Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol

• Published in: The Lancet (British edition) Vol. 353; no. 9168; pp. 1919 - 1922
• Main Authors: Ahmed, Tahmeed, Ali, Mohammad, Ullah, Mohammad M, Choudhury, Ireen A, Haque, Mohammad E, Salam, Mohammad A, Rabbani, Golam H, Suskind, Robert M, Fuchs, George J
• Format: Journal Article
• Language: English
• Published: London Elsevier Ltd 05-06-1999; Lancet; Elsevier Limited
• Subjects: Anti-Bacterial Agents; Antibiotics; Bangladesh - epidemiology; Biological and medical sciences; Case-Control Studies; Child Nutrition Disorders - mortality; Child Nutrition Disorders - therapy; Child, Preschool; Children & youth; Clinical Protocols; Combined Modality Therapy; Dehydration - therapy; Diarrhea; Diarrhea - mortality; Diarrhea - therapy; Diarrhea, Infantile - mortality; Diarrhea, Infantile - therapy; Diet Therapy; Drug Therapy, Combination - therapeutic use; Fluid Therapy; Health care; Humans; Infant; Malnutrition; Medical sciences; Metabolic diseases; Mortality; Other nutritional diseases (malnutrition, nutritional and vitamin deficiencies...); Population; Treatment Outcome; Bangladesh; Human; Prognosis; Mortality; Nutrition disorder; Diarrhea; Early stage; Treatment; Digestive diseases; Intestinal disease; Severe; Malnutrition; Therapeutic protocol; Child; Comparative study; Nutrition Disorders; Southern Asia; Oral Rehydration; Child Mortality; Diseases; Bangladesh; Asia; Population; Research Report; Developing Countries; Demographic Factors; Population Dynamics
• ISSN: 0140-6736; 1474-547X
• DOI: 10.1016/S0140-6736(98)07499-6

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 standardised protocol for acute-phase treatment of children with severe malnutrition and diarrhoea, with the aim of reducing mortality.
We compared severely malnourished children with diarrhoea aged 0–5 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 standardised-protocol group included children admitted to the ICDDR, B Hospital, Dhaka between Jan 1, 1997, and June 30, 1997, while those admitted between Jan 1, 1996, and June 30, 1996, before the protocol was implemented, were the non-protocol group.
Characteristics on admission of children on standardised protocol (n=334) and non-protocol children (n=293) were similar except that more children on standardised protocol had oedema, acidosis, and
Vibrio cholerae isolated from stools. 199 (59·9%) of children on standardised protocol were successfully rehydrated with oral rehydration solution, compared with 85 (29%) in the nonprotocol group (p<0·0001). Use of expensive antibiotics was less frequent in children on standardised protocol than in the other group (p<0·0001). Children on standardised protocol had fewer episodes of hypoglycaemia than non-protocol children (15
vs 30, p=0·005). 49 (17%) of children on nonprotocol treatment died, compared with 30 (9%) children on standardised protocol (odds ratio for mortality, 0·49, 95% CI 0·3–0·8, p=0·003).
Compared with non-protocol management, our standardised protocol resulted in fewer episodes of hypoglycaemia, less need for intravenous fluids, and a 47% reduction in mortality. This standardised protocol should be considered in all children with diarrhoea and severe malnutrition.