Prevalence, outcome and quality of care among children hospitalized with severe acute malnutrition in Kenyan hospitals: A multi-site observational study

Abstract

Background: Severe acute malnutrition (SAM) remains a major cause of admission and inpatient mortality worldwide in children aged less than 5 years. In this study, we explored SAM prevalence and outcomes in children admitted in 13 Kenyan hospitals participating in a Clinical Information Network (CIN). We also describe their immediate in-patient management.

Methods: We analyzed data for children aged 1-59 months collected retrospectively from medical records after discharge. Mean, median and ranges were used to summarize pooled and age-specific prevalence and mortality associated with SAM. Documentation of key signs and symptoms (S/S) and performance of indicators of quality of care for selected aspects of the WHO management steps were assessed. Logistic regression models were used to evaluate associations between documented S/S and mortality among SAM patients aged 6-59 months. Loess curves were used to explore performance change over time for indicators of selected SAM management steps.

Results: 5306/54140 (9.8%) children aged 1-59 months admitted with medical conditions in CIN hospitals between December 2013 and November 2016 had SAM. SAM prevalence identified by clinicians and case fatality varied widely across hospitals with median proportion (range) of 10.1% (4.6-18.2%) and 14.8% (6.0-28.6%) respectively. Seventeen variables were associated with increased mortality. Performance change over time of management steps varied across hospitals and across selected indicators but suggests some effect of regular audit and feedback.

Conclusion: Identification of SAM patients, their mortality and adherence to in-patient management recommendations varied across hospitals. An important group of SAM patients are aged less than 6 months. Continued efforts are required to improve management of SAM in routine settings as part of efforts to reduce inpatient mortality.

Fig 1. Flowchart of selection and classification of potential severe acute malnutrition cases in the CIN hospitals.

CIN- Clinical Information Network, SAM: -Severe acute malnutrition, ¹Minimum data records–data entry restricted to biomedical and outcome data that is required by the national reporting system ²Groups A, B and C are mutually exclusive.

Fig 2

Documentation of WHZ score among all children 1 to 5 months (panel a) and WHZ score and MUAC documentation among all subgroups of SAM aged 6 to 59 months in 13 CIN hospitals over time (panel b): WHZ (blue line) and MUAC (red line).

Fig 3. Cluster adjusted mean performance (solid line) with 95% confidence band portraying adherence to recommended guidelines over time for SAM management steps with sufficient data.

Step 7: Red line is F75 prescribed and blue line is correct F75 dose.