Study setting and population:
This retrospective cohort study was conducted at Minia University Maternity and Children Hospital; the only referral and teaching hospital in Minia governorate, Egypt. This hospital provides a wide range of health care services for urban and rural populations from near and far districts in Minia Governorate. The hospital has a Nutrition Rehabilitation Unit which serves as a treatment center for children with malnutrition based on the standardized WHO protocol.
All children under five years of age who were admitted with SAM to the nutrition rehabilitation ward during the period from January to December 2018 were recruited for this study. SAM was diagnosed by the presence of severe wasting [z score for weight for height (WHZ) <–3.0 SD and/or the presence of nutritional edema . Children with extreme WHZ, height for age z scores (HAZ) or weight for height z scores (WHZ) were excluded.
A total of 154 children were hospitalized with SAM; however, a total of 19 caregivers were unwilling to participate, leaving 135 children eligible for the study, with a response rate 87.7%. An informed consent was taken from children’s caregivers. During hospitalization, 13 (9.6%) children died and 122 (90.4%) were discharged alive with a follow-up plan. Parents of 18 discharged children refused to participate in the follow-up plan; leaving 104 children in the follow-up plan. Of those 104 children, 47 were last seen at one month after discharge, with no knowledge of outcomes; therefore, were treated them as censored in the survival analyses, seven have died and 50 children survived until at least the end of follow-up period; 24 weeks post-discharge (Supplemental Figure I).
All admitted children with SAM were managed according to the WHO protocol for management of SAM [1, 3] and passed through initial stabilization phase (with the use of F75) and rehabilitation phase (F100). Whenever needed, other lines of treatment were also provided according to the WHO guidelines updates  after performing the required investigations such as stool analysis, complete blood picture, levels of C-reactive protein, blood glucose level, serum electrolytes (Na, K and ionized Ca), renal function tests and liver function tests. A daily check of weight gain during the treatment course was conducted and any complications appeared during period of admission were managed.
Data collection procedure
The sources of data were the inpatients hospital records and checklists that were developed according to the standard treatment protocol for the management of SAM. Information collected were patient-related data, anthropometric measurements, comorbidities, type of SAM, treatment lines and others. Age and measurements of weight and height were plotted on the WHO and Z-score Growth Charts to determine the percentiles for each parameter. These data were collected at the time of enrollment, during hospitalization, at discharge and at follow-up appointments.
During hospital stay, children’ parents/guardians were interviewed using a detailed structured questionnaire which inquired about socioeconomic status and contact details (phone and address). The questionnaire included five sections with weighted questions (education and occupation of the mother; education of the father; crowding index; family income and sanitary conditions of the house). The socioeconomic status of children’s families was then classified according to the modified El-Sherbini’s socioeconomic score into four categories; < 15, very low social standard; 15–20, low social standard; 20–25, middle social standard and 25–30, high social standard .
Children were discharged from the hospital not on the basis of specific anthropometric measurement , but after achieving the following WHO criteria: a well and alert child with good appetite and without medical complications including resolving of edema [1,3].
All of the enrolled children who have survived hospitalization were requested to attend follow-up appointments for six months post-discharge as per routine follow-up schedule for the Nutrition Rehabilitation Unit in the hospital. Follow-ups were planned weekly for the first two weeks following discharge and biweekly thereafter. Routine procedures in each follow-up appointment included taking anthropometric measurements and vital signs, as well as assessing and managing of any current illness.
The main study outcome was to estimate the likelihood of a long-term post-treatment survival; six months post-discharge.
Data entry and analyses were all done with IBM compatible computer using the SPSS for windows software version 22. Graphics were edited by the Excel Microsoft office 2013 software.
Quantitative data were presented by mean and standard deviation, while qualitative data were presented by frequency distribution. In the univariate analyses, the crosstabs command with the Fisher’s exact test was used to compare between proportions and to impute the Hazard ratios (HRs) and 95% confidence Intervals (CIs) for dichotomous variables.
A Kaplan–Meier curve was plotted for the cumulative survival across follow-up appointments’ time, and multivariable-adjusted HRs; 95% CIs were calculated by the Cox proportional hazard model that included variables which were significantly associated with the outcome in the univariate analysis. A statistically significant level was considered when a two sided p-value was less than 0.05.