Several underlying clinical conditions influenced treatment outcomes of severe acute malnutrition among under-five children in South Ethiopia: a retrospective cross-sectional study

doi:10.21203/rs.3.rs-4812355/v1

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Several underlying clinical conditions influenced treatment outcomes of severe acute malnutrition among under-five children in South Ethiopia: a retrospective cross-sectional study

https://doi.org/10.21203/rs.3.rs-4812355/v1

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Background: Severe acute malnutrition (SAM) occurs due to a recent rapid weight loss or failure to gain weight. Despite implementation of comprehensive treatment approaches, mortality attributed to SAM remains high in low-income countries, and little is known about underlying clinical conditions contributing to this in the context of Ethiopia. This study aimed to assess clinical conditions influencing the treatment outcomes of SAM in under-five children in South Ethiopia.

Methods: We conducted an institution-based cross-sectional study by retrospectively reviewing medical records of under-five children admitted with SAM to selected hospitals in South Ethiopia between November, 2017 and November, 2019. Data regarding socio-demographic and clinical characteristics were retrieved from Therapeutic Feeding Unit (TFU) registration logbooks and medical records. Logistic regression was used to determine clinical conditions associated with treatment outcomes of SAM in terms of death and cure. A significant association was determined at a P value of <0.05 with 95% confidence interval. Data were analysed using SPSS version 24.

Results: Of 417 children whose medical records were reviewed, 230 (55%) were male with the majority (66%) of them being in the age group of greater than 24 months. Regarding the outcomes of SAM treatment, 374 (90%) children were cured and 43 (10%) were dead. Admission with hypothermia (AOR: 3.02; CI: 1.33-6.83), tuberculosis infection (AOR: 4.13; CI: 1.78-9.62), anaemia (AOR: 3.25; CI: 1.29-8.20), shock (AOR: 2.88; CI: 1.23-6.72) and dehydration (AOR: 2.93: CI: 1.12-7.69) were independently associated with death due to SAM.

Conclusions: This study revealed the prevalence of SAM associated under-five death above the minimum acceptable standard. Several underlying clinical conditions contributed to the occurrence of death suggesting the need for strengthening management of the conditions.

severe acute malnutrition

treatment outcomes

under-five children

South Ethiopia

Severe acute malnutrition (SAM) is a form of under-nutrition characterised by a very low weight relative to height at a particular age-also known as wasting (1, 2). Globally, 52 million under-five children suffer from wasting and 17 million from severe wasting with 14 million of these living in sub-Saharan Africa (SSA) (3). Despite implementation of comprehensive management approaches to improve treatment outcomes in terms of reducing death and increasing cure rate, mortality related to SAM remains high in Ethiopia (4). The cure rate in the country (which 43.5%) is much less than the sphere minimum standard (> 75%) while death rate is much higher (29%) compared to the standard of < 10% (5, 6).

Underlying clinical conditions play a crucial role in predicting the treatment outcomes of SAM in under-five children. Infectious diseases such as tuberculosis (TB) and HIV, and medical conditions including anaemia and pneumonia decrease cure rate and increase the likelihood of death (7–11). On the other hand, medical criteria for treatment admission have also been reported to be associated with the treatment outcomes of SAM. For instance, appetite test failure, lower mid-upper arm circumference (MUAC) and presence of bilateral pitting oedema are associated with increased death rate (8, 10, 12, 13).

Integrated approaches are required to effectively manage such clinical conditions and then SAM in under-five children (14). However, the presence of considerable contextual variations in their influence substantially limited suggesting evidence-based interventions to enhance such approaches (1, 8, 10–12, 15–22). Therefore, this study aimed to assess underlying clinical conditions affecting the treatment outcomes of SAM in terms of cure and death in under-five children in South Ethiopia.

Study area and design

We conducted an institution-based retrospective cross-sectional study at two of five referral hospitals present in South Ethiopia – namely Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital and Wolaita Sodo University Teaching Referral Hospital. The hospitals were selected based on the prevalence of SAM in the surrounding community and associated number of under-five children admitted with the condition during the study period (21).

Sample size determination

The minimum sample size required for this study was estimated using a two-population proportion formula (23) by considering various assumptions: 95% confidence level, 80% power, 1:1 ratio of children with SAM in exposed and unexposed groups in terms of having sepsis and 5.9% proportion of death in the unexposed group with odds ratio of 2.9, based on previous research (24). Accordingly, a total of 417 participants were required by considering the possibility of 10% incomplete medical records.

Sampling technique

Medical records of under-five children with SAM who were admitted to Therapeutic Feeding Units (TFU) at the selected hospitals between November, 2017 and November, 2019 were reviewed to retrieve treatment related information. The serial number in the registration booklet was used as a sampling frame to systematically select the medical records. The estimated sample size was proportionally allocation to each hospital based on the number of under-five children admitted with SAM. The interval for systematic sampling (K) was determined by dividing the total number of under-five children admitted with SAM to the allocated sample size (N/n). The first value was chosen using a lottery method. Accordingly, 216 records were selected from Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital and 201 from Wolaita Sodo University Teaching Referral Hospital.

Inclusion criteria

Under-five children with SAM who were admitted to TFU at the selected referral hospitals during the study period were eligible for the study.

Exclusion criteria

Children with an incomplete record, defaulting on treatment, and those who were transferred out were excluded.

Data collection procedure

Data regarding socio-demographic and clinical characteristics were retrieved from TFU registration logbooks and medical records. Four trained professionals who had a tertiary qualification in paediatric nursing retrieved data under the regular supervision of the principal investigator (TEG). The data collectors made prompt communications with the principal investigator in order to obtain immediate feedback for any gaps identified.

Measurements and variables

Dependent variable

Our main outcome variable is a proportion of children died out of those who were admitted for SAM treatment. Alternatively, the proportion of children cured was measured in terms of a number of children discharged after completing the treatment.

Independent Variables

Socio-demographic information including age, sex and residence of participating children was retrieved from the registers along with clinical criteria for admission such as: the presence of bilateral pitting oedema (of level + 3), MUAC < 11.5 cm, weight for height (WFH) of < 70% and failed appetite test. Information related to other underlying clinical conditions including: hypothermia (defined as rectal body temperature < 35.5 degree Celsius or axillary body temperature < 35 degree Celsius), hypoglycaemia (i.e., blood glucose level < 3mmol/litre or < 54gm/dl) and anaemia (i.e., severe palmar pallor or haemoglobin level < 4g/dl) (25) was also retrieved together with comorbidities such as pneumonia, dehydration, TB and HIV.

Data analysis

After cleaning and checking for completeness, data were entered into EpiData version 3.1 and analysed using SPSS version 24 (26). Descriptive statistics such as frequencies and percentages were computed for categorical variables. Multiple logistic regression was used to determine covariates associated with death due to SAM. Variables with a P value of < 0.2 in univariate analyses were purposefully selected to be included in a multivariate analysis. A significant association between covariates and the outcome variable was determined at a P value of < 0.05 with 95% confidence interval for adjusted odds ratios.

Socio-demographic characteristics

Of 417 children whose medical records were reviewed, 55% were male. The majority (66%) of children were older than 24 months and most (63%) were from rural areas (see Table 1).

Table 1

Socio-demographic characteristics of under-five children admitted to treatment for severe acute malnutrition in South Ethiopia (N = 417)
Variable	Category	N (%)
Sex	Male	230 (55.16)
Sex	Female	187 (44.84)
Age	≤ 24 months	140 (33.57)
Age	> 24 months	277( 66.43)
Residence	Urban	155 (37.17)
Residence	Rural	262 (62.83)

Clinical characteristics

The majority of children (80%) had an appetite test failure and had MUAC < 11.5cm (70%) during admission. Almost two-thirds (63%) had WFH < 70% and 40% were with bilateral pitting oedema. Half of the children (50%) were suffering from pneumonia while 63% had diarrhoea and 47% being dehydrated (see Table 2).

Table 2

Clinical characteristics of under-five children admitted to treatment for severe acute malnutrition in South Ethiopia (N = 417)
Variable	Category	N (%)
Appetite test failure	No	83 (19.90)
Appetite test failure	Yes	334 (80.10)
MUAC	> 11.5cm	125 (29.98)
MUAC	< 11.5cm	292 (70.02)
Bilateral pitting oedema	No	249 (59.71)
Bilateral pitting oedema	Yes	168 ( 40.29)
Weight for height (WFH)	≥ 70%	154 ( 36.93)
Weight for height (WFH)	< 70%	263 (63.07)
Hypoglycemia	No	275 ( 65.95)
Hypoglycemia	Yes	142 (34.05)
Hypothermia	No	296 (71.15)
Hypothermia	Yes	121 (29.02)
Pneumonia	No	209 (50.12)
Pneumonia	Yes	208 (49.88)
Tuberculosis	No	352 (84.41)
Tuberculosis	Yes	65 (15.59)
Dehydration	No	223 (53.48)
Dehydration	Yes	194 (46.52)
Shock	No	271 ( 64.99)
Shock	Yes	146 (35.01)
Sepsis	No	279 (66.91)
Sepsis	Yes	138 (33.09)
Diarrhea	No	154 (36.93)
Diarrhea	Yes	263 (63.07)
Anemia	No	288 ( 69.06)
Anemia	Yes	129 (30.94)
MUAC: Mid upper arm circumference

Treatment outcomes and associated factors

Regarding the outcomes of SAM treatment, 90% of the children were cured and the remaining 43 (10%) were dead. Among underlying clinical conditions analysed, the presence of hypothermia, TB, shock, anaemia and dehydration were independently associated with death due to SAM. While the presence of hypothermia (AOR: 3.02; 95%CI: 1.33–6.83) and anaemia (AOR: 3.25; 95%CI: 1.29–8.20) increased the likelihood of SAM-related death by more than threefold, admission with shock (AOR: 2.88; 95%CI: 1.23–6.72) and dehydration (AOR: 2.93; 95%CI: 1.12–7.69) increased this by almost three fold. The odds of death were more than four times higher (AOR: 4.13; 95%CI: 1.78–9.62) in children with TB infection compared to those not having the infection (see Table 3).

Table 3

Logistic regression results of factors associated with treatment outcomes of severe acute malnutrition in under-five children in South Ethiopia
Variable		Death		COR (95% CI)	AOR (95% CI)
Variable		Yes (%)	No (%)	COR (95% CI)	AOR (95% CI)
Age in months	≤ 24	129 (92.14)	11(7.86)	0.65 (0. .31-1.34)	0.84 (0.32–2.20)
Age in months	> 24	245 (88.45)	32 (11.55)	1	1
Sex	Female	164 (87.70)	23 (12.30)	1.47 (0.78–2.77)	1.21 (0.53–2.79)
Sex	Male	210 (91.30)	20 (8.70)	1	1
MUAC	< 11.5cm	258 (88.36)	34 (11.64)	1.69 (0 .79- 3.66)	0.62 (0.21–1.85)
MUAC	> 11.5cm	116 (92.80 )	9 (7.20)	1	1
WFH	< 70%	232 (88.21)	31 (11.79)	1.58 (0. .79-3.18)	1.34 (0.51–3.52)
WFH	> 70%	142 (92.21)	12 (7.79)	1	1
Hypoglycemia	Yes	116 (81.69)	26 (21.85)	4.62 (2.40–8.89)	1.26 (0.45–3.58)
Hypoglycemia	No	258 (93.82)	17 (6.18)	1	1
Hypothermia	Yes	95 (79.17)	26 (21.49)	4.06 (2.12–7.78)	3.02 (1.33–6.83) *
Hypothermia	No	278 (93.92)	18 (6.08)	1	1
TB	Yes	48 (73.85)	17 (26.15)	4.44 (2.24–8.79)	4.13 (1.78–9.62) *
TB	No	326 (92.61)	26 (7.39)	1	1
Shock	Yes	117 (80.14)	29 (19.86)	4.55 (2.31–8.93)	2.88 (1.23–6.72) *
Shock	No	257 (94.83)	14 (5.17)	1	1
Diarrhea	Yes	226 (85.93)	37 (14.07)	4.04 (1.66–9.81)	2.77 (0.81–9.42)
Diarrhea	No	148 (96.10)	6 (3.90)	1	1
Anemia	Yes	104 (80.62)	25 (19.38)	3.61 (1.89–6.88)	3.25 (1.29–8.20) *
Anemia	No	270 (93.75)	18 (6.25)	1	1
Dehydration	Yes	161 (82.99)	33 (17.01)	1	1
Dehydration	No	213 (95.52)	10 (4.48)	4.37 (2.09–9.12)	2.93 (1.12–7.69) *
AOR: adjusted odds ratio; COR: crude odds risk ratio; CI: confidence interval; MUAC: Mid upper arm circumference; TB: Tuberculosis; WFH: Weight for height
^*Statistically significant association at P < 0.05

This study identified a relatively large magnitude of death (10%) among under-five children taking treatment for SAM compared to most previous reports in other parts of the country (21, 22, 27–29) and elsewhere in SSA (30–32) suggesting that the international target of achieving less than 10% death rate (33) is yet to be attained in the study settings. Our study identified important underlying clinical conditions affecting the success of SAM treatment.

Children admitted with hypothermia were more likely to die during the course of the treatment compared to those without the condition. In children with SAM, hypothermia often results from adaptation to the low caloric intake or reduced energy expenditure. It may also indicate coexisting hypoglycaemia or serious infection (25). Metabolic changes following hypothermia often causes poor appetite leading to loss of stored energy and severe wasting (marasmus) increasing the risk of death (10, 25, 34–36). The current finding supports the clinical significance of hypothermia for the success of SAM treatment that has previously been reported by many studies (8, 14, 17, 24, 27, 29, 33, 35). It underscores the importance of an appropriate management of the condition during admission to SAM treatment in accordance with the national and international guidelines (25, 34).

Another clinical condition significantly associated with death among children on SAM treatment is admission with shock. Sock is a commonly co-existing clinical condition in children with SAM and often accompanied by dehydration and sepsis (25). Beyond being an independent predictor of death per se in this and several other studies (1, 37–40), severe dehydration leads to shock in SAM cases particularly when exacerbated by other clinical conditions such as septicaemia (41). Many studies previously reported shock as one of the most common causes of death in children under SAM treatment (34, 42). It seems imperative to identify and manage early the potential causes of shock in addition to handling the case itself.

The presence of anaemia during admission increased the likelihood of death due to SAM. Anaemia is also one of the most common co-existing clinical conditions with SAM, which might be attributable to micronutrient (especially of iron) deficiency mainly as a result of appetite loss, bacteraemia and/or other possible infections due to depletion of immunity (1, 34). The link between anaemia and death among children under SAM treatment is well established (1, 8, 15, 27, 43–45) suggesting the importance of timely management of the causes as well as the condition in order to enhance effectiveness of the treatment.

Children with TB were more likely to die while taking SAM treatment compared to those without the infection. The risk of TB in children under SAM is high due to lower immunity attributable to SAM itself and other possible co-existing immune suppressing infections such as HIV (30, 46). TB co-existence with SAM severely compromises already weakened immunity and further complicates the condition leading to poor treatment outcome (1, 34). TB is among the known clinical conditions adversely affecting SAM treatment (11, 12, 18, 44, 47) requiring early diagnosis and treatment.

Our study is subject to several limitations. The study did not include treatment defaulters and children who were transferred out who might have different treatment outcomes than those included in the study. The use of medical records as a data source limited our capacity to consider other relevant contextual variables (especially those related to socioeconomic circumstances) in the analyses. Causality between the predictor variables and the outcome variable cannot be claimed as the study analysed the data at point in time. Although it is highly likely that the results are similar in other settings as they are of mostly clinical and physiological conditions, purposeful selection of the health care facilities may limit generalisability of some of the findings.

This study identified a higher prevalence of death among children under SAM treatment in South Ethiopia compared to minimum standards set by international guidelines. Various underlying clinical conditions including: hypothermia, shock, dehydration, anaemia and TB contributed to poor treatment outcome. Implementation of appropriate preliminary management strategies are recommended in order to prevent the clinical conditions from further complicating SAM. Moreover, integrating SAM services into routine community health care system may facilitate early screening and referral of advanced cases.

AOR

Adjusted odds ratio, CI:Confidence interval, HIV:Human immunodeficiency virus

MUAC

Mid upper arm circumference

SAM

Severe acute malnutrition

SPSS

Statistical package for the social science

SSA

sub-Saharan Africa

Tuberculosis

TFU

Therapeutic feeding unit

WFH

Weight for height

Ethics approval and consent to participate

The study obtained ethical approval from the Ethical Review Board of Wachemo University. Formal permissions were obtained from the South Ethiopian Health Bureau and from the authorities of study hospitals. Study specific codes instead of medical identification numbers were used to retrieve data in order to ensure anonymity of information.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Funding

No funding was received for conducting this study.

Author Contribution

TEG conceived the research idea; analysed and interpreted data; drafted the manuscript. TGF, SW, WA and MT participated in the subsequent revisions of the manuscript. All authors read and approved the final manuscript.

Acknowledgement

We would like to thank authorities of participating hospitals for their cooperation and permission to conduct the study.

Data Availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Several underlying clinical conditions influenced treatment outcomes of severe acute malnutrition among under-five children in South Ethiopia: a retrospective cross-sectional study

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Abstract

Background

Methods

Study area and design

Sample size determination

Sampling technique

Data collection procedure

Measurements and variables

Dependent variable

Independent Variables

Data analysis

Results

Socio-demographic characteristics

Clinical characteristics

Treatment outcomes and associated factors

Discussion

Conclusions

Abbreviations

Declarations

Competing interests

Funding

Author Contribution

Acknowledgement

Data Availability

References

Additional Declarations

Status:

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