Prevalence, Clinical Predictors, and Outcome of Hypocalcaemia in Severely-malnourished Underfive Children Admitted to an Urban Hospital in Bangladesh: A Case-Control Study.

Hypocalcaemia is common in severely-malnourished children and is often associated with fatal outcome. There is very limited information on the clinical predicting factors of hypocalcaemia in hospitalized severely- malnourished under-five children. Our objective was to evaluate the prevalence, clinical predicting factors, and outcome of hypocalcaemia in such children. In this case-control study, all severely-malnourished under-five children (n=333) admitted to the Longer Stay Ward (LSW), High Dependency Unit (HDU), and Intensive Care Unit (ICU) of the Dhaka Hospital of icddr,b between April 2011 and April 2012, who also had their total serum calcium estimated, were enrolled. Those who presented with hypocalcaemia (serum calcium <2.12 mmol/L) constituted the cases (n=87), and those admitted without hypocalcaemia (n=246) constituted the control group in our analysis. The prevalence of hypocalcaemia among severelymalnourished under-five children was 26% (87/333). The fatality rate among cases was significantly higher than that in the controls (17% vs 5%; p<0.001). Using logistic regression analysis, after adjusting for potential confounders, such as vomiting, abdominal distension, and diastolic hypotension, we identified acute watery diarrhoea (AWD) (OR 2.19, 95% CI 1.08-4.43, p=0.030), convulsion on admission (OR 21.86, 95% CI 2.57-185.86, p=0.005), and lethargy (OR 2.70, 95% CI 1.633-5.46, p=0.006) as independent predictors of hypocalcaemia in severely-malnourished children. It is concluded, severely-malnourished children presenting with hypocalcaemia have an increased risk of death than those without hypocalcaemia. AWD, convulsion, and lethargy assessed on admission to hospital are the clinical predictors of hypocalcaemia in such children. Presence of these features in hospitalized children with severe acute malnutrition (SAM) should alert clinicians about the possibility of hypocalcaemia and may help undertake potential preventive measures, such as calcium supplementation, in addition to other aspects of management of such children, especially in the resource-poor settings.

Nutrition: basis for healthy children and mothers in Bangladesh.

Recent data from the World Health Organization showed that about 60% of all deaths, occurring among children aged less than five years (under-five children) in developing countries, could be attributed to malnutrition. It has been estimated that nearly 50.6 million under-five children are malnourished, and almost 90% of these children are from developing countries. Bangladesh is one of the countries with the highest rate of malnutrition. The recent baseline survey by the National Nutrition Programme (NNP) showed high rates of stunting, underweight, and wasting. However, data from the nutrition surveillance at the ICDDR,B hospital showed that the proportion of children with stunting, underweight, and wasting has actually reduced during 1984-2005. Inappropriate infant and young child-feeding practices (breastfeeding and complementary feeding) have been identified as a major cause of malnutrition. In Bangladesh, although the median duration of breastfeeding is about 30 months, the rate of exclusive breastfeeding until the first six months of life is low, and practice of appropriate complementary feeding is not satisfactory. Different surveys done by the Bangladesh Demographic and Health Survey, United Nations Children's Fund (UNICEF), and Bangladesh Breastfeeding Foundation (BBF) showed a rate of exclusive breastfeeding to be around 32-52%, which have actually remained same or declined over time. The NNP baseline survey using a strict definition of exclusive breastfeeding showed a rate of exclusive breastfeeding (12.8%) until six months of age. Another study from the Abhoynagar field site of ICDDR,B reported the prevalence of exclusive breastfeeding to be 15% only. Considerable efforts have been made to improve the rates of exclusive breastfeeding. Nationally, initiation of breastfeeding within one hour of birth, feeding colostrum, and exclusive breastfeeding have been promoted through the Baby-Friendly Hospital Initiative (BFHI) implemented and supported by BBF and UNICEF respectively. Since most (87-91%) deliveries take place in home, the BFHI has a limited impact on the breastfeeding practices. Results of a few studies done at ICDDR,B and elsewhere in developing countries showed that the breastfeeding peer-counselling method could substantially increase the rates of exclusive breastfeeding. Results of a study in urban Dhaka showed that the rate of exclusive breastfeeding was 70% among mothers who were counselled compared to only 6% who were not counselled. Results of another study in rural Bangladesh showed that peer-counselling given either individually or in a group improved the rate of exclusive breastfeeding from 89% to 81% compared to those mothers who received regular health messages only. This implies that scaling up peer-counselling methods and incorporation of breastfeeding counselling in the existing maternal and child heath programme is needed to achieve the Millennium Development Goal of improving child survival. The recent data showed that the prevalence of starting complementary food among infants aged 6-9 months had increased substantially with 76% in the current dataset. However, the adequacy, frequency, and energy density of the complementary food are in question. Remarkable advances have been made in the hospital management of severely-malnourished children. The protocolized management of severe protein-energy malnutrition at the Dhaka hospital of ICDDR,B has reduced the rate of hospital mortality by 50%. A recent study at ICDDR,B has also documented that home-based management of severe protein-energy malnutrition without follow-up was comparable with a hospital-based protocolized management. Although the community nutrition centres of the NNP have been providing food supplementation and performing growth monitoring of children with protein-energy malnutrition, the referral system and management of complicated severely-malnourished children are still not in place.

Introduction of routine zinc therapy for children with diarrhoea: evaluation of safety.

On 8 May 2004, the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommended routine administration of zinc in the management of children, aged less than five years, with acute diarrhoea. In making the recommendation, WHO and UNICEF also suggested careful monitoring for adverse events associated with routine administration of zinc, particularly unusual or excess vomiting. The study assessed, in a phase IV trial, i.e. post-marketing surveillance of zinc, the occurrence of adverse events during the first hour after the administration of the first dose of zinc in children with acute or persistent diarrhoea. The study was conducted at the Dhaka Hospital of ICDDR,B and at an outpatient clinic operated by a local health NGO-Progoti Samaj Kallyan Protisthan (PSKP), Dhaka, Bangladesh. Eligible children, aged 3-59 months, were treated with 20 mg of zinc sulphate provided in a dispersible tablet formulation. The children were observed for 60 minutes following the initial treatment with zinc for adverse events, with particular attention given to vomiting or regurgitation. During the one-year observation period, 42,440 children (male 57% and female 43%) received zinc, and 20,246 (47.8%) of them were observed. Regurgitation and/or vomiting occurred in 4,392 (21.8%) of the children; 90.8% of these children had vomiting only once, 8.7% twice, and 0.5% more than twice. No children revisited the hospital for recurrent vomiting following their discharge. A significant proportion of infants and children may experience vomiting or regurgitation, usually once, following the administration of the first dose of zinc. This is a transient phenomenon that did not impact on continuation of treatment with zinc.

Presence of neutral fat in stool and its association with aetiology and presenting features of diarrhoea in children.

Enteric infections, impaired digestion, loss of villous cells, and poor absorption of fat may lead to presence of neutral fat in stool, particularly in children with diarrhoea. We aimed to examine the association between presence of neutral fat in stool and aetiology of diarrhoea and nutritional status of the patients at different age groups. A total of 13,171 patients aged 5 days-106 years enrolled in the Diarrhoeal Disease Surveillance System of the Dhaka Hospital of ICDDR,B during 1996-2001 were studied. Presence of neutral fat in faecal specimens, aetiology of diarrhoea, and nutritional status in children below 5 years of age were determined and analysed. Of the total study individuals, 7,671 (58%) had neutral fat in their faecal specimens. Neutral fat was more frequently present in faeces of individuals infected with rotavirus in all age groups or in enterotoxigenic E. coli (ETEC) infection in children 0-23 months old while compared with those who did not have these infections (p=0.005, p=0.014, respectively). Neutral fat was less frequently (p<0.001) present in malnourished 0-23 months old children. Presence of neutral fat in the stool in diarrhoea due to rotavirus and in young childhood ETEC diarrhoea signifies compromised gastrointestinal function due to these infections. The mechanism of persistence of neutral fat in the stool of such patients, and its nutritional and clinical implications require further studies.

Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh.

The study analyzed data from a systematic sample of children, aged less than five years, who presented with persistent diarrhoea (diarrhoea of more than 14 days duration). It aims to differentiate (a) non-severe persistent diarrhoea (with no or mild dehydration) and (b) severe persistent diarrhoea (with moderate or severe dehydration), and to identify individual characteristics associated with severe persistent diarrhoea. In total, 7,505 patients, who represented a 4% systematic sample of the patient population, were seen during January 1993-December 1995. Of them, 297 (4%) presented with persistent diarrhoea. The male:female ratio was 2:1. Eighty-three percent of them had mild or no dehydration, and 17% had moderate or severe dehydration. Severe malnutrition of the study patients defined as weight-for-age z-score < -3, weight-for-length z-score < -3 and length-for-age z-score < -3 were 33.9%, 9.7%, and 22.7% respectively. Only 3% had oedematous malnutrition, and 11% had xerophthalmia. Factors independently associated with severe persistent diarrhoea by logistic regression analyses were: number of watery stool > 10 times during the last 24 hours prior to admission (OR, 10.0; CI, 1.2-87, p = 0.03), lower respiratory tract infection (OR, 111; CI, 4.2-2955, p = 0.004), and lack of mothers' education (OR, 7.8; CI, 1.4-41.9, p = 0.016) after controlling for confounders. Awareness and health education of mothers or caregivers and better case management during acute diarrhoeal episode might prevent the development of severe persistent diarrhoea in young children. In addition, children with severe persistent diarrhoea might need special attention to have adequate rehydration and control of extraintestinal infections, including respiratory tract infection.

Shelf-life of pre-cooked rice oral rehydration salt packets.

The shelf-life of pre-cooked rice oral rehydration salts (ORS) at the household level was studied in urban Dhaka. To prepare the packets, cooked rice was dried and ground to fine powder and the salt ingredients were mixed according to the World Health Organization formulation. For each half liter packet, 10 g glucose was replaced by 25 g of instant cooked rice powder. The packets were kept in different environments for three months among 30 households of varying socioeconomic status. At monthly intervals, two packets from each family were collected for laboratory tests. Physical characteristics of ORS such as color and dispersibility remained the same throughout the three month study period. However, in the third month flavor changed slightly. The electrolyte concentration of the prepared solution remained the same at the end of the first, second and third months. However, progressive but minimal increase in moisture content of the packets was noted over the allotted time period. This increase in moisture was less when the mixture was packed in double thin layer polythene bags as opposed to the single layer bags. In conclusion, the shelf-life of pre-cooked rice ORS remains stable at least up to three months when stored at the household level. Therefore, pre-cooked rice ORS can be kept at households for future use in the event of diarrheal episodes.

Study of makeshift hospital during cholera outbreak.

This is a report on the study of utilization pattern of a makeshift hospital during a major cholera outbreak, by analyzing data on dehydration status, distance covered, number of deaths averted, and operation-wise comparison with other permanent facilities. To avoid unnecessary deaths due to dehydration and to ensure prompt and adequate care to suddenly accumulated debilitated patients, the makeshift hospital intervened. Subsequent to the intervention, a gradual reduction in patient admissions and cholera case accumulations was noted. Nearly half the cholera cases attending the makeshift hospital came from relatively far (13 + miles). The reporting of the majority (72%) of cholera patients with none-to-mild dehydration indicates an increased awareness of the need for early treatment during a cholera outbreak. Early attendance of diarrhoeal patients probably saved more patients by preventing shock and complications. Para-professionals given a short training accomplished similar efficacy as in a permanent facility. Nearer the affected areas, a simple but effective temporary facility is more effective than a sophisticated facility which is further away and takes several hours to reach, with risk to patients.