Roxanne Assies

Malnutrition among infants aged under 6 months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2011–2022), describing the prevalence and time trends of infant u6m wasting (weight‐for‐length z‐score [WLZ] < −2), stunting (length‐for‐age z‐score [LAZ] < −2), and underweight (weight‐for‐age z‐score [WAZ] < −2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 10 years, Bangladesh has seen some reduction in stunting and underweight, while wasting has remained relatively stable. In 2022, out of 440 infants u6m, 10.2% were wasted, 11.2% stunted, 11.3% underweight, 0.2% concurrently wasted/stunted. This translates to 178,394 infants u6m being wasted, 195,884 stunted, and 197,633 underweight, in 2022. Between the years 2011 and 2022, 30.3% of participants had at least one form of anthropometric deficit. Length (171) had more missing values than weight (79). WAZ had the lowest percentage of flagged data (0.5%) compared to WLZ (6.1%) and LAZ (2.5%). Underweight was associated with residence, wealth status, maternal age at delivery, maternal BMI, maternal height, maternal level of education, exclusive breastfeeding status and fever in the past 2 weeks. Factors associated with wasting were survey year, the sex of the household head, wealth status, maternal educational level, maternal age at delivery, infant age, and place of delivery. Our findings support the urgent need to roll out the 2023 WHO Guidelines in Bangladesh. They are also consistent with other recent literature highlighting potential advantages of weight‐for‐age (WAZ) as a measure of undernutrition. Given multiple associated factors, packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

Malnutrition among infants aged under six months (u6m) is a global public health problem. As countries begin implementing 2023 WHO malnutrition guidelines, local prevalence and epidemiology must be well understood. We analysed Bangladesh Demographic Health Survey data (2004 – 2022), describing the prevalence and time trends of infant u6m wasting (weight-for-length z-score [WLZ] <-2), stunting (length-for-age z-score [LAZ] <-2), and underweight (weight-for-age z-score [WAZ] <-2). In bivariate and multivariate analyses, we tested the association between wasting and underweight and established risk factors for malnutrition. Over the last 20 years, Bangladesh has seen a substantial reduction in stunting and underweight while wasting has remained relatively stable. In 2022, out of 476 infants u6m, 10.6% were wasted, 12.8% stunted, 13.7% underweight, 0.5% concurrently wasted/stunted, and 14.8% were reported small at birth. This translates to 185,390 infants u6m being wasted, 223,867 stunted, and 239,608 underweight, in 2022. WAZ had the lowest percentage of flagged data (0.8%) compared to WLZ (6.0%) and LAZ (6.4%). Underweight was associated with delivery place, small birth size, infant sex, post-natal check-ups, fever in the past 2 weeks, drinking water source, maternal BMI, and maternal height. Fewer factors were associated with being wasted, including the sex of the household head. Our findings support the urgent need to roll out 2023 WHO Guidelines in Bangladesh. They also support the superiority of underweight as a measure of undernutrition. Packages of care tackling a wide range of potential underlying causes are important for effective local interventions tailored to this age group.

OBJECTIVES: To evaluate the feasibility, reliability, and diagnostic implications of performing the pediatric Rapid Ultrasound for Shock and Hypotension (p-RUSH) in children with undifferentiated shock upon hospital presentation in a low-resource setting (LRS). DESIGN: Prospective observational study from February 2019 to December 2019. SETTING: Pediatric emergency department (ED) of a large academic referral hospital in Blantyre, Malawi. PATIENTS: Children (2 mo to 16 yr old) with shock upon presentation to the pediatric ED. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thirty children with shock were enrolled, of whom 14 died. The p-RUSH was performed upon admission to the ED, before administration of an IV fluid bolus. The p-RUSH was performed within a median time of 11.5 minutes, and 92.3% of the image frames in 4-second video clips were interpretable. Images were scored by two independent reviewers and the qualitative and quantitative assessments were compared and showed positive correlations as follows: 1) qualitative assessments of cardiac performance vs. left ventricle ejection fraction and fractional shortening measurements (r = 0.684 and r = 0.616, respectively, both p < 0.05) and 2) qualitative assessment of inferior vena cava (IVC) collapsibility vs. IVC collapsibility index (r = 0.470; p < 0.05). The interobserver agreement between cardiac and IVC qualitative assessments yielded a kappa statistic of up to 0.850 (cardiac views) and 0.275 (IVC collapsibility). Both reviewers applied a novel algorithmic flow diagram to diagnose the shock phenotype. In 23 of 30 children, the flowchart could be completed, which suggested either hypovolemic or distributive shock as the most common phenotype. CONCLUSIONS: In a Malawian pediatric ED, the p-RUSH was feasible and qualitative assessments were reliable. This 2019 proof-of-concept test provides a basis for further external validation of the p-RUSH and our algorithm for identifying shock phenotypes, which may lead to individualizing care of children presenting with shock in LRSs.

Shock is considered one of the most important mechanisms of critical illness in children. However, data on paediatric shock in sub-Saharan Africa is limited, which constrains development of effective treatment strategies. We aimed to describe the prevalence, mortality, and aetiology of paediatric shock in a tertiary hospital in Malawi. Children aged two months to 16 years presenting with shock (FEAST criteria; respiratory distress and/or impaired consciousness, and at least one sign of impaired circulation; capillary refill>3 seconds, cold extremities, weak pulse, or severe tachycardia) to the emergency department were included and followed-up prospectively using routinely collected data between February 2019 and January 2020. Prevalence, mortality and aetiology of shock were reported for both the FEAST criteria and World Health Organization (WHO) definition. The association between aetiology and mortality was assessed with univariable analysis. Of all screened admissions (N = 12,840), 679 (5.3%) children presented with shock using FEAST criteria and the mortality was 79/663 (11.9%). WHO-defined shock applied to 16/12,840 (0.1%) and the mortality was 9/15 (60.0%). Main diagnoses were viral/reactive airway diseases (40.4%), severe pneumonia (14.3%), gastroenteritis (11.3%) and presumed sepsis (5.7%). Children diagnosed with presumed sepsis and gastroenteritis had the highest odds of dying (OR 11.3; 95%-CI:4.9–25.8 and OR 4.4; 95%-CI:2.4–8.2). Considering the high mortality, prevalence of paediatric shock (FEAST and WHO definitions) in Malawi is high. Sepsis and gastroenteritis are diagnoses associated with poor outcome in these children. Consensus on a clinical meaningful definition for paediatric shock is essential to boost future studies.

Objectives: Shock is a life-threatening condition in children in low- and middle-income countries (LMIC), with several controversies. This systematic review summarizes the etiology, pathophysiology and mortality of shock in children in LMIC.Methods: We searched for studies reporting on children with shock in LMIC in PubMed, Embase and through snowballing (up to 1 October 2019). Studies conducted in LMIC that reported on shock in children (1 month–18 years) were included. We excluded studies only containing data on neonates, cardiac surgery patients or iatrogenic causes. We presented prevalence data, pooled mortality estimates and conducted subgroup analyses per definition, region and disease. Etiology and pathophysiology data were systematically collected.Results: We identified 959 studies and included 59 studies of which six primarily studied shock. Definitions used for shock were classified into five groups. Prevalence of shock ranged from 1.5% in a pediatric hospital population to 44.3% in critically ill children. Pooled mortality estimates ranged between 3.9-33.3% for the five definition groups. Important etiologies included gastroenteritis, sepsis, malaria and severe anemia, which often coincided. The pathophysiology was poorly studied but suggests that in addition to hypovolemia, dissociative and cardiogenic shock are common in LMIC.Conclusions: Shock is associated with high mortality in hospitalized children in LMIC. Despite the importance few studies investigated shock and as a consequence limited data on etiology and pathophysiology of shock is available. A uniform bedside definition may help boost future studies unravelling shock etiology and pathophysiology in LMIC.