Comorbidities and Factors Associated with Mortality among Children under Five Years Admitted with Severe Acute Malnutrition in the Nutritional Unit of Jinja Regional Referral Hospital, Eastern Uganda

The Spectrum of Pathogens Associated with Infections in African Children with Severe Acute Malnutrition: A Scoping Review

Understanding the interplay between infections and severe acute malnutrition is critical in attaining good clinical outcomes when managing malnourished children. However, review studies describing the profile of the associated pathogens in the malnourished African paediatric population are sparse in the literature. We aimed to identify the spectrum of pathogens from studies reporting infections in severely malnourished African children, as well as the antibiotic resistance pattern and clinical outcomes. A systematic literature review of the PubMed database was conducted following PRISMA guidelines from January 2001 to June 2024. The search algorithm was ((marasmus) OR (kwashiorkor) OR (severe acute malnutrition) OR (protein energy malnutrition)) AND (Africa). For a more comprehensive retrieval, an additional search algorithm was deployed: ((HIV) OR (tuberculosis)) AND (severe acute malnutrition). We included 60 studies conducted between 2001 and 2024. Most of the studies were from East Africa (n = 45, 75%) and Southern Africa (n = 5, 8.3%). A total of 5845 pathogens were identified comprising 2007 viruses, 2275 bacteria, 1444 parasites, and 119 fungal pathogens. The predominant pathogens were HIV, Mycobacterium tuberculosis, and malaria parasites accounting for 33.8%, 30%, and 24.2% of pathogens identified. Antibiotic susceptibility testing was documented in only three studies. Fatality rates were reported in 45 studies and ranged from 2% to 56% regardless of the category of pathogen. This review affirms the deleterious effect of infections in malnourished patients and suggests a gross underdiagnosis as studies were found from only 17 (31.5%) African countries. Moreover, data on fungal infections in severely malnourished African children were nearly absent despite this population being at risk. Thus, there is an urgent need to prioritize research investigating African children with severe acute malnutrition for fungal infections besides other pathogens and improve the availability of diagnostic tools and the optimized usage of antibiotics through the implementation of antimicrobial stewardship programmes.

Severe acute malnutrition among children under the age of 5 years

BACKGROUND

Severe acute malnutrition (SAM) poses a significant threat to child health globally, particularly in low- and middle-income countries. Zambia, like many Sub-Saharan African nations, faces high rates of child malnutrition, with SAM contributing significantly to under-five mortality. Therefore, this study aimed to determine the prevalence and factors associated with SAM.

METHODS

This retrospective cross-sectional study was conducted at Livingstone University Teaching Hospital in Zambia (LUTH). SAM was defined according to the World Health Organization (WHO) criteria as either weight-for-height less than -3 standard deviations, mid-upper arm circumference (MUAC) less than 115 mm, or presence of bilateral pitting edema in children between 6 months and 5 years old who were attended to between 2020 and 2022. Data abstraction from pediatric patient records was conducted between August 2023 and January 2024. The records without the age and outcome variable were excluded. A total of 429 participants between 6 months and 5 years old were included, with demographic, clinical, and hematological parameters analyzed. Univariable and multivariable logistic regression were employed to investigate factors associated with SAM.

RESULTS

Overall, 429 medical records were included in the study and the prevalence of SAM was 27.0% (n = 116). Age group 6-24 months (Adjusted Odds Ratio [AOR]: 11.60; 95% Confidence Interval [CI]: 3.34-40.89, p<0.001), living with HIV (AOR:3.90; 95% CI: 1.14-13.70, p = 0.034), Tuberculosis (TB) (AOR:22.30, 95% CI: 4.53, 110.3, p < 0.001), comorbidities (AOR: 2.50; 95% CI 1.13, 5.88, p = 0.024) and platelet count (AOR: 1.00; 95% CI 1.00, 1.00, p = 0.027) were positively associated with SAM.

CONCLUSIONS

This study found a high prevalence of SAM, exceeding the WHO target of reducing SAM to 5% by 2025. SAM was associated with younger age (6-24 months), HIV infection, TB, comorbidities and platelet count. Therefore, there is need to enhance strategies aimed at reducing SAM among young children, children living with HIV, TB and comorbidities, particularly by intensive treatment, continuing and strengthening nutrition services.

Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries

In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).

Survival Status and Predictors of Tuberculosis Development Among Under 5 Children Admitted With Severe Acute Malnutrition in Ethiopia: A Retrospective Cohort Study

Introduction. The burden of severe acute malnutrition (SAM) remains unacceptably high worldwide. The burden of Tuberculosis (TB) co-occurring with SAM in under 5 children is a significant focus for the improvement of child health. The co-existence of these diseases are significantly enhancing the associated morbidity, mortality, and hospitalization costs among this population. Objective. To determine survival status and predictors of TB development in under 5 children with SAM in Asella Referral and Teaching Hospital, Ethiopia. Methods. A retrospective cohort study was done in 247 under 5 children with SAM between January 01/2018 and December 31/2022. Systematic sampling technique was used to select the study participants. Data extraction format was used to collect data from the patient's medical chart. EpiData version 4.6.0.6 was used for data entry and exported to STATA version 14.2 for statistical analysis. Result. This study includes 247 under 5 children with SAM with a response rate of 100%. Regarding to the survival status; 24(17%) of under 5 children with SAM have developed the events (TB) and the rest of them, 205(83%) were censored. The incidence density rate (IDR) of TB in under 5 children with SAM was 45.51 per 100 (95% CI: 33.63, 61.58) children-months observation. The cumulative incidence of TB was 17% (95% CI: 12.79, 22.25). Multivariable Cox proportional hazard analysis revealed that: having a history of TB contact (AHR = 5.56, 95% CI: 2.77, 11.15, P-value = .000), having a history of bottle feeding (AHR = 4.95, 95%CI: 1.08, 22.77, P-value = .040), did not take F100 (AHR = 1.71, 95% CI: 1.12, 7.25, P-value = .00) were statistically significant predictors of TB development. Conclusion. This study shows that the IDR of TB was high. Having a history of TB contact, history of bottle feeding, and not taking F100 were significant predictors of TB development. It is vital to address these predictors to prevent the development of TB in this population. Moreover, early screening of TB in these children should get high emphasize.

Prevalence and Determinants of Diarrhea, Fever, and Coexistence of Diarrhea and Fever in Children Under-Five in Bangladesh

Diarrhea and fever are prevalent childhood illnesses with potentially severe consequences, especially when they co-occur. This study investigates the prevalence and determinants of diarrhea, fever, and their coexistence among children under-five in Bangladesh. Data from the 2017-2018 Bangladesh Demography and Health Survey (BDHS) were analyzed using multivariable stepwise logistic regression with backward selection. This study found that 5.0% for diarrhea, 34.0% for fever, and 3.0% for the coexistence of both illnesses. Common factors associated with childhood diarrhea and fever included the child's age (12-23 months), and the mother's education. Diarrhea was associated with households with improved water sources and children in the Barisal division, while fever was linked to underweight children and those from more affluent backgrounds. The coexistence of both was significantly linked to underweight children, higher birth orders, and children from the Rajshahi division. Notably, child illnesses were associated with parental education, higher socio-economic status, and access to improved drinking water sources. Diarrhea affects one in 20 children, fever affects one in three, and the coexistence of both conditions affects one in 35 children in Bangladesh. The findings need further research and policy reviews to develop effective interventions and improve child health in Bangladesh.

Anemia in African malnourished pre-school children: A systematic review and meta-analysis

Generating accurate epidemiological data on the magnitude of anemia in malnourished children is a vital step for health policymakers. Therefore, this study is aimed to synthesize the overall magnitude of anemia in African malnourished pre-school children. We have searched the databases PubMed/MEDLINE, Embase, Scopus, Web of Science, Google Scholar, and Google to identify relevant articles. Joana Brigg’s Institute critical appraisal tool was used to assess the quality of articles. A random-effects model was applied to estimate the pooled prevalence of anemia in malnourished children. The I2 statistics were used to examine heterogeneity among the included studies. In the presence of heterogeneity, a subgroup analysis has been used. The funnel plot analysis and Egger’s tests were used to investigate the presence of publication bias. A total of 15 articles with 12,211 study participants were included in this study. Anemia was observed in 57.53% (95% CI: 47.05, 68.01) of African malnourished pre-school children. Moreover, the prevalence of anemia was 58.52% (95% CI: 43.04, 73.81) and 56.18% (95% CI: 40.24, 72.13) in HemoCue and auto-machine diagnosis method of anemia, respectively. This review showed that the magnitude of anemia was high among African malnourished pre-school children. Therefore, planning preventive measures to decrease anemia and its complications in malnourished children in Africa is an important step.

Incidence and predictors of severe acute malnutrition mortality in children aged 6-59 months admitted at Pawe general hospital, Northwest Ethiopia

Background

Severe acute malnutrition (SAM) is defined as a weight-for-height < -3z scores of the median WHO growth standards, or visible severe wasting or the presence of nutritional edema. SAM related mortality rates in under-five children are well documented in Ethiopia but data on their predictors are limited. We aimed to document factors associated with SAM related mortality to inform better inpatient management.

Methods

A facility-based retrospective cohort study was conducted among children admitted due to SAM at Pawe General Hospital, Northwest Ethiopia, from the 1^st of January 2015 to the 31^st of December 2019. Data from the records of SAM children were extracted using a standardized checklist. Epi-Data version 3.2 was used for data entry, and Stata version 14 was used for analysis. Bi-variable and multivariable Cox regression analyses were conducted to identify predictors of mortality. Variables with P<0.05 were considered significant predictors of mortality.

Results

Five-hundred sixty-eight SAM cases were identified of mean age was 27.4 (SD± 16.5) months. The crude death rate was 91/568 (16.02%) and the mean time to death was determined as 13 (±8) days. Independent risk factors for death were: (i) vomiting AHR = 5.1 (1.35–21.1, p = 0.026), (ii) diarrhea AHR = 2.79 (1.46–5.4, p = 0.002), (iii) needing nasogastric therapy AHR = 3.22 (1.65–6.26, p = 0.001), (iv) anemia AHR = 1.89 (1.15–3.2, p = 0.012), and (v) being readmitted with SAM AHR = 1.7 (1.12–2.8, p = 0.037).

Conclusion

SAM mortality was high in under-five children in our setting. The identified risk factors should inform treatment and prevention strategies. Improved community health education should focus on healthy nutrition and seeking early treatment. Inpatient mortality may be reduced by stricter adherence to treatment guidelines and recognizing early the key risk factors for death.

Determinants of Mortality Among Severely Malnourished Children in Northern Nigeria

Objectives

Severe Acute Malnutrition is a significant cause of mortality in children under the age of 5 years in low-resource settings, including Northern Nigeria. The study aimed to determine the associations between selected risk factors and mortality outcomes in children admitted with SAM in a facility in Katsina State, Northern Nigeria.

Methods

A prospective observational cohort of 201 children aged 6 to 59 months who were admitted with severe acute malnutrition (SAM) in stabilization centers in Katsina State, Northern Nigeria between May 18, 2021, and July 20, 2021, (63 days) were assessed followed up. Outcomes were analyzed using Kaplan-Meir analysis to estimate time to death, and Cox proportional-hazard regression model was used to determine predictors of mortality.

Results

The log-rank test showed significant differences in the probability of death between categories of diarrheal status (log-rank statistic = 9.760, P = .021) and presence of existing disease (comorbidity) (log-rank statistic = 5.338, P = .021). The study identified that severely malnourished children admitted with comorbidities showed significant association with time to event (death) (AHR: 4.109, 95% CI: 1.51, 32.60). The estimated mean time until death was 57.9 days (±3.0) for children without comorbidities and 20.1 (±3.0) days for children with comorbidities. The median survival time was 18 days for children with comorbidities.

Conclusion

The presence of comorbidities was significantly associated with mortality. Severely malnourished children with comorbidities had 4 times higher mortality risk than severely malnourished children admitted without comorbidities. Clinicians and health workers should give due emphasis to the early detection and effective management of comorbidities in children with severe acute malnutrition.