Morbidity and outcome among under-five children with Severe Acute Malnutrition admitted to Community Inpatient Therapeutic feeding centres in Katsina State, Northwest Nigeria:  A retrospective review of health records (2010-2016)

doi:10.21203/rs.3.rs-1425192/v1

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Research Article

Morbidity and outcome among under-five children with Severe Acute Malnutrition admitted to Community Inpatient Therapeutic feeding centres in Katsina State, Northwest Nigeria: A retrospective review of health records (2010-2016)

https://doi.org/10.21203/rs.3.rs-1425192/v1

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Background

Severe Acute malnutrition among under –five children remain a huge public health and economic burden in Saharan Africa. We investigated the morbidity and outcome of under-five children admitted into CMAM stabilisation centres and managed for complicated severe acute malnutrition.

Methods

It was a retrospective review of CMAM stabilization centres registers. It was conducting focusing of demographic; morbidity, anthropometry and outcome of data which was extracted on all children 0–60 months admitted in CMAM six stabilization centres, in four local government areas of Katsina state from September 2010 to November 2016 were retrospectively reviewed. Descriptive analysis was used to compare performance indicator with Sphere project reference standard (the minimum standard to be attained during nutritional therapy). Cox –proportional hazard regression analysis was performed to estimate the predictors of recovery rate at p < 0.05 and Kaplan Meier curve were used to predict the length of stay on the ward

Result

A total of 6925 records of children with complicated SAM during the period under review, comprising 3570 males and 3,352 females. Marasmus was the most common form of severe acute malnutrition (86%). Overall outcome met the minimum sphere standard for inpatient management of SAM. Oedematous SAM (13.9%) have lowest survival rate on Kaplan Meier graph. There were significantly different mortality during the ‘lean season’ – May to August (CHR = 1.228, 95% CI = 0.942–1.599), MUAC at admission (CHR = 1.731, 95% CI = 1.072–2.796), MAUC at Exit (CHR = 3.057, 95% CI = 3.057 (1.974–4.734), Type of acute malnutrition – Marasmus (CHR = 0.417, 95% CI = 0.325–0.536), Transfer from OTP (CHR = 2.377, 95% CI 1.855–3.047) and weight gain (CHR = 0.210, 95% CI = 0.149–0.295) were found to be significant predictors to time-to-outcome with p value < 0.05.

Conclusion

We find that despite high turnover of complicated SAM cases in the stabilization, community approach to inpatient management of acute malnutrition leads to early detection; reduce delay to access care and mortality of complicated SAM cases. With training and retraining, community health workers can play a vital role inpatient management of SAM in resource limited setting.

Complicated SAM

Under-five

Recovery time

CMAM

Nigeria

Globally, about 150 million under five children are estimated to be too short for their age and about 50 million too thin for their height ¹. Most of the world’s wasted children are living in South Asia and Sub-Saharan Africa ^1,2 and account for about 50% of direct or indirect cause of global under-five mortality ^3,4. In Nigeria, 37% of children were short for their age, 7% were thin for their height, 22% were heavy for their height and only 29% of children under the age 6 months were breastfed exclusively ⁵. In the 2018 NDHS, there were mark variation by zone in the prevalence of stunting and wasting. The Northwest region of Nigeria, where this study was conducted has the highest per cent of stunted children (57%) and wasted children (9%) above the National average while the Southeast has least of 18% of children stunted (18%) and wasted (5%) children.

Malnutrition, in all its forms is due to deficiency, excesses or imbalance in a person’s intake of energy and/ or nutrients. Malnutrition includes under nutrition, micronutrient-related malnutrition and overweight, obesity and diets –related non communicable disease ⁶. Undernutrition includes wasting (Acute malnutrition), stunting (chronic malnutrition) and underweight (both acute and chronic malnutrition) and micronutrient deficiency. Severe acute malnutrition could present as wasting (Marasmus), oedema (Kwashiorkor), or both wasting and oedema (Marasmic kwashiorkor) ⁷. Features suggestive of Marasmus include wizened face, miserable but alert, prominent bony of the ribs, baggy pant appearance due to loss of subcutaneous fat and muscle in the gluteal and perianal region, diarrhoea very common. Kwashiorkor is characterised by oedema, moon face appearance with puffy eyes, dermatitis, anaemia, and hepatomegaly.

The World Health Organization (WHO) defines SAM in children aged 6–59 months as weight for height/length below ratio < -3SD, the presence of any bilateral pitting oedema (when all other non-nutritional causes are excluded), and/or a mid-upper arm circumference (MUAC) of < 11.5 cm. While SAM in infant less than 6 month is defined as weight for length ration <-3SD only as MUAC is not reliable in infant less than 6 month ⁷. According to WHO guideline, SAM without medical complication can be effectively managed as outpatient in a community-based setting while SAM children with clinical co morbidity (poor appetite, signs of infection, severe oedema, hypothermia, lethargy, hypoglycaemia, vomiting, diarrhoea with dehydration, severe anaemia) should be managed as inpatients in a stabilisation centre ^7,8. The international indicators according to SPHERE to evaluate the quality of management of SAM is cure rate of a least 75% and death rate less than 10% ⁸.

The causes of under nutrition are broad and interwoven, however, immediate cause include lack of access to highly nutritious foods, especially in low socio-economic context and infectious disease, like diarrhoea, pneumonia, measles and malaria which has caused them to lose weight. Other causes include poor maternal health and nutrition, and/or inappropriate infant and young child feeding and care in early life ⁹ (WHO, 2018). Adequate nutrition is crucial for a child’s physical and cognitive development.

In 2010 to 2016, Katsina state was supported by Save the Children to implement an integrated Community-based Management of Acute Malnutrition (CMAM) for under–five in Baure, Daura, Dutsi and Zango Local Government Areas (LGA), Katsina state, Northwest region of Nigeria. The CMAM strategy consists of community outreach and mobilisation; Inpatient treatment in the stabilization centres (SC) for management of SAM cases with medical complications; and outpatient care in Outpatient therapeutic programme (OTP) for management of SAM without medical complications. The success of a CMAM programme relies on early case finding combined with effective follow up actions at the community level. Therefore community volunteers were selected and trained to identify malnourished children using Mid-Upper Arm Circumference (MUAC) strip and referred depending on the severity of malnutrition ^7,9. In the OTP, SAM cases that developed medical complication are referred to the SC for inpatient care ^7,8. At health facility level, health care workers were annual training in World Health Organization (WHO) treatment guidelines for management of SAM with co morbidity in the in-patient setting ⁴.

This study investigated the morbidity and outcome of under-five children admitted into CMAM stabilisation centres and managed for complicated severe acute malnutrition.

Study design

The study was a retrospective quantitative review of CMAM inpatient centres registers records. The sample collected comprised of records from September 2010 to November 2016.

Study setting

This study was done at two secondary healthcare facility (General Hospital Daura and General Hospital Baure) and four primary healthcare facility (Comprehensive Health Centre Daura, Comprehensive Health Centre Dutsi, Comprehensive Health Centre Zango, Maternal and Child Health Centre Zango) designated as CMAM stabilization centres across four Local Government Area (LGA), namely Baure, Daura, Dutsi and Zango in Katsina state, Northwest region of Nigeria. The stabilisation centres situated in rural communities and admitted only under five children with complicated SAM. The communities are predominantly rural setting, Hausa/Fulani-Muslims. The majority are agrarian and nomad. Total bed capacity in the 6 centres is 60 and they admit all year round. For the four primary healthcare facilities, the wards are managed by Community Health Workers (CHWs) trained in the inpatient management SAM, while the two secondary health facilities were managed by nurses. These health workers received yearly refresher training in the inpatient management of the SAM.

All the children were managed using the WHO 10 step to inpatient management of SAM. For children 6–59 months, once the child is stabilized, they are transfer to one of the OTP, to continue nutritional rehabilitation with peanut based ready-to-use food until full recovery. HIV serology for children older than 19 months of age was done using Rapid diagnostic test. However, majority of the participants were not screened because of the inconsistency in the supplied of the kits. All children found to be HIV infected were referred to secondary health facility for Antiretroviral therapy .

Population and sampling procedures

All children of age 6–59 month of age children admitted to the stabilization centres between 2010 and 2016 were eligible for the study. Admission to the unit is based on the presence of bilateral pitting oedema and /or MUAC < 11.5 cm for children 6–59 months with medical complications. Children < 6 month were admitted based on weight for height Z-scores (WHZ) < − 3 standard deviations (SD). However, this group of patients were not included in the study. Figure 1 Flow chart of the sampling procedure.

Data management and analysis

The data were extracted from the CMAM inpatient records directly into Microsoft Excel for cleaning and then exported to the Statistical Package for Social Science (SPSS) version 23 for analysis. The variables obtained were from children under-five children admitted directly from the community and transfers from OTP centres. Variables extracted include socio-demographic (Age, gender, place of admission), anthropometry at admission and discharge (MUAC, weight), forms of malnutrition (Marasmus, Marasmus-Kwashiorkor and Kwashiorkor), outcome (stabilised, death, defaulter, and non-responder), length of stay and average weight gain.

The time it takes for severely malnourished children to be discharged from the stabilisation centres is the dependent outcome variation (time of recovery). The independent factors include age, sex, facility of admission, MUAC & weight at admission and discharge, length of stayed and weight gain. The Kolmogrov smirnov test of normality was used to check the normality of the distributions for continuous variable which was statistically significant p < 0.05 Multicollinearity test between independent variables indicate there was no correlation – Variance inflation factor < 10. Data were described using frequency distribution and measures of central tendency and dispersion. Kaplan-Maier Curve and Long rank test were used to estimate cumulative survival probability and to compare survival status probability across different groups.

Bivariable and multivariable Cox regression were used to identify predictors of time-to-recovery and outcome. Variables with p-value less than 0.05 during bivariate analysis were considered as variable for multivariate analysis. A sensitivity analysis was done to ascertain whether the findings of this study would have been different if the missing data had been included in the analysis. A dichotomous variable was then created using the total number of missing and present data in the dependant variable mortality. The variable was then cross tabulated in chi square to compare whether there were more missing values than known values in the independent variables. The analysis shows that generally the known data was more than the missing. Consequently, it can be inferred that the results could not have changed significantly if all the missing data were added to the analysis.

Ethical Approval

Institutional Review Board (IRB) approval was obtained from Katsina State Health Research Ethics committee/Operations Research Advisory Council (ORAC) upon submission of the study design and data collection instruments prior to the commencement of the survey. The ORAC is domiciled in the Katsina State Ministry of Health.

Population and demographic characteristics, anthropometry, and admission outcomes

Overall number of under–five children enrolled into the study were 6925, the males constitute 52% (3570) with a boys-to-girls ratio of 1.06. Their median age was 16 months (IQR 10–24 months). The mean (±SD) age of the children was 17.58 months (±9.75) and 88% were ages ≤24 month. Transfers from OTP were 65% (4943) while 35% were referrals from the communities. Marasmus constituted 86.0% of direct admission, followed by Kwashiorkor (11.8%) and Marasmus - Kwashiorkor (2.1%). The median MUAC at admission was 10.17 cm (IQR 9.50 – 11.00), mode was 11.0 cm and 66.5% have MUAC <11.0 cm. The mean weight at admission was 5.67kg (±1.88 SD), median weight was 5.6kg (IQR 4.7 – 6.5) and mode 6 kg. 82.4% has weight ≤7kg and 19.4% has weight ≤4kg. Most admission (42%) occur within the ‘lean season’ (May to August) with corresponding higher mortality than other months Table 1 and Figure 2.

Table 1 Bivariable Cox Proportional Hazard Regression Model for Predictors of Death from complicated SAM in Northwest Nigeria

	SAM
Variable	All SAM (6925) n%	Alive (6925) n%	Death (285) n%	Crude Hazard Rate (95% CI)
Sex (n=6,925)
Male	3,570 (52%)	3435 (96%)	135 (4%)	1
Female	3,352 (48%)	3202 (96%)	150 (4%)	0.883 (0.691 – 1.130)
Age (N=6925)
6 – 24	6.101 (88%)	5850 (96%)	251 (4%)	1
25 – 59	824 (12%)	790 (96%)	31 (4%)	0.985 (0.683 - 1.421)
Month of Admission (N=6925)				.
January - April	1,410 (20%)	1375 (98%)	35 (2%)	1
May - August	2,735 (42%)	2600 (95%)	135 (5%)	0.542(0.363-0.809)*
September - December	2,772 (38%)	2657 (96%)	115 (4%)	1.228(0.942-1.599)*
Weight at Admission (N=6924)
<6	4,067 (59%)	3904 (96%)	163 (4%)	1
6+	2,857 (41%)	2735 (96%)	122 (4%)	1.136 (0.887-1.457)
Weight at Exit (N=6621)
<6	3343 (50%)	3203 (96%)	140 (4%)	1
6+	3278 (50%)	3170 (97%)	108 (3%)	0.850 (0.652-1.108)
MUAC at Admission (N=6925)
<11.5	6102 (88%)	5837 (96%)	265 (4%)	1
11.5+	823 (12%)	803 (97%)	20 (3%)	1.731 (1.072-2.796)*
MUAC at Exit (N=6925)
<11.5	5376 (78%)	5114 (95%)	262 (5%)	1
11.5+	1549 (22%)	1526 (98%)	23 (2%)	3.057 (1.974-4.734)*
Morbidity (N=6846)
Marasmus	1639 (24%)	1517 (93%)	122 (7%)	0.417 (0.325-0.536)*
				1
Marasmic-Kwashiorkor	41 (1%)	39 (95%)	2 (5%)	2.305 (.318-16.703)
				1
Kwashiorkor	223 (3%)	208 (93%)	15 (7%)	0.642(0.359 -.1.148)
				1
Transfer from OTP	4943 (72%)	4801 (97%)	142 (3%)	2.377(1.855-3.047)*
				1
Residence (N=6925)
Baure⁺	806 (12%)	774 (96%)	32 (4%)	1
Dutsi*	875 (13%)	841 (96%)	34 (4%)	1.543 (1.417-1.680)*
Daura^+*	2394 (35%)	2319 (97%)	75 (3%)	1.504 (1.361-1.663)*
Zango*	2850 (41%)	2706 (95%)	144 (5%)	1.247 (1.147-1.356)
Weight gain (g/kg/day) (N=5866)
<8	2570 (44%)	2425 (94%)	175 (6%)	1
8+	3296 (56%)	3252 (99%)	44 (1%)	0.210 (0.149-0.295)*

Owing to missing data, values may not add up. *P value <0.05

Z test

To test the hypothesis that there was no difference between the means of the MUAC (M =10.19 cm, SD = 1.30) and weight at admission (M = 5.66, SD = 1.88), and MUAC (M=10.526 cm, SD = 1.30) and weight at exit (M=5.95, SD 1.60), a dependent sample t-test was performed. The correlations between the means of the MUACs and weights before and after intervention were estimated at r = .55, p <0.05 and r=54, p<0.05 respectively, suggesting that the dependent sample t-test is appropriate in this case. The null hypothesis that the CMAM intervention did not cause any change in the mean of the MAUC & weight before and after was rejected, t (21.652) = 6279, p<0.05and t (13.718) = 6571, p<0.05. Thus, the MUAC and weight at exit was statistically significantly higher than the at admission. Cohen’s d was estimated at 0.27 (MUAC) and 0.169 (Weight) which is a small effective based on Cohen’s (1992) guideline

Treatment outcome

The records indicated that 5944 (86%) of SAM children 6-59 months were stabilised and transfer to OTP, which was above the minimum recovery rate of 75% recommended in SPHERE standard, while 285 (4%) died during treatment which was lower than the SPHERE standard recommendation of 10% mortality. Moreover, 176 (67%) mortality occurred in the first 7 days of admission. The mean LOS was 6.64 days (±4.65), mode 4 and median length of stay for children who were discharged was 6.00 days (IQR 4.00 to 8.00 days). Majority of patient (69%) spent at least 7 days on admission. The average weight gain during the inpatient treatment phase was 6.8 g/kg/day for non-oedematous malnutrition Table 2.

Table 2 Comparison of treatment outcome with SPHERE standard indictors

Discharge outcome (N=6925)		Result	SPHERE Standards
Transfer to OTP (6-59month)	5944	86%	>75%
Death	285	4%	<10%
Defaulter	269	4%	<15%
Non responder	8	-	-
Other	211	-	-
Average Length of stayed (N=6925)		6.64 days	<30 days
Weight gain (g/kg/day) (N=5866)		6.8 g/kg/day	≥8 g/kg/day

Survival analysis

There were 6925 children with SAM considered for survival analysis with a median nutritional recovery time of the entire cohort to be 6 days (95% CI: 5.944–6.056). The greatest number and proportion of terminal events (death) occurred within the first 7 days 196. The cumulative probability of recovery at the end of one week was 95%; and recovery at the end of two week was 92%; that of surviving at the end of four weeks was 91% Table 3 and Figure 1. Kaplan Meier failure curves showed that children with Kwashiorkor had increased risk of dying independent of other factors Figure 3.

Table 3 Life table analysis of severely acutely malnourished children treated at CMAM stabilization centres Northwest Nigeria from September 2010 to November 2016.

Interval Start Time	Number Entering Interval	Number Withdrawing during Interval	Number Exposed to Risk	Number of Terminal Events	Proportion Terminating	Proportion Surviving	Cumulative Proportion Surviving at End of Interval
0-7	5738	3328	4074.000	196	.05	.95	.95
7-14	2214	1621	1403.500	45	.03	.97	.92
14-21	548	288	404.000	7	.02	.98	.91
21-28	253	51	227.500	0	.00	1.00	.91
28-35	202	34	185.000	3	.02	.98	.89
35-42	165	40	145.000	0	.00	1.00	.89
42-49	125	7	121.500	0	.00	1.00	.89
49-56	118	4	116.000	0	.00	1.00	.89
56-63	114	8	110.000	0	.00	1.00	.89
63-70	106	16	98.000	1	.01	.99	.88
70-77	89	87	45.500	2	.04	.96	.84

Cox regression analysis

Bivariate Cox regression analysis was run for the following independent variables, Sex, Age, month of admission, MUAC and weight at admission and discharge, type of morbidity, weight gain and length of stay in the hospital. Subsequently, the bivariable analysis finding showed that the ‘lean season’ – May to August (CHR=1.228, 95% CI=0.942-1.599), MUAC at admission (CHR=1.731, 95% CI =1.072-2.796), MAUC at Exit (CHR =3.057, 95% CI=3.057 (1.974-4.734), Type of acute malnutrition – Marasmus (CHR=0.417, 95% CI= 0.325-0.536), Transfer from OTP (CHR=2.377, 95% CI 1.855-3.047) and weight gain (CHR=0.210, 95% CI=0.149-0.295) were found to be significant predictors to time-to-recovery with p value < 0.05, hence considered eligible for the multivariable cox regression analysis. Accordingly, after adjusting for different variables month of admission, MUAC at admission and exit, type of morbidity- marasmus, transfers from OTP, weight gain were found to be independent predictors of recovery time in severely malnourished children admitted to the CMAM stabilization centres Table 4.

Table 4 Multivariable cox regression of predictor of mortality in CMAM stabilization centre in Katsina State

Variable	Adjusted Hazard Ratio	P-value
Month of Admission
January – April	1	0.009
May – August	0.491(0.288-0.838)	0.009
September - December	1.118(0.805-1.551)	0.506
MUAC (cm) at admission
<11.5	1
11.5+	0.990(0.547-1.790)	0.974
MUAC (cm) at Exit
<11.5	1
11.5+	0.521(0.306-0.890)	0.017
Weight gain(g/kg/day)
<8	1
8+	0.239(0.169-0.340)	0.000
Marasmus
No	1
Yes	2.144(1.079-4.260)	0.029
OTP
No	1
Yes	1.105(0.558-2.190)	0.775

Time-to-death patterns of the SAM children across selected variables. Hence, there were statistically significant difference in the survival rates among children admitted during the ‘lean season’, their MAUC at exit, type of morbidity- marasmus and weight gain (p< 0.05).

The study revealed that the recovery from complicated SAM after a maximum of 63 days was 95.7% and 4.3% of children died. The finding of this study revealed that the minimum SPHERE standard was met in the inpatient CMAM intervention within the study period. The low mortality in the study could be attributed to the community linkages with early detection of complication and referral to closet stabilisation centre. Early detection and referral of complicated SAM case is the hallmark of community approach to inpatient management of acute malnutrition. Studies done in a Ethiopia ^10,11, Malawi ¹² and Zambia ¹³ in tertiary hospitals setting was mortality was 12.2%, 10.1% and 46% respectively. In contrast to these previous, this study was done in four primary health facilities and two secondary health facility and majority of the staff are Community health works Primary health facility and majority of the health worker are community health worker in the primary health care facility and nurses in the secondary health facility. However these community health workers had yearly training on inpatient management of complicated acute malnutrition.

This study highlighted the importance of community approach to the treatment of SAM in reducing death due to complicated severe acute malnutrition. Most malnourished children are in rural communities; early detection, timely referral and access to healthcare are a key determinant to survival of complicated SAM. Tertiary health facility with sub specialities in paediatric and child appear to be the ideal setting for inpatient management of complicated SAM. However, most tertiary, and secondary health facility are several kilometres away these communities and may explained the reason for the high mortality in the review studies. Drawing from this study, training community health worker and nurse on inpatient management of complicated SAM and integrated management of childhood illness could save the life of millions of under-five malnourished children in rural communities.

In the study the average LOS for children 6-59 months was 7.42 days, which was far less than most studies in Ethiopia, Ghana, and India. These could be attributed to the fact that inpatient centres are stabilization centre, and the stabilization phase of inpatient management is 7 days to treat complications of SAM, where you have Outpatient Therapeutic centres close the patient home, the rehabilitation phase can be continued in these centres. The communities where this study was conducted have over 50 outpatient posts across these communities supported by Save the Children international. This is important in setting of high SAM caseloads like the one in our study. Higher LOS in other studies may have been due to lack of outpatient therapeutic centres; however, there are risks of nosocomial infection and increase wait time for areas with high turnover of complicated SAM case.

The study revealed that, the average weight gain od SAM children complicated SAM children in the stabilization centres was 6.8g/kg body weight /day, which is less than the international standard cut off point of minimum average weight gain ≥8g/kg body weight/day. This finding is far less than similar study conducted in Ethiopia (11.2g/kg/day), India (12.1g/kg/day). The result may be attributed to majority of SAM case were discharged within the first 7 days stabilization phase of inpatient car. Usually, in the stabilization phase, SAM children are commenced on cautious feeding with F75, a special formula designed to help the child recover normal metabolic function and nutrition-electrolyte balance but there is minimal weight gain.

Marasmus was the most common morbidity similar to other studies in Ethiopia and Malawi ^10–12. However, some studies in Zambia and Sudan reported Kwashiorkor to be the most common morbidity ^13,14. While Munthali et al. (2015) argued that one reason could be that the food in Zambia is carbohydrate based and most protein rich diet many are not available in the required quantities. However, the nutritional situational is not different from this current study. There may be reason beyond the quality of food. The study also reviewed that SAM children with oedematous malnutrition have greater risk of mortality compared to non-oedematous. In this study, majority of the children with Kwashiorkor died within 7 days of admission. This consistent with another study in Malawi ¹² and highlight oedematous SAM as high risk form of Acute malnutrition.

The study revealed there were significantly different recovery rates in the type of morbidity, age group, MAUC at admission and weight gain. As period of admission and MUAC have positive predictive outcome. In this study, most admission and mortality were in the lean season and malaria season, highlighting the role of inadequate food supply ¹⁵ and malaria ^16–18 morbidity and mortality of complicated SAM. In a study on the prevalence of malaria done in the same region, malaria prevalence was highest in the ‘lean season’ with malaria cases over 50% of case in a year ^19,20. Studies have investigated the association of clinical factors and SAM outcome in inpatient setting. While majority of studies were done with patient admitted in tertiary hospital with the technology and facilities to make definitive diagnosis of co morbidity, the SAM children in this study were managed in primary health care facilities designated as stabilization centres, majority by community health extension workers that were trained in WHO guideline for inpatient management with limited professional capacity and facility to make a definitive clinical diagnosis of medical complications. There are challenges in appropriately triaging malnourished children during initial evaluation and with assessing changes in their clinical status during admission. This challenge is due to less reliably classic clinical signs of severe infection (fever, tachycardia, and tachypnoea), and therefore the severity of illness may be unnoticed in children with SAM. The approach is also efficient in non-emergency situations in Low- and Middle-Income Countries (LMICs) where the malnutrition inpatient care model is not sustainable because of poor infrastructure and lack of skilled professional health workers.

The study demonstrates that the stabilization centres for CMAM intervention in the rural communities of Katsina state met the minimum sphere standard for inpatient care for complicated SAM cases. The study revealed community health worker play a vital role in ensuring access and care for complicated SAM, if they are appropriately trained and utilised in primary health facility in rural communities. The study also highlights the need for integrated management of childhood illnesses policy and intervention that factors the role of ‘lean season’ and seasonal malaria on the morbidity and mortality of severely malnourished under five children in this region. The study highlights the intervention statistically significant different the anthropometry (MUAC and Weight) at admission and exit, even though, the effect is small. Mid-Upper Arm Circumference, marasmus SAM, season and weight gain were predictor inpatient care outcome for complicated SAM.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Morbidity and outcome among under-five children with Severe Acute Malnutrition admitted to Community Inpatient Therapeutic feeding centres in Katsina State, Northwest Nigeria: A retrospective review of health records (2010-2016)

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