A hospital based Study on Co-morbidities in children with severe acute malnutrition

Introduction: Severe acute malnutrition, is characterized by wasting (marasmus), oedema (as a result of kwashiorkor), or both (marasmic kwashiorkor), and occurs mostly in children. Globally, co morbidities such as diarrhoea, acute respiratory tract infections and Malaria, which results from a relatively defective immune status, remain the major causes of death among children with severe acute malnutrition. This study was carried out to find out co-morbidities such as infections and micronutrient deficiencies in children with severe acute malnutrition. Methods: In this hospital based descriptive type of observational study, 125 severe acute malnourished children were included. Patients undergo relevant investigation to find out associated infectious co morbidities. Micronutrient deficiencies assessed by clinical signs. Results: 42% had diarrhea and 27% had acute respiratory tract infections as co morbid condition. Tuberculosis was diagnosed in 13% of cases. Anemia was present in 86% cases. Signs of vitamin B and vitamin A deficiency were seen in 24% and 6% cases. 97% children have inadequate vitamin D levels. Conclusions: Timely identification and treatment of various co-morbidities is likely to break undernutrition-disease cycle, and to decrease mortality and improve outcome. Nearly all SAM patients have inadequacy of Vitamin D. So Vitamin D supplement should be given to all SAM patients.


Introduction
Severe Acute Malnutrition (SAM) is defined as a weight for height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid upper arm circumference of less than 110 mm in children age 1-5 years [1]. Severe acute malnutrition, is characterized by wasting (marasmus), oedema (as a result of kwashiorkor), or both (marasmic kwashiorkor), and occurs mostly in children [2].
According to the national family health survey prevalence of severe wasting is 7.9% as per WHO Child Growth Standards [3]. Out of 19 million children suffering from severe acute malnutrition in all developing countries, 8 million are in India, twice than in sub-Saharan Africa. Severe acute malnutrition affects an estimated 20 million children under 5 years of age and is associated with 1-2 million preventable child deaths each year [4].
Severe acute malnutrition (SAM) results from a nutritional deficit that is often complicated by marked anorexia and concurrent infective illness [5]. Similarly, malnutrition increases one's susceptibility to and severity of infections and is thus a major component of illness and death from disease. Globally, comorbidities such as diarrhoea, acute respiratory tract infections and Malaria, which results from a relatively defective immune status, remain the major causes of death among children with SAM [6]. Anemia, Vitamin B complex deficiency, Vitamin D deficiency, Vitamin A deficiency, Scurvy are the common micronutrient deficiencies seen in severe acute malnourished Children [7]. This study was carried out to find out co-morbid ities such as infections and micronutrient deficiencies in children with severe acute malnutrition.

Methods
This study was conducted in the Department of Pediatric Medicine, Sir Padampat Mother and Child Health Institute, attached to SMS Medical College, Jaipur from May 2014 to April 2015. A total of 125 cases presenting with severe acute malnutrition were enrolled of age 6 to 59 months. Severe acute malnutrition among children of six to fifty nine month of age is defined by WHO and UNICEF as any of the following [8]-1. Weight for height below -3 standard deviation of median WHO growth reference 2. Mid upper arm circumference below 11.5 cm 3. Presence of bipedal oedema 4. Visible severe wasting Children whose guardians refuse to give positive consent and those who died before taking necessary investigations were excluded. Children with major congenital malformations and those with chronic systemic diseases such as chronic kidney disease, chronic liver disease were also excluded.
This study was descriptive type of observational study. The clinical and the demographic information were recorded on a pre-structured proforma, together with the detail history, physical and detailed systemic examination.
Weight, length/height, Mid-Upper Arm Circumference (MUAC) and weight for height/ length were determined from each study participant. Socioeconomic status of study subjects was assessed as advised by Modified Kuppuswamy scale of social classification which is based on occupation, education of the parents and income of the family [9]. Contact with tuberculosis was determined by either contact with open case of pulmonary tuberculosis recently or if there is history that the child was in contact of open case of tuberculosis in last two year of time. Immunization status of study subjects was assessed as per schedule of National Immunization Programme (NIP) [10].
Infectious co morbidities defined as per following criteria-Diarrhoea was defined as three or more loose stools per day for any time duration. Persistent diarrhoea was defined as an episode of diarrhoea, of presumed infectious etiology, which starts acutely but lasts for more than 14 days. Chronic diarrhoea was defined as insidious onset diarrhoea of >2 weeks duration in children. Acute respiratory tract infection was defined as short duration of cough (< 2 weeks) or respiratory difficulty, age-specific fast breathing (above normal for age category), auscultatory and/or chest x-ray findings.
UTI (Urinary tract infection) was diagnosed on the basis of suggestive clinical symptoms along with positive urine culture report. Measles was defined as generalized maculopapular rash lasting for ≥ 3 days, fever (≥ 38.3°C, if measured) along with cough, coryza (i.e. runny nose) or conjunctivitis (i.e. red eyes). Meningitis was diagnosed on the basis of suggestive clinical features and confirmed by CSF examination and neuroimaging.
Indian Academic of Peadiatric algorithm was applied to diagnose the tuberculosis in children in this study [11]. Anaemia was defined on the basis of WHO reference values of hemoglobin (Hb) in children in age group of 6 to 59 months [12].

Anemia
Hb level (gm/dl) Mild Moderate Severe 10 -10.9 7 -9.9 < 7 Micronutrient deficiencies were assessed by clinical signs during general physical examination in these children except Vitamin D status which was determined by laboratory test. Vitamin A deficiency defined clinically by presence of night blindness, Bitot's spots, corneal xerosis and/ or ulcerations, corneal scars caused by keratomalacia. Vitamin B complex deficiency defined clinically by presence of angular stomatitis, cheilosis, glossitis, dermatitis, tingling/numbness in the extremities. Scurvy defined clinically by gum bleeding, loose teeth, Joint pains, Dry scaly skin, delayed wound-healing with suggestive findings of X-ray long bones.
Vitamin D status (25 Hydroxy Vitamin D) in study subjects was determined by laboratory test by chemiluminescence method using ADIVA CENTOR XP machine. Vitamin D deficiency is defined as serum levels of 25(OH)D less than 20 ng/dL whereas 21-29 ng/dL is considered to be insufficient [13].
A written, informed consent was obtained from parents. Clearance from Departmental Ethics Committee was taken prior to the start of the study. All participants had the option to withdraw from the study anytime during their hospital stay.
All filled questionnaires were checked and coded on Microsoft Office Excel Worksheet and any missing data or information was actively searched from patient's files. Descriptive cross tabulations were formed to examine for associations.

Results
Baseline characteristics-In this study, 125 children with severe acute malnutrition were included. Among the cases, 30 (24%) were completely immunized, 82 (65%) were partially immunized while 13 (10%) were unimmunized. 95 (76%) children were found to receive exclusive breast feeding till 6 month of age. While complimentary feeding started in only 31 (25%) children at 6 month of age. History of contact with tuberculosis was present in 17 (14%) children. (Table no.

1)
Clinical data-The most common presenting complaint which was seen in current study was fever. That was present in 93 (74.4%) of cases. Other more common presenting complaints in study subjects were loose motion in 55(44%), cough in 51 (40.8%), decreased oral acceptance in 32 (25.6%), vomiting in 28 (22.4%). 25(20%) children presented with Respiratory distress. Other less common presenting complaints were irritability in 19 (15.2%) children, swelling over body either localized or generalized in 17 (13.6%) children, Seizures of any type in 11 (8.8%) children and rashes over body in 6 (4.8%) children. (Table no.

Discussion
Severe acute malnutrition is a well recognized emergency situation with substantial morbidity and mortality that requires immediate and effective treatment. Prompt initiation of appropriate treatment of both complications such as hypoglycemia, hypothermia, dehydration, electrolyte imbalance, infections and the underlying cause can significantly reduce associated morbidity and mortality.
Most of the studies are related to infectious comorbidities while only few studies are related to micronutrient deficiencies in severely malnourished children. Mean age of children reporting with malnutrition was similar to other studies and there was significant male predominance in malnourished children [14].
This may be due to ignorance about the health checkups of female children. However, no definite causal relationship was found for this male preponderance. Our study show less coverage of immunization in our study area which is likely due to ignorance and unawareness about immunization.
In our study about two third children had the history of recurrent hospitalization; either by same illness or other illness. In study by Yoann Madec el al history of recurrent hospitalization was present in 4.7% children only [15]. Unhygienic living conditions and poor socioeconomic status may be the cause of increased rate of hospitalization in our study subjects. Rate of exclusive breast feeding found to be more in our study but weaning not started at recommended age which is predisposing factor for malnutrition. In present study, Diarrhoea was found to be the most common infectious co-morbidity. Acute respiratory tract infections were found to be the second most common co-morbidity followed closely by tuberculosis. In a Colombian study, 68.4% of malnourished children were suffering from diarrhea and 9% had sepsis at the time of admission [16].
Two African studies also showed high incidence of diarrhea in SAM children of 49% and 67% [17,18].Though previous reports have described malnutrition as an important risk factor for pneumonia than for diarrhea [19], diarrhea was the major co-morbid condition found in our study. A study from Africa also reported a comparable incidence of respiratory illness and tuberculosis (18% each) in admitted SAM Children [20]. Measles has severe consequences on the nutritional status. A previous Indian study [8] showed only 3.8% of children with past history of measles but we found a higher proportion. Malaria and HIV infection were previously reported as major co-morbidities with total prevalence of 21% and 29.2%, respectively [21] but In our study malaria, HIV were not found to be as comorbid condition.
Overlapping nature of protein-energy malnutrition and micronutrient deficiencies is well understood and it is seen that lack of one micronutrient is typically associated with deficiency of others [22]. Anemia and vitamin D deficiency were the two most common micronutrient deficiencies associated with malnutrition in our study, and this is consistent with the previous reports [23].
In previous studies vitamin D status is accessed by clinical examination and radiological findings but in our study vitamin D status is accessed by laboratory test. So we found higher incidence of Vitamin D deficiency. Absence of a comparative group, no biochemical evaluation for micronutrient deficiencies and nonassessment of contributing factors for these deficiencies were the main lacunae of the study.
Our institute is the only referral centre and the major hospital that provides primary to tertiary care for children in this region. The geographic location of our hospital may have led to an enrollment bias.
Our study suggest that malnutrition is predicted by age less than two years, failure to start complimentary feeding at recommended age, recurrent hospitalization, taking unbalanced diet, lack or incomplete immunization and lower socioeconomic status.

Conclusion
Apart from nutritional rehabilitation, timely identification and treatment of co-morbidities like diarrhea, acute respiratory tract infection, anemia and micronutrient deficiencies is vital in malnourished children, so as to break undernutrition-disease cycle, and to decrease mortality and to improve outcome.
Nearly all SAM patients have inadequacy of Vitamin D. So Vitamin D supplement need to be given to all SAM patients.
Funding: Nil, Conflict of interest: None initiated, Perission from IRB: Yes