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.
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
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.