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- ItemOpen AccessAn evaluation of the prevalence, characteristics, outcomes and predictors of shock in children admitted to paediatric wards at Queen Elizabeth Central Hospital in Blantyre, Malawi(Kamuzu University of Health Sciences, 2021-06-01) Kumwenda, MercyShock is an important pathophysiological mechanism of death in children in low-resource settings. Despite this, limited data is available on the prevalence, causes and outcome of shock in children in these settings. We performed a prospective study to assess the prevalence, aetiology and risk factors of death in children with shock. This data will be essential to improve guidelines and interventions to reduce shock related mortality in children. Methods: A prospective descriptive study was performed from 1st February 2019 to 31st January 2020 at Queen Elizabeth Central Hospital (QECH) paediatric department. ALL paediatric admissions screened for shock as defined by FEAST were recruited. The criteria used were impaired consciousness and/or respiratory distress in combination with at least one sign of impaired perfusion: a capillary refill time (CRT) >3 seconds, cold peripheries, weak radial pulse volume and/or severe tachycardia. The WHO definition of shock was used as a comparative definition. Demographic, clinical, laboratory and outcome data were collected from the patient records. Predictors for death were assessed using univariate and multivariate models. Results: Out of 12840 admissions, 679 had shock resulting in a prevalence of 5.3%. Of these 505 were included in the study of 15/439 (3.4%) fulfilled the more stringent WHO criteria for shock. The median age was 17 months and ranged from 2 months to 16 years. Respiratory distress was reported in 397/488 (81.4%), fever in 383/495 (77.4%), vomiting or diarrhoea was reported in 183/484 (37.8%) and 127/478 (26.6%) respectively and severe malnutrition was documented in 39/471 (8.3%). Severe anaemia (Hb ≤5g/dL) was present in 19/334 (5.7%), and 67/395 (17.7%) tested positive for malaria. HIV prevalence was vi 27/358 (7.5%) and blood cultures were positive in 8/176 (4.5%). The main clinical diagnoses on discharge were viral/reactive lower respiratory tract diseases 211/470 (44.9%), pneumonia 89/470 (18.8%), gastroenteritis 64/470 (13.6%) and presumed sepsis 57/470 (12.0%). Overall mortality in shocked children was 79/679 (11.6%). We constructed two multivariate models aimed at a) predicting outcome, and b) assessing disease associated outcomes. Clinical factors predictive of death were low coma score (AOR = 4.9, 95% CI = 2.2 - 11.1), delayed CRT (AOR = 3.5, 95% CI = 1.4 – 8.5) and dehydration (AOR 5.9, 95% CI 3.2 – 11.1). The main clinical diagnoses of children that died were presumed sepsis 34/76 (44.7%), gastroenteritis 21/76 (23.7%), severe malaria 13/76 (17.1%), severe malnutrition 9/76 (11.8%) and meningitis 8/76 (10.5%). In the explanatory model for causative factors, having a diagnosis of presumed sepsis (AOR = 9.9, 95% CI = 4.1 – 23.8) or gastroenteritis (AOR = 3.7, 95% CI = 1.8 – 7.4) was associated with increased mortality, while having viral/reactive airways disease was not associated with death (AOR = 0.02, 95% CI = 0.005 – 0.079). Conclusion: Shock is a common diagnosis in children seen at QECH in Malawi using the modified FEAST criteria, affecting 1 in 18 admissions. The actual prevalence of children with shock may be lower as the FEAST definition we used may have overestimated shock prevalence. This was evidenced by the fact that approximately 40% of those that qualified had a purely respiratory condition and only 3.4% of those who qualified fit the very strict WHO definition. This discrepancy underlines the lack of a valid bedside definition for shock in children in Malawi. In our population, mortality was high at 11%. The children who present with a low BCS, delayed CRT and dehydration were more likely to die. The diagnoses of sepsis, gastroenteritis and malaria were contributors to death. This might underscore the importance of their prompt treatment.
- ItemOpen AccessCardiac disease in children with HIV-associated chronic lung disease at Queen Elizabeth Central Hospital, Blantyre, Malawi(Kamuzu University of Health Sciences, 2021-01-01) Mapurisa, Gugulethu NewtonOver the past decade, more perinatally-infected children have survived despite previous assertions that few would reach adolescence. More complications of the chronic human immunodeficiency virus (HIV) are surfacing with improving survival. These include HIV, chronic lung disease (HCLD), and cardiac disease (1-5). Such complications were previously associated with delayed diagnosis and poor HIV control. However, there is growing evidence that prolonged disease by itself predisposes to cardiac disease (6,7). Cardiac disease in HCLD has not been researched in children stable on ART. The study aimed to describe the cardiac symptoms in HIV-infected children with chronic lung disease, who are stable on antiretroviral therapy (ART), and identify the prevalence of cardiac dysfunction. The study was conducted at Queen Elizabeth Central Hospital, QECH, a large teaching hospital in Blantyre, Malawi. It was a nested study in a prospective randomised controlled trial that corecruited consenting trial participants with HCLD who had been on ART for more than six months with virological suppression. Chronic lung disease was determined by spirometry of (FEV1 z-score < -1.0) with no reversibility (< 12%). Participant demographics were collected, and cardiac echocardiograms were done at baseline using a Sonosite M-turbo machine (8). Clinical data and demographic data were collected and analysed using STATA 14. Fourty-nine (49) of the 180 participants were recruited. The median age was 14.5 years; the interquartile range [IQR] was 8.4 – 19.8 years; 51.1% female. The mean CD4 cell counts were 640 ± 439 (87 – 2969). The mean Medical Research Council (MRC) dyspnea score was 2.3 ± v 1. Rheumatic heart disease was confirmed in 3 (6%) who were already on treatment at recruitment. 0 (0%) having pulmonary hypertension. In conclusion, our findings demonstrate low cardiac dysfunction and pulmonary hypertension levels in this cohort of HCLD in children. However, there is significant co-morbidity with acquired heart disease in this group set of children. Longer-term follow-up of these children is essential to identify if further cardiac dysfunction does not emerge in children on ART for a longer duration.
- ItemOpen AccessAssociation of neonatal hypothermia with morbidity and mortality in a tertiary hospital in Malawi(Kamuzu University of Health Sciences, 2021-11-21) Phoya, FrankNeonatal hypothermia is a major risk factor for morbidity and mortality in the first 28 days of life. Studies conducted, in high resource setting have shown the impact of hyperthermia on morbidity and mortality in the first 28 days of life, which has lead to better implementation of prevent measures. In sub-Saharan Africa, very limited data on the effect of hyperthermia on morbidity and mortality is available. Due to lack of data, this has led to poorly implemented interventions and slow reduction in the neonatal mortality rate. This study aimed to document the level of neonatal morbidity and mortality, associated with neonatal hypothermia. It determined whether hypothermia at 5 minutes, on admission to the neonatal unit (NU), or at 24 hours, had the highest association with morbidity and mortality. This prospective observational study which was conducted at Queen Elizabeth Central Hospital, Blantyre Malawi recruited neonates with a birth weight greater than 1000 grams. Temperatures were recorded at birth, on admission and 4 hourly thereafter. Clinical course and outcome were reviewed. Data were analysed using Stata v.15 and p <0.05 was considered statistically significant. Between August 2018 to March 2019, 120 neonates were enrolled, of which 112 had complete data and were included in the data analysis. Hypothermia at 5 minutes after birth was noted in 74% (83), 77% (86) on admission to the NU and 38% (24/63) at 24 hours. Neonates who had hypothermia 5 minutes after birth were more likely to have hypothermia on admission to the NU compared to normothermic subjects (p<0.01). Hypothermia on admission to the NU was significantly associated with mortality (100% v.72%, p=0.02) but not hypothermia at 5 minutes nor at 24 hours. After adjusting for potential confounders, the odds ratio of Apgar scores <6 at 1 minute for mortality was 5.66 (95% CI 1.55-20.70) for neonates with hypothermia compared to normothermia, and of hypothermia at 5 minutes for hypothermia on admission to NU was 13.31 (95% CI 4.17-42.54. This study highlights the large proportion of hospitalized neonates who are hypothermic on admission and the association between neonatal hypothermia and poor outcome in terms of morbidity and mortality. Our findings suggest that a strong predictor of mortality is neonatal hypothermia on admission to the NU, and that early intervention in the immediate period after delivery could decrease the incidence of hypothermia and reduce associated morbidity and mortality.
- ItemOpen AccessAn audit of antimicrobial treatment practices and laboratory diagnostics in febrile paediatric patients at Mzimba South District Hospital(2022-03-01) Manda, Happy, AbrahamBackground: It is a recommendation clinician to use Standard Treatment Guidelines (STG) to come up with presumptive diagnosis or order laboratory tests to support the diagnosis. Adherence to STG alone is a global concern. Objective: This study was to evaluate the antimicrobial prescribing practices among febrile paediatric patients in relation to Malawi Standard Treatment Guidelines (MSTG) and laboratory findings or usage at Mzimba South District Hospital (MSDH). Methods: This was a retrospective cross-sectional study using mixed methods where quantitative and qualitative methods were employed. Three hundred and sixty case notes for paediatric patients admitted to the children's ward from January to December 2017 were assessed. Findings: The common febrile illness diagnosed were malaria 194 (53.9%), sepsis 108(38.3%) and pneumonia 99(27.5%). The use of MSTG and laboratory investigations in prescribing was at 18.1% and 28.3% respectively. Despite the availability of MSTG and laboratory tests to guide antimicrobial prescribing practices, Amoxicillin was prescribed in 90%, Benzylpenicillin 85%, and Gentamicin 69% of febrile ill patients regardless of the malaria positive test results or the diagnosis. Artesunate and LA were prescribed in malaria negative patients in the final diagnosis of malaria at 49 (38.1%), sepsis 44 (40.7%) and pneumonia 19 (19.9 %). Conclusion: The laboratory tests and MSTG had minimal support to antimicrobial prescribing practices at MSDH. Prescribers prefer the use of empirical treatment with a focus on broad spectrums and if in dilemma consult the seniors. We recommend establishment of antimicrobial stewardships to monitor antimicrobial use and advocate on MSTG use. Furthermore, we recommend strengthening microbiology facilities to support identification of microbe and antimicrobial susceptibility.