JOURNAL OF TROPICAL PEDIATRICS, VOL. 61, NO. 1, 2015
Brief report
Late presentation to hospital services necessitates greater
community-based care for malnourished children
by Anna M. Rose
UCL Medical School, London, WC1E 6BT, UK
Correspondence: Anna M. Rose, UCL Medical School, Gower Street, London, WC1E 6BT, Tel: 02073367980;
Fax: 01480880024. E-mail <[email protected]>.
Summary
The records for all paediatric deaths (ages 0–14) in a large hospital in urban Southern Africa were
examined for a 3 year period (January 2007 to February 2010), to explore the role of malnutrition in
paediatric mortality in this region. A total of 516 records were obtained, demonstrating that malnutrition was the primary or secondary cause of death in 35% of cases. It was also found that children
presented very late to hospital services, with an average length of final admission of only 0–3 days. The
rate of human immunodeficiency virus (HIV) infection was found to be very high, although low testing
rates limits the analysis of these figures. Malnutrition remains an important factor in paediatric
mortality in southern Africa, contributing to approximately 35% of deaths. Furthermore, fatal cases
presented very late to hospital services. In light of this, increased community-based therapy would be
beneficial. Implementation of universal HIV testing would also be valuable.
Key words: paediatric malnutrition, paediatric mortality, HIV, developing countries.
Introduction
Malnutrition is one of the biggest challenges faced by
global child health, affecting more than one quarter
of less than 5 year olds in the developing world.
Clinically, severe acute malnutrition (SAM) can be
defined as a weight-for-height z-score of less than
2, or a mid-upper arm circumference of less than
11.5 cm in children aged 1–5 years [1]. SAM can present as non-oedematous severe wasting (marasmus)
or oedematous disease (kwashiorkor).
Each year, malnutrition is directly responsible for
1 million childhood deaths and contributes to over
3.5 million deaths in children aged less than 5 years,
although this might be an underestimate given low
levels of accurate death certification in resource-limited settings (RLS) [2, 3]. Malnutrition impairs the
Acknowledgments
The author expresses thanks to the excellent nursing
and medical staff on the two paediatric wards that
cared for the children during their final illnesses.
Gratitude is also expressed to the staff at the medical
records office who allowed AMR to use office space
and greatly facilitated collection of data.
immune system, increasing susceptibility, severity
and duration of infections; indeed, SAM triples the
mortality in measles, pneumonia and diarrhoea [1].
Malnutrition and stunting are risk factors for
delayed mental development, poor school performance and reduced intellectual capacity which, in
turn, affect economic productivity at national level
[4]. This engenders a vicious cycle of poverty, illhealth and malnutrition. Furthermore, the effects of
paediatric malnutrition are not limited to childhood;
for example, women who are stunted as a result of
childhood malnutrition are at increased risk of obstetric complications [4].
Human immunodeficiency virus (HIV) infection
and malnutrition often coexist and the two conditions overlap and interact. Meta-analysis of 17
large studies demonstrated that 29.2% of children
presenting with SAM were HIV positive and, importantly, mortality from SAM is more than three times
higher in HIV-positive children than their HIV-negative peers [5].
In this work, the role of malnutrition in paediatric
deaths in an urban hospital setting in Southern
Africa was examined. The HIV status and timing of
presentation of those children dying from malnutrition was also analysed.
ß The Author [2014]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
doi:10.1093/tropej/fmu059
Advance Access published on 10 November 2014
61
BRIEF REPORT
Materials and Methods
The study was conducted in a small city in subSaharan Africa, with the aim of establishing the
role of malnutrition in child mortality in this
region. The city has a population of almost 150 000
people, with rapid development in recent years due to
the burgeoning of tourism activities and associated
infrastructure. The country is a RLS, with a gross
domestic product per capita of US$743 and approximately 85% of the population living below the poverty line [6]. Malnutrition is a major problem, with
49% of the population being undernourished; furthermore, infant mortality remains high with almost
180 deaths per 1000 live births [6]. The study was
designed as a research project and written authorization was obtained from the local Ministry of Health
Government Office, who were responsible for approval of research projects within the hospital.
The hospital records for all paediatric deaths in a
large public hospital in the city were examined for the
period of January 2007 to February 2010. The
gender, age at death, length of final admission, primary and secondary causes of death (CoD) and HIV
status (where known) were documented in record
books by nursing staff on the paediatric wards; the
cause of death was specified verbally to nursing staff
by the paediatric doctors. The author collated the
data from the record books in the months of July
to August 2010. The data were analysed using standard statistical methods (Z-test for comparison of proportions, Mann–Whitney U for comparison of
means, these being considered significant if
p < 0.05). Skewness was assessed using FisherPearson standardized moment coefficient (G1), this
being considered significant if the absolute value of
the ratio (G1/[6/N]2) was greater than 2.
Results
A total of 516 death records for children less than the
age of 14 years were obtained. SAM was the primary
CoD in 128 cases (24.8%) and the secondary CoD in
a further 55 cases (10.7%). Males and females were
equally affected (p ¼ 0.5287). The median age for
primary SAM cases was 18 months, whereas in
the secondary group the median age was 15
months—although this difference was not significant
(p ¼ 0.08). SAM was an important cofactor in deaths
from infectious diseases, particularly gastroenteritis
and respiratory tract infections such as pneumonia
and pulmonary tuberculosis (Fig. 1).
The data were analysed for length of final admission (LoFA) in the primary and secondary CoD
groups. In both groups this showed a very short
LoFA, with strongly skewed data. In the group
where SAM was the primary CoD, the average
LoFA was only 0–3 days (mode ¼ 0, median ¼ 3).
The true average LoFA is likely closer to 0, given
the heavy positive skew of the data (G1 skewness
62
coefficient ¼ 1.625, significant). A similar picture
was observed in the group where SAM was the secondary CoD with an average LoFA was 0–2 days
(mode ¼ 0 days, median ¼ 2 days). These data were
also positively skewed, meaning the true average is
even lower than it appears (G1 ¼ 1.187, significant)
(Fig. 2).
HIV status was known in 37 of the primary cases
and, of these, 31 were HIV positive (83.4%). HIV
status was recorded in only nine cases where malnutrition was the secondary CoD, of which seven were
positive (77.8%). Although startling high, it is likely
that these figures are biased, due to two reasons.
Firstly, high risk children are more likely to be
tested and, secondly, a positive result is far more
likely to be recorded in the death records than a
negative result.
Discussion
Analysis of hospital records from a large public hospital in Southern Africa demonstrated that SAM remains a major CoD in children, especially infants less
than 2 years of age. It is a common primary CoD and
also an important risk factor for mortality due to
infectious diseases, being implicated in 35% of
deaths in this study.
Strikingly, it was demonstrated that children presented to hospital services very late, with the final
admissions being—on average—less than 3 days.
Indeed, over 22% of children died on the day of
admission. This could, in part, be due to difficulty
in accessing hospital services—for example, distance
and transport are reported as the major barriers to
accessing paediatric health services in many developing countries [7]. Fear and suspicion of Western
medical intervention have also been observed
across sub-Saharan Africa and is indicative of a
far greater and complex problem that might play
a role in late presentation to medical services [8,
9]. Furthermore, the cost of inpatient medical treatment in countries where public health care is not
available is prohibitive, this again ostracizing the
poorest in the community, who are at highest risk
of SAM.
These findings highlight an urgent need for more
effective community-based interventions (such as
ready-to-use therapeutic food, RTUF), as these
would allow commencement of therapy at an earlier
stage. When correctly administered, home-based
therapy with RTUF has been shown to have an excellent recovery rate [10]. There are several factors
contributing to their success in recent years including
low cost, ease of administration, and widespread
availability. However, there remains a large discrepancy between HIV-infected and HIV-uninfected children—treatment with RTUF appears to be much less
effective in HIV positive children, with case fatality
rates remaining up to 50% [11].
Journal of Tropical Pediatrics
Vol. 61, No. 1
BRIEF REPORT
FIG. 1. Primary cause of death in children where SAM was listed as the secondary cause of mortality. The study
demonstrated that infectious diseases, in particular gastroenteritis and respiratory tract infections, were the major
primary CoD accounting for 283 deaths. SAM was listed as the secondary CoD in 55 of deaths from infectious
diseases (19.4%); it is again clear that gastroenteritis and respiratory tract infections (pneumonia, pulmonary
tuberculosis) are the most frequent primary infections.
FIG. 2. Analysis of LoFA (in days) of children dying from SAM demonstrated late presentation to medical
services. The modal average LoFA was 0 days in both groups analysed and, given the heavy positive skew of the
data set, this is likely to be the fairest representation of the true average.
Journal of Tropical Pediatrics
Vol. 61, No. 1
63
BRIEF REPORT
The rate of HIV infection among children dying
from SAM appeared to be high; however, the low
rate of testing of children being admitted to the hospital prevented any solid analysis. Implementation of
universal HIV testing of all children admitted to hospital would allow robust conclusions to be drawn
about the frequency of HIV among children dying
from malnutrition. It would also allow better care,
as SAM on a background of HIV is considered to be
a separate clinical entity and, therefore, HIV positive
children require different treatment for SAM [12].
In summary, SAM contributed to approximately
35% of deaths of children in an urban setting in
Southern Africa and fatal cases presented very late
to hospital services. In light of this, increased community-based therapy would be beneficial.
Implementation of universal HIV testing would also
be valuable.
References
1. Alcoba G, Kerac M, Breysse S, et al. Do children with
uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis. PLoS
One 2013;8:e53184.
2. Johnson HL, Liu L, Fischer-Walker C, et al. Estimating
the distribution of causes of death among children age
1-59 months in high-mortality countries with incomplete death certification. Int J Epidemiol 2010;39:
1103–14.
3. Park SE, Kim S, Ouma C, et al. Community
management of acute malnutrition in the developing
world. Pediatr Gastroenterol Hepatol Nutr 2012;15:
210–9.
64
4. World Health Organisation. Nutrition Landscape
Information System (NLIS) Country Profile
Indicators: Interpretation Guide. Geneva, Switzerland,
2010, p. 1. ISBN 978 92 4 159995 5.
5. Fergusson P, Tomkins A. HIV prevalence and mortality among children undergoing treatment for severe
acute malnutrition in sub-Saharan Africa: a systematic
review and meta-analysis. Trans R Soc Trop Med Hyg
2009;103:541–8.
6. United Nations. Department of Economic and Social
Affairs. National Trends in Population, Resources,
Environment and Development: Country Profiles.
United Nations, New York. 2006.
7. Martinez AM, Khu DT, Boo NY, et al. Barriers to
neonatal care in developing countries: parents’ and providers’ perceptions. J Paediatr Child Health 2012;48:
852–8.
8. Kingori P, Muchimba M, Sikateyo B, et al. ‘Rumours’
and clinical trials: a retrospective examination of a
paediatric malnutrition study in Zambia, southern
Africa. BMC Public Health 2010;10:556.
9. Geissler PW, Pool R. Editorial: popular concerns about
medical research projects in sub-Saharan Africa—a critical voice in debates about medical research ethics. Trop
Med Int Health 2006;11:975–82.
10. Manary MJ, Ndkeha MJ, Ashorn P, et al. Home based
therapy for severe malnutrition with ready-to-use food.
Arch Dis Child 2004;89:557–61.
11. Heikens GT, Bunn J, Amadi B, et al. Blantyre Working
Group. Case management of HIV-infected severely
malnourished children: challenges in the area of highest
prevalence. Lancet 2008;371:1305–7.
12. Rose AM, Hall CS, Martinez-Alier N. Aetiology and
management of malnutrition in HIV-positive children.
Arch Dis Child 2014;99:546–51.
Journal of Tropical Pediatrics
Vol. 61, No. 1