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Predicting mortality for paediatric inpatients where malaria is uncommon
Dana C Clifton1, Habib O Ramadhani, Levina J Msuya
1Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
Insights
In low malaria transmission areas, Integrated Management of Childhood Illness (IMCI) criteria effectively predict non-malarial severe illness deaths in children. Clinical examination is crucial for prognosis, as laboratory results were less predictive.
Area of Science:
- Pediatrics
- Infectious Diseases
- Global Health
Background:
- Sub-Saharan Africa is experiencing an increase in children residing in low malaria transmission zones.
- Accurate identification of non-malarial severe illness is critical for improving pediatric outcomes in these regions.
Purpose of the Study:
- To evaluate the effectiveness of Integrated Management of Childhood Illness (IMCI) criteria in predicting inpatient mortality among children with severe non-malarial febrile illness.
- To assess the utility of clinical signs versus laboratory results in determining prognosis for severe pediatric illness in a low malaria transmission setting.
Main Methods:
- A prospective cohort study was conducted with febrile pediatric inpatients at a tertiary referral center in northern Tanzania.
- Data were collected using IMCI criteria, and diagnostic specimens were obtained.
- Statistical analysis identified factors associated with inpatient death.
Main Results:
- Out of 466 participants, 7.3% died. Malaria was diagnosed in only 2.4% of cases.
- Clinical signs such as prolonged capillary refill time, inability to drink, lethargy, and respiratory difficulty were significantly associated with inpatient death.
- Severe wasting and a low Blantyre Coma Scale (BCS) score were independent predictors of mortality.
Conclusions:
- IMCI criteria demonstrated good performance in predicting inpatient death from non-malarial causes in a low malaria transmission area.
- Clinical examination proved more valuable than laboratory results for assessing prognosis.
- Healthcare providers should consider local malaria prevalence to avoid over-diagnosis and ensure timely treatment for non-malarial severe illnesses.
Objective:
As the proportion of children living low malaria transmission areas in sub-Saharan Africa increases, approaches for identifying non-malarial severe illness need to be evaluated to improve child outcomes.
Design:
As a prospective cohort study, we identified febrile paediatric inpatients, recorded data using Integrated Management of Childhood Illness (IMCI) criteria, and collected diagnostic specimens.
Setting:
Tertiary referral centre, northern Tanzania.
Results:
Of 466 participants with known outcome, median age was 1.4 years (range 2 months-13.0 years), 200 (42.9%) were female, 11 (2.4%) had malaria and 34 (7.3%) died. Inpatient death was associated with: Capillary refill >3 s (OR 9.0, 95% CI 3.0 to 26.7), inability to breastfeed or drink (OR 8.9, 95% CI 4.0 to 19.6), stiff neck (OR 7.0, 95% CI 2.8 to 17.6), lethargy (OR 5.2, 95% CI 2.5 to 10.6), skin pinch >2 s (OR 4.8, 95% CI 1.9 to 12.3), respiratory difficulty (OR 4.0, 95% CI 1.9 to 8.2), generalised lymphadenopathy (OR 3.6, 95% CI 1.6 to 8.3) and oral candidiasis (OR 3.4, 95% CI 1.4 to 8.3). BCS <5 (OR 27.2, p<0.001) and severe wasting (OR 6.9, p<0.001) were independently associated with inpatient death.
Conclusions:
In a low malaria transmission setting, IMCI criteria performed well for predicting inpatient death from non-malarial illness. Laboratory results were not as useful in predicting death, underscoring the importance of clinical examination in assessing prognosis. Healthcare workers should consider local malaria epidemiology as malaria over-diagnosis in children may delay potentially life-saving interventions in areas where malaria is uncommon.
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