variables ◽

Single Center ◽

Diabetes Status ◽

Reoperation Rates

Abstract Objective We hypothesize that reoperation rates of spinal cord stimulation (SCS) systems utilizing percutaneous leads are comparable to those utilizing paddle leads. We attempt here to characterize causes for those reoperations and identify any related patient characteristics. Design and Subjects This study is a single-center retrospective chart review of 291 subjects (410 operations) who underwent at least one permanent SCS implantation utilizing percutaneous or paddle leads over a 10-year period at the Medical University of South Carolina. Methods Charts were reviewed for height, weight, body mass index, gender, race, age, stimulator type, type of reoperation, diabetes status, history and type of prior back surgery, top lead location, and number of leads placed. Comparisons of patient and procedural characteristics were conducted using a two-sample t test (continuous variables), chi-square, or Fisher exact approach (categorical variables). Univariate and multivariate Cox regression models were developed, identifying associations between patient characteristics, SCS characteristics, reoperation rates, and time to reoperation. Results Thirty point five eight percent of subjects (89/291), required at least one reoperation. The reoperation rate was 27.84% for percutaneous systems (N = 54/194) and 27.78% for percutaneous systems (N = 60/216). Time to reoperation also did not differ between the two systems (hazard ratio [HR] = 1.06, 95% CI = 0.70–1.60). Of all factors examined, younger age at time of placement was the only factor associated with risk of reoperation (HR = 0.73, 95% CI = 0.62–0.87, P < 0.001). Conclusions Our data suggest that reoperation rates and time to reoperation between percutaneous and paddle leads are clinically similar; therefore, rates of reoperation should have no bearing on which system to choose.

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The effects of psychosocial stimulation on the development, growth, and treatment outcome of children with severe acute malnutrition age 6–59 months in southern Ethiopia: a parallel group cluster randomized control trial (EPSoSAMC study)

BMC Public Health ◽

10.1186/s12889-019-7916-5 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Tesfalem T. Tessema ◽

Andamlak G. Alamdo ◽

Tewodrose G. Yirtaw ◽

Fana A. Deble ◽

Eyoel B. Mekonen ◽

...

Keyword(s):

Treatment Outcome ◽

Inpatient Care ◽

Severe Acute Malnutrition ◽

Scientific Evidence ◽

Acute Malnutrition ◽

Southern Ethiopia ◽

Parallel Group ◽

Psychosocial Stimulation ◽

Cluster Randomized

Abstract Background Severe Acute Malnutrition (SAM) remains a major cause of child mortality. To improve the management and survival of children the World Health Organization (WHO) endorsed the protocol for the management of SAM. The protocol suggested the integration of psychosocial stimulation as part of the medico-nutritional care process to prevent the long-term adverse developmental impact of the SAM. However, there is little scientific evidence behind the recommended stimulation intervention. Method A parallel-group cluster-randomized controlled trial will be conducted among 144 children with SAM age 6–59 months in Southern Ethiopia. The study will have two groups where: children with SAM admitted in the intervention health facilities will receive psychosocial stimulation in addition to the routine inpatient care and for 6 months after discharge. Children with SAM admitted in the SC of the control health facilities will receive the routine inpatient care without psychosocial stimulation and home-based follow up for 6 months after discharge. All mothers/ caregivers will also receive uniform health education on child health-related issues. The primary outcome of the study will be child development while the secondary outcomes will include child growth and treatment outcome. All outcomes will be assessed four times: at enrollment, upon discharge from the SC, at 3 and 6 months of follow up. The data will be analyzed using STATA Version 15 Statistical Software. The anthropometric Z-scores and percentile of the median will be calculated child using WHO Anthro Version 3.2.2 Statistical Software. To assess the overall effect of the intervention by controlling other potential contributing factors, a generalized linear mixed model will be used. Discussion The present study will have an important contribution in generating supplementary evidence regarding the effect of psychosocial stimulation interventions on the development and growth outcomes of children with SAM. The study will further address the impact of the intervention on treatment outcome indicators that are still under-researched areas requiring new scientific evidence. Trial registration Pan African Clinical Trials Registry -PACTR201901730324304. Registered 25 November 2018, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=5739

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Vanishing congenital lung malformations: What is the incidence of true regression?

Journal of Neonatal-Perinatal Medicine ◽

10.3233/npm-210740 ◽

2021 ◽

pp. 1-7

Author(s):

C. Griggs ◽

M. Schmaedick ◽

C. Gerall ◽

W. Fan ◽

C. Orlas ◽

...

Keyword(s):

Neonatal Intensive Care ◽

Statistical Significance ◽

Multivariable Analysis ◽

Retrospective Chart Review ◽

Categorical Variables ◽

Continuous Variables ◽

Chi Square ◽

Exact Test ◽

Congenital Lung Malformation ◽

Nicu Admission

BACKGROUND: A congenital lung malformation (CLM) that is diagnosed on prenatal ultrasound exam may subsequently become undetectable on later scans, a “vanishing” CLM. OBJECTIVE: The purpose of our study is to characterize the prenatal natural history and postnatal outcomes of “vanishing” lesions treated at our institution. METHODS: We performed a retrospective chart review of 107 patients diagnosed prenatally with CLM at our institution. Comparisons were made using Kruskal-Wallis or t-test for continuous variables and Fisher’s exact test or Chi-Square test for categorical variables. Multivariable analysis using logistic regression was performed. RESULTS: Of the 104 patients, 59 (56.7%) had lesions that became sonographically undetectable on serial ultrasound scans. Patients with lesions that vanished prenatally tended to need less Neonatal Intensive Care Unit (NICU) admission at birth (persistent CLM: 54.8%vs vanished CLM: 28.8%), decreased need for supplemental O2 at birth (persistent CLM: 31.0%vs vanished CLM: 11.9%), and decreased delay in feeds (persistent CLM: 26.2%vs vanished CLM: 8.5%) compared to those with persistent CLM. After multivariate analysis controlling for maternal steroid administration and sex, admission to NICU maintained a slight statistical significance, with patients in the vanishing CLM group 2.5 times less likely to be admitted to the NICU. None of our patients whose lesions vanished prenatally required mechanical ventilation. Eighty-six patients underwent postnatal computed tomography (CT) chest. Only 2 patients had lesions that regressed on postnatal CT. CONCLUSION: Lesions that vanish on prenatal imaging may be associated with improved clinical outcomes. The rate of true regression at our institution was as low as 2.3%.

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Rethink Your Transjugular Intrahepatic Portosystemic Shunt (TIPS): Pre-TIPS Infection Predicts Post-TIPS Infection and Post-TIPS Portosystemic Encephalopathy

EMJ Hepatology ◽

10.33590/emjhepatol/19-00204 ◽

2020 ◽

pp. 34-41

Author(s):

Jenna Koblinski ◽

Margaret C. Liu ◽

Roy U. Bisht ◽

Paul Kang ◽

Mark Wong ◽

...

Keyword(s):

Transjugular Intrahepatic Portosystemic Shunt ◽

Odds Ratio ◽

Portal Pressure ◽

Retrospective Chart Review ◽

Portosystemic Shunt ◽

Categorical Variables ◽

Continuous Variables ◽

Exact Test ◽

Portosystemic Encephalopathy ◽

Intrahepatic Portosystemic Shunt

Abstract Objective: Transjugular intrahepatic portosystemic shunt (TIPS) is used for decompression of elevated portal pressure; however, there are potential complications. The aim of this study was to compare the risk of complications of TIPS in those who had an episode of infection within 6 months prior to TIPS to those without an infection prior. Methods: A retrospective chart review was performed on patients who underwent TIPS at a single transplant centre over 8 years. They were divided into two groups: patients without infection during the 6 months prior to TIPS (n=349) and those with an infection prior (bacterial/fungal) (n=53). The Wilcoxon rank-sum test was used to compare continuous variables while chi-squared analysis and Fisher’s exact test was used for categorical variables. Multiple logistic regression was used to ascertain the association between pre-TIPS infection status and likelihood of post-TIPS infection. Results: In the group of patients who had an infection before TIPS, 26.4% (n=14) had an episode of infection after the procedure, while in the group without infection prior, 16.2% (n=55) had an infection after the procedure (p=0.047; odds ratio: 2.08). In the pre-TIPS infection group, 54.7% (n=29) had an episode of portosystemic encephalopathy post-TIPS versus 39.6% (n=134) in the group without infection before TIPS (p=0.046; odds ratio: 1.93). Conclusion: Pre-TIPS infection within 6 months of TIPS procedure is a risk factor for post-TIPS portosystemic encephalopathy and infection. Further studies are needed to determine the potential benefit of antibiotic prophylaxis in patients who had an infection in the 6 months preceding TIPS placement.

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Bacterial infections in hospitalised severely malnourished children in Durban, South Africa

Southern African Journal of Infectious Diseases ◽

10.4102/sajid.v33i5.139 ◽

2018 ◽

Vol 33 (5) ◽

Author(s):

Lionel Nyamurenje ◽

Moherndran Archary

Keyword(s):

Bacterial Infections ◽

Severe Acute Malnutrition ◽

Retrospective Chart Review ◽

Acute Malnutrition ◽

Hiv Positive ◽

Gram Negative ◽

Malnourished Children ◽

Area Of Concern ◽

Gram Negative Organisms ◽

Hiv Negative

Background: Severe acute malnutrition (SAM) results in alterations of host defence mechanisms, which leads to increased susceptibility to infections. This study describes culture-confirmed bacterial infections in a cohort of HIV-negative severely malnourished children and compares it with a previously described cohort of HIV-positive children.Methods: A retrospective chart review was conducted of all HIV-negative children with SAM admitted to King Edward Hospital, Durban between January 1, 2015 and December 31, 2015. All positive bacterial cultures obtained within 2 days of admission (admission infections) and during 2 to 30 days of admissions (hospital acquired infections) were documented. A cohort of HIV-positive children with SAM was prospectively recruited between July 2012 and February 2015 at the same facility for the MATCH study.Results: A total of 101 patients were eligible for the study, 53% were HIV unexposed; 73% of the total 250 cultures obtained were during admission. Escherichia coli (E. coli) contributed 26% of all positive cultures on admission. Significant differences were noted in laboratory variables between HIV-negative vs. HIV-positive children admitted with SAM. Extended-spectrum betalactamase (ESBL) producers in HIV-positive patients constituted 40% of all Gram-negative isolates vs. 24% in HIV-negative patients.Conclusion: Gram-negative organisms remain an area of concern in both HIV-positive and HIV-negative patients with SAM with resistant organisms more prevalent in HIV-positive patients. Prevention of mother-to-child transmission of HIV reduces prevalence and incidence of HIV, which has been shown to contribute to the burden of bacterial infections in malnourished children.

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Clinical Spectrum and Comorbidity Pattern of Severe Acute Malnutrition in Hospitalised Children Age between 6 Months to 59 Months

10.21203/rs.3.rs-446283/v1 ◽

2021 ◽

Author(s):

Ashutosh Kumar Sharma ◽

Ghanshyam Das ◽

Durgesh Shukla

Keyword(s):

Nutrition Education ◽

Work Performance ◽

Severe Acute Malnutrition ◽

Public Health Problem ◽

Sub Saharan Africa ◽

Acute Malnutrition ◽

Categorical Variables ◽

Comprehensive Treatment ◽

Treatment Unit ◽

Co Morbidity

Abstract BACKGROUND The prevalence of underweight children in India is the highest in the world, and is nearly double that of Sub-Saharan Africa. Poor nutrition in the first 1000 days of a child’s life leads to stunted growth, impaired cognitive ability, reduced school and work performance. The mortality rate and duration of stay in hospital with oedematous SAM has remained unacceptably high. Such high mortality in inpatients has been attributed to co-morbidities.METHOD Descriptive hospital based study was done in the Department of Paediatrics, Kamla Raja Hospital, Gwalior from October 2018 to October 2020. Children 6-59 months of age with severe acute malnutrition admitted in severe acute malnutrition treatment unit were enrolled. WHO criteria were used to define severe acute malnutrition. The quantitative variables were described as mean ± standard deviation and categorical variables were in terms of proportion.RESULT Out of 29036 children, 1020 have severe acute malnutrition, constitute prevalence of 3.51%. A total of 400 cases met eligibility criteria and exploited. Sex ratio male and female 52.5%:47.5%. The peak prevalence was found in age group between 6-12 months (55%). Anaemia (68.25%) was found to be the commonest co morbidity, and then pneumonia (17.75%) dehydration (16.5%) followed by sepsis (13.5%). Most common chief complaint was fever (69%), followed by cough (38%) and watery loose motion (38%).CONCLUSION Severe acute malnutrition remains severe public health problem and mainly affects children under 24 months. Commonest causes are poor feeding practices, improper care of sick child at home, low maternal BMI. Maternal nutrition, education, media awareness, domestic decision, adequate nutrition of the girl child, early identification of anaemia, diarrhoea, pneumonia, sepsis and comprehensive treatment can reduces the morbidity and mortality.

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Safety, Tolerability, Efficacy and Logistics of Administration of Three Types of Therapeutic Feeds to Children with Severe Acute Malnutrition (SAM)

International Journal Of Nutrition ◽

10.14302/issn.2379-7835.ijn-18-2262 ◽

2018 ◽

Vol 3 (1) ◽

pp. 10-15

Author(s):

Saunik Sujata ◽

Phadke Mrudula ◽

Nair Raji ◽

Khosla Jatin ◽

Patel Tarun ◽

...

Keyword(s):

Randomized Trial ◽

Severe Acute Malnutrition ◽

Acute Malnutrition ◽

Open Label ◽

Recovery Rates ◽

Number Of Children ◽

Rich Food ◽

The Difference

Objective: To analyse safety, tolerability, efficacy and logistic issues related to administration of 3 types of therapeutic feeds to children with severe acute malnutrition (SAM) from tribal district of Nandurbar, Maharashtra. Design: A three arm open label, block randomized trial using 3 therapeutic feeds i.e. commercially available ready to use therapeutic feed (C-RUTF), locally prepared ready to use therapeutic feed ( L-RUTF) & amylase rich food(ARF) was given to 1092 tribal children of SAM in Nandurbar District, Maharashtra, India during 2014-2015. Setting: Tribal district of Nandurbar, Maharashtra. Participants: 1092 children of SAM, 766 on C-RUTF, 184 on L-RUTF & 143 on ARF followed on treatment for 8 weeks. Outcomes: The recovery rates in the three groups, any untoward effects during treatment and logistic aspects of procurement, delivery, storage & administration of therapeutic feeds. Results: Total number of children with SAM were 1092. Gr 1 – Out of 765 children of SAM, 404 (52.8%) recovered on C-RUTF. Gr 2 – 80 (43.5%) recovered out of 184 on L-RUTF. Gr 3 – 64 (44.8%) recovered on ARF at the end of 8 weeks of treatment, the difference being statistically significant between C-RUTF & others. Out of 38 children on C-RUTF, it was observed that 1 had diarrhoea, 1 had vomiting, 1 had fever, 4 children reported more activity in terms of playfulness, more speaking & smiling. 31 children had nothing specific to report. Out of 34 children on L-RUTF, 6 children reported diarrhoea, 1 had vomiting & 4 children reported fever. 3 children reported more activity. 23 children had nothing specific to report. Out of 19 children on ARF, 1 had diarrhoea, 1 had vomiting, 1 had fever, 3 reported more activity. 13 had nothing specific to report. Untoward effects were noted in 3 out of 38 (7.89%) in C-RUTF group, 11 out of 34 (32.35%) in L-RUTF group and 3 out of 19 (15.7%) in ARF group. Conclusion: C-RUTF was found to be more efficacious, with least untoward effects, easy to administer and was more palatable when compared to L-RUTF & ARF.

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