患有腹泻的严重营养不良儿童的死亡率及标准化管理方案的应用

Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol.

作者信息

Ahmed T, Ali M, Ullah M M, Choudhury I A, Haque M E, Salam M A, Rabbani G H, Suskind R M, Fuchs G J

机构信息

Clinical Sciences Division, ICDDR, B: Centre for Health and Population Research, Dhaka, Bangladesh.

出版信息

Lancet. 1999 Jun 5;353(9168):1919-22. doi: 10.1016/S0140-6736(98)07499-6.

DOI:10.1016/S0140-6736(98)07499-6

PMID:10371570

Abstract

BACKGROUND

Severely malnourished children have high mortality rates. Death commonly occurs during the first 48 h after hospital admission, and has been attributed to faulty case-management. We developed a standardised protocol for acute-phase treatment of children with severe malnutrition and diarrhoea, with the aim of reducing mortality.

METHODS

We compared severely malnourished children with diarrhoea aged 0-5 years managed by non-protocol conventional treatment, and those treated by our standardised protocol that included slow rehydration with an emphasis on oral rehydration. The standardised-protocol group included children admitted to the ICDDR,B Hospital, Dhaka between Jan 1, 1997, and June 30, 1997, while those admitted between Jan 1, 1996, and June 30, 1996, before the protocol was implemented, were the non-protocol group.

FINDINGS

Characteristics on admission of children on standardised protocol (n=334) and non-protocol children (n=293) were similar except that more children on standardised protocol had oedema, acidosis, and Vibrio cholerae isolated from stools. 199 (59.9%) of children on standardised protocol were successfully rehydrated with oral rehydration solution, compared with 85 (29%) in the non-protocol group (p<0.0001). Use of expensive antibiotics was less frequent in children on standardised protocol than in the other group (p<0.0001). Children on standardised protocol had fewer episodes of hypoglycaemia than non-protocol children (15 vs 30, p=0.005). 49 (17%) of children on non-protocol treatment died, compared with 30 (9%) children on standardised protocol (odds ratio for mortality, 0.49, 95% CI 0.3-0.8, p=0.003).

INTERPRETATION

Compared with non-protocol management, our standardised protocol resulted in fewer episodes of hypoglycaemia, less need for intravenous fluids, and a 47% reduction in mortality. This standardised protocol should be considered in all children with diarrhoea and severe malnutrition.

摘要

背景

严重营养不良的儿童死亡率很高。死亡通常发生在入院后的头48小时内，且一直被归因于不当的病例管理。我们制定了一项针对重度营养不良且伴有腹泻儿童的急性期治疗标准化方案，旨在降低死亡率。

方法

我们将0至5岁患有腹泻的重度营养不良儿童分为两组，一组采用非标准化方案的传统治疗，另一组采用我们的标准化方案治疗，该方案包括缓慢补液并强调口服补液。标准化方案组包括1997年1月1日至1997年6月30日期间入住达卡国际腹泻疾病研究中心（ICDDR,B）医院的儿童，而在该方案实施前，即1996年1月1日至1996年6月30日期间入院的儿童为非标准化方案组。

研究结果

标准化方案组（n = 334）和非标准化方案组（n = 293）儿童入院时的特征相似，只是标准化方案组中有更多儿童出现水肿、酸中毒，且粪便中分离出霍乱弧菌。标准化方案组中有199名（59.9%）儿童通过口服补液成功补液，而非标准化方案组中这一比例为85名（29%）（p<0.0001）。标准化方案组儿童使用昂贵抗生素的频率低于另一组（p<0.0001）。标准化方案组儿童发生低血糖的次数少于非标准化方案组儿童（分别为15次和30次，p = 0.005）。非标准化方案治疗的儿童中有49名（17%）死亡，而标准化方案组中有30名（9%）死亡（死亡比值比为0.49，95%置信区间为0.3 - 0.8，p = 0.003）。