Clinical profile and outcome of children with severe acute malnutrition

Das K1, Swain A2, Nayak A.S.3, Behera S.4, Satpathy S.K.5

1Dr. Kedarnath Das, Associate Professor, 2Dr. Arakhita Swain, Associate Professor, 3Dr. Alok Satyaprakash Nayak, Senior Resident, 4Saiprasanna Behera, Research Associate in Paediatrics, 5Dr. S.K. Satpathy, Professor, All authors are affiliated with Department of Pediatrics, SCB Medical College and S.V.P. P.G. Institute of Pediatrics, Cuttack, Odisha, India.

Address for Correspondence: Dr. Kedarnath Das, Associate Professor, Department of Paediatrics, SCB Medical College and S.V.P.P.G. Institute of Pediatrics, Cuttack, Odisha. E-mail id dr.kedar2008@gmail.com

Abstract

Introduction: Severe Acute Malnutrition (SAM) is a unique type of severe malnutrition and is different from severe underweight and severe stunting. This study evaluated the clinical manifestations among the children admitted to the SCB medical college and SVP PGIP and elucidated further the factors associated with severe malnutrition among the undernourished children and finally the outcome in terms of cured or mortality. Materials and Methods: This hospital-based cross-sectional time-bound study with follow-up component was conducted by using technique of sampling without replacement. Children aged 1-60 months admitted to SCB MCH and SVPPGIP during September 2013 to September 2015, having features of SAM were considered for the study population. After detailed history and physical examination, relevant investigations were done and critical analysis made. Results: Total 130 patients with SAM constituted the study population. The overall prevalence of SAM was 2.5 %. Majority were non edematous SAM (Marasmus) (77%) and rest were oedematous (Kwashiorkor).There was no variation in sex as both male and female patients were with equal percentage (50%). About 12.3 % of children with SAM were less than 2 months, 47.7 % between 2 to 12 months, and 40% were above 12 months. Conclusion: Malnutrition is predicted by age less than two years, living with single parent, taking unbalanced diet, lack or incomplete immunization and low level of maternal education. Co-morbidities associated with malnutrition were pneumonia, pulmonary tuberculosis, urinary tract infection. Mortality is predicted by age less than one year, peasant parents, having severe malnutrition, dehydration, hypothermia, and hypoglycemia.

Keywords: - Severe Acute Malnutrition, Marasmus, Kwashiorkor

Manuscript received: 4th May 2017, Reviewed: 14th May 2017
Author Corrected: 22nd May 2017, Accepted for Publication: 29th May 2017

Background

Malnutrition is one of the leading causes of morbidity and mortality in children throughout the world. In the developing world, prevalence of malnutrition among under-fives is 41% with an estimated 230 million (39%) children being chronically malnourished [1, 2]. It is responsible for 60% of the 10 million deaths annually among children under five [3]. In India; more than 33% of under 5 deaths are associated with malnutrition [4]. Severe Acute Malnutrition (SAM) is a unique type of severe malnutrition and is different from severe underweight and severe stunting. It affects about 20 million children globally and contributes to an estimated one million deaths every year [5]. In India, 6.4% of under–5 children suffer from SAM [4, 6].

Severe acute malnutrition (SAM) is defined by very low weight-for-height/length (Z- score below -3 SD of the median WHO child growth standards), or a mid-upper arm circumference < 115 mm, or by the presence of nutritional edema [4]. The spectrum includes severe as well as mild forms [7]. The case fatality rate in SAM can be brought down to 7-10% from the present rate of 23.5% to 50% [4]. SAM significantly increases the risk of death in children less than five years of age.

In Odisha the prevalence of under nutrition is still high. Data from UNICEF global database on child malnutrition showed that 10% of under-fives were moderately and severely wasted [8]. Abrupt weaning with diluted animal milk and lack of breast-feeding contribute to malnutrition in the first year of life, while in the second year it is due to the inadequate intake of protein and calories, which lead to starvation [9]. Malnourished survivors are left with mental developmental delay, poor school performance and reduced intellectual achievements [2,10,11,12].

There is paucity of data regarding prevalence, clinical manifestation and outcome of SAM in Odisha. This study therefore is aimed at determining the prevalence, clinical manifestation, outcome and the predictors of death among undernourished children admitted to SCB MEDICAL COLLEGE and SVPPGIP.

Aims and Objectives

To determine the:-
1. Prevalence of severe malnutrition among undernourished children,
2. Risk factors associated with SAM children,
3. Common co-morbidities in severe malnourished children, and
4. Outcomes of children with SAM, aged 1-60 months admitted to SCB medical college and SVPPGIP paediatric wards.

Materials and Methods

This hospital-based, cross-sectional, time bound, study with follow up component was conducted at SCB Medical College and SVPPGIP during a period extending from September 2013 to September 2015.The sampling technique adopted was “Sampling without Replacement”.

All children aged 1 to 60 months, diagnosed with severe malnutrition were admitted for care and follow up in the general ward if any complications are present or in the Nutrition Rehabilitation Center (NRC) if no complications. All were screened for their nutritional status and those found to have severe acute malnutrition were included in this study after fully satisfying the following criteria.
A) For infants 6 months to 5 years, a) Weight-for-height less than -3 SD and/or b) Visible severe wasting and/or Mid Upper arm circumference (MUAC) < 11.5 cm and/or c) Nutritional edema of both feet.
B) For infants <6 months of age, with length more than 49cm a) Weight-for-length less than -3 SD and/or, b) Visible severe wasting and/or Nutritional edema of both feet.
C) For infants < 6 months of age, with length less than 49cm, if there was severe visible wasting.

Following children were excluded from the study:-
a) Causes of Severe Acute Malnutrition like cleft lip, cleft palate, GERD, pyloric stenosis and other surgical condition, chronic renal failure, congenital heart diseases, liver disorders, asthma, mental retardation, cerebral palsy, suspected cases of inborn error of metabolism etc.
b)  Children of less than 1 month of age and more than 5 years of age.
c)  Other causes of edema like Nephrotic Syndrome.
d)  Refusal of consent by parents or caregivers.

Out of 11,000 children (aged 1- 60 months) admitted during September 2013 to September 2015, 275 children were having features of SAM. 133 children were excluded basing on exclusion criteria. Out of rest 142 children having features of severe acute malnutrition, 12 cases left against medical advice leaving 130 cases for the final study.

Results

The overall prevalence of severe acute malnutrition in our study population is 2.5%. Among 130 cases of SAM, majority were non edematous SAM (Marasmus) (77%) and rest (23%) belonged to oedematous SAM (Kwashiorkor).

There is no variation in sex both males and females being equally distributed. About 12.3 % children with SAM belonged to age group < 2 months, 47.7% between 2 months to 12 months whereas 40% were above 12 months. Low birth weight (14.6%), absence of exclusive breast feeding up to 6 months of age (45.4%), Delayed introduction of complimentary feeding beyond 6 months with inadequate quantity and improper dilution (10.8%) and incomplete immunization (20%) were major risk factors for SAM (Figure 1). About 50.8 % presented with Lethargy, 35.4 % had Skin changes, 34.6 % had Diarrhoea, and 33.8 % had Fever and 30.8 % Cough. Visible Severe Wasting, Hair changes, Oedema, Vomiting, Dehydration and Shock were presenting features in 30 %, 24.6 %, 23 %, 22.3 %, 15.4 % and 10.8 % respectively. (Figures 2 and 3).

Among the co-morbid conditions precipitating the SAM, UTI (83.8 %) was the commonest followed by Anaemia (48.5 %) and Hypoglycaemia (15.4 %) (Table 1). Mantoux test was reactive and chest x-ray was abnormal with positive contact history in 3.1% of the study population suggesting Tuberculosis.

The various predictors of outcome in SAM in our study population were found by descriptive statistical analysis. The various clinical manifestations having significant relationship with outcome in this study population of 130 SAM patients are vomiting (p=0.004), dehydration (p=0.001) shock (p=0.001), edema (p=0.037) acute respiratory tract infection (p=0.011), hair changes (p=0.001) lethargy (p=0.001). Among various socio-demographic factors, only exclusive breast feeding is having significant association with outcome (p=0.016). Of various co-morbidities and laboratory parameters, hypoglycaemia (p=0.001) mantoux status (p=0.007) CRP status (p=0.001) chest X-ray finding (p=0.001) and blood culture (p=0.001) are having significant association with outcome in our study.

But age class, sex, exclusive breast feeding, socio-economic status, skin changes, hair changes, anaemia, UTI, kidney and renal dysfunction does not have significant association with outcome in our study as p value in all these cases are >0.05.

figure01
Figure 1- Risk Factors of SAM in the Study Population (N=130)

 figure02
Figure 2- Clinical Manifestations of SAM in the Study Population (N=130)

 figure03
Figure 3: Clinical Manifestations of SAM in the Study Population (N=130)

Table No-1: Categorisation of study population according to co-morbidities (n=130)

Variables

 

Frequency

Percentage (%)

Hypoglycemia

Present

20

15.4

Absent

110

84.6

Anaemia

Present

63

48.5

Absent

67

51.5

UTI

Present

21

83.8

Absent

109

16.2

Table-2: Outcome in Relation to Baseline Characteristics in the Study Population (N=130)
    

Variables

 

Outcome

P Value

Cured (n=117) (%)

Death (n=13) (%)

Age class

<2 months

14 (12%)

2 (15.4%)

0.776

>2 months-<12 months

55 (47%)

7 (53.8%)

12months to 60 month

48 (41%)

4 (30.8%)

Sex

MALE

59 (50.4%)

6 (46.2%)

0.77

FEMALE

58 (49.6%)

7 (53.8%)

Low Birth Weight

yes

18 (15.4%)

1 (7.2%)

0.456

No

99 (84.6%)

12 (92.3%)

Exclusive Breast Feeding

yes

68 (58.1%)

3 (23.1%)

0.016

No

49 (41.9%)

10 (76.9%)

Delayed Complimentary Feeding

yes

13 (11.1%)

1 (7.7%)

0.706

No

104 (88.9%)

12 (92.3%)

Complete Immunization

yes

94 (80.3%)

10 (76.9%)

0.77

No

23 (19.7%)

3 (23.1%)

Socio Economic Status

upper

3(2.6%)

0(0.0%)

0.482

upper middle

33(28.2%)

1(7.7%)

lower middle

47(40.2%)

7(53.8%)

upper lower

32(27.4%)

5(38.5%)

lower

2(1.7%)

0(0.0%)

Latrine

present

32(27.4%)

1(7.7%)

0.122

absent

85(72.6%)

12(92.3%)

Diarrhoea

present

39(33.3%)

6(46.2%)

0.357

absent

78(66.7%)

7(53.8%)

Vomiting

present

22(18.8%)

7(53.8%)

0.004

absent

95(81.2%)

6(46.2%)

Dehydration

present

13(11.1%)

7(53.8%)

0.001

absent

104(88.9%)

6(46.2%)

Shock

yes

3(2.6%)

11(84.6%)

0.001

no

114(97.4%)

2(15.4%)

Fever

present

37(31.6%)

7(53.8%)

0.108

absent

80(68.4%)

6(46.2%)

Edema

present

24(20.5%)

6(46.2%)

0.037

absent

93(79.5%)

7(53.8%)

Acute Respiratory Tract Infection

present

32(27.4%)

8(61.5%)

0.011

absent

85(72.6%)

5(38.5%)

Skin Changes

present

39(33.3%)

7(53.8%)

0.142

absent

78(66.7%)

6(46.2%)

Hair Changes

present

24(20.5%)

8(61.5%)

0.001

absent

93(79.5%)

5(38.5%)

Signs of vitamin deficiency

present

21(17.9%)

4(30.8%)

0.266

absent

96(82.1%)

9(69.2%)

Visible Severe Wasting

present

33(28.2%)

6(46.2%)

0.18

absent

84(71.8%)

7(53.8%)

Lethargy

present

53(45.3%)

13(100%)

0.001

absent

64(54.7%)

0(0.0%)

Hypoglycemia

present

11(9.4%)

9(69.2%)

0.001

absent

106(90.6%)

4(30.8%)

Anemia

present

57(48.7%)

6(46.2%)

0.861

absent

60(51.3%)

7(53.8%)

Mantoux

positive

2(1.7%)

2(15.4%)

0.007

negative

115(98.3%)

11(84.6%)

CRP

positive

40(34.2%)

11(84.6%)

0.001

negative

77(65.8%)

2(15.4%)

Chest x ray

normal

98(83.8%)

6(46.2%)

0.001

abnormal

19(16.2%)

7(53.8%)

Renal function

Normal

114(97.4%)

12(92.3%)

0.31

Abnormal

3(2.6%)

1(7.7%)

Liver function

Normal

116(99.1%)

12(92.3%)

0.057

Abnormal

1(0.9%)

1(7.7%)

Urinary tract infection

Present

19(16.2%)

2(15.4%)

0.937

Absent

98(83.8%)

11(84.6%)

Blood culture

Positive

7(6.0%)

11(84.6%)

0.001

Negative

110(94.0%)

2(15.4%)

Discussion

In this study population comprising of 130 cases of SAM, majority were non edematous SAM (Marasmus) (77%) and rest (23%) were oedematous (Kwashiorkor). Similar results were found in studies by Amsalu et alin North West Ethiopia with marasmus (75%) and kwashiorkor (25%) [3]. In this study population, there is no variation in sex as both male and female patients were with equal percentage (50%) which was the observation in other studies [7].

About 12.3% with SAM were of < 2 months age group, 47.7% between 2months to 12 months and 40% were above 12 months (60% belonged to <1 year of age). It is similar to the observation made by Aguayo et al, where 77.7% of SAM patient were 6-23 months old in Jharkhand [7].

Low birth weight is a major risk factor for SAM due to low level of immunity status and high incidence of infection in them. In this study, low birth weight was present in 14.6% of study population. Lack of vaccination was related to poor care, families with major problems in education, low social economic class and single parents, all of whom had lower care for their children both in nutrition and disease prevention. Similar result was found in the study by Oworetalin, East Africa showing strong association between SAM and incomplete immunization [8].

Lethargy was the most common presenting feature (50.8%). Among other features, Skin changes, Diarrhoea, Fever, Cough, Visible Severe Wasting, Hair changes, Oedema, Vomiting, Dehydration and Shock were presenting features in 35.4%, 34.6 %, 33.8 %, 30.8 %, 30 %, 24.6 %, 23 %, 22.3 %, 15.4 % and 10.8 % respectively. Study by Aguayo et al done in Jharkhand [7] showed diarrhoea / severe dehydration in 2.3% SAM cases. Hypoglycaemia was found in 15.4% of SAM children in this study and anaemia was found to be present in 48.5% cases. UTI was found as co-morbidity with SAM in 16.2% in the study population.

Sex, parents’ occupation, family income, family sizes were not statistically significant in this study similar to other studies which showed no association between malnutrition and these factors [9, 10, 11, 12].

Outcome of interest were determined after following up the patients in the hospital. The outcome of the study was categorized into two categories i.e. cured and death. Out of the 130 patients of SAM in the study group, 117 patients (90%) were cured and discharged with variable number of admission days and 13 patients (10%) died due to various complications.

The various predictors of outcome in SAM of the study population were found by descriptive statistical analysis. The various clinical manifestations having significant relationship with outcome in this study population of 130 SAM patients have been summarized in Table-2 along with the p values.

Summary and Conclusions

The overall prevalence of severe acute malnutrition in our study population is 2.5%.Among 130 cases of SAM, majority were non edematous SAM (Marasmus) (77%) and edematous SAM (Kwashiorkor) is less (23%). Most cases were from Cuttack (30.8%) followed by Jaipur (12.3%) and Kendrapada (8.5%).There is no variation in sex as both male and female patients were with equal percentage (50%).In this study 12.3% children with SAM were of < 2months, 47.7% are between 2months to 12 months and 40% were above 12 months

Prevalence of under-nutrition in our setting is high and majority of the admitted children have marasmus type of malnutrition. Malnutrition is predicted by age less than two years, living with single parent, taking unbalanced diet, lack or incomplete immunization and low level of maternal education. Co-morbidities associated with malnutrition were pneumonia, pulmonary tuberculosis, urinary tract infection. Severely malnourished children are staying longer at hospital and have a higher mortality. Mortality is high in our setting in under-nutrition which is predicted by age of less than one year, peasant parents, having severe malnutrition, dehydration, hypothermia and hypoglycemia.

Abbreviations Used: - S.C.B -Sriram Chandra Bhanj, SVPPGIP- Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, SAM-severe acute malnutrition, Nutrition Rehabilitation Center (NRC), HIV-Human Immunodeficiency virus, LBW-Low Birth weight, EBF-Exclusive Breast Feeding, CRP-C-reactive protein.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

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How to cite this article?

Das K, Swain A, Nayak A.S, Behera S, Satpathy S.K. Clinical profile and outcome of children with severe acute malnutrition.2017;4(05):350-356.doi:10. 17511/ijpr.2017.05.10.