Improving the Management of Dysglycemia in Children in the Developing World

Hubert, Bernard; Pussard, Eric

doi:10.4269/ajtmh.14-0212

Cited by 4 publications

(7 citation statements)

References 34 publications

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“…Both hypo and hyperglycemia occur frequently in sick children and have been associated with increased risk of deaths in pediatrics units [ 1 , 2 ]. Neonates and young children are particularly susceptible to hypoglycemia leading to the well recognized long term sequelae especially with prolonged fasting [ 3 – 7 ].…”

Section: Introductionmentioning

confidence: 99%

“…Young children have a limited tolerance for fasting [ 1 ]. Hypoglycemia in non-neonate children is independently associated with poor outcomes in the tropics [ 13 – 19 ].…”

Section: Introductionmentioning

confidence: 99%

“…International paediatric guidelines recognize blood glucose below 3 mmol/L in children with severe disease as a therapeutic indication for treatment [ 44 ]. In surveys, the prevalence of hypoglycemia has been infrequently assessed using different thresholds in critically ill non-neonate children admitted to hospitals in the tropics [ 1 , 12 – 13 , 15 , 17 – 18 , 22 , 28 , 45 – 48 ].…”

Section: Introductionmentioning

confidence: 99%

“…Hypoglycemia can mimic various clinical signs or aggravate a more obvious disease. Systematic screening for hypoglycemia in sick children is now recommended by WHO [ 42 ] and point of care tools are becoming more available in referral hospitals [ 1 , 48 ]. When diagnostic tools are not available, a systematic treatment of assumed hypoglycemia is recommended for children with severe malnutrition [ 42 ].…”

Section: Introductionmentioning

confidence: 99%

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High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country

Hubert

Sayavong

Pussard³

2016

PLoS ONE

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IntroductionHypoglycemia is a recognized feature of severe malaria but its diagnosis and management remain problematic in resource-limited settings. There is limited data on the burden and prognosis associated with glycemia dysregulation in non-neonate children in non-malaria areas. We prospectively assessed the abnormal blood glucose prevalence and the outcome and risk factors of deaths in critically ill children admitted to a national referral hospital in Laos.MethodsConsecutive children (1 month-15 years) admitted to the pediatric ward of Mahosot hospital, were categorized using the integrated management of childhood illness (IMCI). Blood glucose was assessed once on admission through a finger prick using a bedside glucometer. Glycemia levels: hypoglycemia: < 2.2 mmol/L (< 40 mg⁄ dl), low glycemia: 2.2–4.4 mmol/L (40–79 mg⁄ dl), euglycemia: 4.4–8.3 mmol/L (80–149 mg⁄ dl), and hyperglycemia: > 8.3 mmol/L (≥150 mg⁄ dl), were related to the IMCI algorithm and case fatality using univariate and multivariate analysis.ResultsOf 350 children, 62.2% (n = 218) were severely ill and 49.1% (n = 172) had at least one IMCI danger sign. A total of 15 (4.2%, 95%CI: 2.4–6.9) had hypoglycemia, 99 (28.2%, 95%CI: 23.6–33.3) low glycemia, 201 (57.4%, 95% CI: 52.0–62.6) euglycemia and 35 (10.0%, 95% CI: 7.0–13.6) hyperglycemia. Hypoglycemia was associated with longer fasting (p = 0.001) and limited treatment before admission (p = 0.09). Hypoglycemia and hyperglycemia were associated with hypoxemia (SaO2) (p = 0.001). A total of 21 (6.0%) of the children died: 66.6% with hypoglycemic, 6.0% with low glycemic, 5.7% with hyperglycemic and 1.4% with euglycemic groups. A total of 9 (2.5%) deaths occurred during the first 24 hours of admission and 5 (1.7%) within 3 days of hospital discharge. Compared to euglycemic children, hypoglycemic and low glycemic children had a higher rate of early death (20%, p<0.001 and 5%, p = 0.008; respectively). They also had a higher risk of death (OR: 132; 95%CI: 29.0–596.5; p = 0.001; and OR: 4.2; 95%CI: 1.1–15.6; p = 0.02; respectively). In multivariate analyses, hypoglycemia (OR: 197; 95%CI: 33–1173.9), hypoxemia (OR: 5.3; 95%CI: 1.4–20), presence of hepatomegaly (OR: 8.7; 95%CI: 2.0–37.6) and having an illiterate mother (OR: 25.9; 95%CI: 4.2–160.6) were associated with increased risk of death.ConclusionHypoglycemia is linked with a high risk of mortality for children in non malaria tropical settings. Blood sugar should be monitored and treatment provided for sick children, especially with danger signs and prolonged fasting. Further evaluations of intervention using thresholds including low glycemia is recommended in resource-limited settings. Research is also needed to determine the significance, prognosis and care of hyperglycemia.

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Section: Introductionmentioning

confidence: 99%

“…Young children have a limited tolerance for fasting [ 1 ]. Hypoglycemia in non-neonate children is independently associated with poor outcomes in the tropics [ 13 – 19 ].…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country

Hubert

Sayavong

Pussard³

2016

PLoS ONE

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“…The ability to identify hypoglycaemia is not sufficient if the appropriate therapy remains unavailable [23], and this may be a more pronounced problem in lower-level facilities that lack intravenous infusions. When there are complete stock-outs of dextrose infusions, health workers reported that they dissolve sugar in water and give it to the child orally.…”

Section: Discussionmentioning

confidence: 99%

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

Lindsjö

Chirambo

Langton

et al. 2018

Global Health Action

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Background: Acutely sick children in resource-constrained settings who present with hypoglycaemia have poor outcomes. Studies have questioned the current hypoglycaemia treatment cut-off level of 2.5 mmol/l. Improved knowledge about health workers’ attitudes towards and management of hypoglycaemia is needed to understand the potential effects of a raised cut-off level. Objective: This research explored health workers’ perceptions about managing acutely ill children with hypoglycaemia in a Malawian referral hospital. A secondary objective was to explore health workers’ opinions about a potential increase in the hypoglycaemia cut-off level. Methods: We used a qualitative design with semi-structured individual interviews performed with health workers in the Paediatric Accident and Emergency Unit at Queen Elizabeth Central Hospital, Malawi, in October 2016. Data were analysed using latent content analysis. Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee P.01/16/1852. Results: Four themes were formed that described the responses. The first, ‘Critical and difficult cases need easy treatment’, showed that health workers perceived hypoglycaemia as a severe condition that was easily manageable. The second, ‘Health system issues’, revealed challenges relating to staffing and resource availability. The third, ‘From parental reluctance to demand’, described a change in parents’ attitudes regarding intravenous treatments. The fourth, ‘Positive about the change but need more information’, exposed health workers’ concerns about potential risks of a raised cut-off level for hypoglycaemia treatment, as well as benefits for the patients. Conclusions: Health workers perceived hypoglycaemia as a severe condition that is easy to manage when the required equipment and supplies are available. Due to the common lack of test equipment and dextrose supplies, health workers have adopted alternative strategies to diagnose and manage hypoglycaemia. A change to the hypoglycaemia treatment cut-off level raised concerns about potential risks, but was also thought to be of benefit for some patients.

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What are the barriers preventing the screening and management of neonatal hypoglycaemia in low-resource settings, and how can they be overcome?

Irvine

Harris

2023

matern health, neonatol and perinatol

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Over 25 years ago, the World Health Organization (WHO) acknowledged the importance of effective prevention, detection and treatment of neonatal hypoglycaemia, and declared it to be a global priority. Neonatal hypoglycaemia is common, linked to poor neurosensory outcomes and, if untreated, can cause seizures and death. Neonatal mortality in low and lower-middle income countries constitutes an estimated 89% of overall neonatal deaths. Factors contributing to high mortality rates include malnutrition, infectious diseases, poor maternal wellbeing and resource constraints on both equipment and staff, leading to delayed diagnosis and treatment. The incidence of neonatal hypoglycaemia in low and lower-middle income countries remains unclear, as data are not collected.Data from high-resource settings shows that half of all at-risk babies will develop hypoglycaemia, using accepted clinical thresholds for treatment. Most at-risk babies are screened and treated, with treatment aiming to increase blood glucose concentration and, therefore, available cerebral fuel. The introduction of buccal dextrose gel as a first-line treatment for neonatal hypoglycaemia has changed the care of millions of babies and families in high-resource settings. Dextrose gel has now also been shown to prevent neonatal hypoglycaemia.In low and lower-middle income countries, there are considerable barriers to resources which prevent access to reliable blood glucose screening, diagnosis, and treatment, leading to inequitable health outcomes when compared with developed countries. Babies born in low-resource settings do not have access to basic health care and are more likely to suffer from unrecognised neonatal hypoglycaemia, which contributes to the burden of neurosensory delay and death.

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Improving the Management of Dysglycemia in Children in the Developing World

Cited by 4 publications

References 34 publications

High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country

High Mortality Risk in Hypoglycemic and Dysglycemic Children Admitted at a Referral Hospital in a Non Malaria Tropical Setting of a Low Income Country

‘We just dilute sugar and give’ health workers’ reports of management of paediatric hypoglycaemia in a referral hospital in Malawi

What are the barriers preventing the screening and management of neonatal hypoglycaemia in low-resource settings, and how can they be overcome?

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