Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya

Philip Bejon, Shebe Mohammed, Isaiah Mwangi, Sarah H Atkinson, Faith Osier, Norbert Peshu, Charles R Newton, Kathryn Maitland, James A Berkley, Philip Bejon, Shebe Mohammed, Isaiah Mwangi, Sarah H Atkinson, Faith Osier, Norbert Peshu, Charles R Newton, Kathryn Maitland, James A Berkley

Abstract

Background: Malnutrition is common in the developing world and associated with disease and mortality. Because malnutrition frequently occurs among children in the community as well as those with acute illness, and because anthropometric indicators of nutritional status are continuous variables that preclude a single definition of malnutrition, malnutrition-attributable fractions of admissions and deaths cannot be calculated by simply enumerating individual children.

Objective: We determined the malnutrition-attributable fractions among children admitted to a rural district hospital in Kenya, among inpatient deaths and among children with the major causes of severe disease.

Design: We analyzed data from children between 6 and 60 mo of age, comprising 13,307 admissions, 674 deaths, 3068 admissions with severe disease, and 562 community controls by logistic regression, using anthropometric z scores as the independent variable and admission or death as the outcome, to calculate the probability of admission as a result of "true malnutrition" for individual cases. Probabilities were averaged to calculate attributable fractions.

Results: Z scores < -3 were insensitive for malnutrition-attributable deaths and admissions, and no single threshold was both specific and sensitive. The overall malnutrition-attributable fraction for in-hospital deaths was 51% (95% CI: 42%, 61%) with midupper arm circumference. Similar malnutrition-attributable fractions were seen for the major causes of severe disease (severe malaria, gastroenteritis, lower respiratory tract infection, HIV, and invasive bacterial disease).

Conclusions: Despite global improvements, malnutrition still underlies half of the inpatient morbidity and mortality rates among children in rural Kenya. This contribution is underestimated by using conventional clinical definitions of severe malnutrition.

Figures

FIGURE 1.
FIGURE 1.
The sensitivity and specificity of z score thresholds for diagnosis of malnutrition-attributable admission to hospital or death are shown for height-for-age z score (HAZ), weight-for age z score (WAZ), weight-for-height z score (WHZ), and midupper arm circumference (MUAC)–for-age z score. n = 12 207 for deaths and controls; n = 11 254 for admissions and controls.
FIGURE 2.
FIGURE 2.
The malnutrition-attributable (Attrib) fractions for admissions and deaths are shown according to z score and for all admissions. A separate graph shows the attributable fractions for each analysis, according to height-for-age z score (HAZ), weight-for age z score (WAZ), weight-for-height z score (WHZ), and midupper arm circumference (MUAC)–for-age z score. n = 12 207 for deaths and controls; n = 11 254 for admissions and controls.

References

    1. Briend A, Dykewicz C, Graven K, Mazumder RN, Wojtyniak B, Bennish M. Usefulness of nutritional indices and classifications in predicting death of malnourished children. Br Med J (Clin Res Ed) 1986;293:373–5.
    1. Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008;371:243–60.
    1. Vella V, Tomkins A, Borghesi A, Migliori GB, Ndiku J, Adriko BC. Anthropometry and childhood mortality in northwest and southwest Uganda. Am J Public Health 1993;83:1616–8.
    1. Fawzi WW, Herrera MG, Spiegelman DL, el Amin A, Nestel P, Mohamed KA. A prospective study of malnutrition in relation to child mortality in the Sudan. Am J Clin Nutr 1997;65:1062–9.
    1. Smedman L, Sterky G, Mellander L, Wall S. Anthropometry and subsequent mortality in groups of children aged 6-59 months in Guinea-Bissau. Am J Clin Nutr 1987;46:369–73.
    1. Group TKS. Anthropometric assessment of young children's nutritional status as an indicator of subsequent risk of dying. J Trop Pediatr 1983;29:69–75.
    1. Rogers WO, Atuguba F, Oduro AR, Hodgson A, Koram KA. Clinical case definitions and malaria vaccine efficacy. J Infect Dis 2006;193:467–73.
    1. Mwangi TW, Ross A, Snow RW, Marsh K. Case definitions of clinical malaria under different transmission conditions in Kilifi District, Kenya. J Infect Dis 2005;191:1932–9.
    1. Pelletier DL, Frongillo EA Jr, Habicht JP. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality. Am J Public Health 1993;83:1130–3.
    1. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995;73:443–8.
    1. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. A methodology for estimating the contribution of malnutrition to child mortality in developing countries. J Nutr 1994;124(supp):2106S–22S.
    1. Garenne M, Maire B, Fontaine O, Briend A. Distributions of mortality risk attributable to low nutritional status in Niakhar, Senegal. J Nutr 2006;136:2893–900.
    1. de Onis M, Frongillo EA, Blossner M. Is malnutrition declining? An analysis of changes in levels of child malnutrition since 1980. Bull World Health Organ 2000;78:1222–33.
    1. Berkley JA, Lowe BS, Mwangi I, et al. Bacteremia among children admitted to a rural hospital in Kenya. N Engl J Med 2005;352:39–47.
    1. WHO. Pocket book of hospital care for children. Geneva, Switzerland: WHO, 2005.
    1. Berkley JA, Versteeg AC, Mwangi I, Lowe BS, Newton CR. Indicators of acute bacterial meningitis in children at a rural Kenyan district hospital. Pediatrics 2004;114:e713–9.
    1. Marsh K, Forster D, Waruiru C, et al. Indicators of life-threatening malaria in African children. N Engl J Med 1995;332:1399–404.
    1. Bejon P, Berkley JA, Mwangi T, et al. Defining childhood severe falciparum malaria for intervention studies. PLoS Med 2007;4:e251.
    1. Gwer S, Newton CR, Berkley JA. Over-diagnosis and co-morbidity of severe malaria in African children: a guide for clinicians. Am J Trop Med Hyg 2007;77:6–13.
    1. Waterlow JC, Buzina R, Keller W, Lane JM, Nichaman MZ, Tanner JM. The presentation and use of height and weight data for comparing the nutritional status of groups of children under the age of 10 years. Bull World Health Organ 1977;55:489–98.
    1. Waterlow JC. Protein-energy malnutrition: the nature and extent of the problem. Clin Nutr 1997;16(suppl 1):3–9.
    1. Maitland K, Pamba A, Newton CR, Levin M. Response to volume resuscitation in children with severe malaria. Pediatr Crit Care Med 2003;4:426–31.
    1. Snow RW, Schellenberg JR, Forster D, Mung'ala VO, Marsh K. Factors influencing admission to hospital during terminal childhood illnesses in Kenya. Int J Epidemiol 1994;23:1013–9.
    1. Schaible UE, Kaufmann SH. Malnutrition and infection: complex mechanisms and global impacts. PLoS Med 2007;4:e115.
    1. Nyakeriga AM, Troye-Blomberg M, Chemtai AK, Marsh K, Williams TN. Malaria and nutritional status in children living on the coast of Kenya. Am J Clin Nutr 2004;80:1604–10.
    1. Lengeler C. Insecticide-treated bednets and curtains for preventing malaria. Cochrane Database Syst Rev 2004;(2):CD000363.
    1. Schellenberg D, Cisse B, Menendez C. The IPTi Consortium: research for policy and action. Trends Parasitol 2006;22:296–300.
    1. Greenwood BM, Weber MW, Mulholland K. Childhood pneumonia–preventing the world's biggest killer of children. Bull World Health Organ 2007;85:502–3.
    1. Hartling L, Bellemare S, Wiebe N, Russell K, Klassen TP, Craig W. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children. Cochrane Database Syst Rev 2006;(3):CD004390.
    1. Cunliffe N, Nakagomi O. Introduction of rotavirus vaccines in developing countries: remaining challenges. Ann Trop Paediatr 2007;27:157–67.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir