Predictors of undesirable treatment outcomes of severe acute malnutrition among inpatient children in Addis Ababa, Ethiopia: a retrospective cohort study

The United Nations’ first Millennium Development Goal (MDGs) to “eradicate extreme poverty and hunger” was measured by assessing a set of indicators, which included the prevalence of underweight children under the age of 5 years [1]. The extreme situation of malnutrition, not uncommon among children under the age of 5 years, is referred to as Severe Acute Malnutrition (SAM). The World Health Organization (WHO) defines SAM based on three anthropometric indicators: low weight for height/length ratio (WFH) below − 3 SD, presence of nutritional edema, and/ or a mid-upper arm circumference (MUAC) of less than 115 mm [2, 3]. The WHO guidelines for treatment of complicated SAM (SAM children who have clinical features of infection, metabolic disturbance, severe edema, hypothermia, vomiting, severe dehydration, severe anemia or a lack of appetite), suggests the establishment of inpatient care for the treatment and rehabilitation of severely malnourished individuals [2, 3].

Worldwide, in 2018 alone, 5.3 million children under the age of 5 years died, of which nutrition related factors contributed to about 45% of all child deaths. Children in Sub-Saharan Africa are more than 15 times likely to die before the age of 5 years than children in developed regions [4]. It is often the case that children with severe acute malnutrition have a higher risk of death from relatively common childhood illnesses such as diarrhea, pneumonia and malaria [4‐6].

The United Nations Sustainable Development Goals (SDGs) are based on the MDGs which were adopted in 2015. While the MDGs were conceived particularly for developing counties, the SDGs are meant to address all UN member states and are considerably more comprehensive and ambitious than MDGs. The SDG Goal 2.2 is focused on ending all forms of malnutrition as it is noted to be the dominant cause of death among children under 5 years [3]. Ethiopia is one of the nations registered to have high child mortality rates for ages five and below. Though this mortality rate has been significantly reduced from earlier years, it is still considered high (55.2 deaths per 1000 live births in 2018) [7]. According to the 2019 Ethiopian Mini Demographic and Health Survey report, 37% of under five children were stunted, 12% severely stunted, 7% wasted, 1% severely wasted, 21% underweight and 6% severely underweight [8].

The minimum international standard set for management of SAM according to SPHERE standards is a cure rate of at least 75% and death rate less than 10% [9]. However, the case fatality rates in hospitals treating SAM in developing countries have remained high. A meta-analysis which was done in low and middle-income settings for inpatient treatment of complicated SAM shows a case fatality rate of 14% (range 5–30%) [10, 11]. There have been numerous factors attributed to high fatality cases in children admitted to inpatient care [12, 13]. Hypoglycemia, infection, anemia, dehydration, hypothermia, electrolyte imbalance, HIV and TB infection, age and sex were among the factors associated with high fatality rate of children with severe acute malnutrition [13].

Therefore, treatment for SAM with medical complications, requires further clinical insight and analysis. The intent of this study was to examine predictors of undesirable treatment outcomes of severely malnourished children hospitalized under the inpatient management scheme of SAM with medical complications.

A total of 677 children with SAM were admitted to Yekatit 12 Hospital Medical College between 2013 to 2016; 373 were excluded from the study and while 304 were deemed eligible. Amongst these eligible cases, 25 were dropouts and 20 were transfer outs to other institutions; both groups were excluded from the analysis as their treatment outcomes could not be determined. Thus, we analyzed a total of 259 children with SAM in this study (Fig. 1). There was no significant statistical difference between background characteristics of the excluded sample and children included in this study.

We analyzed 259 children 6–59 months old with complicated SAM admitted to Yekatit 12 Hospital Medical College from 2013 to 2016 and found that the cure, death and defaulter rate were 70.4,12.2 and 8.2% respectively. The rate of weight gain was 8.13 g/kg/day and 16 days was the average length of hospital stay. The median nutritional recovery time of the entire cohort was found to be 17 days (95% CI: 15.615–18.385). The greatest proportion of death occurred within the first 7 days. Sepsis and presence of HIV antibody were found to be independent predictors of undesirable treatment outcome, negatively influencing the survival probability of children with SAM. A similar effect was also identified in other studies [11, 18].

The study revealed that 12.2% of the children died during the follow up period which was higher than the SPHERE standard recommendation of 10% mortality rate [9]. In contrast, it was significantly less compared to findings of similar studies conducted in Zambia with a 46% mortality rate [19] and Hawassa University Referral Hospital(Ethiopia) with15.2% death rate [20]. Previous similar studies carried out in Gedo zone in southern Ethiopia and in Jimma town documented an observed similar mortality rate of 9.3 and 12.6% respectively [18, 21].

The recovery rate of SAM children admitted to Yekatit 12 Hospital Medical College (70.4%) was below the minimum recovery rate recommended in the SPHERE standard, which is listed as of 75%. This discrepancy may be attributed to issues of intuitional capacity or the hospital’s status as a referral health institution dealing with the latter stages of the illness which in turn results in higher rate of morbidity within the first 7 days of admission. Some institutional factors which could likely contribute to slow recovery rate include high staff turnover, high case load, lack of training, lack of quality assurance procedures, availability of medical supplies and poor ward infrastructure, including lack of isolated rooms for malnourished children [22, 23].

In this study, the defaulter rate was 8.2%. This was consistent with the minimum international standard of < 15% set for management of severe acute malnutrition. This was also consistent with other similar studies conducted in Ethiopia [21, 24].

The average length of hospital stay was 16 days which was in line with the minimum international standard set for management of severe acute malnutrition (SPHERE standard). The standard recommends an average length of stay of less than 30 days [9]. Our finding was also in line with other similar studies conducted in Ethiopia [11, 18, 21].

An average weight gain of 8.13 g/kg/day for children with non-edematous malnutrition was computed for the study sample. This result was within the SPHERE standard, which is 8 g/kg/day [9]. The average weight gain in this study was similar to other studies [18, 21, 25]. Average weight gain for children with edematous malnutrition was difficult to compute as there was no documentation about the date when the edema resolved, and weight gain was recorded.

Sepsis and presence of HIV antibody were found to be independent predictors of undesirable treatment outcomes. Adjusting for other variables, children with sepsis had a higher risk for undesirable treatment outcome compared with their counterparts. This was in agreement with other reports from low resource settings in sub-Saharan Africa [19, 26, 27]. Although sepsis was less common in this study (8.4%), compared to other comorbidities, it was found to be an independent predictor of undesirable outcome. Malnutrition and infection/sepsis have a synergistic relationship, where malnutrition inhibits immune response and infectious diseases can exacerbate malnutrition and result in increased severity, duration and frequency of infection [28]. Furthermore, the diagnosis of infection in malnourished children was difficult because clinical manifestations of infection such as fever may not be apparent [14]. The synergistic effects of malnutrition and infection would eventually lead to higher risk of mortality. Similarly, the risk of undesirable treatment outcomes in children with SAM who tested positive for HIV antibody 3.2(C. I 1.045–9.846) times higher than their counterparts. Similar studies have also documented that children who tested positive for HIV antibody were 3 times more like to die [3, 10, 11].

The main predictors of undesirable treatment outcomes for SAM children admitted to Yekatit 12 Hospital Medical College in the specified time frame were HIV and sepsis.

The study has also demonstrated that the overall treatment outcomes were not in congruence with the SPHERE standard recommendation. The observed mortality rate was higher than the recommended standard and the cure rate was below the minimum rate recommended by the SPHERE standard.

Since the presence of HIV and sepsis were found to be the predictors of undesirable treatment outcomes, appropriate diagnosis and management should be put in place with special attention to those diagnosed with sepsis.

It should be noted that additional resources and special attention should be given to SAM children undergoing treatment for SAM within the first 7 days of admission.