Rytter Maren Jh, Babirekere-Iriso Esther, Namusoke Hanifa, Christensen Vibeke B, Michaelsen Kim F, Ritz Christian, Mortensen Charlotte G, Mupere Ezekiel, Friis Henrik
Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark;
Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
Am J Clin Nutr. 2017 Feb;105(2):494-502. doi: 10.3945/ajcn.116.140822. Epub 2016 Dec 28.
Children who receive in-hospital treatment of severe acute malnutrition often have high mortality rates, and the reasons are not well understood.
We assessed risk factors for death in children who were treated for malnutrition in a hospital.
In a prospective observational study of 120 children who were receiving in-hospital treatment of severe acute malnutrition in Uganda with therapeutic formulas F-75 and F-100, we collected data on symptoms, clinical findings, plasma markers of refeeding syndrome (electrolytes and phosphate), and acute phase reactants, and recorded the nutritional therapy given in hospital.
Seventeen children (14%) died. Clinical risk factors for death were the presence of oral thrush (HR: 5.0; 95% CI: 1.6, 15.2), a caretaker-reported severity of illness on a visual analog scale (HR: 1.7; 95% CI: 1.1, 2.6), impaired consciousness (HR: 16.7; 95% CI: 3.1, 90.4), and a capillary refill time >2 s (HR: 3.9; 95% CI: 1.4, 11.3). HIV infection was not associated with mortality (HR: 3.0; 95% CI: 0.7, 12.4), which was most likely due to low power. Biochemical risk factors were a plasma C-reactive protein concentration >15 mg/L on admission and low plasma phosphate that was measured on day 2 (HR: 8.7; 95% CI: 2.5, 30.1), particularly in edematous children. The replacement of F-75 with unfortified rice porridge to ameliorate diarrhea was associated with a higher risk of death, particularly if given during the first 2 d (HR: 5.0; 95% CI: 1.9, 13.3), which was an association that remained after adjustment for potential confounders (HR: 69.5; 95% CI: 7.0, 694.6).
Refeeding syndrome may occur in children who are treated for malnutrition, even with moderately low plasma phosphate, and, in particular, in children with edematous malnutrition. The replacement of F-75 with unfortified rice porridge is associated with increased risk of death, which is possibly mediated by lowering plasma phosphate. The identified clinical risk factors may potentially improve the triage of children with malnutrition. This trial was registered at www.isrctn.com as ISRCTN55092738.
接受重度急性营养不良住院治疗的儿童死亡率往往较高，其原因尚不清楚。
我们评估了在医院接受营养不良治疗的儿童的死亡风险因素。
在一项前瞻性观察研究中，对乌干达120名接受重度急性营养不良住院治疗并使用F - 75和F - 100治疗配方的儿童，我们收集了症状、临床检查结果、再喂养综合征的血浆标志物（电解质和磷酸盐）以及急性期反应物的数据，并记录了在医院给予的营养治疗。
17名儿童（14%）死亡。死亡的临床风险因素包括口腔念珠菌感染（风险比：5.0；95%置信区间：1.6，15.2）、照护者在视觉模拟量表上报告的疾病严重程度（风险比：1.7；95%置信区间：1.1，2.6）、意识障碍（风险比：16.7；95%置信区间：3.1，90.4）以及毛细血管再充盈时间>2秒（风险比：3.9；95%置信区间：1.4，11.3）。HIV感染与死亡率无关（风险比：3.0；95%置信区间：0.7，12.4），这很可能是由于检验效能低。生化风险因素是入院时血浆C反应蛋白浓度>15mg/L以及第2天测得的血浆磷酸盐水平低（风险比：8.7；95%置信区间：2.5，30.1），特别是在水肿儿童中。用未强化的米粥替代F - 75以改善腹泻与更高的死亡风险相关，特别是在最初2天给予时（风险比：5.0；95%置信区间：1.9，13.3），在对潜在混杂因素进行调整后这种关联仍然存在（风险比：69.5；95%置信区间：7.0，694.6）。
即使血浆磷酸盐水平中度偏低，尤其是在水肿型营养不良儿童中，接受营养不良治疗的儿童也可能发生再喂养综合征。用未强化的米粥替代F - 75与死亡风险增加相关，这可能是通过降低血浆磷酸盐介导的。所确定的临床风险因素可能潜在地改善对营养不良儿童的分诊。该试验在www.isrctn.com上注册，注册号为ISRCTN55092738。
