Mortality and morbidity patterns in under-five children with severe acute malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based records (2009-2013)

Tendai Munthali, Choolwe Jacobs, Lungowe Sitali, Rosalia Dambe, Charles Michelo, Tendai Munthali, Choolwe Jacobs, Lungowe Sitali, Rosalia Dambe, Charles Michelo

Abstract

Background: Severe acute malnutrition has continued to be growing problem in Sub Saharan Africa. We investigated the factors associated with morbidity and mortality of under-five children admitted and managed in hospital for severe acute malnutrition.

Methods: It was a retrospective quantitative review of hospital based records using patient files, ward death and discharge registers. It was conducted focussing on demographic, clinical and mortality data which was extracted on all children aged 0-60 months admitted to the University Teaching Hospital in Zambia from 2009 to 2013. Cox proportional Hazards regression was used to identify predictors of mortality and Kaplan Meier curves where used to predict the length of stay on the ward.

Results: Overall (n = 9540) under-five children with severe acute malnutrition were admitted during the period under review, comprising 5148 (54%) males and 4386 (46%) females. Kwashiorkor was the most common type of severe acute malnutrition (62%) while diarrhoea and pneumonia were the most common co-morbidities. Overall mortality was at 46% with children with marasmus having the lowest survival rates on Kaplan Meier graphs. HIV infected children were 80% more likely to die compared to HIV uninfected children (HR = 1.8; 95%CI: 1.6-1.2). However, over time (2009-2013), admissions and mortality rates declined significantly (mortality 51% vs. 35%, P < 0.0001).

Conclusions: We find evidence of declining mortality among the core morbid nutritional conditions, namely kwashiorkor, marasmus and marasmic-kwashiorkor among under-five children admitted at this hospital. The reasons for this are unclear or could be beyond the scope of this study. This decline in numbers could be either be associated with declining admissions or due to the interventions that have been implemented at community level to combat malnutrition such as provision of "Ready to Use therapeutic food" and prevention of mother to child transmission of HIV at health centre level. Strategies that enhance and expand growth monitoring interventions at community level to detect malnutrition early to reduce incidence of severe cases and mortality need to be strengthened.

Keywords: Comorbidity; HIV; Hospital; Mortality; Severe acute malnutrition; Under-five children; Zambia.

Figures

Figure 1
Figure 1
Shows mortality trends by year and admission.
Figure 2
Figure 2
Shows morbidity trends by year and admissions.
Figure 3
Figure 3
Shows children with Marasmus were more likely to die compared to children with Kwashiorkor or Marasmic-kwashiorkor.

References

    1. UNICEF: WHO (World Health Organization)/World Bank . Levels and Trends in Child Malnutrition. New York, Geneva, and Washington, DC: UNICEF-WHO-The World Bank Joint Child Malnutrition Estimates; 2012.
    1. Bhan MK, Bhandari N, Bahl R. Management of the severely malnourished child: perspective from developing countries. BMJ: Med J. 2003;326:146–51. doi: 10.1136/bmj.326.7381.146.
    1. Collins S. Community-based therapeutic care: a new paradigm for selective feeding in nutritional crises. Humanitarian Policy Network paper 48. London: Overseas Development Institute; 2004.
    1. Deconinck H, Swindale A, Grant F, Navarro-Colorado C. Review of community-based management of acute malnutrition CMAM in the post-emergency context: synthesis of lessons on integration of CMAM into national health systems in Ethiopia, Malawi and Niger. Washington DC: FANTA; 2008.
    1. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417–40. doi: 10.1016/S0140-6736(07)61693-6.
    1. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of severe acute malnutrition in children. Lancet. 2006;368:1992–2000. doi: 10.1016/S0140-6736(06)69443-9.
    1. Morris SS, Cogill B, Uauy R. Effective international action against undernutrition: why has it proven so difficult and what can be done to accelerate progress? Lancet. 2008;371:608–21. doi: 10.1016/S0140-6736(07)61695-X.
    1. Ministry of Health. DRAFT Integrated Management of Acute Malnutrition Zambia. Lusaka; 2012.
    1. United Nations standing committee on nutrition. Scaling Up Nutrition. A framework for action. Reprint; 2011. (accessed on 03 December 2013).
    1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243–60. doi: 10.1016/S0140-6736(07)61690-0.
    1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–51. doi: 10.1016/S0140-6736(13)60937-X.
    1. CSO M, TDRC U. Macro International Inc.(2009): Zambia Demographic and Health Survey 2007. Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia, and Macro International Inc, Calverton, Maryland, USA.
    1. Charles Michelo RM. Set criteria might have high potentials in the management of severely malnourished children in Zambia, evidence from an evaluation of an ‘Outpatient Therapeutic Care Program (OTP)’ in selected communities in Lusaka urban, Zambia. Med J Zambia. 2012;39(3):6–12.
    1. Benson T, Shekar M, et al. Trends and issues in child undernutrition. In: Jamison DT, Feachem RG, Makgoba MW, et al., editors. Disease and mortality in Sub-Saharan Africa. 2. Washington DC: World Bank; 2006.
    1. Mugode RHMC. Staff competencies at health facilities implementing an outpatient therapeutic programme for severely acute malnourished children. Med J Zambia. 2014;40(3):85–92.
    1. Organisation WH . Guideline update: Technical aspects of the management of severe acute malnutrition in infants and children. Development DoNfHa ed. GENEVA: WHO; 2013.
    1. Commission NFaN . Report on the assessment of malnutrition trends in hospitals in Zambia, National. Lusaka: National Food and Nutrition Commission; 2008.
    1. Trehan I, O’Hare BA, Phiri A, Heikens GT. Challenges in the management of HIV-infected malnourished children in sub-Saharan Africa. AIDS Res Ther. 2012;2012:8.
    1. Irena AH, Mwambazi M, Mulenga V. Diarrhea is a major killer of children with severe acute malnutrition admitted to inpatient set-up in Lusaka. Zambia Nutr J. 2011;10:110–115. doi: 10.1186/1475-2891-10-110.
    1. Latham MC. Human Nutrition in the Developing World. Rome, Italy: (No 29) Food & Agriculture Organisation of the United Nations; 1997.
    1. Musoke PM, Fergusson P. Severe malnutrition and metabolic complications of HIV-infected children in the antiretroviral era: clinical care and management in resource-limited settings. Am J Clin Nutr. 2011;94:1716S–20. doi: 10.3945/ajcn.111.018374.
    1. Maitland K, Berkley JA, Shebbe M, Peshu N, English M, Newton CRC. Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol? PLoS Med. 2006;3(e500):222–225.
    1. Bachou H, Tylleskär T, Kaddu-Mulindwa DH, Tumwine JK. Bacteraemia among severely malnourished children infected and uninfected with the human immunodeficiency virus-1 in Kampala, Uganda. BMC Infect Dis. 2006;6:160. doi: 10.1186/1471-2334-6-160.
    1. Fuchs JG. Antioxidants for children with kwashiorkor. In BMJ: British Medical Journal, vol. 330, 12 may 2005 edition; 2005; Issue 7500:1095.
    1. Amadi B, Kelly P, Mwiya M, Mulwazi E, Sianongo S, Changwe F, et al. Intestinal and systemic infection, HIV, and mortality in Zambian children with persistent diarrhea and malnutrition. J Pediatr Gastroenterol Nutr. 2001;32:550–554. doi: 10.1097/00005176-200105000-00011.
    1. Heikens GT. How can we improve the care of severely malnourished children in Africa? PLoS Med. 2007;4:e45. doi: 10.1371/journal.pmed.0040045.
    1. Asafo-Agyei SB, Antwi S, Nguah SB. HIV infection in severely malnourished children in Kumasi, Ghana: a cross-sectional prospective study. BMC Pediatr. 2013;13(1):181. doi: 10.1186/1471-2431-13-181.
    1. Ashworth A, Chopra M, McCoy D, Sanders D, Jackson D, Karaolis N, et al. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet. 2004;363:1110–15. doi: 10.1016/S0140-6736(04)15894-7.
    1. De Onis M, Blössner M. The World Health Organization global database on child growth and malnutrition: methodology and applications. Int J Epidemiol. 2003;32:518–26. doi: 10.1093/ije/dyg099.
    1. Ubesie AC, Ibeziako NS, Ndiokwelu CI, Uzoka CM, Nwafor CA. Under-five protein energy malnutrition admitted at the University of in Nigeria teaching hospital, Enugu: a 10 year retrospective review. Nutr J. 2012;11:43. doi: 10.1186/1475-2891-11-43.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir