Study area and period
Institution based retrospective cohort study was conducted from January 2017 to June 2018. The study was conducted at The Indus Hospital, which is a tertiary care facility in the suburbs of Karachi, Pakistan. Around 1200-1300 malnourished children are seen annually in this hospital, which include a mix of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). Community based rehabilitation of uncomplicated malnourished children is done in outpatient department of Indus Hospital by counseling and recommendation of fortified home-based staple diet plans with regular follow up.
Sample size and sampling procedure
All children with ages ranging from 6–59 months with malnutrition, that had been treated at Indus nutrition rehabilitation clinic (NRC), from January 2017 to June 2018were included in the study. Those children who did not have proper records were excluded from the study. Children with secondary malnutrition due to other medical conditions or children who had edema due to other causes were also excluded from the study.
Nutrition rehabilitation clinic (NRC) is conducted twice weekly in the outpatient department of Indus Hospital. The clinic caters to malnourished children with ages ranging from 6 month- 5 years. Malnutrition is diagnosed based on weight, height and mid upper arm circumference cut-off values prescribed by WHO. At enrollment nutritional details of each child is recorded on pilot tested, predesigned questionnaire which includes nutritional history and details of physical examination. Examination is done for anthropometry and clinical features like edema, dermatosis, anemia, rickets and eye changes. If there are clinical signs of malnutrition, then relevant labs are sent. Children with rickets and anemia are treated with oral iron and vitamin D3 supplements. The dosages of iron and vitamin D are prescribed according to WHO protocols. If there is severe anemia children are transfused. Vitamin B12 deficiency is treated with oral Cobalamin according to institutional protocol. All the malnourished children are given multiple micronutrient powder (MNP) and zinc supplements. Antibiotics are given when needed.
Mothers are counseled on age appropriate feeding practices and hygiene strategies through Infant young child feeding practices (IYCF) counseling cards. Caregivers are counseled on preparing recipes of various nutrient dense home-based diets. The diet plans are made by the nutritionist at Indus hospital using ingredients which are indigenous and available in normal households. Demonstration for quantity and texture of food is done by showing spoons and measuring cups. Brochures containing pictorial and written instructions in Urdu are also given to the mothers. Meal frequencies ranging from 2-6 times per day are advised based on age of child. For non-breast-fed children milk and milk products are added. About 150-220 Kcal/kg/day of calories and 3-5 g/kg/day of proteins are advised. Calories and proteins are gradually escalated in the diet.
Children are regularly followed according to severity of malnutrition. Moderately malnourished children are followed 3 weekly whereas severely malnourished children are followed fortnightly. At every follow up visit history taking and physical examination is done along with nutritional counseling. If a child is absent for 6 consecutive weeks, then he is considered as defaulter. The child is considered recovered when weight for height/length Z- score is >-1.0 SD, or mid upper arm circumference is > 12.5 cm, whichever comes first. The children after recovery are followed for 2 months to ensure continuous weight gain.
Severe acute malnutrition (SAM): SAM is labeled if any of the three criteria is present (i) weight for height/length Z- score <-3.0, or (ii) mid upper arm circumference <11.5 cm, or (iii) pitting pedal edema (3).
Moderate acute malnutrition (MAM): MAM is labeled if weight for height/length Z- score is <-2.0, or (ii) mid upper arm circumference is between 11.5- 12.5 cm (3).
Anemia: Severe when hemoglobin is less than 6 g/dl and moderate when hemoglobin level is between 6.1-11 g/dl (3).
Vitamin B12 deficiency: Plasma vitamin B 12 level < 203 pg/mL (12).
Rickets: Serum 25(OH) D levels at < 30 nmol/L with or without clinical signs of Rickets (13).
Weight gain: Weight gain is calculated in g/Kg/day. 5g/kg/day is considered adequate weight gain (14).
Edema: Presence of pitting edema on dorsum of feet or shin of legs or peri-orbital edema
Data collection procedure
A structured data abstraction form was used for data collection. Data was gathered for demographic characteristics, feeding, micronutrient, anthropometric and nutritional details at enrollment and on follow-up. Data was collected by nutritionists and doctor. The data abstraction form was adopted from WHO guidelines (3) and Sphere standard for management of severe acute malnutrition (14).
Data management and analysis
The statistical analysis was performed using Stata 16.0 software. Normality assessment of continuous variables was done on the basis of skewness and kurtosis. Normally distributed variables were reported as mean [SD] whereas median (IQR) was calculated for skewed variables. Paired T test was applied to compare the entry and exit variables for normally distributed variables, while Wilcoxon sign rank test was used for non-normal data. The categorical data was presented as frequencies and percentages. McNemars test was applied to measure the difference between (2x2) variables, whereas others with more than two categories were assed via McNemars Bowker test. P value < 0.05 was considered to be significant.