Reduction of unnecessary transfusion and intravenous fluids in severely malnourished children is not enough to reduce mortality

Abstract

Aim: To test whether standardising the use of blood transfusions and intravenous (IV) infusions could reduce fatality in severely malnourished children admitted to Mulago Hospital, Kampala. Methods: Improved adherence to the WHO protocol for blood transfusion and IV fluids was effected in patients with severe malnutrition by continuous medical education. A 'before and after' design was used to study 450 severely malnourished children (weight-for-height ,23 Z-score or presence of oedema) under 60 months of age. A total of 220 pre-and 230 post-'improved practice' patients were enrolled consecutively during the periods September to November 2003 and September to December 2004, respectively. Patients were followed up until discharge or death. The Kaplan-Meier survival curve and the Cox regression hazard model were used for univariate and multivariate analyses, respectively. Results: Overall case fatality was 23.6% (52/220) in the pre-period and 24.8% (57/230) in the post-period (p50.78). Most of the deaths occurred in the 1st week of admission (73%, 38/52 in the pre-period and 61%, 35/57 in the post-period) and were of children who had received blood transfusion or IV infusion or both in the pre-period. Mortality in children transfused and/or infused was significantly reduced in the post-period (82%, 31/38 in the preperiod vs 23%, 8/35 in the post-period, p50.008). In the post-period, there was a significant reduction in the number of inappropriate blood transfusions (18%, 34/194 vs 3.5%, 8/230, p50.01) and IV fluid infusions (27%, 52/194 vs 9%, 20/230, p,0.001). Survival improved in children who received blood transfusions in the post-period [hazards ratio (HR) 0.22, 95% CI 0.30-1.67 vs HR 4.80, 95% CI 1.71-13.51], as did that of children who received IV infusions (HR 2.10, 95% CI 0.84-5.23 vs HR 3.91, 95% CI 1.10-14.04). Conclusion: Management according to the WHO protocol for severe malnutrition can reduce the need for blood and IV infusions. However, further studies are required to verify whether full implementation of the WHO protocol reduces the high case fatality in sub-Saharan hospitals.

Efficacy of World Health Organization guideline in facility‐based reduction of mortality in severely malnourished children from low and middle income countries: A systematic review and meta‐analysis

“…Although, the WHO guidelines for the management of SAM represent a major advancement in reduction of SAM‐related deaths in LMICs, the guideline implementation varies within and between countries causes large variation of CFR . This study found that, majority of the facilities in Asia had adequate resources to manage SAM in comparison to Africa and Latin America, where most of the facilities lacked adequately trained human resource, lack of supplies, inadequate space and resources and faulty case‐management . Despite of having better equipped facilities, Bangladeshi children admitted with acute severe complications died within 2 days whereas children from Africa with chronic condition survived up to 4 weeks .…”

“…17 This study found that, majority of the facilities in Asia had adequate resources to manage SAM 14,18 in comparison to Africa and Latin America, where most of the facilities lacked adequately trained human resource, lack of supplies, inadequate space and resources and faulty case-management. 5,13,15,16,[19][20][21] Despite of having better equipped facilities, Bangladeshi children admitted with acute severe complications died within 2 days 14,18 whereas children from Africa with chronic condition survived up to 4 weeks. 13 Thus, the severity of illness and presence of different co-morbid condition might have played crucial role behind high CFR in SAM children.…”

Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process

“…In terms of recent studies, we found one before/after study [25], two retrospective chart reviews [26,27], one quasi-experimental study [28] and four prospective cohorts [29-33] that examined the case fatality rates and recovery rates of children with SAM treated according to the WHO protocol or an adapted WHO protocol. There was also one cluster RCT that compared inpatient treatment to home-care and day-care treatment [34,35]; this study contained methodological issues and did not adequately describe the intervention (see additional file 3 for study assessment).…”

Inpatient management of severe malnutrition: time for a change in protocol and practice

“…32 However, a subsequent study of 450 severely malnourished children with appropriate use of transfusions and infusions failed to reduce the case fatality rate which remained at 24.8%. 33 Despite the unchanged overall mortality, the change to appropriate blood transfusions and IV infusions did improve outcomes.…”