Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): a prospective cohort study

Abstract

Background: Management of Severe Acute Malnutrition (SAM) plays a vital role in achieving global child survival targets. Effective treatment programmes are available but little is known about longer term outcomes following programme discharge.

Methods: From July 2006 to March 2007, 1024 children (median age 21.5 months, IQR 15-32) contributed 1187 admission episodes to an inpatient-based SAM treatment centre in Blantyre, Malawi. Long term outcomes, were determined in a longitudinal cohort study, a year or more after initial programme discharge. We found information on 88%(899/1024).

Results: In total, 42%(427/1024) children died during or after treatment. 25%(105/427) of deaths occurred after normal programme discharge, >90 days after admission. Mortality was greatest among HIV seropositive children: 62%(274/445). Other risk factors included age <12 months; severity of malnutrition at admission; and disability. In survivors, weight-for-height and weight-for-age improved but height-for-age remained low, mean -2.97 z-scores (SD 1.3).

Conclusions: Although SAM mortality in this setting was unacceptably high, our findings offer important lessons for future programming, policy and research. First is the need for improved programme evaluation: most routine reporting systems would have missed late deaths and underestimated total mortality due to SAM. Second, a more holistic view of SAM is needed: while treatment will always focus on nutritional interventions, it is vital to also identify and manage underlying clinical conditions such as HIV and disability. Finally early identification and treatment of SAM should be emphasised: our results suggest that this could improve longer term as well as short term outcomes. As international policy and programming becomes increasingly focused on stunting and post-malnutrition chronic disease outcomes, SAM should not be forgotten. Proactive prevention and treatment services are essential, not only to reduce mortality in the short term but also because they have potential to impact on longer term morbidity, growth and development of survivors.

Figure 1. FuSAM study flow chart - all admissions to MOYO.

(OTP = ‘Outpatient Treatment Programme’ – the outpatient part of treatment; T/F = transfer out to different programme). ‘Still sick’ children were seen or reported to be clinically unwell at follow-up but details were not always known.

Figure 2. Kaplan Meier failure curve, all patients.

Figure 3. Kaplan Meier failure curves, by HIV serostatus.

The tables below figures 2 and 3 show numbers at risk at the beginning of a particular time period. Deaths are in parentheses. Numbers at risk are not simply those previous at-risk minus deaths. Other outcomes also result in children being removed from further analysis (being ‘censored’). With this denominator change, the y-axis is mortality probability rather than percentage. Whilst our main outcomes focus is on the first year post-discharge, for completeness, data is presented until the last child's follow-up.

Figure 4. Boxplot showing weight-for-height, weight-for-age and height-for-age of the ex-malnourished surviving child (M) (n = 386) compared to sibling controls (S) (n = 277).