Elsevier

The Journal of Pediatrics

Volume 210, July 2019, Pages 26-33.e3
The Journal of Pediatrics

Original Article
Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda

https://doi.org/10.1016/j.jpeds.2019.03.014Get rights and content

Objective

To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition.

Study design

A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality.

Results

Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score.

Conclusions

Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.

Section snippets

Methods

The study was a prospective cohort study nested in a randomized, controlled intervention trial assessing the effect of probiotics on diarrhea in 400 children with cSAM.20 The study was conducted at Mwanamugimu Nutrition Unit, Mulago National Referral Hospital, Kampala, Uganda, between March 2014 and September 2015. Children aged 6-59 months with cSAM were eligible for the study. SAM was defined as weight-for-height z-score (WHZ) of less than −3 or a mid-upper arm circumference (MUAC) of less

Results

Of 400 children enrolled, the median age was 15.0 months (IQR, 11.2-19.2 months) and 58% were boys. Two-thirds (66%) had edematous malnutrition, 11% (n = 43) were confirmed to have HIV, and 61% (n = 244) were reported by caregivers to have diarrhea at the time of admission. The median duration of diarrhea present at admission was 7 days (IQR 4-21 days) and 43% of the 244 children (n = 103) presenting with diarrhea reported persistent diarrhea with 14 or more days of diarrhea before admission.

Discussion

In our study, days with diarrhea during hospitalization were strongly correlated with mortality. The OR for mortality was 1.4 for each additional day of diarrhea during hospitalization. As reported elsewhere from this study, children admitted with diarrhea had a 2.2-fold higher hazard ratio of dying compared with children admitted without diarrhea.19 In Kenya, Talbert et al found a higher mortality in children with SAM admitted with or having any diarrhea during the hospitalization period

Data Statement

Data sharing statement available at www.jpeds.com.

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    Funded by University of Copenhagen, Chr. Hansen A/S, Denmark and Innovation Fund Denmark.

    The authors declare no conflicts of interest.

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