Clinical study of comorbidities in children hospitalized with severe acute malnutrition at tertiary care centre

 

Abstract               Background: Undernutrition remains a leading cause of childhood morbidity and mortality in India and in many parts of the world. Severe Acute malnutrition remains a major cause of mortality in children with severe wasting.Children with SAM are at a greater risk of dying from common infections, increases the frequency and severity of such infections and contributes to delayed recovery. In present study, we focus on comorbid conditions present in hospitalized SAM children. Material and Methods: This prospective, observational study was conducted on patients admitted in paediatric ward with the diagnosis of severe acute malnutrition (SAM) based on WHO classification. Results: Out of 100 cases in our study, 58% were males and 42% were females. Most common age group involved was 6-11 months age group (47 children) and non-oedematous malnutrition (87 %) was more common. 86 % children were partially immunized or unimmunized, while 71% of the patients belonged to lower socio-economic class. In present study acute gastroenteritis (45 cases) followed by anemia (38 cases), acute respiratory tract infections (28 cases) and urinary tract infection (20 cases) were most common associated co- morbidity. Mortality was noted in 3 cases. Conclusion: Diarrhea, Respiratory tract infections and anaemia are the most common co morbid conditions with severe acute malnourished children. Prompt and aggressive management along with nutritional rehablilitation are major factors for successful treatment.

Keywords: Severe Acute Malnutrition, Comorbidities, under 5 children

 

INTRODUCTION

Undernutrition remains a leading cause of childhood morbidity and mortality in India and in many parts of the world, and thus, the World Health Organization (WHO) has launched the United Nations Decade of Action on Nutrition, 2016-2025¹. Over the past decade India’s record of high economic growth has not transformed nutritional status of its population to the necessary extent: latest research shows that despite doubling the rate of stunting reduction in the past 10 years from the previous decade, India still has the largest share of the world’s undernourished population².Severe acute malnutrition (SAM) is defined by a very low weight for height (below −3z scores of the median WHO growth standards), by visible severe wasting, or by the presence of nutritional edema³. Severe Acute malnutrition remains a major cause of mortality in children with severe wasting- a widespread form of SAM is nine times higher than those in well-nourished children⁴. India’s fourth National Family Health Survey (NFHS-4) indicates that the prevalence of severe wasting is 7.5%⁵.Children with SAM are at a greater risk of dying from common infections, increases the frequency and severity of such infections and contributes to delayed recovery. Severe acute malnutrition and infections can create a potentially lethal cycle of worsening illness and deteriorating nutritional status. Although nutritional rehabilitation is the mainstay of therapy in hospitalized SAM children, their outcome is dependent on the comorbidities present. In present study, we focus on comorbid conditions present in hospitalized SAM children.

 

MATERIAL AND METHODS

This prospective, observational study was conducted in the Department of Paediatrics, RVM Institute of Medical Sciences and Research Centre over a period of one year from January 2018 to December 2018. Institutional ethical committee approval was taken for the study. A written and informed consent was obtained from the parents.

Inclusion criteria

• Patients admitted in paediatric ward with the diagnosis of severe acute malnutrition (SAM) based on WHO classification.

Exclusion criteria

• Age less than 6 months or more than 5 years of age,
• Children with mild to moderate malnutrition, not fitting
• Presence of major congenital malformations.
• Not willing to participate in study.

A written and informed consent was obtained from the parents. A detailed history along with complete anthropometry and physical examination was documented and relevant laboratory investigations were done according to the clinical presentation. Clinical progress, treatment and outcome noted for each patient. Data were entered into excel sheet, and the statistical analysis of data was performed with appropriate tests. Statistical analysis was done using descriptive statistics.

 

RESULTS AND DISCUSSION

Severe acute malnutrition is preventable and treatable cause of childhood morbidity and mortality⁶. MANAGEMENT of SAM children need multidisciplinary approach including medical support, nutritional therapy, also needs social encouragement of parents. After applying inclusion and exclusion criteria 100 cases were included in study. Out of 100 cases in our study, 58% were males and 42% were females. Singh K et al⁴ also noted more male cases while others noted more female cases^7,8. We found most common age group involved was 6-11 months age group (47 children), while total no. below 24 months was 75. Mathur A et al.79.8% of children were below 24 months of age⁹.In present study, non-oedematous malnutrition (87 %) was more common than oedematous malnutrition (13 %), this finding was similar to other studies^10,11, however in another study Kwashiorkor was the most common type of severe acute malnutrition¹². 86 % children were partially immunized or unimmunized, while 71% of the patients belonged to lower socio-economic class according to Modified Kuppuswamy classification. Both these factors are well known risk factors for malnutrition and related co-morbidities. In present study acute gastroenteritis (45 cases) followed by acute respiratory tract infections (28 cases) and urinary tract infection (20 cases) were most common associated infective co- morbidity. similar finding were noted in other Indian¹³ and foreign studies^14,15 also. Diarrhea and acute respiratory conditions are major symptoms while admission, should be managed aggressively to bring down the high mortality associated with SAM. Other co-morbid conditions like HIV, meningitis, malaria, measles, skin infections and worm infestations were also noted in some cases. Anaemia (38%) was the most common Nutritional Deficiency associated comorbidity. Overlapping nature of protein–energy malnutrition and micronutrient deficiencies were well understood and it is seen that lack of one micronutrient is typically associated with deficiencies of other. The high incidence of anaemia in these children could be due to nutritional factors as well as incident helminthic infections. We discharged 39 cases after target weight gain, 48 cases were discharged without target weight gain but with adequate weight gain. Mortality was noted in 3 cases, rest 10 were defaulters.

 

Table 1: Demographic profile of study population.

Table 2: Infective Co-Morbidities in the Study Population

 

CONCLUSION

Diarrhea, Respiratory tract infections and anaemia are the most common co morbid conditions in admitted severe acute malnourished children. Prompt and aggressive management along with nutritional rehablilitation are major factors for successful treatment. But management of social factors responsible for undernutrition is more important because “Prevention is better than cure”.

 

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