Abstract
BackgroundHyperlactataemia and metabolic acidosis are important risk factors for malaria death, but measuring lactate at the point of care is not financially viable in many resource-poor settings. This study aimed to identify combinations of routinely available parameters that could identify children at high risk of hyperlactataemia.MethodsUsing data from a study of Gambian children aged six months to 16 years with severe or uncomplicated malaria, logistic regression modelling with a forward stepwise model selection process was used to develop a predictive model for hyperlactataemia from routinely available demographic, clinical and laboratory parameters. Potential predictors of hyperlactataemia considered for the modelling process were patient characteristics (age, sex, prior use of anti-malarials, and weight percentile for age), respiratory symptoms (deep breathing, irregular respiration, use of accessory muscles of respiration, lung crepitations, grunting respiration, cough, and age-specific respiratory rate), other clinical parameters recorded at presentation (duration of symptoms, Blantyre coma score, number of convulsions prior to admission, axillary temperature, dehydration, severe prostration, splenomegaly) and laboratory measures from blood tests (percentage parasitaemia, white cell count, lymphocyte count, neutrophil count, monocyte count, platelet count, haemoglobin level, blood glucose level).Results495 children were included, and 68 (14%) had laboratory-confirmed hyperlactataemia (lactate > 7 mmol/L). Four features were independently associated with increased hyperlactataemia risk in a multivariable age- and sex-adjusted model: lower Blantyre score (odds ratio (OR) compared to score 5 = 2.68 (95% CI, 1.03-6.96) for score 3–4 and 6.18 (95% CI, 2.24-17.07) for score 0–2, p = 0.001), higher percentage parasitaemia (OR = 1.07 (1.03-1.11) per 0031% increase, p < 0.001), high respiratory rate for age (OR = 3.09 (1.50-6.38) per unit increase, p = 0.002), and deep breathing (OR = 2.81 (1.20-6.60), p = 0.02). Cross-validated predictions from the final model achieved area under the receiver operating characteristic curve of 0.83.ConclusionsThis study identified predictors of hyperlactataemia requiring only simple bedside clinical examination and blood film examination that can be carried out in resource-limited settings to quickly identify children at risk of dangerously raised lactate. A simple spreadsheet tool implementing the final model is supplied as supplementary material.
Highlights
Hyperlactataemia and metabolic acidosis are important risk factors for malaria death, but measuring lactate at the point of care is not financially viable in many resource-poor settings
Potential predictors of hyperlactataemia considered for the modelling process were patient characteristics, respiratory symptoms, other clinical parameters recorded at presentation and laboratory measures from blood tests
In a study of 495 Gambian children with uncomplicated or severe malaria, four features were identified that were independently associated with an increased risk of hyperlactataemia in a multivariable age- and sex-adjusted model: lower Blantyre score, higher percentage parasitaemia, high respiratory rate for age, and presence of deep breathing
Summary
Hyperlactataemia and metabolic acidosis are important risk factors for malaria death, but measuring lactate at the point of care is not financially viable in many resource-poor settings. Metabolic acidosis is one of the most frequent presentations defining severe malaria [3], and is associated with a high risk of death in African children with severe malaria, no matter whether it is captured as base excess [4,5], lactataemia [4,6,7,8,9,10], or by clinical signs of respiratory distress, such as deep breathing or lower chest wall in-drawing [4,7,11]. The consumables for lactate measurement devices are expensive and generally unavailable in resource-poor settings [6,14] It would, be desirable to have more observed clinical and laboratory features that could identify children at risk of high lactate during a malaria episode
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