ABSTRACT

Background: The World Health Organization has a clinical and syndromic approach to the management of severe acute malnutrition which recognises that laboratory investigations are often not possible where children with severe malnutrition present. In low- and middle-income countries including Papua New Guinea, rates of death from severe malnutrition in many hospitals remain 10% or more.

Aim: To evaluate the clinical predictors of death and the association between disturbances of electrolytes and haematological investigations in children with severe malnutrition and the risk of mortality.

Methods: The clinical and laboratory predictors of death in a prospective cohort of 150 children with severe malnutrition admitted to a provincial hospital in Papua New Guinea were analysed. The clinical signs and electrolytes, complete blood count and liver function tests at presentation and on Days 3 and 5 were recorded.

Results: The strongest independent predictors of mortality at assessment on admission were a low child Glasgow coma scale (≤12), hypoxaemia (SpO₂ <90%), prolonged capillary refill (>3 seconds) and dysnatraemia (<130 or >150 mmol/L). The area under the receiver operating characteristics curve for these four variables was 0.93.

Conclusions: That three of these four criteria correspond closely to the WHO Emergency Clinical Signs reinforces the value of a system of triage and risk assessment in children with severe malnutrition. If a child has emergency signs they should be managed in an area on the ward where close monitoring and supportive care can be provided, the WHO guidelines for severe malnutrition followed, and other specific care provided. Measurements of serum sodium, particularly in children with diarrhoea and dehydration, is also important in risk assessment and management.

摘要

背景：世界卫生组织对严重急性营养不良的管理采用临床和综合治疗方法，该方法认识到在患有严重营养不良的儿童的情况下通常无法进行实验室调查。在包括巴布亚新几内亚在内的低收入和中等收入国家，许多医院的严重营养不良死亡率仍保持在 10% 或更高。

目的：评估严重营养不良儿童死亡的临床预测因素以及电解质紊乱与血液学检查与死亡风险之间的关系。

方法：分析了巴布亚新几内亚省级医院收治的 150 名严重营养不良儿童的前瞻性队列中的临床和实验室预测因素。记录就诊时以及第 3 天和第 5 天的临床体征和电解质、全血细胞计数和肝功能测试。

结果：入院时评估死亡率的最强独立预测因子是儿童格拉斯哥昏迷评分低 (≤12)、低氧血症 (SpO ₂  <90%)、毛细血管再充盈时间延长 (>3 秒) 和钠血症 (<130 或 >150 mmol /L)。这四个变量的受试者工作特征曲线下面积为 0.93。

结论：这四项标准中的三项与世卫组织紧急临床症状密切对应，这加强了对严重营养不良儿童进行分类和风险评估的系统的价值。如果儿童出现紧急症状，应在病房内可以提供密切监测和支持性护理、遵循世界卫生组织严重营养不良指南并提供其他特殊护理的区域进行管理。血清钠的测量，特别是在腹泻和脱水儿童中，在风险评估和管理中也很重要。