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      Prevalence and outcome of stress hyperglycaemia among severely malnourished children admitted to Mulago referral and teaching hospital in Kampala, Uganda

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          Abstract

          Background

          Stress hyperglycaemia is a transient increase in blood glucose level during stressful events and is common in critically ill children. Several studies have demonstrated increased risk of mortality in these children. There is paucity of information on this subject in sub Saharan Africa.

          The aim of this study was to describe the prevalence, outcome and factors associated with stress hyperglycaemia among children with severe acute malnutrition (SAM) admitted to the Mwanamugimu nutrition unit of Mulago hospital in Uganda.

          Methods

          This study was conducted from August 2015 to March 2016 at the Mwanamugimu nutrition unit of Mulago hospital among severely malnourished children aged 1 to 60 months. Random blood sugar levels were measured. Stress hyperglycaemia was considered as a random blood sugar > 150 mg/dl. The final outcome was ascertained at death or discharge. Statistical analysis was done using the Chi square test and logistic regression.

          Results

          Two hundred and thirty-five children were enrolled of whom 50% were girls. The median age was 5.1 months (range 1–60 months). Stress hyperglycaemia was present in 16.6% of the 235 participants. Several factors were significantly associated with stress hyperglycaemia at bivariate analysis; but on logistic regression, only presence of oral sores was associated with stress hyperglycaemia: (Odds ratio 2.61; 95% CI 1.02–6.65).

          Mortality was higher among children with stress hyperglycaemia (56.4%) compared to (12.8%) in the non-hyperglycaemic group: OR 8.75; 95% CI 4.09–18.70).

          Conclusion

          The prevalence of stress hyperglycaemia was 16.6% and was associated with high mortality. It is important to monitor blood glucose levels of severely malnourished children. Hitherto, the main concern among severely malnourished children has been hypoglycaemia. Innovative ways of preventing and managing stress hyperglycaemia among these children are urgently needed.

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          Most cited references14

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          Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive care unit.

          Kupper Wintergerst, Bruce Buckingham, Laura Gandrud … (2006)
          We evaluated retrospectively plasma glucose levels and the degree of hypoglycemia, hyperglycemia, and glucose variability in a PICU and then assessed their association with hospital length of stay and mortality rates. Electronic medical records at the Packard Children's Hospital at Stanford University were reviewed retrospectively for all PICU admissions between March 1, 2003, and March 31, 2004. Patients with a known diagnosis of diabetes mellitus were excluded. The prevalence of hyperglycemia was defined with cutoff values of 110, 150, and 200 mg/dL. Hypoglycemia was defined as < or = 65 mg/dL. Glucose variability was assessed with a calculated glucose variability index. In 13 months, 1094 eligible admissions generated 18865 glucose values (median: 107 mg/dL; range: 13-1839 mg/dL). Patients in the highest maximal glucose quintile had a significantly longer median PICU length of stay, compared with those in the lowest quintile (7.5 days vs 1 day). Mortality rates increased as patients' maximal glucose levels increased, reaching 15.2% among patients with the greatest degree of hyperglycemia. Hypoglycemia was also prevalent, with 18.6% of patients (182 of 980 patients) having minimal glucose levels of < or = 65 mg/dL. There was an increased median PICU length of stay (9.5 days vs 1 day) associated with glucose values in the lowest minimal quintile, compared with those in the highest quintile. Hypoglycemia was correlated with mortality rates; 16.5% of patients with glucose levels of < or = 65 mg/dL died. Glucose variability also was associated with increased length of stay and mortality rates. In multivariate logistic regression analyses, glucose variability, taken with hyperglycemia and hypoglycemia, showed the strongest association with mortality rates. Hyperglycemia and hypoglycemia were prevalent in the PICU. Hypoglycemia, hyperglycemia, and, in particular, increased glucose variability were associated with increased morbidity (length of stay) and mortality rates.
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            Severe acute malnutrition and infection

            Kelsey D Jones, James A. Berkley (2014)
            Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.
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              Persistent hyperglycemia in critically ill children.

              Edward Faustino, Michael Apkon (2005)
              To determine the prevalence and prognostic significance of hyperglycemia among critically ill nondiabetic children. We performed a retrospective cohort study using point-of-care blood glucose measurements, hospital administrative databases, and a computerized information system; 942 nondiabetic patients admitted to our Pediatric Intensive Care Unit (PICU) from October 2000 to September 2003 were included. The prevalence of hyperglycemia was based on initial PICU glucose measurement, highest value within 24 hours, and highest value measured during PICU stay up to 10 days after the first measurement. Primary outcome was in-hospital death with PICU lengths of stay (LOS) as secondary outcome. Through the use of three cutoff values (120 mg/dL, 150 mg/dL, and 200 mg/dL), the prevalence of hyperglycemia was 16.7% to 75.0%. The relative risk (RR) for dying increased for maximum glucose within 24 hours >150 mg/dL (RR, 2.50; 95% confidence interval (CI), 1.26 to 4.93) and highest glucose within 10 days >120 mg/dL (RR, 5.68; 95% CI, 1.38 to 23.47). LOS was decreased for admission glucose >120 mg/dL and 150 mg/dL but increased for all threshold values for maximum glucose within 10 days. Hyperglycemia occurs frequently among critically ill nondiabetic children and is correlated with a greater in-hospital mortality rate and longer LOS.
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                Author and article information

                Contributors
                Anita Tumwebaze:
                ORCID: http://orcid.org/0000-0003-0525-9356
                anitamuhumuza@gmail.com
                Elizabeth Kiboneka: bethkiboneka@gmail.com
                Jamir Mugalu: mugalu89@yahoo.com
                Edward M. Kikabi: drmarkeddys@gmail.com
                James K. Tumwine: kabaleimc@gmail.com
                Journal
                Journal ID (nlm-ta): BMC Nutr
                Journal ID (iso-abbrev): BMC Nutr
                Title: BMC nutrition
                Publisher: BioMed Central (London )
                ISSN (Electronic): 2055-0928
                Publication date (Electronic): 12 December 2018
                Publication date PMC-release: 12 December 2018
                Publication date Collection: 2018
                Volume: 4
                Electronic Location Identifier: 49
                Affiliations
                ISNI 0000 0004 0620 0548, GRID grid.11194.3c, Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, , Makerere University, ; Kampala, Uganda
                Author information
                http://orcid.org/0000-0003-0525-9356
                Article
                Publisher ID: 258
                DOI: 10.1186/s40795-018-0258-3
                PMC ID: 7050710
                PubMed ID: 32153910
                SO-VID: 76cd2950-abd2-47c6-be94-5e57aeb3758b
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 12 June 2018
                Date accepted : 29 November 2018
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                Keywords: stress hyperglycaemia,severe acute malnutrition
                Data availability:
                Keywords: stress hyperglycaemia, severe acute malnutrition

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