Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study

Ngari, Moses; Fegan, Greg; Mwangome, Martha; Ngama, Mwanajuma; Mturi, Neema; Scott, John A.; Bauni, Evasius; Nokes, D. James; Berkley, James A.

doi:10.1111/ppe.12348

Cited by 71 publications

(57 citation statements)

References 29 publications

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“…There were more admissions and deaths in children aged 5–9 years, but there was higher case fatality among those aged 10–14 years (14.1%). Pneumonia case fatality rates (CFRs) have not been reported before in these age groups and, perhaps surprisingly they are similar to those reported in hospital-based pneumonia studies of children under 5 years: studies from sub-Saharan Africa report rates ranging from 5% to 10.4% 18 21–25. These include pneumonia mortality rates from studies within the CIN: for children aged between 2 and 59 months one study reported CFR of 5.9%,21 and another reported 5%, the latter excluded children with severe acute malnutrition, meningitis and HIV 18…”

Section: Discussionsupporting

confidence: 59%

Risk factors for death among children aged 5–14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

et al. 2019

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IntroductionThere were almost 1 million deaths in children aged between 5 and 14 years in 2017, and pneumonia accounted for 11%. However, there are no validated guidelines for pneumonia management in older children and data to support their development are limited. We sought to understand risk factors for mortality among children aged 5–14 years hospitalised with pneumonia in district-level health facilities in Kenya.MethodsWe did a retrospective cohort study using data collected from an established clinical information network of 13 hospitals. We reviewed records for children aged 5–14 years admitted with pneumonia between 1 March 2014 and 28 February 2018. Individual clinical signs were examined for association with inpatient mortality using logistic regression. We used existing WHO criteria (intended for under 5s) to define levels of severity and examined their performance in identifying those at increased risk of death.Results1832 children were diagnosed with pneumonia and 145 (7.9%) died. Severe pallor was strongly associated with mortality (adjusted OR (aOR) 8.06, 95% CI 4.72 to 13.75) as were reduced consciousness, mild/moderate pallor, central cyanosis and older age (>9 years) (aOR >2). Comorbidities HIV and severe acute malnutrition were also associated with death (aOR 2.31, 95% CI 1.39 to 3.84 and aOR 1.89, 95% CI 1.12 to 3.21, respectively). The presence of clinical characteristics used by WHO to define severe pneumonia was associated with death in univariate analysis (OR 2.69). However, this combination of clinical characteristics was poor in discriminating those at risk of death (sensitivity: 0.56, specificity: 0.68, and area under the curve: 0.62).ConclusionChildren >5 years have high inpatient pneumonia mortality. These findings also suggest that the WHO criteria for classification of severity for children under 5 years do not appear to be a valid tool for risk assessment in this older age group, indicating the urgent need for evidence-based clinical guidelines for this neglected population.

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Section: Discussionsupporting

confidence: 59%

Risk factors for death among children aged 5–14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

et al. 2019

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“…Current guidelines recommend that children admitted with cSAM are discharged and transferred to community care when their medical complications, including oedema, are resolving, they are clinically well and alert, and have good appetite, rather than hospital discharge being based on anthropometric criteria (WHO, 2019). However, children with cSAM experience a high rate of mortality and readmission in the months following hospital discharge especially in sub-Saharan Africa (Berkley et al, 2016;Chhibber et al, 2015;Dubray et al, 2008;Kerac et al, 2009;Moisi et al, 2011;Ngari et al, 2017;Trehan et al, 2013;Veirum, Sodeman, Biai, Hedegård, & Aaby, 2007;Wiens et al, 2013;Wiens et al, 2015). Recent systematic reviews reported paediatric post-discharge mortality rates in resource-poor countries of up to 18% that may exceed in-hospital mortality rates in many settings (Nemetchek et al, 2018;Wiens et al, 2013).…”

Section: Introductionmentioning

confidence: 99%

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study

Gonzales

Ngari

Njunge

et al. 2019

Maternal & Child Nutrition

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Hospital readmission is common among children with complicated severe acute malnutrition (cSAM) but not well‐characterised. Two distinct cSAM phenotypes, marasmus and kwashiorkor, exist, but their pathophysiology and whether the same phenotype persists at relapse are unclear. We aimed to test the association between cSAM phenotype at index admission and readmission following recovery. We performed secondary data analysis from a multicentre randomised trial in Kenya with 1‐year active follow‐up. The main outcome was cSAM phenotype upon hospital readmission. Among 1,704 HIV‐negative children with cSAM discharged in the trial, 177 children contributed a total of 246 readmissions with cSAM. cSAM readmission was associated with age<12 months (p = .005), but not site, sex, season, nor cSAM phenotype. Of these, 42 children contributed 44 readmissions with cSAM that occurred after a monthly visit when SAM was confirmed absent (cSAM relapse). cSAM phenotype was sustained during cSAM relapse. The adjusted odds ratio for presenting with kwashiorkor during readmission after kwashiorkor at index admission was 39.3 [95% confidence interval (95% CI) [2.69, 1,326]; p = .01); and for presenting with marasmus during readmission after kwashiorkor at index admission was 0.02 (95% CI [0.001, 0.037]; p = .01). To validate this finding, we examined readmissions to Kilifi County Hospital, Kenya occurring at least 2 months after an admission with cSAM. Among 2,412 children with cSAM discharged alive, there were 206 readmissions with cSAM. Their phenotype at readmission was significantly influenced by their phenotype at index admission (p < .001). This is the first report describing the phenotype and rate of cSAM recurrence.

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“…The WHZ was calculated using the 2006 WHO child growth standards [16]. The weight of the children during admission was done using an electronic scale (Seca, Birmingham, UK) that has a weekly check for consistency [5,17]. The heights of the children were measured with a stadiometer (Seca 215, Birmingham, UK) [18] except for children with less than 2 years and those who could not stand whose length was measured using a standard calibrated board.…”

Section: Outcome and Explanatory Variablesmentioning

confidence: 99%

A space-time analysis of recurrent malnutrition-related hospitalisations in Kilifi, Kenya for children under-5 years

Wambui

Musenge

2019

BMC Nutr

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Background: Globally, malnutrition underlies 45% of under-5 s mortality, mainly from potentiating common infections such as diarrhoea and pneumonia. Malnutrition as a public health problem is not evenly disbursed because of disparities in food insecurity and health, and children commonly suffer recurrent episodes of opportunistic infections. We aimed to understand better the spatial and temporal structure of multiple paediatric hospital admissions associated with malnutrition-related illnesses. This paper aimed to investigate the spatialtemporal variations in malnutrition-related recurrent morbidity of children under-5 years from the Kilifi County in Kenya between 2002 and 2015. Methods: The study included data from children under-5 years old who had more than one admission to a rural district hospital in Kenya within the Kilifi Health and Demographic Surveillance System (KHDSS). The primary outcome was a malnutrition-related admission, based on wasting (WHZ <-2) or nutritional oedema. Individual, household and environmental level covariates were examined as exposures. We first fitted a SARIMA model for the temporality, and the Moran's Index affirmed spatial clustering in malnutrition admissions. Kulldorf Statistics using SaTScan were applied to detect hotspots. Then, bivariate analysis was done using repeated values tabulation and analysis of covariance (ANCOVA). Inferential analysis was done using a mixed effect multivariable negative-binomial regression model, adjusting for spatiotemporal random effects. Results: A total of 2821 children were admitted more than once, giving a total of 6375 admissions. Of these 6375 admissions, 1866 were malnutrition-related, and 3.9% (109/2821) of the children with repeat admissions died. There was a seasonal pattern of re-admissions, peaking from May to July over the years. Hotspots were found in both the Northern and Southern areas of the KHDSS, while the areas near Kilifi Town were least affected. We found that disease severity was most likely associated with a malnutrition re-admission to the hospital. Conclusion: Disease severity was strongly associated with admission with malnutrition but its effect reduced after adjusting for the spatial and temporal random effects. Adjusting for clustering in space and in time (spatialtemporal) in models helps to improve the understanding of recurrent hospitalisations involving malnutrition.

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Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study

Cited by 71 publications

References 29 publications

Risk factors for death among children aged 5–14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

Risk factors for death among children aged 5–14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study

A space-time analysis of recurrent malnutrition-related hospitalisations in Kilifi, Kenya for children under-5 years

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