title: Treatment Failure and Mortality amongst Children with Severe Acute Malnutrition Presenting with Cough or Respiratory Difficulty and Radiological Pneumonia.
abstract: BACKGROUND
  Appropriate intervention is critical in reducing deaths among under-five, severe acutely malnourished (SAM) children with danger signs of severe pneumonia; however, there is paucity of data on outcome of World Health Organisation (WHO) recommended interventions of SAM children with severe pneumonia. We sought to evaluate outcome of the interventions in such children.
  
  
  METHODS
  We prospectively enrolled SAM children aged 0-59 months, admitted to the Intensive Care Unit (ICU) or Acute Respiratory Infection (ARI) ward of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), between April 2011 and June 2012 with cough or respiratory difficulty and radiological pneumonia. All the enrolled children were treated with ampicillin and gentamicin, and micronutrients as recommended by the WHO. Comparison was made among pneumonic children with (n = 111) and without WHO defined danger signs of severe pneumonia (n = 296). The outcomes of interest were treatment failure (if a child required changing of antibiotics) and deaths during hospitalization. Further comparison was also made among those who developed treatment failure and who did not and among the survivors and deaths.
  
  
  RESULTS
  SAM children with danger signs of severe pneumonia more often experienced treatment failure (58% vs. 20%; p<0.001) and fatal outcome (21% vs. 4%; p<0.001) compared to those without danger signs. Only 6/111 (5.4%) SAM children with danger signs of severe pneumonia and 12/296 (4.0%) without danger signs had bacterial isolates from blood. In log-linear binomial regression analysis, after adjusting for potential confounders, danger signs of severe pneumonia, dehydration, hypocalcaemia, and bacteraemia were independently associated both with treatment failure and deaths in SAM children presenting with cough or respiratory difficulty and radiological pneumonia (p<0.01).
  
  
  CONCLUSIONS
  The result suggests that SAM children with cough or respiratory difficulty and radiologic pneumonia who had WHO-defined danger signs of severe pneumonia more often had treatment failure and fatal outcome compared to those without the danger signs. In addition to danger signs of severe pneumonia, other common causes of both treatment failure and deaths were dehydration, hypocalcaemia, and bacteraemia on admission. The result underscores the importance for further research especially a randomized, controlled clinical trial to validate standard WHO therapy in SAM children with pneumonia especially with danger signs of severe pneumonia to reduce treatment failures and deaths.
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; Dhaka Hospital, icddr,b, Dhaka, Bangladesh.
authors.forename: Mohammod Jobayer
authors.initials: MJ
authors.lastname: Chisti
authors.affiliation: Research & Clinical Administration and Strategy (RCAS), icddr,b, Dhaka, Bangladesh.
authors.forename: Mohammed Abdus
authors.initials: MA
authors.lastname: Salam
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; Dhaka Hospital, icddr,b, Dhaka, Bangladesh.
authors.forename: Pradip Kumar
authors.initials: PK
authors.lastname: Bardhan
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Abu S G
authors.initials: AS
authors.lastname: Faruque
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Abu S M S B
authors.initials: AS
authors.lastname: Shahid
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: K M
authors.initials: KM
authors.lastname: Shahunja
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Sumon Kumar
authors.initials: SK
authors.lastname: Das
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh; Dhaka Hospital, icddr,b, Dhaka, Bangladesh.
authors.forename: Md Iqbal
authors.initials: MI
authors.lastname: Hossain
authors.affiliation: Centre for Nutrition & Food Security (CNFS), International Centre for Diarhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh.
authors.forename: Tahmeed
authors.initials: T
authors.lastname: Ahmed
mesh_terms: D002675:Child, Preschool; D003371:Cough / Q000150:complications*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007362:Intensive Care Units; D008297:Male; D010343:Patient Admission; D011014:Pneumonia / Q000150:complications* / Q000175:diagnosis; D011871:Radiology; D012119:Respiration; D012307:Risk Factors; D000067011:Severe Acute Malnutrition / Q000150:complications / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy*; D017211:Treatment Failure