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Outcome of severely malnourished children treated according to UNICEF 2004 guidelines: a one-year experience in a zone hospital in rural Ethiopia.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008 Sep; 102(9):939-44.Malnutrition still has a dramatic impact on childhood mortality in sub-Saharan African countries. Very few studies have tried to evaluate the outcome of severely malnourished children treated according to the UNICEF 2004 guidelines and reported fatality rates are still very high. During 2006, 1635 children were admitted to the paediatric ward of St. Luke Catholic Hospital in Wolisso, South West Shewa, Ethiopia. Four hundred and ninety-three (30.15%) were severely malnourished and were enrolled in the study. We reviewed the registration books and inpatient charts to analyze their outcome. A mortality rate of 7.1% was found, which is significantly lower than reported in the literature. 28.6% of deaths occurred within 48 h of admission; the recovery rate was 88.4%; the drop-out rate was 4.5%. Early deaths were due to the poor condition of the children on admission, leading to failure of treatment. Late mortality was considered to be related to electrolyte imbalances, which we were unable to measure. The clinical skills of nursing and medical staff were considered an important factor in improving the outcome of malnourished patients. We found that proper implementation of WHO guidelines for the hospital treatment of severely malnourished children can lead to a relatively low mortality rate, especially when good clinical monitoring is assured.
METHODS AND FINDINGS IN EXPERIMENTAL AND CLINICAL PHARMACOLOGY. 1992 May; 14(4):289-95.UNICEF promotes the use of a very effective, inexpensive treatment of dehydration in developing countries: oral rehydration therapy (ORT), which is oral administration of a solution with equimolar concentrations of sodium and glucose (osmolality of about 300 mosmol). The solution is isotonic with respect to total body water when it reaches the small intestine. It expands the extracellular fluid without changing serum osmolality, thus, brain edema does not occur. Further, metabolic degradation of glucose eventually releases free water. On the other hand, intravenous rehydration with saline solution can be lethal, causing excess free water to expand shrunken cells and, thereby, causing brain swelling, rupture of blood vessels and hemorrhage. Yet, physicians and other health workers in developed countries have been quite sow to accept ORT. Leading conditions of dehydration include insensible loss of water and heat through evaporation from the respiratory tract and skin (common in dry air, hot environment, and fever), sensible loss of water and heat through perspiration (common in hot, humid environment and with warm and absorbent clothing), and irritation of the intestinal mucosa by allergies, infections, toxins, and intolerance to some nutrients, resulting in diarrhea. Diarrhea is indeed the main cause of dehydration. Other causes of dehydration are: failure of the hypothalamus to secrete antidiuretic hormone (ADH), kidney unresponsiveness to ADH, diabetes mellitus, protein-rich nutrition, catabolic states, and brush-border lactase after weaning. Physiological changes in dehydration consist of rigidity of the connective tissue (vascular system and lungs) and intracellular fluid loss to the extracellular spaces, resulting in dry mucous membranes, shrunken muscle cells in the lips and the tongue, soft eyes, and adverse effects to the central nervous system. Children become dehydrated more readily than adults, but they tolerate it better.
INDIAN JOURNAL OF PUBLIC HEALTH. 1990 Jan-Mar; 34(1):35-7.Oral rehydration therapy (ORT) prevents severe morbidity and death from mild to moderate dehydration from acute diarrhea for all ages and all etiologies. WHO advises ORT fluid to contain 3.5 g sodium chloride, 3.5 g potassium chloride, 2.5 g sodium bicarbonate or 2.9 g trisodium citrate dihydrate, and 20 g glucose all dissolved in 1 1 of water. This fluid does not reduce stool volume or frequency and does not curtail duration thus it is not always acceptable. Improved ORT is needed, however. The glucose concentration cannot be increased above the present 2% since an increased concentration would intensify diarrhea and dehydration. Researchers are working on an improved solution (Super ORS) which would rehydrate the body and actively bring on reabsorption of endogenous secretions in the intestine. Thus this improved ORS would reduce stool volume, shorten duration of diarrhea, and allow early introduction of feeding. Even though some studies demonstrate that fortified ORS with the amino acid glycine decreases stool volume by 49-70% and duration of diarrhea 28-30%, other studies indicate that it induces excess sodium concentrations in the blood. 1 study demonstrates that in comparison with the standard ORS, ORS fortified with the amino acid L-alanine reduced the severity of symptoms and the need for fluid in patients afflicted with cholera and enterotoxigenic Escherichia coli. Further studies reveal that rice powder based ORS (50-80 g/l) reduces stool volume 24-49% and duration of duration 30%. The advantage of using rice is that when it hydrolyzes glucose, amino acids, and oligopeptides emerge. Each 1 of these chemicals facilitate sodium absorption through separate pathways. Disadvantages include the fuel must be used to cook the rice, rice based ORS ferments within 8-24 hours making it useless, and the rice or pop rice needs to be ground.
JOURNAL OF PEDIATRICS. 1987 Sep; 111(3):475-6.Experiments directed at finding the most effective oral rehydration solutions for children with diarrhea, by using a jejunally perfused healthy rat model may not be relevant. The experiments predicted that 110 mM glucose and 60 mEq/L Na+ would maximize water absorption and maintain isotonicity. In rats with artificially induced diarrhea, persistent net Na+ secretion and reduced absorption of bicarbonate and water were observed during perfusion of glucose-saline solutions. Thus the relevance of the healthy rat model to human diarrheal disease therapy requires validation before advancing to therapeutic recommendations. In most pediatric patients with diarrhea, the gastrointestinal luminal fluid contains 60 mEq/L Na+ and no glucose other than what is ingested. The WHO recommended oral formula contains 90 mEq/L Na+ and 111 mmol/L glucose. In some studies patients are given 90 mEq/L Na+ for 2 hours (8 oz/hr), followed by water for 1 hour, then 90 mEq/L Na+ for 2 more hours. This regimen produced greater initial Na+ absorption than a mixture of 60 mEq/L Na+, and causes less hyponatremia. The most efficiently absorbed solution is the WHO solution alone with no extra water, according to numerous studies.
Lancet. 1980 May 17; 1(8177):1082.This letter reports rehydration of 7 infants by an oral solution similar to the UNICEF formulation. This solution contained: sodium chloride (3.5 gm), sodium bicarbonate (2.5 gm), potassium chloride (1.5 gm), and glucose (20 gm) dissolved in 1 liter of potable water. When admitted, 2 patients were hypernatremic and 5 had normal sodium levels. All children were well-nourished. They were given the oral glucose-electrolyte solution at admission, and in all cases treatment had to be interrupted after a mean period of 41+ or -9 hours due to high levels of potassium in 6 cases and aggravation of preexisting hypernatremia in the other. Average oral volume was 140 ml/kg. It is recommended that well-nourished children be given the UNICEF oral therapy formulation for no more than 24 hours, since potassium loading seems probable.