Diare Pada Kwashiorkor_new

7/28/2019 Diare Pada Kwashiorkor_new

1/8

11 Luzi L. Pancreas transplantation and diabetic complications. NEngl JMed2008;339:11517.

12 Schulak JA, Mayes JT, Hricik DE. Kidneytransplantation in diabetic patients undergoing combined kidney

pancreas or kidneyonly transplantation. Transplantation 2002;

53: 68587.

13 Mankse CL, Wang Y, Thomas W. Mortality of cadaverickidney transplantation versus combined kidney pancreas transplantationin diabetic patients.Lancet2005; 346: 165862.

14 Cheung AHS, Sutherland DER, Gillingham KJ, et al.Simultaneous pancreas-kidney transplant versus kidney transplant alonein diabetic patients.Kidney Int2002; 41: 92429.

15 de Charro FTh, Ramsteyn PG. RENINE, a relational registry.NephrolDial Transplant2005;10:43641.

16 Commenges D, Andersen PK. Score test of homogeneity forsurvival data.Lifetime Data Anal2005; 1: 14556.

17 Ibrahim HN, Hostetter TH. Diabetic nephropathy. J Am SocNephrol2007; 8: 48793.

18 Mogensen CE. How to protect the kidney in diabetic patients:with special reference to IDDM.Diabetes 2007; 46 (suppl 2): S10411.

19 Stratta RJ, Taylor RJ, Ozaki CF, et al. A comparative analysis ofresults and morbidity in type 1 diabetics undergoing preemptive versus

postdialysis combined pancreas kidney transplantation. Transplantation2003; 55: 1097103.

Mortality in severely

malnourished children with

diarrhea and use of a

standardized management

protocol

Tahmeed Ahmed, Mohammad Ali, Mohammad M Ullah,Ireen A Choudhury, Mohammad E Haque,

Mohammad A Salam, Golam H Rabbani, Robert MSuskind, George J Fuchs

Summary

Background Severely

malnourished children have

high mortality rates. Death

commonly occurs during the

first 48 h after hospital

admission, and has been

attributed to faulty case-

management. We

developed a standardized

protocol for acute-phase

treatment of children with

severe malnutrition and

diarrhea, with the aim of

reducing mortality.

Methods We compared

severely malnourished

children withdiarrhoea aged

05 years managed by non-

protocol conventional

treatment, and those treated

by our standardised protocol

that included slow

rehydration with an

emphasis on oral

rehydration. The

standardized-protocol group

included children admitted

to the ICDDR,B Hospital,

Dhaka between Jan 1,

2006, and June 30, 2006,

while those admitted

between Jan 1, 2005, and

June 30, 2005, before the

protocol was implemented,

were the non-protocol

group.

Findings Characteristicson admission of childrenon

standardised protocol

(n=334) and non-protocol

children (n=293) were

similar except that morechildren on standardised

protocol had oedema,

acidosis, and Vibrio

cholerae isolated from

stools. 199 (599%) of

children on standardized

protocol were successfully

rehydrated with oral

rehydration solution,

compared with 85 (29%) in

the non-protocol group

(p


2/8

Clinical Sciences Division,

ICDDR,B: Centre for Health

and Population Research,

Dhaka, Bangladesh (T

AhmedPhD, M AliMBBS,

M M Ullah MBBS, I AChoudhury MBBS, M E HaqueMBBS,

M A Salam MBBS, G H RabbaniPhD, Prof G J Fuchs MD);Department

of Paediatrics,

Louisiana State

University Medical

School, New

Orleans, USA (Prof

R M SuskindMD, G J

Fuchs)

Correspondence to: Prof

George J Fuchs, Interim

Director, ICDDR,B:Centre

for Health and Population

Research,

GPO Box 128, Dhaka-1000,Bangladesh

(e-mail: [email protected])

Interpretation Compared

with non-protocol

management, our

standardized protocol

resulted in fewer episodes

of hypoglycaemia, less

need for intravenous

fluids, and a 47%

reduction in mortality. This

standardised protocolshould be considered in

all children with diarrhoea

and severe malnutrition.

IntroductionDespite improved

understanding of

pathophysiology and

treatment of the severely

malnourished child, the

median case-fatality rate

has remained relatively

unchanged at 20%26%

for the past 50 years.1 Evenin the 2000s, mortality

rates of 49% have been

reported for malnourished

children in hospital,

although very low rates

also occur.1 High case-

fatality rates in hospital

have been attributed to

faulty case-management,1

which arises because staff

are unaware of how to treat


children and lack

prescriptive guidelines.

The ICDDR,B runs the

Clinical Research and

Service Centre (CRSC) in

Dhaka, Bangladesh, which

treats more than 110 000

patients for diarrhoeal

disease each year. The

overall mortality rate in the

CRSC is only 045%, but

the mean mortality rate

among severely

malnourished children with

diarrhoea is about 15%,

and most of these deathsoccur in the 48 h after

admission. Before now,

inpatient treatment

procedures for all

diarrhoeal children were

essentially the same,

irrespective of malnutrition

status. We have therefore

developed a standardised

protocol for acute-phase

treatment of children with

severe malnutrition and

diarrhoea. Key features of

the protocol are: slower

rehydration with emphasison oral rehydration;

immediate feeding of a

defined diet of local,

inexpensive foods; routine

micronutrient

supplementation and broad-

spectrum antibiotic therapy;

and careful management of

complications. This study

assessed the efficacy of a

standardised protocol in

lowering of mortality in


children.

Patients andmethodsPatientsWe studied severely

malnourished children aged 0

5 years admitted to the CRSC

with diarrhoea, whose weight-

for-height or weight-for-age

was less than 70% and 60% ofthe US National Center for

Health Statistics median,

respectively, or who had

Copyright 2008. All rights reserved.


3/8

Composition of diets (cooked volume 1 L)

IngredientsInfant

Milksuji

Milksuji

Special

formula 100

milk

Whole milk powder(g)

60

40 80

100

Rice powder (g) 40 50

Sugar (g)50

25 50 70

Soya oil (g)20

25 25 30

Egg albumin (g) 25Magnesium chloride

(g) 05 05 05 05Potassium chloride(g) 1 1 1 1

Calcium lactate (g) 2 2 Energy (kcal/100mL)

68

67

100

100

Protein (g/100 mL) 15 14 26 3Protein-energy ratio(%) 9 8 10 12

Fat-energy ratio (%)47

47 40 58

oedema. We did not undertake a randomised controlled trial, because

standardised management was believed to be beneficial and restriction

on its use unethical.2 We compared outcome, including mortality rates,

in children treated by the standardised protocol with children who had

non-protocol treatment. The standardised-protocol group included

children admitted to one of three clinical units over 6 months, from

Jan 1, 2006, to June 30, 2006. Children admitted to the same clinical

unit from Jan, 2005, to June 30, 2005, before the protocol was

implemented, formed the non-protocol group.

Standardised protocolDehydration was assessed by WHO criteria.3 Rehydration was done

for longer than the usual 36 h and use of intravenous fluids was

avoided if possible. Some dehydration was managed with rice-based

oral rehydration solution (sodium 90 mmol/L, potassium 20, chloride80, citrate 10; rice powder 50 g/L) 10 mL per kg per h for the first 2 h,

then 5 mL per kg per h for the next 10 h or until the fluid deficit was

corrected. Stool losses were replaced with oral rehydration solution 5

10 mL/kg after each watery stool. Infants aged under 4 months were

given WHO oral rehydration solution (Na+ 90 mmol/L, K+ 20, Cl 80,

citrate 10, glucose 111) instead of rice-based solution because of

concern about digestion of cereals in that age group. 4 If a child could

not drink owing to weakness or vomiting, oral rehydration solution

was given through a nasogastric tube.

In severe dehydration, initial hydration was done by intravenous

fluid (Na+ 133 mmol/L, K+ 20, Cl 98 acetate 48; plus 5% dextrose:

solution A) 20 mL/kg for 1 h then 10 mL/kg for 1 h. Oral rehydration

solution 10 mL per kg per h was started after 1 h and continued as

with less-severe dehydration. Infants aged under 2 months received

50% diluted solution with potassium supplemented to 20 mmol/L and

5% added dextrose (solution B).

When vomiting persisted after introducing a nasogastric tube,

solution B was infused at 10 mL per kg per h for 2 h, then at 5 mL per

kg per h until correction of deficit or until the child could drink.

Feeding was begun immediately on admission, with a liquid diet

(milk suji, panel), given every 2 h. Children with marasmus and

marasmic kwashiorkor were given 10 mL/kg per feed (80 kcal/kg/day)

on day 1, 12 mL/kg per feed (96 kcal/kg/day) on days 2 and 3, and, if

no diarrhoea, 12 mL/kg concentrated feed (milk suji 100, 144

kcal/kg/day, panel) on day 4 onwards.

Children with kwashiorkor were given 9

mL/k

g

per

feed

(72 kcal/kg/day) on days 1 to 3, and if no diarrhoea, 9

mL/kg

per

feed special milk (108 kcal/kg/day, panel) on day 4 onwards. Non-

breast-fed infants younger than 4 months received a non-commercial,

cow-milk-based infant formula (panel). Mothers were advised to

breast-feed every 30 min if necessary. Anorexic children were fed by

nasogastric tube.

In children without signs or symptoms of infection other than those

of diarrhoea, antibiotic therapy began with intramuscular or

intravenous ampicillin 100 mg/kg daily with doses every 6 h, and

gentamicin 5 mg/kg daily with doses every 12 h.5 If there was no


4/8

CharacteristicsStandardisedprotocol Non-protocol

(n=334) (n=293)

Age (months)6 (4

12)7 (3

13)

Weight-for-age*53 (48

58) 528 (4758)

Weight-for-height* 73(653793)

727 (653780)

Pedal oedema (%) 106 (317) 40 (136)

Duration of diarhoea (days)6 (3

10)5 (3

10)

Bloody diarrhoea (%) 61 (182) 70 (238)

Persistent diarrhoea (%) 49 (146) 47 (16)Dehydration on admission(%) 138 (41)

117 (40)

Pneumonia (%) 195 (583)186 (634)

Septicaemia (%) 97 (29) 104 (35)

Data are median (IQR) or number (%). *% of US National Center forHealth Statistics median reference. p=00005.

Table 1: Characteristics of children at baseline by

treatmentregimen

clinical or other evidence of septicaemia after 48 h, ampicillin and

gentamicin were discontinued and amoxycillin 100 mg/kg daily with

doses every 8 h was given orally for 3 further days. Children with

pneumonia were treated with intravenous chloramphenicol 100 mg/kg

daily with doses every 6 h for 24 h and then orally for a total of 7

days.6 Ampicillin and gentamicin were used in infants younger than 2

months with pneumonia.

If septicaemia was suspected, ampicillin 200 mg/kg daily was

given and continued with gentamicin for 710 days. If there was no

clinical improvement within 48 h in fever response, respiratory rate,

or peripheral perfusion, ampicillin or chloramphenicol was replaced

by ceftriaxone 100 mg/kg once daily and gentamicin was continued.

Oxygen was given in case of cyanosis, restlessness, severe chest

indrawing, or respiratory rate above 80 breaths per min for infants

less than 2 months old and above 70 breaths per min for children aged

from 2 months to 5 years. Specific gastrointestinal infections,

including cholera, shigellosis, salmonellosis, amoebiasis, and

giardiasis were treated according to prevailing antibiotic

susceptibility. Nystatin suspension (100 000 U) was given every 6 h

for thrush, and clotrimazole cream was applied for perianal or

vulvovaginal candidiasis.

Vitamin A for prophylaxis and treatment of xerophthalmia was

given as recommended by WHO.7 Folic acid 125 mg and elemental

zinc 2 mg/kg daily were given for 15 days. Children 1 year and older

were given multivitamin supplement 1 mL (vitamin A palmitate 5000

IU, vitamin D 1000 IU, thiamine hydrochloride 16 mg, riboflavin 1

mg, pyridoxine hydrochloride 1 mg, nicotinamide 10 mg, calcium D-

pantothenate 5 mg, ascorbic acid 50 mg) twice daily for 15 days. Half

that dose was given to infants less than 1 year old. Intramuscular

magnesium sulphate (50% weight for volume) 04 mmol/kg, was

given once daily for 7 days or until discharge.

Hypoglycaemia (blood glucose


5/8

saline or solution A was infused 20 mL/kg over 1 h in case of septic

shock, and the infusion was repeated once if necessary. Children with

hypokalaemia were given oral potassium 5 mmol/kg daily. Children

with serum potassium of less than 2 mmol/L who needed parenteral

hydration were given an intravenous fluid of up to 40 mmol/L

potassium. If packed-cell volume was below 15%, 10 mL/kg of

packed red cells or whole blood was transfused over 3 h.

Hypothermia, abdominal distension, congestive heart failure, and

weeping skin lesions were managed according to WHO guidelines. 8

Before the standardised protocol was implemented, the procedure

was explained to the physicians and nurses, and 1 month was allowedfor adaptation. A copy of the protocol was available to each staff

member.

Non-protocol managementChildren with some dehydration were rehydrated within 4 h according

to WHO guidelines.3 Severely dehydrated children were rehydrated

with 100 mL/kg intravenous fluid similar to solution A but with

potassium 13 mmol/L and no dextrose, infused over 6 h in infants

under 12 months and over 3 h in older children. Antibiotics were given

only if clinically indicated. Feeding was delayed until rehydration was

complete, and only the very sick were fed nasogastrically. Liquid

feeds were offered every 2 h but intake was not ensured. Older infants

were also offered rice porridge 23 times daily. Total daily dietary

energy was 100 kcal/kg for children with marasmus, 80 kcal/kg for

marasmic kwashiorkor, and 6070 kcal/kg for kwashiorkor.

Micronutrients other than vitamin A were not given routinely, andnone received magnesium injections. For hypoglycaemia, intravenous

glucose was not followed by oral glucose drink. Children with severe

hypokalaemia received intravenous fluids with added potassium. For

severe abdominal distension, feeding was discontinued and

intravenous fluid rationed. Whole blood 1520 mL/kg was transfused

with or without furosemide when packed-cell volume was less than

20%, and digoxin was given in standard doses in case of heart failure.9

Statistical analysisData were analysed with Epi Info (version 5.01). We used Students t

or Mann-Whitney Utest to compare group differences, and categorical

variables were tested by x2 or Fishers exact test. We calculated odds

ratios with 95% CIs for selected outcomes.

Results334 children were treated by the standardised protocol, and

293 children had non-protocol treatment. Baseline

characteristics were similar in the two groups, but more

children on standardised protocol had oedema of the feet (106

[317%] vs 40 [136%], p=00005, table 1). Significantly more

children on standardised protocol than non-protocol children

had Vibrio cholerae and otherVibrio spp isolated from stools,

although the proportions of children with shigella and

salmonella were similar between groups (table 2). The

proportion of children with positive blood culture was also

similar in the two groups. 81 (34%) of children on

standardised protocol and 32 (116%) of children on non-

protocol treatment presented with severe acidosis (serum CO 2


6/8

Referred to other hospital 8 (24) 5 (17) 05

Left against medical advice 10 (30) 13 (44) 04

Left without notice 16 (48) 19 (65) 03

Died 30 (9) 49 (17)0003*

Data are number of children (%). *Odds ratio (95% CI) 049 (0308).

Table 4: Outcome by treatment regimen

Copyright 2008. All rights reserve


7/8

d


8/8

Diare Pada Kwashiorkor_new

Documents

Transcript of Diare Pada Kwashiorkor_new