Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi

ABSTRACT

Background

Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the ‘WHO 10 Steps’ and mortality in children with SAM is not fully understood.

Methods

Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6–36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients’ charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the ‘WHO 10 Steps’ were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression.

Results

Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27–20.78], shock (aOR 18.54, 95% CI 3.87–88.90), HIV-positive (aOR 5.32, 95% CI 1.76–16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11–5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90–8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16–8.44).

Conclusion

HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.

KEYWORDS:

• Mortality
• quality of care
• severe acute malnutrition
• clinical risk factors
• Malawi

Acknowledgments

The authors wish to thank all the patients and caregivers for involvement in the study, the KCH paediatric staff for the tireless care of these patients, and the data clerks for diligent management of the patient data. We also thank Baylor College of Medicine Children’s Foundation Malawi, UNC Children’s Foundation and UNC Project Malawi for the guidance and support which made the project possible.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Data Availability statement

The data that support the funding of this study are available from the corresponding author on reasonable request.

Additional information

Funding

This paragraph should be moved to end of the article, before References The use of REDCap was supported by the National Center for Advancing Translational Sciences (NCATS), NIH (Grant Award Number UL1TR001111). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Notes on contributors

Bryan J. Vonasek

Bryan J. Vonasek is a fourth-year Paediatrics and Global Child Health resident physician at Baylor College of Medicine, USA.

Msandeni Chiume

Msandeni Chiume is head of the Department of Paediatrics, Kamuzu Central Hospital, Malawi.

Heather L. Crouse

Heather L. Crouse is an Associate Professor of Pediatrics in the Pediatric Emergency Medicine Section, Baylor College of Medicine, USA.

Susan Mhango

Susan Mhango is the lead nutritionist at Baylor College of Medicine Children’s Foundation Malawi.

Alexander Kondwani

Alexander Kondwani is a nutritionist and paediatric clinical officer at Kamuzu Central Hospital, Malawi.

Emily J. Ciccone

Emily J. Ciccone is an Infectious Diseases fellow, University of North Carolina Chapel Hill School of Medicine, USA.

Peter N. Kazembe

Peter N. Kazembe is a paediatrician and the retired executive director of Baylor College of Medicine Children’s Foundation Malawi.

Wilfred Gaven

Wilfred Gaven is a lecturer at the Malawi College of Health Sciences, Blantyre, Malawi.

Elizabeth Fitzgerald

Elizabeth Fitzgerald is an assistant professor of Pediatric Emergency Medicine, University of North Carolina Chapel Hill School of Medicine, USA, and Director of UNC Pediatric Global Health.