Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?

Abstract

Background: With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines.

Methods and findings: Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%).

Conclusions: Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.

Figure 1. Annual Admissions of Children with Severe Malnutrition and Case Fatality Rates

Prior to 2000, malnutrition was defined as weight for age (WAZ) less than −4 or oedematous malnutrition. Annual admissions rates: 1991–1998 (3,800), 1998–2000 (4,877), 2001 (5,136), 2002 (4,878), 2003 (5,583), and 2004 (5,004).

Figure 2. Timing of In-Hospital Death

Day 14 represents the percentage of all deaths (176) that occurred in the second week (day 14 to 20), and day 21 represents the percentage of all deaths that occurred on or after 21 d of inpatient treatment.

Figure 3. Value of the Signs of Dehydration and Delayed Capillary Refill Time (dCRT) in 905 Severely Malnourished Children with and without Diarrhoea

Diarrhoea is defined as more than three watery motions per 24 hours. “Dehydration signs” are sunken eyes and/or decreased skin turgor.

Figure 4. Monthly Admission of Children with Severe Malnutrition (Bars) and Percentage Case Fatality (Line) for 2001–2002

In July 2001, during a period of 6-h temperature surveillance, the routine prescription of a blanket (see blanket symbol) was added to the treatment chart, and in August 2001 (see cup symbol), F75 and F100 were prepared (day and night) in a specifically devoted “milk kitchen” with dedicated trained workers to expressly supply the malnourished with warm milk feeds every 4 h, or as required.