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Treatment outcome among children under-five years hospitalized with severe acute malnutrition in St. Mary’s hospital Lacor, Northern Uganda

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Severe malnutrition contributes to more than 60 % of deaths in children in developing countries. The minimum international standard set for management of severe acute malnutrition is a cure rate of at least 75 % and death rate of less than 10 %, yet the outcome of severely malnourished children treated in most hospitals in developing countries remain poor. This study was conducted to determine the treatment outcomes among severely malnourished children admitted at St. Mary's hospital Lacor in Northern Uganda during a one year period in order to inform clinical decisions to maximize management of severely malnourished children. This was a retrospective study involving 251 severely malnourished children treated at St. Mary's hospital Lacor within a one year period in 2014. Patients' medical records in the facility therapeutic feeding unit were retrospectively reviewed using a check list to collect basic demographic, clinical, and treatment outcome data of the sampled study patients. The UNICEF treatment outcome categories were used, and further grouped into three summary categories: "successful (cured)", "died" and "potentially unsatisfactory". Data were entered, cleaned and analyzed using statistical package SPSS version 13. For categorical data, proportions with 95 % confidence intervals, odds ratio and Chi-square test to compare different groups were used. Multivariate analysis using logistic regression was used to analyze the association between treatment outcome and potential associated factors. P values less than 0.05 was considered for statistical significance. The study consisted 251 patients and the treatment outcome was successful (cured) in 168 (66.9 %) and potentially unsatisfactory in 53 (21.2 %), while 30 (11.9 %) died. Hypothermia and HIV infection were the factors significantly associated with mortality among the severely malnourished children in the current study. The treatment cure rate of severely malnourished children admitted at St. Mary's hospital Lacor of 66.9 % is below the accepted standard of least 75 % cure rate. A high proportion of patients died (11.9 %) or defaulted (8.0 %). Hypothermia and HIV infection were the factors significantly associated with mortality. We recommend that in order to address the high default rate, home based care through the outpatient therapeutic care should be strengthened.
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R E S E A R C H A R T I C L E Open Access
Treatment outcome among children under-
five years hospitalized with severe acute
malnutrition in St. Marys hospital Lacor,
Northern Uganda
Richard Nyeko
*
, Valeria Calbi, Boniface Otto Ssegujja and Grace Flona Ayot
Abstract
Background: Severe malnutrition contributes to more than 60 % of deaths in children in developing countries. The
minimum international standard set for management of severe acute malnutrition is a cure rate of at least 75 %
and death rate of less than 10 %, yet the outcome of severely malnourished children treated in most hospitals in
developing countries remain poor.
This study was conducted to determine the treatment outcomes among severely malnourished children admitted
at St. Mary's hospital Lacor in Northern Uganda during a one year period in order to inform clinical decisions to
maximize management of severely malnourished children.
Methods: This was a retrospective study involving 251 severely malnourished children treated at St. Mary's hospital Lacor
within a one year period in 2014. Patients' medical records in the facility therapeutic feeding unit were retrospectively
reviewed using a check list to collect basic demographic, clinical, and treatment outcome data of the sampled study
patients. The UNICEF treatment outcome categories were used, and further grouped into three summary categories:
"successful (cured)", "died" and "potentially unsatisfactory". Data were entered, cleaned and analyzed using statistical
package SPSS version 13. For categorical data, proportions with 95 % confidence intervals, odds ratio and Chi-square test
to compare different groups were used. Multivariate analysis using logistic regression was used to analyze the association
between treatment outcome and potential associated factors. P values less than 0.05 was considered for statistical
significance.
Results: The study consisted 251 patients and the treatment outcome was successful (cured) in 168 (66.9 %) and
potentially unsatisfactory in 53 (21.2 %), while 30 (11.9 %) died. Hypothermia and HIV infection were the factors
significantly associated with mortality among the severely malnourished children in the current study.
Conclusions: The treatment cure rate of severely malnourished children admitted at St. Mary's hospital Lacor of 66.9 %
is below the accepted standard of least 75 % cure rate. A high proportion of patients died (11.9 %) or defaulted (8.0 %).
Hypothermia and HIV infection were the factors significantly associated with mortality. We recommend that in order to
address the high default rate, home based care through the outpatient therapeutic care should be strengthened.
* Correspondence: richard_nyeko@yahoo.com
Department of Paediatrics and Child Health, St. Marys Hospital Lacor, P.O
Box 180, Gulu, Uganda
© 2016 Nyeko et al. Open Access This 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.
Nyeko et al. BMC Nutrition (2016) 2:19
DOI 10.1186/s40795-016-0058-6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Malnutrition is a contributing factor to nearly 60 % of the
over 10 million deaths that occur annually among children
under five years old in developing countries [1], where 2 %
of children (about 13 million children) suffer from severe
acute malnutrition [2]. Uganda has one of the highest
child mortality rates in the world [3], 40 % of which is
attributed to malnutrition as the underlying cause [4].
Most of these deaths are preventable and easily treatable.
The minimum international standard set for manage-
ment of severe acute malnutrition is a cure rate of at least
75 % and death rate less than 10 % [5]. However, the
case-fatality rates in hospitals treating severe acute mal-
nutrition in developing countries have remained high
(average 2030 %) and has not changed much since the
1950s [6] in spite of the fact that clinical management pro-
tocols capable of reducing case-fatality rates to 15%[7]
have been in existence for over 30 years.
Despite the success of the current treatment protocols
when implemented in specialized units, the adherence to
the guidelines is variable, and their publication has not
led to widespread decrease in case-fatality rates in most
hospitals in the developing countries [8, 9]. The persist-
ence of high case-fatality rates is therefore commonly
attributed to inappropriate case management as a result
of poor knowledge [6, 10]. Evidence from a review of treat-
ment practices worldwide showed that many health ser-
vices use discredited practices and that staff are unfamiliar
withmodern,effectiveguidelinesforthemanagementof
severe malnutrition [10]. For instance, although both WHO
and Uganda national guidelines for management of severe
acute malnutrition recommend withholding transfusion
unless a severely malnourished childs hemoglobin
level is <4 g/dl [11], and withholding intravenous in-
fusion unless a child has signs of severe dehydration
or is in shock, a recent study in Uganda showed that
these guidelines were not followed [12].
This study examined the potential risk factors for mor-
tality among severely malnourished children admitted in
St. Marys hospital Lacor in Northern Uganda to generate
information on a score of individual mortality risks which
could be used to identify children at highest risk of death
for whom more intensive care may be needed.
Methods
Study setting
The study was conducted at St. Marys hospital Lacor, a
private not-for-profit tertiary health care facility located in
Gulu district, northern Uganda and serving a number of
rural districts in northern Uganda. The hospital serves a
very poor population in a highly challenging social and eco-
nomic environment. Severe acute malnutrition (SAM), de-
fined as weight-for-height/length < 3z-scoreand/ormid
upper arm circumference (MUAC) <11.5 cm, or presence
of bilateral pitting pedal oedema [13], is the 6
th
leading
cause of admission among children under five years in the
hospital. It accounts for up to 13 % of the total mortality
among children under-five, with a case fatality rate of
15.4 % [14]. In the hospital, children diagnosed with severe
acute malnutrition who have medical complications are
hospitalized and treated according to the national guideline
using a two phased approach (initial and rehabilitation
phases) [11, 15]. The initial treatment phase is focused on
stabilizing the childs condition by careful re-feeding using
F75 and identifying and treating life-threatening complica-
tions such as dehydration, hypoglycaemia, hypothermia,
infections, and very severe anaemia among others [16]. The
rehabilitation phase involved increasing the energy and
nutrient content of the therapeutic feeds (transition from
F75 to F100) to recover lost weight. Most older children
(>2 years of age) were also started on nutritious solid food
in this phase. At the same time, play therapy to stimulate
the childs emotional, cognitive and physical development
were initiated in this phase both individually and in small
groups.
Study design
This was a retrospective descriptive study involving 251
severely malnourished children treated in St. Marys
hospital Lacor within a one year period in 2014. The mini-
mum sample size was calculated using the formula for
cross sectional studies by Leslie Kish [17] using a standard
normal value corresponding to 95 % confidence interval
(1.96); an absolute error between estimated and true value
of 5 % (0.05), and an estimated treatment success (cure)
rate for hospitalized severely malnourished children of
79.4 % as reported in Niger [18]. The study population
comprised severely malnourished children aged 359
months hospitalized at the hospital between January to
December 2014. The WHO classification of severe acute
malnutrition was used: A severely malnourished child
was one whose weight-for-height/length was less than 3
z-score (severe wasting) and/or mid upper arm cir-
cumference <11.5 cm, or who had bilateral pitting
pedal oedema [13]. These were then broadly classified,
for the purpose of management, as either oedematous
or non-oedematous severe acute malnutrition. Patients
with missing age (3 children) and those aged less than
3 months (11 children) and >60 months (37 children)
were excluded from the study.
Sampling procedures
Patientsmedical records in the facility therapeutic feeding
unit were retrospectively reviewed and a sampling frame
for all the eligible patients listed into an excel program
which was then used to randomly select the required
sample size of 251 from among the eligible patient popu-
lation. A check list was then used to collect information
Nyeko et al. BMC Nutrition (2016) 2:19 Page 2 of 7
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regarding basic demographic, clinical, and treatment out-
come of the sampled study patients.
The treatment outcome was divided into five categories
according to guideline-defined criteria. These included:
cured (finished treatment and achieved a weight-for-height
of 85 %); default (left the therapeutic feeding centre/
nutrition rehabilitation ward before completing treat-
ment); non-respondents (did not respond to treatment
after 40 days on treatment); transfer out (patients whose
treatment results are unknown due to transfer to another
health facility or outpatient therapeutic program), and
died (patients who died from any cause during the course
of treatment). These were further grouped into three sum-
mary outcome categories: successful(cured), diedand
potentially unsatisfactory(non-response, default, and
transfer out).
Statistical analysis
Data were coded, entered, cleaned, stored and analyzed
using Statistical Package for Social Scientists (SPSS)
version 13 (the dataset file is available on request to the
corresponding author). Categorical variables were sum-
marized as frequencies and proportions, while continu-
ous variables as means, median and standard deviations
(SD). In the bi-variate analysis, odds ratios, 95 % confi-
dence interval (CI), and chi-square test were used to
measure the strength of association between the factors
considered and the dependent variable, while the students
t-test was used for continuous variables. Multivariate ana-
lysis using logistic regression was used to determine the
factors that were significantly associated with treatment
outcome. Included in the model at multivariate analysis
were factors that were significant at bivariate analysis and
those with scientific plausibility even though they were
not significant at bivariate analysis. P-value <0.05 was con-
sidered for statistical significance. Results were summa-
rized in texts, tables and bar graphs.
Ethical considerations
Being a retrospective evaluation of standard treatment
guidelines, individual patient consent was deemed imprac-
ticable. However, electronic databases created for this
analysis were stripped of personal health identifiers and
maintained securely and confidentially. This study was ap-
proved by the hospitals research and ethics committee and
consent to publish the results of the study was obtained
from the hospital administration.
Results
During the one year study period 402 severely malnour-
ished children were admitted to the hospitalsnutritionunit
(Fig. 1). Of these, we enrolled and evaluated the treatment
outcome of 251 severely malnourished children aged 359
months (mean age 24.2 [SD 16.0] and median of 21.0).
Majority,154(61.4%)ofthechildrenwerebetween3and
24 months of age (Fig. 2), about two-third (61.0 %) of
whom were males. Whereas up to 70 (27.9 %) of the mal-
nourished children were HIV positive, only 24 (32.9 %)
were on antiretroviral therapy (ART). Over half of the chil-
dren (58.2 %) had oedematous severe acute malnutrition,
and only 61.8 % of the children were immunized up to date.
The other characteristics of the children are summarized in
Patients registered in TFC
register in 2014, n=402
Children considered
for sampling (n=351)
Female 98 (39.0%)
Enrolled (n=251)
Cured
101 (66.0%)
Cured
67 (68.3%)
Died 13 (13.3%)
Died 17 (11.1%)
Male 153 (61.0%)
51 Excluded:
11 were children <3mo
37 were children >60mo
3 had missing age
Unsatisfactory
35 (22.9%)
Unsatisfactory
18 (18.4%)
Fig. 1 Study profile
Nyeko et al. BMC Nutrition (2016) 2:19 Page 3 of 7
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Table 1. Of the 251 severely malnourished hospitalized chil-
dren, 168 (66.9 %) were successfully discharged as cured, 30
(11.9 %) died, and the rest had potentially unsatisfactory
outcome comprising defaulting treatment (8.0 %), transfer
out (9.6 %), and non-response (3.6 %).
At bivariate analysis, HIV negative children were signifi-
cantly more likely to have a successful treatment outcome
(76.9 %) compared to their HIV positive counterparts,
who were more likely to die (18.6 % vs 9.6 %), P<0.001,
χ
2
= 19.981. The mean age of the children who died
(18.87 months) was lower than that of the children who
achieved a cure (25.13 months) and those with potentially
unsatisfactory outcome (24.26 months), but this was not
statistically significant (F=1.966,P= 0.142). Children with
non-oedematous severe acute malnutrition were more
likely to die during the course of their management com-
pared to those with oedematous acute malnutrition (16
[15.2 %] vs 14 [9.6 %]), but this was not statistically signifi-
cant, P=0.077,χ
2
= 5.115 (Table 2).
Very low body temperature (hypothermia) also had a sig-
nificantly increased association with mortality (χ
2
=7.788,
P= 0.020). Similarly, children who received IV fluid infusion
were significantly more likely to die compared to those who
did not receive IV fluids (31.7 % vs 5.0 %), P< 0.001. In the
same breath, significantly higher proportion of children that
received blood transfusion died (27.6 %) compared to those
who were not transfused (5.0 %), P< 0.001, χ
2
= 17.797
(Table 3). Majority of these deaths occurred in the first few
days following IV infusion or blood transfusion (42.9 %
within 24 h; 57.1 % within 48 h, and 71.4 % within 72 h
after IV fluid infusion/blood transfusion).
At multivariate analysis, hypothermia and HIV infec-
tion were the only factors significantly associated with
poor treatment outcome (mortality) among the severely
malnourished children in the present study. Children
with hypothermia were about five times more likely to die
(OR 4.940, p= 0.017), while HIV infected children were
three times more likely to die (OR 3.087, p= 0.010). The
other factors that remained in the model even though they
were not statistically significant were persistent diarrhoea
and presence of visible severe wasting (Table 4).
Discussion
The adherence to current available treatment guidelines is
expected to contribute to improved survival by achieving
a high cure rate and reducing death rate among severely
0
10
20
30
40
50
3-12mo 13-24 25-36 37-48 49-59
46 47
28
15 17
33
28
19
13
5
Numbers
Age in years
Male
Female
Fig. 2 Age-sex distribution of the study population
Table 1 Baseline characteristics of the study population
Characteristics Number Percent
Mean age 24.2 (16.0)
a
Sex:
Male 153 61.0
Female 98 39.0
HIV status:
Positive 70 27.9
Negative 156 62.2
Unknown 24 9.6
Exposed 01 0.4
¶ART:
Yes 23 32.9
No 47 67.1
Immunization status:
Up to date 155 61.8
Partial 56 22.3
Not immunized 4 1.6
Unknown 36 14.3
Temperature
<35 °C 15 6.1
35 °C 231 93.9
Degree of dehydration
Severe dehydration 24 9.6
Some dehydration 28 11.1
No dehydration 199 79.3
Degree of pallor
Severe pallor 34 13.5
Mild-moderate pallor 99 39.5
Not clinically pale 118 47.0
District of residence:
Gulu 86 34.3
Amuru 78 31.1
Oyam 54 21.5
Others 33 13.1
Type of severe malnutrition:
Oedematous 146 58.2
Non-oedematous 105 41.8
a
Mean and Standard deviation
¶ Only those with confirmed HIV positive status were considered
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malnourished children. The present study assessed the
treatment outcome in 251 severely malnourished children
aged 359 months admitted at St. Marys hospital Lacor
in Uganda within a one year period. Our main findings
show that hypothermia and HIV infection seems to con-
tribute significantly to poor outcome.
The high mortality rate as found in the present study
accords with previous findings of high case fatality rate
in hospitalized severely malnourished children in other
African countries [6, 12, 19, 20]. However, our findings
show a much higher mortality rate than that reported in
studies in Ethiopia [5] and Niger [18], but much lower
than that reported in another Ugandan and other studies
[12, 21, 22]. This difference could be attributed to the
fact that most children in our study setting are brought
to the hospital at critical stages of their illnesses as a
result both of late referrals as well as late health care
seeking. In addition, differences in the level of health
care could also be the other possible factors for the con-
trasting variation in outcomes.
Hypothermia was significantly associated with an in-
creased risk of mortality among severely malnourished
children in the present study. The negative consequence
of hypothermia in relation to mortality among severely
malnourished children has been documented in previous
studies [12, 21], and may be explained by the fact that
hypothermia in these children is an indicator of serious in-
fections as well as hypoglycaemia two common causes
of death among severely malnourished children. Similarly,
children who were HIV infected were significantly more
likely to die during treatment compared to their HIV
negative counterparts who were more likely to have a suc-
cessful outcome. HIV infection as a risk factor for poor
outcome among severely malnourished children as found
in the present study agrees with findings previously re-
ported by other authors [12, 23], but contrasts with results
from another Ugandan study which found no adequate as-
sociation between HIV positive status and death attrib-
uted to the effect of HIV being overshadowed by the
prominent effect of fluid overload [12]. However, the find-
ings in the present study may not be surprising since both
HIV and malnutrition tend to accelerate the progression
of each other, a phenomenon that could have been com-
pounded in this case by the increased risk of concurrent
opportunistic infections given that majority of the HIV in-
fected children in the current study were ART naïve.
Though IV infusions, either in the form of an I.V fluid
infusion or blood transfusion were associated with an
increased risk of mortality, these were not statistically
significant at multivariate analysis. This finding, how-
ever, compares well with that from previous studies
[10, 12, 21], and could be due to the fact that the use
of IV fluids/blood transfusion serve as markers of se-
verity of malnutrition. In addition, the fact that most
of these deaths occurred soon after transfusion or in-
fusion means that fluid overload could also be a
plausible consequence of IV infusion/blood transfu-
sion contributing to mortality, and corroborates the
general recommendation to restrict transfusions or in-
fusions of severely malnourished children [24, 25].
Table 2 Baseline characteristics associated with categorized treatment outcome
Cured N= 168(%) Died N= 30(%) Potentially unsatisfactory N= 53(%) χ
2
P-value
¶Mean age 25.13(16.89) 18.87(13.19) 24.26(14.10) 1.966
π
0.142
Age in months:
312 53(67.1) 14(17.7) 12(15.2) 5.128 0.077
Above 12 115(66.9) 16(9.3) 41(23.8)
Sex:
Male 101(66.0) 17(11.1) 35(22.9) 0.856 0.652
Female 67(68.3) 13(13.3) 18(18.4)
§HIV status:
Positive 33(47.1) 13(18.6) 24(34.3) 19.981 <0.001*
Negative 120(76.9) 15(9.6) 21(13.5)
Immunization status:
Not up to-date 111(71.6) 14(9.0) 30(19.4) 4.812 0.090
Up to-date 57(59.4) 16(16.7) 23(24.0)
Type of severe malnutrition:
Oedematous 106(72.6) 14(9.6) 26(17.8) 5.115 0.077
Non-oedematous 62(59.1) 16(15.2) 27(25.7)
Chi-squared (d.f. = 2) reported for categorical variab les and
π
Unadjusted ANOVA (F statistic) for numerical values, ¶ mean (SD)
§Only those with known HIV status were considered, *P-value significant (<0.05)
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Whereas children with non-oedematous malnutrition
(severe wasting) were more likely to die than those with
oedematous malnutrition, this was not statistically sig-
nificant. These findings, however, mirror that reported by
Moges et al. (2009) in Ethiopia [22], but contrasts with
that reported by Bachou et al. [12], and could be explained
by the fact that malnourished children with severe wasting
in the current study were more likely to be HIV positive
(39.1 %) compared to those with oedematous malnutrition
(25.4 %), thus increasing their vulnerability to death.
There was no significant difference in treatment outcome
with regard to the patientsage, though younger infants
aged 312 months were more likely to die compared to
children above one year of age. This finding agrees with
that by Teferi et al. in Ethiopia [5], and could reflect the
fact that majority of the severely malnourished children in
the current study were in the younger age group 324
months, coupled with the fact that complications and
mortality due to infectious diseases are generally higher in
young infants, exacerbated in this case by severe acute
malnutrition.
Limitations of the study
Being a retrospective study, other factors that could have
important bearing on treatment outcome, including
Table 3 Clinical characteristics associated with treatment outcome
Cured N= 168(%) Died N= 30(%) Potentially unsatisfactory N= 53(%) χ
2
P-value
Vomiting
Yes 41(65.0) 11(17.5) 11(17.5) 2.710 0.258
No 127(67.6) 19(10.1) 42(22.3)
Diarrhoea
Yes 85(65.9) 21(16.3) 23(17.8) 5.557 0.062
No 83(68.0) 9 (7.4) 30(24.6)
Duration of diarrhoea
14 days 16(61.5) 8 (30.8) 2(7.7) 5.654 0.059
<14 days 70(66.7) 14(13.3) 21(20.0)
Oral thrush
Yes 10(58.8) 4(23.5) 3(17.7) 2.328 0.312
No 158(67.5) 26(11.1) 50(21.4)
Visible severe wasting
Yes 61(63.5) 16(16.7) 19(19.8) 3.287 0.197
No 107(69.0) 14(9.1) 34(21.9)
Temperature <35 °C
Yes 6(40.0) 5(33.3) 4(26.7) 7.788 0.020*
No 158(68.4) 25(10.8) 48(20.8)
Dehydration
Yes 32(61.5) 11(21.2) 9(17.3) 5.382 0.068
No 136(68.3) 19(9.6) 44(22.1)
IV fluids
Yes 16(39.0) 13(31.7) 12(29.3) 32.188 <0.001*
No 137(75.7) 9(5.0) 35(19.3)
Blood transfusion
Yes 15(51.7) 8(27.6) 6(20.7) 17.797 <0.001*
No 137(75.7) 9(5.0) 35(19.3)
Chi-squared (d.f. = 2) reported for categorical variab les, *P-value significant (<0.05)
Table 4 Logistic regression for factors independently predicting
mortality
Characteristics Odd ratio 95 % CI p-value
Temperature <35 °C 4.940 1.33218.321 0.017*
Diarrhoea 14 days 3.342 0.1051.111 0.074
Visible severe wasting 2.221 0.7436.635 0.153
HIV positive 3.087 1.3077.292 0.010*
* P-valu e significant (<0.05), CI = 95 % confidence interval
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biochemical laboratory parameters and health system
factors (diagnostic capacity, knowledge and skills, refer-
ral system, and patient monitoring) among others could
not be analyzed because they were either not done or
not documented.
Conclusions
The treatment cure rate of severely malnourished chil-
dren admitted at St. Marys hospital Lacor of 66.9 % is
below the accepted standard of least 75 % cure rate. A
high proportion of patients died (11.9 %) or defaulted
(8.0 %), a situation which is of public health concern that
needs consideration. Factors significantly associated with
poor treatment outcome (mortality) in the study setting are
hypothermia and HIV infection. We recommend that in
order to address the high default rate, home based care
through the outpatient therapeutic care should be strength-
ened through training of lower level healthcare workers in
outpatient therapeutic care, as well as decentralizing ser-
vices to lower health facilities to make home-based treat-
ment of severely malnourished children without medical
complications possible.
Abbreviations
HIV: human immunodeficiency virus; ART: antiretroviral therapy; WHO: World
Health Organization.
Competing interests
The authors declare that they have no competing interests.
Authorscontributions
RN was the initiator of the study and contributed to the study design, data
collection, analysis and interpretation of results. VC contributed to getting
relevant literature, design of the study and interpretation of results, BOS
contributed to data collection, analysis and interpretation and GFA
contributed to data collection. All authors contributed to drafting the
manuscript, including reading and approving the final manuscript.
Acknowledgements
We acknowledge all the staff of the nutrition unit and the department of
Paediatrics, St. Marys hospital Lacor for their support and inputs towards this
study. A special tribute goes to the children whose information contributed
to this study.
Received: 19 August 2015 Accepted: 18 March 2016
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... However, the case fatality rates in hospitals treating SAM in developing countries have remained high at 20-30 % (7) inspite of existing clinical management protocols capable of reducing these rates (7,8) . A retrospective study to determine the treatment outcome of severely malnourished children in St. Mary's Hospital Lacor, Northern Uganda, showed a CFR of 11·9 % (7) . ...
... However, the case fatality rates in hospitals treating SAM in developing countries have remained high at 20-30 % (7) inspite of existing clinical management protocols capable of reducing these rates (7,8) . A retrospective study to determine the treatment outcome of severely malnourished children in St. Mary's Hospital Lacor, Northern Uganda, showed a CFR of 11·9 % (7) . ...
... However, the case fatality rates in hospitals treating SAM in developing countries have remained high at 20-30 % (7) inspite of existing clinical management protocols capable of reducing these rates (7,8) . A retrospective study to determine the treatment outcome of severely malnourished children in St. Mary's Hospital Lacor, Northern Uganda, showed a CFR of 11·9 % (7) . ...
Article
Full-text available
Globally, severe acute malnutrition (SAM) accounts for >1/3–0⋅5 of deaths in children <5 years, and approximately 54 % deaths in developing countries. The minimum international standard set for the management of SAM is a cure rate of at least 75 % and death rate <10 %. The present study was conducted to determine treatment outcome and associated factors among children 1–5 years hospitalised with SAM in Lacor and Gulu Regional Referral Hospital (GRRH) in 2017. A retrospective observational method supplemented with a qualitative inquiry was done. A total of 317 patients’ records were reviewed in either hospital; checklist data were analysed using SPSS version 16 with P- values <0⋅05 considered for statistical significance. The case fatality rate (CFR) was 12⋅6 % (GRRH) and 9⋅5 % (Lacor). The average length of stay (LOS) was 14⋅69 d (GRRH) and 14⋅10 d (Lacor). There was statistical significance between Human Immunodeficiency Virus (HIV) status, blood transfusion, type of SAM, treatment provision at admission, antibiotics, mid-upper arm circumference (MUAC), hospital category and treatment outcome. In total, ten key informants were interviewed and they reported the presence of co-infections and severity of SAM complications as having an important bearing on treatment outcome. A significant proportion of patients were discharged not cured 19⋅9 % (Lacor) v . 16⋅4 % (GRRH). The CFR in GRRH was higher than the WHO recommendation. The LOS in both hospitals was within recommended. These results provide a generalisable problem in most African hospitals and could explain the persistently high rates of SAM in Africa.
... In Northern Uganda, a study by Nyeko et al. [7] on treatment outcome among children with severe acute malnutrition in Lacor Hospital revealed a proportion of 11.9% with hypothermia and HIV being the factors strongly associated with mortality. Another study by Nabukeera-Barungi et al. [8] on predictors of mortality in children with severe acute malnutrition in Mulago Hospital in Kampala showed a proportion of 9.8%, with infections being the major contributors of mortality. ...
... The mortality of 14.5% meaning 1.5 death out of 10 or every 3 deaths out of 20 patients is higher compared to the mortality found in central and northern Uganda by International Journal of Pediatrics Nabukeera-Barungi et al. [8] in Mulago National Referral Hospital and Nyeko et al. [7] in Lacor Hospital that showed a mortality of 9.8% and 11.9%, respectively. This could be explained by the study setting that is congested with many patients with nurse to patients' ratio of 1 to 26. ...
... This could be explained by an increased susceptibility to opportunistic infections and other comorbidities that could worsen their prognosis. This finding was in line with that of Nyeko et al. [7] in northern Uganda that revealed a significant association between HIV and mortality among children with SAM, 18.6% versus 9.6% in children HIV negative with OR = 3:1 (1.307-7.292), but it differed from that of Nabukeera-Barungi et al. [8] that found an association between HIV status of the children and mortality on bivariate analysis that disappeared on multivariate analysis after adjusting for age and sex of the children. ...
Article
Full-text available
Background. Mortality among children with severe acute malnutrition remains an immense health concern in the hospitals in developing countries, but its attributes are not completely assessed in various hospital settings. The aim of this study was to determine the proportion of mortality, the comorbidities, and factors associated with in-hospital mortality among children under five years of age admitted with severe acute malnutrition at Jinja Regional Referral Hospital, Eastern Uganda. Methods. This was a hospital-based analytical and descriptive prospective cohort study conducted in the nutritional unit of Jinja Regional Referral Hospital. A total of 338 children and their caretakers who met the criteria were consecutively enrolled into the study. Descriptive statistics were used to each of the independent factors, and comorbidities were subjected to chi-squared test followed by logistic regression analysis to assess its association incidence of mortality among children. All independent variables with values ≤ 0.05 were entered into a multivariate model for factors and comorbidities independently. Factors and comorbidities with values ≤ 0.05 were considered as associates of mortality among children. Results. Of the 338 children under 5 years of age enrolled, 49 (14.5%) died, although the majority of children were diagnosed with dehydration, 128 (37.9%); pneumonia, 127(37.6%); and malaria, 87(25.7%). Anemia (, 95% CI: 1.23-6.62, ), bacteremia (, 95% CI: 3.62-29.01, ), HIV (, 95% CI: 1.42-16.30, ), TB (, 95% CI: 1.28-14.49, ), and shock (, 95% CI: 9.05-410.28, ) were the comorbidities significantly associated with a likelihood of mortality. Conclusions. The mortality among children under 5 years of age admitted with severe acute malnutrition is still high (14.5% versus 5%). The comorbidities are significantly associated with mortality. The clinicians are recommended to follow-up closely patients with severe acute malnutrition and to focus on the critical comorbidities identified. 1. Introduction Globally, severe acute malnutrition affects around 16 million children under 5 years. The risk of death is among children with SAM is nine times greater than well-nourished children [1]. SAM is a significant direct or indirect contributing factor in approximately half of the 5.9 million deaths of children aged under 5 years worldwide [1]. SAM remains a major cause of child morbidity and mortality worldwide, and of the 7.6 million deaths among children under 5 years, approximately 35% are due to nutrition-related factors, and 4.4% of deaths have been shown to be specifically attributable to severe wasting [2]. The majority of the cases of SAM occur in developing countries and are related to chronic poverty, lack of education, poor hygiene, limited access to food, and poor diet, resulting in significant barriers to achievement of Sustainable Development Goals [3]. According to UNICEF, WHO, and the World Bank, 14.1 million children under five years in the African region were wasted (4.3 million of them severely) in 2015, and all had wasting rates of 5-10% [1]. Children suffering from wasting have weakened immunity are susceptible to long-term developmental delays, infection, and face an increased risk of death, particularly when wasting is severe [1]. The mortality of children with severe acute malnutrition varies from one region to another, with 21% in Democratic Republic of Congo, 20% in Senegal, and 20% in Uganda [1]. According to UBOS (2016), stunting accounts for 29%, with 4% of children 6–59 months being wasted, that is to say, too thin for height, while 11% of the children were underweight and 4% were obese [4]. In Uganda, more than 30% of the total population faces some level of food insecurity as a result of poverty, high fertility, being landless, and climate-related change [5]. Statistics show that 300,000 children (5% nationally) have acute malnutrition and nearly 120,000 (2%) of them have SAM [4]. SAM is associated with 1.6 million of annual additional morbidity episodes, with 258 million US dollars of economic cost and contributing to 15% of the total child mortalities in Uganda [6]. In addition, malnutrition in Uganda is concentrated in Northern and Eastern regions. Jinja is located in the Eastern region of Uganda which faces lack of access to sufficient food with 5.1% of severe wasting after West Nile which has a prevalence of 5.3% [4]. The nutritional unit of Jinja Regional Referral Hospital has 32 beds with a minimum of 60 admissions per month. This background explains this study assessed the comorbidities and factors associated with in-hospital mortality among children under five years of age admitted with severe acute malnutrition at Jinja Regional Referral Hospital. Severe acute malnutrition is common in sub-Saharan Africa. The association with mortality and morbidities is scanty despite the ample literature on the prevalence and factors associated with SAM. Information pertaining to the association between risk factors for increased mortality among severely malnourished children during periods of admission remains scanty in Jinja. WHO estimates that 60% of all deaths occurring among children under five years of age in developing countries is attributed to childhood malnutrition [1]. Uganda has high prevalence rates of malnutrition. The prevalence of global stunting is estimated at 39.1%, underweight 22.85, and global wasting 4.1%. SAM is associated with 1.6 million of annual additional morbidities episodes with 258 million US dollars of economic cost and contributing to 15% of the total child death [6]. Uganda has not yet succeeded to reduce under 5 years mortality to at least as low as 25 deaths per 1,000 live births according to Sustainable Development Goals. In Northern Uganda, a study by Nyeko et al. [7] on treatment outcome among children with severe acute malnutrition in Lacor Hospital revealed a proportion of 11.9% with hypothermia and HIV being the factors strongly associated with mortality. Another study by Nabukeera-Barungi et al. [8] on predictors of mortality in children with severe acute malnutrition in Mulago Hospital in Kampala showed a proportion of 9.8%, with infections being the major contributors of mortality. Although some studies about mortality in children under five years with severe acute malnutrition have been done in Uganda, those studies were conducted in central and northern Uganda, and there is paucity of data on mortality due to SAM in Eastern Uganda, especially in Jinja. Therefore, this study set out to determine the proportion of mortality, comorbidities, and factors associated with the in-hospital mortality among children who were with SAM in the nutritional unit of JRRH. 2. Methodology 2.1. Study Design This was an analytical descriptive prospective cohort study to determine the proportion of mortality, demographic, biological, socioeconomic factors, and comorbidities associated with mortality among children below 5 years admitted with severe acute malnutrition in the nutritional unit of Jinja Regional Referral Hospital. 2.2. Study Site The study was conducted at Jinja RRH located in southeastern Uganda, approximately 87 kilometers east of Kampala, the capital of Uganda. It is a designated internship hospital where medical graduate internship center and has consultants in medicine and surgery. Jinja RRH also provides comprehensive HIV/AIDS services. It is also a KIU Satellite Teaching Hospital aimed at training undergraduates and postgraduate students including postgraduate in Pediatrics. The nutritional unit is in pediatric ward, around 1 km from the main hospital; it has 32 beds and 3 trained nurses assigned for the ward. Patients are categorized into moderate acute malnutrition, severe acute malnutrition, and edematous and nonedematous malnutrition with a minimum of 80 admissions per month. 2.3. Study Population All children under five years of age admitted with SAM in the nutritional unit of JRRH and their caregivers constituted our population. According to the 2014 census data, Jinja RRH serves a population of 471,242 in Jinja District, and the hospital also serves Bugiri, Kamuli, Iganga, Mayuge, Namutumba, Kaliro, Buyende, Luuka, Namiyongo, and Jinja District. 2.4. Selection Criteria This study included all children under five years of age admitted with SAM in the nutritional unit of Jinja Regional Referral Hospital, and their caregivers who consented were included in this study. Children who were referred for further management were excluded from this study. Also, children with preexisting congenital malformations and cerebral palsy were excluded from this study. 2.5. Sample Size Estimation Daniel population proportion formula and modified Daniel’s formula were used to estimate the sample size [9]. and is the critical value of the normal distribution at (e.g., for a confidence level of 95%, is 0.05, and the critical value is 1.96); MOE is the margin of error, estimated at 0.05. is the estimated proportion of children with SAM that died in based on a study done in Kenya that reported 33% [10]. children with severe acute malnutrition. The overall sample size was 340 children under five years of age admitted with SAM. 2.6. Sampling Technique All children under five years of age admitted with SAM in the nutritional unit of Jinja Regional Referral hospital, who met our inclusion criteria, were consecutively enrolled into the study until when the required sample size has been attained. 2.7. Data Collection Tools The following tools will be used to collect data: questionnaires, tape measure, thermometer, pediatric-size stethoscope, stadiometer, infantometer, WHO chart, vacutainers, gloves, syringes, and culture medium. 2.8. Study Procedures 2.8.1. Screening for Eligibility Screening and inclusion were performed upon admission of the child in the pediatric ward as long as they met inclusion criteria. The principal investigator explained the purpose and the process of the study to the patient and/or guardian, and a written consent was obtained. 2.8.2. Demographic Information and Biological Information Information regarding the place of residence, sex, age and date of birth, and relationship of the child with the caretaker was collected by the principal investigator using the data collection tool. Complaints of diarrhea, vomiting, loss of appetite, fever, cough, and others were also recorded in the data collection tool as well as the child’s immunization history, nutrition history, HIV status, and occupation of the caretaker. All information obtained was entered in the data collection tool. The emergency cases were managed first; information from them was collected later. 2.8.3. Clinical Examination Children underwent fully physical examination and were classified using WHO guideline. Findings on clinical exam were entered in the data collection tool by the principal investigator; they helped to diagnose some comorbidities. All the patients were followed up from admission to the discharge with the clinical care pathway form. 2.8.4. Sample Collection and Laboratory Procedures Blood sample was collected during insertion of IV cannula for measurement of full blood count, blood glucose, blood slide for malaria, and HIV test and culture. Prior to drawing of blood, the area will be swabbed with cotton dipped in ethyl alcohol 70% and iodine to prevent contamination. Three to four milliliters of blood was drawn for blood culture, determination of blood glucose, full blood count, HIV test and blood slide for malaria, and serum electrolytes. The blood sample for culture was taken and analyzed using Automated Blood Culture System (BACTEC) in the main hospital laboratory of JRRH. These laboratory investigations were done on admission except serum electrolytes that was done during transition phase. For the HIV test, pre- and posttest counseling were done. A first Determine® HIV rapid test was performed and confirmed with a 2nd rapid test StatPak®. In case of discordance, a Unigold® test will be done. Children under 18 months with positive rapid tests will be referred for DNA PCR test in the HIV clinic in the Jinja RRH. Blood samples will be taken off only once at admission. Full blood count was analyzed using Sysmex® Automated Hematology Analyser at Jinja RRH. Blood glucose was measured using a Freestyle optium glucometer by the principal investigator at admission. Field stains A and B were done for thick blood smears for malaria and examined by the laboratory technician using the microscope in the pediatric ward laboratory. Early morning gastric aspirate was collected in a sterile container for gene expert at admission. 2.8.5. Comorbidities After getting the history, clinical assessments coupled with laboratory investigations were done to diagnose the comorbidities related to severe acute malnutrition. Those comorbidities were defined according to WHO protocol [11] as follows: Hypoglycemia by the mmol/liter (54 mg/dl), hypothermia by the axillary temperature below 35 degree Celsius, and when the axillary temperature did not register on a normal temperature, we assumed that the child had hypothermia. All the participants with SAM who had watery diarrhea or reduced urine output were assumed to have some dehydration. However, electrolyte imbalance was defined by the serum electrolytes below or above the normal ranges. Bacteremia was defined by the bacterial growth in the blood sample collected using Automated Blood Culture system. Severe pneumonia was defined by cough or difficulty in breathing with or central cyanosis, severe respiratory distress, or signs of pneumonia with a general danger sigh like inability to breastfeed, lethargy, or altered level of consciousness with decreased breath sound, bronchial breath sound, crackles, and pleural rub on auscultation of the chest. Pneumonia was defined by cough with fast breathing for the age, chest in drawing. Severe anemia was defined by hemoglobin below 4 g/dl or 4-6 g/dl in a child with respiratory distress. Shock was defined by lethargy or unconsciousness with cold extremities, capillary refill above 3 seconds, and a weak or fast pulse or a low or immeasurable systolic blood pressure. Confirmed tuberculosis was defined by a positive gene expert. 2.8.6. Patient Management Children with SAM were managed according to updated WHO guidelines. Prescription of treatments for the participants was done by doctors and clinical officers who were availed with guidelines on treating children with SAM. The role of the principal investigator was limited on recommendations. All children were routinely treated with IV Ampicillin and IV Gentamycin that was modified according to the blood culture and sensitivity results. They were also routinely started on a feeding program with F75 formula feeds. Caretakers took the responsibility for the feeding of the children under the supervision of the hospital nutritionist. Children with diarrhea were routinely given zinc tablets in addition to the routine deworming tablet that was given to all the enrolled patients. Those with some dehydration were given ReSoMal solution while those with septic shock were given IV half strength Darrow’s and 5% dextrose solution. All patients were followed up from admission to the discharge according to the WHO protocol. 2.9. Data Analysis The data was entered and cleaned using EPI info version 7 and was exported to STATA 12.0 for further analysis. Sociodemographic was summarized descriptively as frequencies and percentages (categorical variables). In-hospital mortality was analyzed as frequency and percentage and presented in a pie chart. Keeping strata constant, sociodemographic, economic, and biological factors associated with in-hospital mortality were assessed using a Generalized Linear Model to obtain relative risk of mortality. Both bivariate and multivariate analysis were carried out. Crude and adjusted relative risk (RR), their corresponding 95% CI and values were reported. Data presentation was done by using tables. The proportion of comorbidities was assessed for association with in-hospital mortality using frequencies and percentages, and their association with mortality was assessed using logistic regression to obtain the relative risk of mortality. Both bivariate and multivariate analyses were carried out. Data was presented using a table. Statistical significance was considered at . 3. Results Overall, 340 participants under 5 years of age with severe acute malnutrition were consecutively enrolled in the study in the nutritional unit of JRRH after an informed consent of their caregivers from July to September 2019. Of the 340 participants, 2 participants were excluded from the study because of refusal to consent. A total of 338 participants were followed up from admission to discharge. A total of 49 participants died, and 289 participants survived. 3.1. Proportion of Mortality among Children under 5 Years with SAM in JRRH Figure 1 shows that of the 338 children under five years of age admitted with SAM in the nutritional unit of JRRH, a total of 49 children died, giving an overall mortality of 14.5%.
... At admission, 64.4% of participants showed up with other co-morbidities on top of SAM. Majority of children (64.9%) were hospitalized with marasmus (non-edematous) type of SAM, similar with some recent studies in Ethiopia [1,13,[25][26][27][28][29][30][31] but in contrary to that of Jimma [32], Hadiya, Ethiopia [33] and Uganda [34], which reported edematous type of SAM was highly encountered. This variation might be attributable to the multi-faceted causes of SAM all over the world. ...
... It is significantly higher than that of Ayder hospital (11) other similar studies from Bahirdar [13,35], Ghana [20] and Yemen [36]. Nevertheless, it is by greater margin below the minimum international standards [15], in comparison with other study findings in Ethiopia [1,8,24,25,[27][28][29][30][31][32] and similar reports from India, Malawi and Uganda [34,[37][38][39] as well. This might be due to the relatively higher rate of transfer out to nearby health facility, which probably would be to prevent patient overload since one of the study area (AKU-CSH) is the only referral hospital in this particular study area. ...
... This might be due to the relatively higher rate of transfer out to nearby health facility, which probably would be to prevent patient overload since one of the study area (AKU-CSH) is the only referral hospital in this particular study area. Almost a quarter (22.2%) of patients were transferred out to nearby health facility that is above other recently reported study findings in Ethiopia [1,13,25,27,35] Ghana [20], Uganda [34] and Yemen [36]. ...
Article
Full-text available
Background: Severe acute malnutrition is defined by <70% weight for length/height, by visible severe wasting, by the presence of pitting edema, and in children 6 to 59 months of age, mid upper arm circumference <110 mm. Severe acute malnutrition remains to be a worldwide problem, claiming lives of millions of children, especially in sub-Saharan Africa and south Asia. Though the Ethiopian national guideline states the total length of stay in therapeutic feeding units should not be more than four weeks, there is huge difference, varying from 8 to 47 days of stay. Therefore, the objective of this study was to assess length of stay to recover from severe acute malnutrition and associated factors among under five children hospitalized to the public hospitals in Aksum Town. Methods: Sample size was calculated using STATA version 12.0. A retrospective cohort study was conducted using pretested questionnaire in the public hospitals in Aksum on children aged 0-59 months. Cleaned data was entered to Epi info version 7.1.4 and then exported into SPSS version 21 for analysis. Bivariable and multivariable analyses were performed using Kaplan Meier and Cox regression models. During bivariable analysis, variables with p-value < 0.05 were selected for multivariable analysis to identify independent factors associated with length of stay. Results: A total of 564 participants enrolled to the study. The rate of recovery was 56% with median length of stay of 15 days (95% CI: 14.1, 15.9). The independent predictors of length of stay to recovery were presence of diarrhea at admission (AHR = 0.573, 95% CI: 0.415-0.793), being HIV positive (AHR = 0.391, 95% CI: 0.194-0.788), palmar pallor (AHR = 0.575, 95% CI: 0.416-0.794), presence of other co-morbidities at admission (AHR = 0.415, 95% CI: 0.302-0.570) and not being treated with plumpy nut (AHR = 0.368, 95% CI: 0.262-0.518). Conclusions: Length of stay is in the acceptable range of the international and national set of standards. Nevertheless, the recovery rate was lower compared to the Sphere standard. Presence of diarrhea, palmar pallor, HIV other co-morbidities and not treated with plumpy nut were found independent protective factors for recovery from sever acute malnutrition.
... Not only recovery and death rate but also the other outcome indicators in this study showed that there were in the minimum standard set of sphere project values/international standards [9]. The recovery rate in our study is higher than previous findings from Tigray [10], Kamba District [11], Uganda [12], Sudan [13], Tamale Teaching Hospital [14] and India [15]. But it is lower than findings from Jimma University Specialized Hospital [16], Woldiya General Hospital [17], Southern region of Ethiopia [18] and Rural Ethiopia [19]. ...
... The present study also found that higher mortality rate than reports from Tigray [10], Southern region of Ethiopia [18] and India [15]. However, it is lower than reports from Uganda [12], Sudan [13], Jimma University Specialized Hospital [16], Woldiya General Hospital [17] and Rural Ethiopia [19]. The possible explanation for this variation might be differences in quality of services [17] finding. ...
Article
Full-text available
Background: In Ethiopia, the health sector has increased its efforts to enhance good nutritional practices through health education, treatment of extremely malnourished children and provision of micronutrients for mothers and children. But, the poor nutritional status of women and children continues to be still a major public health problem. Methods: A retrospective cohort study was conducted to assess the treatment outcome and associated factors of severe acute malnutrition among a total of 253 children age 6-59 months old. Severe acute malnutrition registration logbook and patient charts were used as a source of data. Data were entered in to Epi-data version 3.1 and exported to SPSS version 20 for analysis. To identify associated factors, Cox proportional hazard analysis was computed and p-value <0.05 at 95% confidence interval was considered as statistically significant.
... These disparities may be attributed to the differences in the level of care given in the current study area and relatively improved diagnostic process of the co-morbidities, which can facilitate prompt care to be given to SAM children to decrease the mortality rate. The studies done in Zambia, Ghana, and Uganda also revealed that 40.5, 13.2, and 11.9%, respectively, of SAM children died, which is significantly higher than the current finding [41][42][43]. This could be because of the variation in the clinical profile of study subjects during admission and difference in the health care system. ...
Article
Full-text available
Background Management of severe acute malnutrition (SAM) has been a program priority in Ethiopia, but it remains the leading cause of mortality in under-five children. Hence, this study aimed to identify the incidence density rate of mortality and determinants among under-five children with severe acute malnutrition in St. Paul’s Hospital Millennium Medical College, 2012 to 2019. Methods A retrospective cohort study was conducted and data were collected using a structured checklist from 673 charts, of which 610 charts were included in the final analysis. The Kaplan-Meier survival curve with Log-rank test was used to estimate the survival time. Bi-variable and multi-variable Cox proportional hazard regression models were fitted to identify determinants of death. Schoenfeld residuals test was used to check a proportional hazard assumption. Goodness of fit of the final model was checked using Nelson Aalen cumulative hazard function against Cox-Snell residual. Results In this study, 61 (10%) children died making the incidence density rate of death 5.6 (95% CI: 4.4, 7.2) per 1000 child-days. Shock (Adjusted Hazard Ratio) [AHR] =3.2; 95% CI: 1.6, 6.3)), IV fluid infusion (AHR = 5.2; 95% CI: 2.4, 10.4), supplementing F100 (AHR = 0.12; 95%CI: 0.06, 0.23) and zinc (AHR = 0.45; 95% CI: 0.22, 0.93) were determinants of death. Conclusion The overall proportion of deaths was within the range put forth by the Sphere standard and the national SAM management protocol. Shock and IV fluid infusion increased the hazard of death, whereas F100 & zinc were found to decrease the likelihood death. Children with SAM presented with shock should be handled carefully and IV fluids should be given with precautions.
... Data from previous studies with a focus on treatment outcome [15][16][17] were considered to calculate the sample size. ...
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Background: In 2018, malnutrition contributed to 45% of all global cause of child death. These early child deaths were due to conditions that could either be prevented or treated with basic interventions. Hence, this study intended to provide a quantitative estimate of factors associated with undesirable treatment outcomes of severe acute malnutrition (SAM). Methods: We studied a retrospective cohort of 304 children aged 6-59 months with complicated SAM admitted to Yekatit 12 Hospital Medical College from 2013 to 2016. We extracted data from hospital records on nutritional status, socio-demographic factors and medical conditions during admission. The analysis was carried out using SPSS version 20. The Kaplan-Meier estimator was employed to analyze the recovery rate of the children treated for SAM and multivariable Cox regression was used to determine factors that predict inpatient undesirable treatment outcomes. Result: From a total of 304 children 6-59 months with SAM, 133 (51.4%) were boys. Marasmus was the most common type (132 (51%)) of severe acute malnutrition. The recovery, death and defaulter rate were 70.4, 12.2 and 8.2% respectively. The main predictors of undesirable treatment outcomes were found to be the presence of HIV antibody (AHR = 3.208; 95% CI: [1.045-9.846]) and sepsis (AHR = 7.677, 95% CI: [2.320-25.404]). Conclusion: The study revealed that the overall treatment outcomes were below the SPHERE standard recommendation. The main predictors of undesirable treatment outcomes among inpatient children treated for SAM were HIV and sepsis. Intervention to reduce undesirable treatment outcomes should focus on comorbidities, especially HIV and sepsis.
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Severe acute malnutrition (SAM) arises as a consequence of a sudden period of food shortage and is associated with loss of a person's body fat and wasting of their skeletal muscle. Many of those affected are already undernourished and are often susceptible to disease. Infants and young children are the most vulnerable as they require extra nutrition for growth and development, have comparatively limited energy reserves and depend on others. Undernutrition can have drastic and wide-ranging consequences for the child's development and survival in the short and long term. Despite efforts made to treat SAM through different interventions and programmes, it continues to cause unacceptably high levels of mortality and morbidity. Uncertainty remains as to the most effective methods to treat severe acute malnutrition in young children. To evaluate the effectiveness of interventions to treat infants and children aged < 5 years who have SAM. Eight databases (MEDLINE, EMBASE, MEDLINE In-Process & Other Non-Indexed Citations, CAB Abstracts Ovid, Bioline, Centre for Reviews and Dissemination, EconLit EBSCO and The Cochrane Library) were searched to 2010. Bibliographies of included articles and grey literature sources were also searched. The project expert advisory group was asked to identify additional published and unpublished references. Prior to the systematic review, a Delphi process involving international experts prioritised the research questions. Searches were conducted and two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full texts of retrieved papers by one reviewer and checked independently by a second. Included studies were mapped to the research questions. Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer. Differences in opinion were resolved through discussion at each stage. Studies were synthesised through a narrative review with tabulation of the results. A total of 8954 records were screened, 224 full-text articles were retrieved, and 74 articles (describing 68 studies) met the inclusion criteria and were mapped. No evidence focused on treatment of children with SAM who were human immunodeficiency virus sero-positive, and no good-quality or adequately reported studies assessed treatments for SAM among infants < 6 months old. One randomised controlled trial investigated fluid resuscitation solutions for shock, with none adequately treating shock. Children with acute diarrhoea benefited from the use of hypo-osmolar oral rehydration solution (H-ORS) compared with the standard World Health Organization-oral rehydration solution (WHO-ORS). WHO-ORS was not significantly different from rehydration solution for malnutrition (ReSoMal), but the safety of ReSoMal was uncertain. A rice-based ORS was more beneficial than glucose-based ORSs, and provision of zinc plus a WHO-ORS had a favourable impact on diarrhoea and need for ORS. Comparisons of different diets in children with persistent diarrhoea produced conflicting findings. For treating infection, comparison of amoxicillin with ceftriaxone during inpatient therapy, and routine provision of antibiotics for 7 days versus no antibiotics during outpatient therapy of uncomplicated SAM, found that neither had a significant effect on recovery at the end of follow-up. No evidence mapped to the next three questions on factors that affect sustainability of programmes, long-term survival and readmission rates, the clinical effectiveness of management strategies for treating children with comorbidities such as tuberculosis and Helicobacter pylori infection and the factors that limit the full implementation of treatment programmes. Comparison of treatment for SAM in different settings showed that children receiving inpatient care appear to do as well as those in ambulatory or home settings on anthropometric measures and response time to treatment. Longer-term follow-up showed limited differences between the different settings. The majority of evidence on methods for correcting micronutrient deficiencies considered zinc supplements; however, trials were heterogeneous and a firm conclusion about zinc was not reached. There was limited evidence on either supplementary potassium or nicotinic acid (each produced some benefits), and nucleotides (not associated with benefits). Evidence was identified for four of the five remaining questions, but not assessed because of resource limitation. The systematic review focused on key questions prioritised through a Delphi study and, as a consequence, did not encompass all elements in the management of SAM. In focusing on evidence from controlled studies with the most rigorous designs that were published in the English language, the systematic review may have excluded other forms of evidence. The systematic review identified several limitations in the evidence base for assessing the effectiveness of interventions for treating young children with severe acute malnutrition, including a lack of studies assessing the different interventions; limited details of study methods used; short follow-up post intervention or discharge; and heterogeneity in participants, interventions, settings, and outcome measures affecting generalisability. For many of the most highly ranked questions evidence was lacking or inconclusive. More research is needed on a range of topic areas concerning the treatment of infants and children with SAM. Further research is required on most aspects of the management of SAM in children < 5 years, including intravenous resuscitation regimens for shock, management of subgroups (e.g. infants < 6 months old, infants and children with SAM who are human immunodeficiency virus sero-positive) and on the use of antibiotics.
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To describe the clinical profile and outcomes of severely malnourished cases admitted at Zewditu Memorial hospital, Ethiopia. A retrospective descriptive data analysis of severely malnourished cases admitted to Zewditu Memorial Hospital from April 2005 to September 2008 was made. A total of 164 cases were enrolled and analyzed for various socio-demographic factors, comorbidities and outcomes. Both bivariate and multivariate models were performed to determine the outcome of the management by explanatory variables. Pearson's chi-square test of independence was used to test the existence of significant association of risk factors with the outcome. A p-value of less than 0.05 denoted significance in differences. The predominant age group suffered from marasmus was the infants (75.4%) while kwashiorkor was prevalent during the second and third year and the difference noted was statistically significant. The mean age for marasmus, kwash and marasmickwash incidence was 16.9, 25.9 and 27.3 months respectively. The proportion of underweight was higher after the age of 60 months. Death occurred in 21.3% of the cases suggesting that mortality rate was higher than the acceptable range (21.3% vs. < 20.0%). Presence of diarrhoea (AOR=3.5, 95%CI=1.2 to 10.2), ocdema (AOR=0.2, 97%CI=0.1 to 0.9), stunting (AOR=3.3, 97%CI=1.2 to 8.2) and short mean duration of hospital stay (AOR=4.4 95%CI=2.0 to 10.1) were predictors of death outcome. The observed case fatality rate is unacceptably high and the risk factors for death are identified. In the face of many shortcomings in the hospital setting, managing uncomplicated cases of severe acute malnutrition is not encouraging when compared with the promising results of community based therapeutic care. We recommend the staffs to be trained and retained.
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Background: In 2006, the Médecins sans Frontières nutritional program in the region of Maradi (Niger) included 68,001 children 6-59 months of age with either moderate or severe malnutrition, according to the NCHS reference (weight-for-height<80% of the NCHS median, and/or mid-upper arm circumference<110 mm for children taller than 65 cm and/or presence of bipedal edema). Our objective was to identify baseline risk factors for death among children diagnosed with severe malnutrition using the newly introduced WHO growth standards. As the release of WHO growth standards changed the definition of severe malnutrition, which now includes many children formerly identified as moderately malnourished with the NCHS reference, studying this new category of children is crucial. Methodology: Program monitoring data were collected from the medical records of all children admitted in the program. Data included age, sex, height, weight, MUAC, clinical signs on admission including edema, and type of discharge (recovery, death, and default/loss to follow up). Additional data included results of a malaria rapid diagnostic test due to Plasmodium falciparum (Paracheck) and whether the child was a resident of the region of Maradi or came from bordering Nigeria to seek treatment. Multivariate logistic regression was performed on a subset of 27,687 children meeting the new WHO growth standards criteria for severe malnutrition (weight-for-height<-3 Z score, mid-upper arm circumference<110 mm for children taller than 65 cm or presence of bipedal edema). We explored two different models: one with only basic anthropometric data and a second model that included perfunctory clinical signs. Principal findings: In the first model including only weight, height, sex and presence of edema, the risk factors retained were the weight/height(1.84) ratio (OR: 5,774; 95% CI: [2,284; 14,594]) and presence of edema (7.51 [5.12; 11.0]). A second model, taking into account supplementary data from perfunctory clinical examination, identified other risk factors for death: apathy (9.71 [6.92; 13.6]), pallor (2.25 [1.25; 4.05]), anorexia (1.89 [1.35; 2.66]), fever>38.5 degrees C (1.83 [1.25; 2.69]), and age below 1 year (1.42 [1.01; 1.99]). Conclusions: Although clinicians will continue to perform screening using clinical signs and anthropometry, these risk indicators may provide additional criteria for the assessment of absolute and relative risk of death. Better appraisal of the child's risk of death may help orientate the child towards either hospitalization or ambulatory care. As the transition from the NCHS growth reference to the WHO standards will increase the number of children classified as severely malnourished, further studies should explore means to identify children at highest risk of death within this group using simple and standardized indicators.
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This systematic review and meta-analysis explored HIV prevalence and mortality in children undergoing treatment for severe acute malnutrition (SAM) in sub-Saharan Africa. It included all studies reporting on HIV infection within a sample of children with SAM where HIV status was assessed using a blood test and SAM was defined using the WHO, Gomez, Wellcome or Waterlow definitions. Children from 17 studies were included in the analysis (n=4891), of whom 29.2% were HIV-infected. HIV-infected children were significantly more likely to die than HIV-uninfected children (30.4% vs. 8.4%; P<0.001; relative risk=2.81, 95% CI 2.04-3.87). HIV-negative children treated within community-based therapeutic care (CTC) programmes had lower mortality (4.3%) than those treated within an inpatient nutrition rehabilitation unit (NRU) (15.1%). There was no significant difference in mortality for HIV-infected children with SAM treated in the CTC (30.0%) or NRU (31.3%) settings. HIV prevalence is high in children with SAM in sub-Saharan Africa, and HIV-infected children are at significantly increased risk of mortality. There is an urgent need to integrate HIV testing and treatment into care for children with SAM in regions of high HIV prevalence.
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To determine the clinical factors that are of prognostic importance in protein-energy malnutrition (PEM), 150 patients admitted into the paediatric wards at the University College Hospital, Ibadan, Nigeria, were studied. Detailed clinical history, anthropometry and biochemical investigations were done immediately on admission. Case fatality rate decreased with age: 75% and 33% in those aged 12 months and below, and 30 to 36 months, respectively. The mortality in marasmus, kwashiorkor and marasmic-kwashiorkor were 35%, 47% and 60%, respectively. Hepatomegaly on admission had no significant impact on prognosis, but mortality increased with increasing hepatomegaly. Growth failure on admission, as measured by weight-for-age, weight-for-height and mid-upper-arm circumference were significantly associated with poor prognosis (p < 0.01, p < 0.01 and p < 0.001, respectively). Hypokalaemia and hyponatraemia were each separately associated with poor prognosis. When both electrolytes were low, more patients died (81%) than when both were normal (24%) (p < 0.001). Similarly, hypoproteinaemia and hypoalbuminaemia were associated with poor prognosis singly and in combination. When both serum proteins and albumin were low, the mortality was 32%, and there were no deaths when both were normal. The outcome in severe PEM is still poor. Good clinical precision in identifying clinical and biochemical prognostic factors, early intervention and good subsequent management are important in reducing mortality in PEM.