The effects of malnutrition on cardiac function in African children

Silverman, Jonathan A.; Chimalizeni, Yamikani; Hawes, Stephen E.; Wolf, Elizabeth R.; Batra, Maneesh; Khofi, Harriet; Molyneux, Elizabeth

doi:10.1136/archdischild-2015-309188

Cited by 17 publications

(18 citation statements)

References 31 publications

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“…El-Sayed et al (2006) agreed that cardiac mass index was significantly lower in children with malnutrition, but that left ventricular function was not significantly reduced 16 . The largest and most recent study (Silverman et al 2016) evaluating baseline cardiovascular function in 272 ‘stable’ Malawian children demonstrated no significant differences in cardiac index, stroke volume index and heart rate between inpatient children with and without SAM 25 .…”

Section: Discussionmentioning

confidence: 98%

“…Concerns regarding use of intravenous fluids in this vulnerable group of children reference impaired cardiovascular function and susceptibility to overload. A number of studies have been conducted over the last 30 years in Africa, Asia, the Americas and Europe that evaluate cardiovascular function in children with SAM using Echocardiography 16 – 25 . However, it should be noted that none of these additional studies have been conducted in the context of the child with SAM receiving rehydration therapy, with the exception of the study by Obonyo et al 8 .…”

Section: Discussionmentioning

confidence: 99%

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Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review

2017

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Background: Rehydration strategies in children with severe acute malnutrition (SAM) and severe dehydration are extremely cautious. The World Health Organization (WHO) SAM guidelines advise strongly against intravenous fluids unless the child is shocked or severely dehydrated and unable to tolerate oral fluids. Otherwise, guidelines recommend oral or nasogastric rehydration using low sodium oral rehydration solutions. There is limited evidence to support these recommendations. Methods: We conducted a systematic review of randomised controlled trials (RCTs) and observational studies on 15 th June 2017 comparing different strategies of rehydration therapy in children with acute gastroenteritis and severe dehydration, specifically relating to intravenous rehydration, using standard search terms. Two authors assessed papers for inclusion. The primary endpoint was evidence of fluid overload. Results: Four studies were identified, all published in English, including 883 children, all of which were conducted in low resource settings. Two were randomised controlled trials and two observational cohort studies, one incorporated assessment of myocardial and haemodynamic function. There was no evidence of fluid overload or other fluid-related adverse events, including children managed on more liberal rehydration protocols. Mortality was high overall, and particularly in children with shock managed on WHO recommendations (day-28 mortality 82%). There was no difference in safety outcomes when different rates of intravenous rehydration were compared. Conclusions: The current ‘strong recommendations’ for conservative rehydration of children with SAM are not based on emerging evidence. We found no clinical trials providing a direct assessment of the current WHO guidelines, and those that were available suggested that these children have a high mortality and remain fluid depleted on current therapy. Recent studies have reported no evidence of fluid overload or heart failure with more liberal rehydration regimens. Clinical trials are urgently required to inform guidelines on routes and rates of intravenous rehydration therapy for dehydration in children with SAM.

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Section: Discussionmentioning

confidence: 98%

Section: Discussionmentioning

confidence: 99%

Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review

2017

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“…However, available evidence suggests that the perturbations of myocardial function are related to complications of sepsis, shock and severe dehydration and not due to ‘heart failure’ 9, 10 . A recent publication by Obonyo et al 2017 demonstrated ‘fluid responsive’ myocardial indices following rehydration in children with SAM and hypovolaemic shock 11 .…”

Section: Introductionmentioning

confidence: 99%

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Houston¹,

Gibb²,

Maitland³

2017

Wellcome Open Res

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Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines

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“…Recommendations suggest avoiding IV fluids in children with SAM due to concerns about the ability of these children to handle significant volume loads and potential susceptibility to fluid overload and cardiac failure. However, available evidence suggests that the perturbations of myocardial function are related to complications of sepsis, shock and severe dehydration and not due to ‘heart failure’ 9 , 10 . A recent publication by Obonyo et al 2017 demonstrated ‘fluid responsive’ myocardial indices following rehydration in children with SAM and hypovolaemic shock 11 .…”

Section: Introductionmentioning

confidence: 99%

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

2017

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Diarrhoea complicates over half of admissions to hospital with Background severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM.: We conducted a systematic review of randomised controlled trials Methods (RCTs) on 18 July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration.: Six RCTs were identified, all published in English and conducted in Results low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities.: *Shock is defined as the presence of all three of the following signs: Prolonged capillary refill time (>3seconds), temperature gradient and weak and fast pulse. ReSoMal -rehydration solution for malnutrition, PO/NG -Oral or nasogastric route, RL+5% -Ringers lactate and 5% dextrose, 1/2SD+5% -½ strength Darrow's solution and 5% dextrose, F75 -primary feeding formula for children with SAM

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The effects of malnutrition on cardiac function in African children

Cited by 17 publications

References 31 publications

Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review

Intravenous rehydration of malnourished children with acute gastroenteritis and severe dehydration: A systematic review

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

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