Community perception and utilization of services for the severe wasted children aged 6-59 months in the Forcibly Displaced Myanmar Nationals and their nearest host communities in Bangladesh: a qualitative exploration.

Introduction: There is a paucity of data on community perception and utilization of services for wasted children in Forcibly Displaced Myanmar Nationals (FDMN) and their nearest host communities. Methods: We conducted a qualitative study to explore community perceptions and understand the utilization of services for severely wasted children among the FDMN and their nearest host communities in Teknaf, Cox's Bazar. We carried out 13 focus group discussions and 17 in-depth interviews with the caregivers of the children of 6-59 months, and 8 key informant interviews. Results: Caregivers' perceived causes of severe wasting of their children included caregivers' inattention, unhygienic practices, and inappropriate feeding practices. However, the context and settings of the FDMN camps shaped perceptions of the FDMN communities. Caregivers in both the FDMN and host communities sought care from healthcare providers for their children with severe acute malnutrition (SAM) when they were noticed and encouraged by their neighbors or community outreach workers, and when their SAM children suffered from diseases such as diarrhea and fever. Some caregivers perceived ready-to-use therapeutic food (RUTF) as a food to be shared and so they fed it to their non-SAM children. Discussion: Caregivers of the children having SAM with complications, in the FDMN and host communities, were reluctant to stay in stabilization centers or complex respectively, due to their households' chores and husbands' unwillingness to grant them to stay. The findings of this study are expected to be used to design interventions using locally produced RUTF for the management of SAM children in the FDMN, as well as to inform the health sector working on SAM child management in the host communities.

Caregivers' socio-cultural influences on health-seeking behavior for their wasted children among forcibly displaced Myanmar Nationals and their nearest host communities.

Introduction: A total of 19% of forcibly displaced Myanmar Nationals (FDMNs) Bangladesh fall within the age range of under five years old, while an average of 1% exhibit severe malnutrition. Cox's Bazar is the closest host community for FDMNs, with similar traditional culture and religion and shared linguistic, ethnic, and cultural ties. Methods: A qualitative study was conducted to investigate the impact of socio-cultural factors on the healthcare-seeking behavior of caregivers of critically malnourished children in FDMN camps and neighboring host communities. Results: The utilization of informal healthcare by caregivers in both populations can be attributed to cultural attitudes, taboos, and peer pressure. The healthcare by practices in the FDMN camps and host towns were primarily affected by household responsibilities, familial assistance in accessing medical services, decisions made by husbands or mothers-in-law, and the availability and accessibility of healthcare facilities. Certain features were identified that prompt caregivers to seek formal treatment in both groups. The efficacy of the treatment was a primary consideration. In instances where conventional remedies and informal treatments proved ineffective in restoring the health of children, others who were invested in their well-being, such as family members and neighbors, advised caretakers to pursue professional medical care. Discussion: Enhanced caregiver awareness of severe wasting, enhanced healthcare accessibility, and increased community volunteer engagement have the potential to facilitate early identification of severely wasted children and mitigate delays in treatment.

Hospital-Based Quasi-Experimental Study on Hydroxychloroquine Pre-Exposure Prophylaxis for COVID-19 in Healthcare Providers with Its Potential Side-Effects.

Considering that it has been more than 24 months since SARS-CoV-2 emerged, it is crucial to identify measures that prevent and control pathogen transmission in workplace settings. Our aim was to report results of a hospital-based program that delivered hydroxychloroquine (HCQ) tablets as COVID-19 prophylaxis to the frontline healthcare workers (HCW)s who cared for COVID-19 patients and to evaluate the efficacy of HCQ. Setting and participants: Quasi-experimental, controlled, single-center study. The included participants were doctors, nurses, health workers, cleaning staff, and non-healthcare supportive staff. The main outcome was contracting COVID-19 anytime during the period of taking the prophylaxis, confirmed by RT-PCR. A total of 336 participants, without any clinical evidence of COVID-19 and without any known contact with family members, were included in the trial; 230 were assigned to HCQ and 106 declined to take any drug. Results: Among the participants, 43 (18.7%) in the HCQ group and 11 (10.4%) participants in the control group developed COVID-19. For the evaluation of side effects, we evaluated 12-lead ECGs of both groups at the baseline and after 4 weeks to monitor QTc interval. A total of 91% (198 of 217) participants in the prophylaxis group and 92% (11 of 12) in the control group had a QTc < 45o msec, which is within normal limits. Conclusions: Although the number of symptomatic infections in health personnel was lower in the control group, the difference was not statistically significant. However, in the absence of any effective pre-exposure prophylaxis medicine for COVID-19, practicing proper infection prevention and control (IPC) and vaccination is the only way forward.

Zinc Supplementation with or without Additional Micronutrients Does Not Affect Peripheral Blood Gene Expression or Serum Cytokine Level in Bangladeshi Children.

Preventive zinc supplementation provided as a stand-alone dispersible tablet, or via home fortification as multiple micronutrient powders (MNPs), has been considered a potential strategy to prevent zinc deficiency and improve health (including immune) outcomes among children in low- and middle-income countries. However, the impact of zinc supplementation on immune profiles has not been well characterized. We sought to define the effect of zinc supplementation on peripheral blood gene expression and cytokine levels among young children in Dhaka, Bangladesh. In a sub-study of a large randomized, controlled, community-based efficacy trial where children 9-11 months of age received one of the following interventions on a daily basis for 24 weeks: (1) MNPs containing 10 mg of zinc; (2) dispersible tablet containing 10 mg zinc; or (3) placebo powder, we used RNA sequencing to profile the peripheral blood gene expression, as well as highly sensitive multiplex assays to detect cytokine profiles. We profiled samples from 100 children enrolled in the parent trial (zinc MNPs 28, zinc tablets 39, placebo 33). We did not detect an effect from either zinc intervention on differential peripheral blood gene expression at the end of the intervention, or an effect from the intervention on changes in gene expression from baseline. We also did not detect an effect from either intervention on cytokine concentrations. Exploratory analysis did not identify an association between undernutrition (defined as stunting, underweight or wasting) and peripheral blood gene expression. Zinc interventions in children did not produce a gene expression or cytokine signature in the peripheral blood. However, this study demonstrates a proof of principle that sensitive multi-omic techniques can be applied to samples collected in field studies.

Association of maternal prenatal selenium concentration and preterm birth: a multicountry meta-analysis.

BACKGROUND: Selenium (Se), an essential trace mineral, has been implicated in preterm birth (PTB). We aimed to determine the association of maternal Se concentrations during pregnancy with PTB risk and gestational duration in a large number of samples collected from diverse populations. METHODS: Gestational duration data and maternal plasma or serum samples of 9946 singleton live births were obtained from 17 geographically diverse study cohorts. Maternal Se concentrations were determined by inductively coupled plasma mass spectrometry analysis. The associations between maternal Se with PTB and gestational duration were analysed using logistic and linear regressions. The results were then combined using fixed-effect and random-effect meta-analysis. FINDINGS: In all study samples, the Se concentrations followed a normal distribution with a mean of 93.8 ng/mL (SD: 28.5 ng/mL) but varied substantially across different sites. The fixed-effect meta-analysis across the 17 cohorts showed that Se was significantly associated with PTB and gestational duration with effect size estimates of an OR=0.95 (95% CI: 0.9 to 1.00) for PTB and 0.66 days (95% CI: 0.38 to 0.94) longer gestation per 15 ng/mL increase in Se concentration. However, there was a substantial heterogeneity among study cohorts and the random-effect meta-analysis did not achieve statistical significance. The largest effect sizes were observed in UK (Liverpool) cohort, and most significant associations were observed in samples from Malawi. INTERPRETATION: While our study observed statistically significant associations between maternal Se concentration and PTB at some sites, this did not generalise across the entire cohort. Whether population-specific factors explain the heterogeneity of our findings warrants further investigation. Further evidence is needed to understand the biologic pathways, clinical efficacy and safety, before changes to antenatal nutritional recommendations for Se supplementation are considered.

Clinical and laboratory characteristics of children under five hospitalized with diarrhea and bacteremia.

BACKGROUND: Diarrhea is one of the leading causes of mortality in children under five globally. When it is associated with bacteremia, mortality is even higher. However, bacteraemia in diarrheal children has gained little attention in spite of its deleterious impact in under-five mortality. So, we aimed to evaluate associated clinical and laboratory factors for death in under-five children hospitalized with both diarrhea and bacteremia. METHODS: In this retrospective cross-sectional study, we used patients' electronic database of Dhaka Hospital of 'icddr,b', and enrolled all under-five children with diarrhea and bacterial growth in their blood samples on admission between June-2014 and May-2017. Clinical and laboratory characteristics were compared between those who died and who survived with a special attention to bacterial pathogens related to deaths and their sensitivity pattern. RESULTS: In a total of 401 diarrheal children with bacteraemia, 45 (11%) died. Although Salmonella Typhi (34%) was the most predominant isolate followed by Staphylococcus species (16%) and Pseudomonas species (9%), children who died more often had E. coli (OR = 5.69, 95% CI = 2.42-13.39, p = <0.001) and Klebsiella bacteraemia (OR = 4.59, 95% CI = 1.84-11.46, p = 0.001) compared to those who survived. However, none of them was significantly associated with deaths in regression analysis when adjusted with other potential confounders. E. coli was 100% resistant to ampicillin, 41% to gentamicin, and 73% to ceftriaxone and Klebsiella species was 96% resistant to ampicillin, 42% to gentamicin, and 62% to ceftriaxone. Study children who died had significantly higher overall resistance pattern shown in World Health Organization (WHO) recommended one of the first line antibiotics in treating childhood sepsis such as ampicillin (80% vs. 50%, p = 0.001) and in second line antibiotic such as ceftriaxone (49% vs. 22%, p = 0.001) compared to the survivors. In logistic regression analysis, after adjusting for potential confounders, we found that clinical sepsis (aOR 3.79, 95% CI 1.60-8.96, p = 0.002), hypoxemia (aOR 4.20, 95% CI 1.74-10.12, p = 0.001), and hyperkalaemia (aOR 2.69, 95% CI 1.05-6.91, p = 0.039) were found to be independent predictors of deaths and receipt of sensitive antibiotic (aOR 0.42, 95% CI 0.18-0.99, p = 0.048) was revealed as the independent protective factor for deaths in this population. CONCLUSION AND SIGNIFICANCE: The results of our data suggest that diarrheal children with bacteremia who died more often had gram negative bacteremia compared to those who survived and these pathogens are highly resistant to WHO recommended first line and second line antibiotics. The results further emphasize the critical importance of early identification of important clinical problems such as clinical sepsis, hypoxemia and hyperkalaemia in diarrheal children and treat them with potential sensitive antibiotic(s) in order to reduce bacteremia related mortality in children with diarrhea, especially in resource limited settings.

Proof-of-concept study of the efficacy of a microbiota-directed complementary food formulation (MDCF) for treating moderate acute malnutrition.

BACKGROUND: Childhood undernutrition remains a significant global health challenge accounting for over half of all under 5 child mortality. Moderate acute malnutrition (MAM), which leads to wasting [weight-for-length z-scores (WLZ) between - 2 and - 3], affects 33 million children under 5 globally and more than 2 million in Bangladesh alone. We have previously reported that acute malnutrition in this population is associated with gut microbiota immaturity, and in a small, 1-month pre-proof-of-concept (POC) study demonstrated that a microbiota-directed complementary food formulation (MDCF-2) was able to repair this immaturity, promote weight gain and increase plasma biomarkers and mediators of healthy growth. Here we describe the design controlled feeding study that tests whether MDCF-2 exhibits superior efficacy (ponderal growth, host biomarkers of a biological state) than a conventional Ready-to-use Supplementary Food (RUSF) in children with MAM over intervention period of 3 months. METHODS: Two separate cohorts of 12-18-month-old children will be enrolled: 124 with primary MAM, and 124 with MAM after having been treated for severe acute malnutrition (post-SAM MAM). We have established several field sites in an urban slum located in the Mirpur district of Dhaka, Bangladesh and at a rural site, Kurigram in the north of Bangladesh. The two groups of children receiving MDCF-2 and RUSF will be compared at baseline (pre-intervention), after 1 month, at the end of intervention (3 months), 1 month after cessation of intervention, and every 6 months thereafter for 4 years. DISCUSSION: This study will determine whether daily, controlled administration of MDCF-2 for 3 months provides superior improvements in weight gain, microbiota repair, and elevated levels of key plasma biomarkers/mediators of healthy growth compared to the control RUSF formulation. The pathogenesis of MAM is poorly defined and there are currently no WHO-approved treatments; results from the current study of children with primary MAM and post-SAM MAM will shed light on the effects of the gut microbiota on childhood growth/development and will provide a knowledge base that may help improve complementary feeding practices. TRIAL REGISTRATION: The primary MAM and post-SAM MAM trials are registered in Clintrials.gov (NCT04015999 and NCT04015986, registered on July 11, 2019, retrospectively registered).

Consequences of Lack of Neonatal Breastfeeding in Infants Hospitalized for Diarrhea at an Urban Hospital, Bangladesh: A Case Control Design.

Background. Exclusive breastfeeding is important for immunity and lack of breastfeeding during the neonatal age impedes that. Our aim was to assess the consequences of lack of breastfeeding on infants with diarrhea in the neonatal period. Methods. In this design, infants from DDSS (Diarrheal Disease Surveillance System) from 2009 to 2013 were studied. Those who did not have breastfeeding or had cessation of breastfeeding at the neonatal age constituted the cases, whereas infants who continued breastfeeding since birth or for at least 6 months since birth constituted the controls. Results. The cases more often presented at a younger age, had an illiterate mother, frequently presented with complicated diarrhea, had severe wasting, and had abnormal mental status compared with the controls. In logistic regression, after adjusting for potential confounders, infants who lacked breastfeeding at the neonatal period had an independent association with dehydrating diarrhea. Conclusions. The results of our analyses suggest that infants with diarrhea who did not have breastfeeding at the neonatal age are prone to develop some or severe dehydration.

Determinants and Outcome of Metabolic Acidosis in Diarrheal Children Under 5 Years of Age in an Urban Critical Care Ward in Bangladesh.

We evaluated the independent determinants and outcome of metabolic acidosis in diarrheal children. Children under 5 years of age admitted with diarrhea and severe respiratory distress in the critical care ward at Dhaka Hospital of icddr,b (International Centre for Diarrhoeal Disease Research, Bangladesh) from April 2010 to April 2014 who had their reports of arterial blood gas analyses were enrolled in the study. We compared clinical and laboratory characteristics between the study children with (cases = 74) and without metabolic acidosis (controls = 65). Metabolic acidosis was defined if pH < 7.35 and HCO3 < 22 mmol/L in ABG. Cases had higher mortality (53% vs 29%, P = .01) compared to controls. After adjustment of potential confounders, for instance, hypokalemia and dehydration, the cases were independently associated with severe sepsis and raised serum creatinine (for both P < .05). Thus, early identification of these features of metabolic acidosis in diarrheal children may help clinicians to have prompt management that may further help reduce mortality in such children especially in resource-limited settings.

Prevalence and risk factors of vitamin D insufficiency and deficiency among 6-24-month-old underweight and normal-weight children living in an urban slum of Bangladesh.

OBJECTIVE: We quantified the prevalence of vitamin D status in 6-24-month-old underweight and normal-weight children and identified the socio-economic and dietary predictors for status. DESIGN: Cross-sectional, baseline data from a nutritional intervention study were analysed. Multinomial logistic regression was used to estimate the odds of being vitamin D deficient or insufficient with the reference being vitamin D sufficient. SETTING: Urban slum area of Mirpur field site, Dhaka, Bangladesh. SUBJECTS: Underweight (weight-for-age Z-score <-2·00) and normal-weight (weight-for-age Z-score ≥-1·00) children aged 6-24 months. RESULTS: Among 468 underweight children, 23·1 % were sufficient, 42·3 % insufficient, 31·2 % deficient and 3·4 % severely vitamin D deficient. Among 445 normal-weight children, 14·8 % were sufficient, 39·6 % insufficient and 40·0 % deficient and 5·6 % severely deficient. With adjusted multinominal regression analysis, risk factors (OR (95 % CI)) for vitamin D deficiency in underweight children were: older age group (18-24 months old; 2·9 (1·5-5·7)); measurement of vitamin D status during winter (3·0 (1·4-6·4)) and spring (6·9 (3·0-16·1)); and maternal education (≥6 years of institutional education; 2·2 (1·0-4·9)). In normal-weight children, older age group (3·6 (1·2-10·6)) and living in the richest quintile (3·7 (1·1-12·5)) were found to be significantly associated with vitamin D insufficiency. CONCLUSIONS: The study demonstrates a significant burden of vitamin D insufficiency and deficiency in both underweight and normal-weight children <2 years of age from an urban slum of Bangladesh. Identification of risk factors may help in mitigating the important burden in such children.

Factors Associated With Pneumonia Among Overweight and Obese Under-Five Children in an Urban Hospital of a Developing Country.

To our knowledge, there are no data on the role of overweight and obesity in childhood pneumonia. We sought to determine that impact of overweight and obesity in such children. In this retrospective chart analysis, we enrolled hospitalized children aged 6 to 59 months in the Dhaka Hospital of the icddr,b, Bangladesh (International Centre for Diarrhoeal Disease Research, Bangladesh), from January 2010 to June 2014. Children with pneumonia having overweight and obesity (body mass index Z score [BMIZ] >2.00) constituted cases (n = 25), and those who had pneumonia without overweight and obesity (BMIZ -2.00 to 2.00) constituted controls (n = 75). Controls were 3-fold of the cases and were randomly selected. Demographic, clinical, and laboratory data of the cases and the controls were compared. The cases more often had diarrhea and dehydration (36% vs 12%, P = .013), hypoxemia (SpO2 < 90% in room air; 28% vs 7%, P = .009) on admission, and required to change antibiotics (32% vs 11%, P = .023) during hospitalization compared to the controls. However, in logistic regression analysis the cases were independently associated with diarrhea (P < .001) and hypoxemia (P = .024) on admission. Our data suggest that overweight and obesity in children with pneumonia is prone to be associated with hypoxemia on admission, which may guide clinicians in promptly managing pneumonia in order to evade its ramification in such children. However, future research with larger samples is imperative to consolidate or refute our observation.

Diarrhea-associated pneumococcal meningitis with complicating hydrocephalus in a child in a resource-limited setting.

INTRODUCTION: Streptococcus pneumonia is the most common and intimidating cause of childhood meningitis. Its delayed diagnosis may be associated with hyponatremia and hypernatremia with fatal outcome. CASE PRESENTATION: A previously healthy nine-month-old Bangladeshi female infant was diagnosed with diarrhea, pneumonia, and convulsion due to hypernatremia. Pneumonia was confirmed by respiratory distress and radiological findings. Routine cerebrospinal fluid study detected pneumococcal meningitis. Ampicillin, gentamicin, and dexamethasone were promptly started. On day three of hospitalization, convulsion re-appeared with worsening of consciousness level. Antibiotics were switched to ceftriaxone and vancomycin, although ultrasonography of the brain revealed no abnormality. Contrast-enhanced computed tomography scan of the head was performed and revealed dilated ventricles with diffused enhancement of meninges and basal cisterns, demonstrating meningitis with ventriculomegaly. Ceftriaxone was replaced by meropenem to control fever. Magnetic resonance imaging (MRI) of the brain confirmed the progression of hydrocephalus. An emergency ventriculo-peritoneal (VP) shunt operation was performed with continuation of antibiotics for 21 days. After three months, follow-up MRI showed reduction of ventricular size with functioning VP shunt in situ with no neurological deficits. CONCLUSIONS: Childhood pneumococcal meningitis may be associated with diarrhea, pneumonia, and other related complication. Appropriate antibiotic therapy alone may not be sufficient to avert complications. Communicating hydrocephalus is potentially an ominous ramification of meningitis even when the ultrasonography result is normal. Rapid diagnosis is imperative to attain good outcome. Evidence advocates further research into the risk factors of meningitis in diarrheal children that may help in early diagnosis and management to reduce meningitis-related fatal outcome.

Experience With Nosocomial Infection in Children Under 5 Treated in an Urban Diarrheal Treatment Center in Bangladesh.

We aimed to evaluate the factors associated with nosocomial infections (NIs) in under-5 children and in bacterial isolates from their blood, urine, and stool. We reviewed all under-5 hospitalized children with clinically diagnosed NIs in the inpatient ward at Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh, between January and December 2012. Comparison was made among the children with (cases = 71) and without NI (controls = 142). NI was defined as the development of new infection 48 hours after admission. Bacterial isolates in urine, blood, and stool were found in 11/52 (21%), 9/69 (13%), and 2/16 (12%) respectively. In logistic regression analysis, the children with NI were independently associated with severe acute malnutrition, congenital anomaly, invasive diarrhea, urinary tract infection on admission, and use of intravenous cannula during hospitalization. Thus, identification of these simple clinical parameters may help in preventive measures being taken to reduce the rate of NIs in such children.

Hypernatremia in Children With Diarrhea: Presenting Features, Management, Outcome, and Risk Factors for Death.

We sought to investigate the magnitude, clinical features, treatment, and outcome of children suffering from hypernatremic diarrhea and to identify risk factors for fatal outcome among them. We reviewed 2 data sets of children <15 years admitted to the in-patient ward of the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b) with diarrhea and hypernatremia (serum sodium ≥150 mmol/L): (a) March 2001 to March 2002 (n = 371) and (b) March 2009 to August 2011 (n = 360). We reviewed their records and collected relevant information for analyses. The prevalence of hypernatremia was 5.1% (371/7212) and 2.4% (360/15 219), case fatality rate was 15% and 19%, respectively. In logistic regression analysis, the risk for death significantly increased in association with serum sodium ≥170 mmol/L, nutritional edema, hypoglycemia, respiratory distress, and absent peripheral pulses and reduced with the sole use of oral rehydration salts (ORS) or ORS following intravenous fluid, if indicated (for all, P < .05). Thus, managing children with hypernatremia using only ORS or ORS following intravenous fluid may help reduce the number of deaths.

Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial.

BACKGROUND: Growth faltering in the first 2 years of life is high in South Asia where prevalence of stunting is estimated at 40-50%. Although nutrition counselling has shown modest benefits, few intervention trials of food supplementation exist showing improvements in growth and prevention of stunting. METHODS: A cluster-randomized controlled trial was conducted in rural Bangladesh to test the effect of two local, ready-to-use foods (chickpea and rice-lentil based) and a fortified blended food (wheat-soy-blend++, WSB++) compared with Plumpy'doz, all with nutrition counselling vs nutrition counselling alone (control) on outcomes of linear growth (length and length-for-age z-score, LAZ), stunting (LAZ < -2), weight-for-length z-score (WLZ) and wasting (WLZ < -2) in children 6-18 months of age. Children (n = 5536) were enrolled at 6 months of age and, in the food groups, provided with one of the allocated supplements daily for a year. RESULTS: Growth deceleration occurred from 6 to 18 months of age but deceleration in LAZ was lower (by 0.02-0.04/month) in the Plumpy'doz (P = 0.02), rice-lentil (< 0.01), and chickpea (< 0.01) groups relative to control, whereas WLZ decline was lower only in Plumpy'doz and chickpea groups. WSB++ did not impact on these outcomes. The prevalence of stunting was 44% at 18 months in the control group, but lower by 5-6% (P ≤ 0.01) in those receiving Plumpy'doz and chickpea. Mean length and LAZ at 18 months were higher by 0.27-0.30 cm and 0.07-0.10 (all P < 0.05), respectively, in all four food groups relative to the control. CONCLUSIONS: In rural Bangladesh, small amounts of daily fortified complementary foods, provided for a year in addition to nutrition counselling, modestly increased linear growth and reduced stunting at 18 months of age.

The MAL-ED cohort study in Mirpur, Bangladesh.

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study site in Bangladesh is located in the capital city of Dhaka in an urban slum that has one of the highest population densities in the world. The site is in the Bauniabadh area of Mirpur, Dhaka. A typical squatter settlement, the average family size of households in Mirpur Bauniabadh is 4.5, with 48% females. About 20% of households have a monthly income of only US$62. About 30% of mothers never attended school, and only 3% obtained secondary school education. The majority of the people are day laborers, garment workers, and transport workers. About 72% of caregivers always wash their hands after helping the child defecate and 6.6% never wash their hands. The diarrheal attack rate for Mirpur is 4.69 episodes per child per year. The study site is representative of a typical urban slum of Dhaka city in terms of demographics, socioeconomic status, and general health indicators.

Hypophosphatemia among severely malnourished children with sepsis in Bangladesh.

BACKGROUND: The interaction between hypophosphatemia (HP) and severe malnutrition has received little attention. This study investigated the prevalence, severity, and risk factors of HP among severely malnourished children with sepsis in Bangladesh. METHODS: Children aged 6-59 months admitted with sepsis to Dhaka Hospital from April 2010 to December 2011 were enrolled in the study and divided into two groups: severe acute malnutrition (SAM) and non-SAM groups. Plasma phosphate and the related biochemical parameters were measured upon admission and on the second and fourth days for both groups and the 10th day or discharge day for the SAM group. RESULTS: The prevalence of HP (plasma phosphate <3.7 mg/dL) was 72.9% and 62.5% (P = 0.26) for 48 SAM and for 56 non-SAM patients, respectively; that of moderate-severe HP (phosphate <2 mg/dL) was 25.0% and 19.6%, respectively (P = 0.51). The plasma phosphate level of 21 SAM patients was significantly lower on the second and fourth days than upon admission (P = 0.03, P = 0.01, respectively); it then recovered on the 10th day or discharge day. On multiple logistic regression analysis, plasma potassium <2.5 mmol/L upon admission was found to be a risk factor for moderate or severe HP (adjusted odds ratio, 7.21; 95% confidence interval: 1.88-27.7). CONCLUSION: HP is common among children with sepsis. Potassium <2.5 mmol/L upon admission is considered a risk factor for moderate or severe HP in children with sepsis.

Hypophosphataemia among severely-malnourished children: case series.

Phosphorus is an essential substance in our body, and hypophosphataemia (HP) is well-described in rickets, refeeding syndrome, diabetic ketoacidosis (DKA), and in chronic alcohol-abuse. However, to our knowledge, HP among severely-malnourished children has not been studied in detail, and information on prevalence, severity, and treatment is scarce. Currently, there are only a few published case reports of HP. This case series describes three cases of HP that presented to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Our first case required mechanical ventilation for respiratory distress associated with severe hypokalaemia (K 1.1 mmol/L) and moderate hypophosphataemia (P 2.1 mg/dL). The second case presented with severe sepsis which was associated with symptomatic hypocalcaemia (Ca 1.68 mmol/L), hypokalaemia (K 1.82 mmol/L), and severe hypophosphataemia (P 0.9 mg/dL). The third case presented with pneumonia and sepsis which were complicated by hypokalaemia (K 2.05 mmol/L) and severe hypophosphataemia (P 1.1 mg/dL). Marked lethargy and severe hypotonia were associated with HP in all of these cases. Manifestations of HP are diverse and can occur in association with other electrolyte imbalances, especially among malnourished children. Malnutrition, combined with sepsis, is one of the major killers of children younger than 5 years of age, and both malnutrition and sepsis can cause HP. It is concluded that the underlying causes of morbidity, including HP, should be actively sought and treated to reduce the mortality of children aged below five years.