维生素A补充对于腹泻影响.pdf

Food and Nutrition Sciences,2013,4,150-155 http:/dx.doi.org/10.4236/fns.2013.42021 Published Online February 2013(http:/www.scirp.org/journal/fns)History of Vitamin A Supplementation Reduces Severity of Diarrhea in Young Children Admitted to Hospital with Diarrhea and Pneumonia Mohammod J.Chisti1,2*,Mohammed A.Salam3,Abu S.G.Faruque1,Hasan Ashraf1,2,Pradip K.Bardhan2,Sumon K.Das1,Sayeeda Huq1,Fahmida Chowdhury4,Shoeb B.Islam2,Tahmeed Ahmed1 1Centre for Nutrition&Food Security(CNFS),International Centre for Diarrhoeal Disease Research,Dhaka,Bangladesh;2Clinical Services(CS),Dhaka,Bangladesh;3Research Administration Services(RAS),Dhaka,Bangladesh;4Centre for Communicable Dis-eases(CCD),Dhaka,Bangladesh.Email:*chistiicddrb.org Received December 21st,2012;revised January 21st,2013;accepted January 30th,2013 ABSTRACT Background:Although the role of vitamin A in childhood pneumonia in association with diarrhea is not fully proven,we did not find any published data demonstrating the impact of lack of vitamin A supplementation in under-five chil-dren who present with the co-morbidities of pneumonia and diarrhea.This study examined whether previous vitamin A supplementation was associated with reduced severity and duration of diarrhea and pneumonia for children presenting with both illnesses.Methods:All admitted children(n=189)aged 0-59 months to the Special Care Ward of the Dhaka Hospital of icddr,b with diarrhea and radiological pneumonia from September-December 2007 were enrolled.We compared clinical features of the children who received(n=96)and did not receive(n=93)high potency capsule vitamin A supplementation during previous immunization according to EPI schedule.Results:In logistic regression analysis,after adjusting for potential confounders such as respiratory rate,lower chest wall in-drawing,severe wasting and systolic blood pressure,vitamin A non-supplemented children with pneumonia and diarrhea more often presented in their early infancy(95%CI 1.01-1.09),had duration of diarrhea for 4 days(95%CI 1.79-11.88),had clinical de-hydration(95%CI 1.2-5.63),and more often required hospitalization for 7 days(95%CI 1.03-8.87).But,there was no significant difference in the clinical features of pneumonia,such as history of cough,respiratory rate,lower chest wall in-drawing,nasal flaring,head nodding,grunting respiration,cyanosis,and inability to drink between the groups.Conclusion:Lack of vitamin A supplementation in under-five children with radiological pneumonia and diarrhea is independently associated with young infancy,duration of diarrhea for 4 days,dehydration and hospitalization for 7 days which underscores the importance of routine supplementation of vitamin A in young infancy.However,lack of vitamin A supplementation did not influence any clinical signs of pneumonia.Keywords:Bangladesh;Diarrhea;Children;Lower Chest Wall In-Drawing;Pneumonia;Vitamin A Supplementation 1.Introduction Pneumonia and diarrhea are the two leading causes of death and morbidity in under-five children in developing countries 1,2.Among the estimated 7.6 million global deaths in under-five children in 2010,pneumonia and diarrhea accounted for 18%and 11%of the deaths re-spectively 3.In many developing countries,these two are the common co-morbidities in under-five children with high morbidity and deaths 4,5.Supplementation of capsule vitamin A has a proven role for the reduction of the incidence of diarrhea 6-8 but its role in childhood pneumonia in association with diarrhea is not fully proven 9.Development of clinical features,especially the danger signs of pneumonia and consequences of di-arrhea usually depends on disease severity.Vitamin A supplementation often reduces disease severity and deaths in malnourished children with diarrhea 7,8,10.The overall benefits of vitamin A supplementation for the prevention of mortality and illness are well estab-lished 11.However,we failed to identify any published literature demonstrating the impact of lack of vitamin A supplementation in under-five children who present with the co-morbidities of pneumonia and diarrhea.A large number of children attend the Dhaka Hospital of the In-*Corresponding author.Copyright 2013 SciRes.FNS History of Vitamin a Supplementation Reduces Severity of Diarrhea in Young Children Admitted to Hospital with Diarrhea and Pneumonia 151ternational Centre for Diarrheal Disease Research,Ba-ngladesh(icddr,b)with diarrhea and pneumonia each year,and they often present with dangers signs of pneu-monia and complications of diarrhea.This study exam-ines if vitamin A supplementation may be associated with benefits for children who become sick with such kind of illness.2.Methods 2.1.Ethics Statement The study(icddr,b;grant no Gr-00233)was approved by the Ethical Review Committee(ERC)of International Cen-tre for Diarrheal Disease Research,Bangladesh(icddr,b)and an informed verbal consent was obtained from parents or guardians of all participating children.Children whose caregivers did not give consent were not included in the study but still received standard hospital care.Originally this data has been obtained from a prospective hospital audit which was initially designed to defend the thesis in Masters of Medicine(MMed)of the primary author in the University of Melbourne(UOM),Melbourne,Aus-tralia.Although the clinical audit is routine for hospital care,and used to be done only with verbal consent from the parents or guardians of the patients following the hospital policy.Parents or guardians were assured about the non-disclosure of information collected from them,and were also informed about the use of data for analysis and using the results for improving patient care activities as well as publication without disclosing the name or identity of their children.A brief verbal consent form describing the above measures to the parent or guardian was used during the audit for documentation of the consent.ERC was quite satisfied with voluntary partici-pation,the maintenance of the rights of the participants and confidential handling of personal information by the hospital audit committee and approved this consent pro-cedure.2.2.Patient Enrollment A clinical audit was performed among those admitted to Special Care Ward(SCW)of the Dhaka Hospital of icddr,b between September and December 2007.Each year,this hospital provides care and treatment to over 120,000 patients of all ages.The majority of the patients come from a poor socio-economic backgrounds living in urban and peri-urban Dhaka,the capital city of Bangla-desh.Being a specialized diarrhea treatment facility,es-sentially all patients attend with diarrhea with or without associated complications,and with or without other health problems.The majority of the patients are under-five children,and malnutrition and pneumonia are the most common co-morbidities among them.On arrival to the hospital triage nurses obtain brief medical history and make a quick assessment of the patients,focusing on the severity and complications of diarrhea and dehydration status but also look for associated health problems.Fol-lowing this,patients are referred either to the emergency physician for re-assessment or are admitted to an appro-priate ward of the hospital.Patients with severe illnesses,including those with abnormal mental status,severe and very severe pneumonia defined by the World Health Or-ganization(WHO)criteria 12,hypoxemia,cyanosis,suspected sepsis,and convulsions are admitted to the SCW for further assessment,closer observation,and mo-nitoring with appropriate laboratory workups and man-agement.After admission to the SCW,attending physi-cians re-evaluate the patients,commence required work ups,and prescribe a management plan.2.3.Study Design This analysis involved all diarrheal children of both sex,aged 0 to 59 months,who were admitted to the SCW with clinical and radiological evidence of pneumonia along with their diarrhea during September-December 2007.Comparison of the clinical features of pneumonia and diarrhea was made between the children under five who received and who did not receive high potency vi-tamin A supplementation one capsule contains 200,000 iu;recommended doses:for children age 1 year:1 cap-sule(8 drops),6 months-1 year:half capsule(4 drops),6 months:1/4th capsule(2 drops)during neonatal pe-riod 13 or 6 months prior to admission which was ear-lier.Pneumonia was clinically diagnosed according to the(WHO)criteria 12 and confirmed by radiological evidence of consolidation or patchy opacities in the lungs.Diarrhea was defined as the passage of three or more abnormally loose or watery stool in the previous 24 hours.Relevant clinical information was collected by attending physicians soon after enrollment of the children into the study,after obtaining oral consents from the parents/attendants.Care givers of the participating children were categorically asked by the attending physicians whether the patient received the supplementation of vitamin A capsule or not and all the care givers of participating children answered the question.Standard hospital guidelines were followed in the clinical management of the study children,which in-cluded correction of dehydration using either Oral Rehy-dration Salts(ORS)solution(generally for children with some dehydration)or intravenous fluids(for those with severe dehydration and also for those who were unable to drink ORS in adequate amounts due to any reason);ap-propriate antimicrobial therapy;diets appropriate for age;and micronutrients,vitamins and minerals as and when indicated.Management of severe protein-energy malnu-Copyright 2013 SciRes.FNS History of Vitamin a Supplementation Reduces Severity of Diarrhea in Young Children Admitted to Hospital with Diarrhea and Pneumonia 152 trition was done in accordance with the hospitals proto-colized guidelines 14,15.2.4.Statistical Methods We developed and pre-tested Case Report Forms(CRF)and finalized them for collection of relevant data from the source document(hospital records).All data were entered onto a personal computer and edited before analysis using SPSS for Windows(version 15.0;SPSS Inc.,Chicago)and Epi Info(version 6.0,USD,Stone Mountain,GA).We compared differences in proportions by Chi-square test or Fisher exact test when indicated,and differences in means by Students t-test or Mann-Whitney test when indicated.A probability of less than 0.05 was considered statistically significant.We assessed strength of association by estimating odds ratio(OR)and its 95%confidence intervals(CI),and used it both in univariate and logistic regression analyses.Socio-demo-graphic and relevant clinical characteristics in association with diarrhea and pneumonia were analyzed and these included age,sex,socio-economic condition,duration of diarrhea,clinical dehydration,breast-feeding status,fever,cough,respiratory rate(counted for one full minute in a calm child),lower chest wall in-drawing(in-drawing of the bony structures of the lower chest wall during inspi-ration),head nodding,nasal flaring,cyanosis,grunting respiration,inability to drink,severe wasting(z score for weight for height 3 of the median of the WHO an-thropometry),hypoxemia(arterial oxygen saturation in air 4 days,presence of clinical dehydration,and the need for hospitalization for 7 days were signifi-cantly higher among those who did not receive vitamin A supplementation in the previous six months(Table 2).4.Discussion Vitamin A supplementation has been reported to reduce severity of childhood diarrhea and clinical dehydration in the following six months 16.Our finding of higher fre-quency of dehydration and the probability of continua-tion of diarrhea beyond four days at home as well as the need for longer hospitalization are consistent with the report.Clinical dehydration in higher proportion of vita-min A non-supplemented children may be explained by the higher rate of isolation of V.cholerae among these children,although the rates of isolation of pathogens was not significantly different between the two groups 13.Longer duration of diarrhea at home recorded during the hospital visit,is common in vitamin A non-supplemented children 13,which might have partly contributed to clinical dehydration in our children who did not receive vitamin A supplementation.Higher proportion of severe malnutrition among vitamin A non-supplemented chil-dren might explain the prolonged hospital stay.Our findings corroborates with findings of earlier studies that observed higher proportion of vitamin A non-supple-mented children to have severe acute malnutrition 7,8,which is also important in explaining other observations in our study.Longer time is necessary for the rehydration of severely malnourished children with diarrhea than their healthier counterparts 15,and they often have se-vere co-infections 17 that might contribute to prolonged hospital stay.Significantly higher proportion of our vi-tamin A non-supplemented children had persistent hy-potension even after correction of clinical dehydration and also in children with no clinical dehydration,which suggests their higher probability for severe sepsis or sep-tic shock.The disease severity was higher in significantly higher proportion of non-supplemented children,which might have contributed to their prolonged hospital stay.Although vitamin A supplementation is recommended up to neonatal age 18,the frequent observation of Copyright 2013 SciRes.FNS History of Vitamin a Supplementation Reduces Severity of Diarrhea in Young Children Admitted to Hospital with Diarrhea and Pneumonia Copyright 2013 SciRes.FNS 153 Table 1.Comparison of clinical characteristics of under-five children with pneumonia and diarrhea who had and had not received vitamin A supplementation.Characteristic Vitamin A non-supplemented children(n=96)Vitamin A supplemented children(n=93)OR 95%CI p Male sex 57(59)44(47)1.63 0.88-3.020.129 Age in months(Mean SD)7.4 10.8 12.2 9.6-0.001 Poor SES(monthly income 5000 taka/month)61(64)54/90(60)1.16 0.62-2.190.729 Clinical dehydration(some or severe)55(57)29(31)2.96 1.56-5.634 days 26(29)9(10)3.52 1.45-8.710.003 Non-breastfed 29(30)33(36)0.77 0.41-1.490.503 Fever on admission(38C)81(84)85(91)0.51 0.19-1.360.210 Cough 83(87)87(94)0.44 0.14-1.320.168 Respiratory rate/minute(mean SD)58.0 20.2 60.5 14.5-0.356 Systolic blood pressure in mm of Hg(mean SD)89.2 28.4 98.8 34.2-0.045 Lower chest wall in drawing 74(78)67(72)1.37 0.67-2.800.448 Nasal flaring 19(20)21(23)0.86 0.40-1.820.799 Head nodding 5(5)2(2)2.50 0.42-19.140.445 Grunting respiration 5(5)2(2)2.50 0.42-19.140.445 Cyanosis 7(7)6(6)1.14 0.33-4.020.820 Inability to drink 39(41)31(34)1.35 0.71-2.550.406 Hypoxaemia(SPO2 90%)54(56)48(52)1.21 0.65-2.230.622 WHZ(7 days 18(19)8(9)2.45 0.94-6.560.069 Isolation of Vibrio cholarae 10/70(14)7/68(10)1.45 0.47-4.570.649 Figures represent n(%),unless specified.OR:odds ratio;CI:confidence interval;SD:standard deviation;WHZ:weight for height z score;SpO2=transcutane