Bryan J Vonasek1, Msandeni Chiume2,3, Heather L Crouse1, Susan Mhango4, Alexander Kondwani2, Emily J Ciccone5, Peter N Kazembe6, Wilfred Gaven7, Elizabeth Fitzgerald8. 1. Department of Pediatrics, Baylor College of Medicine, Houston, USA. 2. Department of Paediatrics, Kamuzu Central Hospital, Lilongwe, Malawi. 3. College of Medicine, University of Malawi, Lilongwe, Malawi. 4. Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi. 5. Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA. 6. City Centre Clinic, Lilongwe, Malawi. 7. Malawi College of Health Sciences, Lilongwe, Malawi. 8. Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, USA.
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.
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.
Entities:
Keywords:
Malawi; Mortality; clinical risk factors; quality of care; severe acute malnutrition
Authors: Emily J Ciccone; Alyssa E Tilly; Msandeni Chiume; Yamikani Mgusha; Michelle Eckerle; Howard Namuku; Heather L Crouse; Treasure B Mkaliainga; Jeff A Robison; Charles J Schubert; Tisungane Mvalo; Elizabeth Fitzgerald Journal: BMJ Glob Health Date: 2020-07