Recovery of children following hospitalisation for complicated severe acute malnutrition

High-dose vitamin D3 to improve outcomes in the convalescent phase of complicated severe acute malnutrition in Pakistan: a double-blind randomised controlled trial (ViDiSAM)

We have previously shown that high-dose vitamin D3 improved weight gain and neurodevelopmental indices in children receiving standard therapy for uncomplicated severe acute malnutrition (SAM). Here we present results of a randomised placebo-controlled trial in Lahore, Pakistan, to determine whether two oral doses of 200,000 international units (IU) vitamin D3 (the first administered on or before the day of hospital discharge and the second administered 14 days later) would benefit children aged 6-59 months during the convalescent phase of complicated SAM. Eligible participants were individually randomised to intervention vs. control arms with a one-to-one allocation ratio and stratification by hospital of recruitment using computer-generated random sequences. Double-blinding to treatment allocation was maintained by concealing allocation from participants' parents or guardians, their medical care providers, and all trial staff. The primary outcome was mean weight-for-height or -length z-score (WHZ) at 2-month follow-up. Secondary efficacy outcomes included mean WHZ at 6-month follow-up and mean lean mass index, Malawi Development Assessment Tool (MDAT) scores and serum 25-hydroxyvitamin D (25[OH]D) concentrations at 2- and 6-month follow-up. The trial has now completed. 259 children were randomised (128 to vitamin D, 131 to placebo), of whom 251 (96.9%) contributed data to analysis of the primary outcome (123 allocated to vitamin D, 128 to placebo). At 2-month follow-up, participants allocated to vitamin D had significantly higher mean serum 25(OH)D concentrations than those allocated to placebo (adjusted mean difference [aMD] 100.0 nmol/L, 95% confidence interval [CI] 72.2-127.8 nmol/L). This was not associated with an inter-arm difference in mean WHZ at 2-month follow-up (aMD 0.02, 95% CI -0.20 to 0.23), or in any anthropometric or neurodevelopmental secondary outcome assessed at 2- or 6-month follow-up. The intervention was safe. In conclusion, high-dose vitamin D3 elevated mean serum 25(OH)D concentrations in children receiving standard therapy for complicated SAM in Pakistan, but did not influence any anthropometric or neurodevelopmental outcome studied. The trial was registered at ClinicalTrials.gov with the identifier NCT04270643.

Novel gastrointestinal tools (GI Tools) for evaluating gut functional capacity in adults with environmental enteropathy in Zambia and Zimbabwe: A cross-sectional study protocol

Background

Environmental enteropathy (EE) is a highly prevalent subclinical inflammatory intestinal disorder associated with growth failure, impaired neurocognitive development, poor response to oral vaccines, and micronutrient deficiencies. However, EE research and clinical trials are hampered by the lack of non-invasive tools for measuring intestinal function in detail. This study aims to develop new tools for the measurement of multiple domains of gut functional capacity.

Methods

The GI TOOLS project is a cross-sectional study that will recruit adults aged 18-65 years with EE in Lusaka, Zambia. Each participant will undergo assessment of gut functional capacity using novel near-point-of-care tools and provide multiple samples for detailed laboratory analyses. Participants will also undergo endoscopy for collection of duodenal biopsies. Novel techniques include stable isotopes approaches to measuring digestion, absorption, and bidirectional transmucosal amino acid flux, a non-invasive fluorescence tool for real-time evaluation of gut permeability, and assessment of reverse permeation of intravenous antibiotics to be carried out separately in Zimbabwe. Stool and duodenal microbiome sequencing using MinION sequencing, metabolome analysis applied to plasma and intestinal fluids, blood immune cell phenotyping, in vitro epithelial barrier models, and duodenal immunohistochemistry will also be used to explore EE in depth. These will all be integrated with gold standard histology and mucosal morphometry, alongside lactulose permeation data, and stool and plasma biomarker analysis. The protocol has been approved by ethics committees and regulators in Zambia, Zimbabwe, and the UK. Participants will give informed consent before they can participate.

Anticipated outcomes

Based on this extensive phenotyping, tests will be developed which can be simplified and refined for use in adults and children with EE, and for clinical trials. Findings from this project will be disseminated through in-person meetings with caregivers and regulatory bodies, presentations at conferences and in peer-reviewed journals.

Paediatric healthcare in Manhiça district through a gender lens: a retrospective analysis of 17 years of morbidity and demographic surveillance data

Background

Sex and gender are important determinants of health. Gender-based health inequities in the paediatric population have been reported in various countries, but data remain limited. In Mozambique, research on this topic is very scarce. Here we aimed to explore whether boys and girls in Manhiça district, southern Mozambique, differ in access to and provision of healthcare.

Methods

This retrospective analysis includes data on all paediatric (<15 years old) visits to six outpatient clinics and admissions to one hospital in Manhiça district from 2004 to 2020, collected through the morbidity surveillance system of the Manhiça Health and Demographic Surveillance System (HDSS). We compared characteristics and outcomes between boys and girls using descriptive statistics, standardised mean differences, and logistic regression. Post-discharge events were analysed using Cox proportional hazards regression and Fine-Gray competing risk regression. Minimum community-based incidence rates of outpatient clinic visits and hospitalisations were calculated using demographic surveillance data from the Manhiça HDSS and analysed with negative binomial regression.

Results

Girls represented 49.2% (560 630 out of 1 139 962) of paediatric visits to outpatient clinics and 45.1% (18 625 out of 41 278) of hospitalisations. The girls-to-boys incidence rate ratio (IRR) for hospitalisations was 0.81 (95% confidence interval (CI) = 0.79-0.84). Both boys and girls experienced symptoms for a median duration of one day (interquartile range (IQR) = 1-2) before seeking care. Severe manifestations at presentation to an outpatient clinic or upon hospitalisation tended to be less frequent in girls (girls-to-boys odds ratios (ORs) = 0.71-1.11). Girls were less frequently referred or admitted to hospital after an outpatient clinic visit (OR = 0.82; 95% CI = 0.79-0.86 and OR = 0.85; 95% CI = 0.84-0.87, respectively). The hospital case fatality ratio was 4.1% in boys and 4.2% in girls. The median duration of hospitalisation was three days (IQR = 2-5) and did not differ between boys and girls. Revisits to outpatient clinics, hospital readmissions, and hospital post-discharge mortality were similar in both groups.

Conclusions

Girls had fewer referrals and admissions to hospital in Manhiça district, but they were also less likely to present with severe manifestations. Other studied indicators of healthcare access and provision were overall similar for boys and girls. Further research is needed to continue assessing potential gender biases and sex differences in paediatric healthcare in Mozambique.

Prediction model for unfavorable treatment outcome for complicated sever acute malnutrition (SAM) in under five children admitted in hospitals at Amhara Region

Background

Severe acute malnutrition (SAM) affects 45 million children worldwide, with 14.89% of Ethiopian children under five suffering from it. This study validates a prediction model and develops risk scores for unfavorable treatment outcomes in SAM patients, addressing the scarcity of risk assessment tools in low-income settings and providing clinicians with a practical tool to improve decision-making.

Methods

A cohort study was conducted among 915 SAM children hospitalized with SAM hospitals in Amhara Region. Data analysis was conducted using STATA 17 and R 4.4.1. A lasso-selected multivariable model developed a nomogram for clinical utility. Model performance was assessed via AUC, calibration plot and validated with bootstrapping. Decision curve analysis evaluated the model's clinical and public health utility.

Results

The incidence of unfavorable treatment outcomes of SAM cases was 27.8% (95% CI: 25, 31). Majority of admitted children in stabilization center were complicated Severe Acute Malnutrition (cSAM) under-five children a magnitude of 89.52% (95% CI: 80.5-99.82). The developed nomogram comprised seven predictors: baseline Oedema, Diarrhea, CBC test results (Anemia), Pneumonia, Folic Acid supplementation, Vitamin A supplementation and IV antibiotic treatment. The AUC of the original model was 91.3% (95% CI: 89.0, 93.5), whereas the risk score model produced prediction accuracy of an AUC of 90.86 (95% CI: 88.6, 92.9). It was internally validated by bootstrapping method, and it has a relatively corrected discriminatory performance. Decision curve analysis indicated a higher net benefit compared to treating all or none, especially for threshold probabilities above 21%.

Conclusion

Our model and risk score demonstrate excellent discrimination and calibration, with minimal accuracy loss from the original, ensuring robust predictive performance. The models can have the potential to improve care and treatment outcomes in the clinical settings. Healthcare professionals prioritize the management of cSAM cases in children, particularly those presenting with baseline edema and co-morbidities such as pneumonia, anemia and diarrhea. Emphasis should be placed on timely interventions, including the administration of folic acid and Vitamin A supplementation, as well as intravenous antibiotics. Implementing a comprehensive care plan that addresses these factors will significantly improve treatment outcomes and enhance recovery in this vulnerable population.

Child play and caregiver support to promote convalescence following severe acute malnutrition in Zimbabwe: The Tamba-SAM pilot study

Children hospitalised for severe acute malnutrition (SAM) have a high risk of mortality, relapse and rehospitalisation following hospital discharge. Current approaches fail to promote convalescence, or to address the underlying social determinants of SAM, meaning that restoration of long-term health, growth and neurodevelopment is not achieved. Although guidelines recommend play and stimulation to promote recovery, most caregivers are not supported to do this at home. We set out to evaluate the feasibility and acceptability of a codesigned intervention package aimed at providing child stimulation through play, and strengthening caregiver capabilities through problem-solving skills, peer support and income-generating activities. We evaluated the intervention in two phases, enroling 30 caregiver-child pairs from paediatric wards in Harare, Zimbabwe, once children who had been hospitalised with SAM were ready for discharge. Children were median 17.8 months old, and 28.6% had human immunodeficiency virus. Trained intervention facilitators (IFs)-lay workers whose own children had previously had SAM-delivered the intervention over 12 weeks with nurse supervision. Qualitative interviews with caregivers and IFs showed that the intervention was feasible and acceptable. Participants reported benefiting from the psychosocial support and counselling, and several started income-generating projects. Caregivers appreciated the concept of play and caregiver-child interaction, and all reported practising what they had learned. By Week 12, caregiver mental health and caregiver-child interaction improved significantly. Overall, the intervention was feasible, acceptable and showed promise in modifying caregiver knowledge, attitudes and practice. An efficacy trial is now needed to evaluate whether the intervention can improve child convalescence following complicated SAM.

Ten-year trends in clinical characteristics and outcome of children hospitalized with severe wasting or nutritional edema in Malawi (2011-2021): Declining admissions but worsened clinical profiles

BACKGROUND

Severe acute malnutrition (SAM) constitutes a substantial burden in African hospitals. Despite adhering to international guidelines, high inpatient mortality rates persist and the underlying contributing factors remain poorly understood.

OBJECTIVE

We evaluated the 10-year trend (2011-2021) in clinical factors and outcomes among children with severe wasting and/or nutritional edema at Malawi's largest nutritional rehabilitation unit (NRU).

METHODS

This retrospective study analyzed trends in presentation and outcomes using generalized additive models. The association between clinical characteristics and mortality or readmission was examined and key features were also related to time to either mortality or discharge.

RESULTS

1497 children (53%, females) were included. Median age at admission (23 months, IQR 14, 34) or anthropometry (i.e., weight-for-age, height-for-age and weight-for-height) did not change over the 10-years. But the prevalence of edema decreased by 40% whereas dehydration, difficulty breathing, and pallor became more common. Yearly HIV testing increased but positive-detection remained around 11%. Reporting of complete vaccination dropped by 49%, and no reduction in 'watch' antibiotic usage was detected. Overall admissions declined but mortality remained around 23% [95%CI; 21, 25], and deaths occurred earlier (5.6 days [95%CI; 4.6, 6.9] in 2011 vs. 3.5 days [95%CI; 2.5, 4.7] in 2021; p<0.001). Duration of hospitalization was shortened and readmissions surged from 4.9% [95%CI; 3.3, 7.4] in 2011 to 25% [95%CI; 18, 33] in 2021 (p<0.001). Age, wasting, having both dehydration and diarrhea, or having vomiting, cough, or difficulty breathing were associated with mortality but these associations did not show any interaction over time.

CONCLUSION

Over 10 years, mortality risk remained high among hospitalized children with SAM and coincided with worsened clinical presentation at admission and increased readmission. Longitudinal data from major NRUs can identify shifts in clinical profiles or outcomes, and this information can be leveraged to promote earlier care-seeking, improved risk stratification, and implementation of more patient-centered treatments.

Systemic biological mechanisms underpin poor post-discharge growth among severely wasted children with HIV

In sub-Saharan Africa, children with severe malnutrition (SM) and HIV have substantially worse outcomes than children with SM alone, facing higher mortality risk and impaired nutritional recovery post-hospitalisation. Biological mechanisms underpinning this risk remain incompletely understood. This case-control study nested within the CHAIN cohort in Kenya, Uganda, Malawi, and Burkina Faso examined effect of HIV on six months post-discharge growth among children with SM and those at risk of malnutrition, assessed proteomic signatures associated with HIV in these children, and investigated how these systemic processes impact post-discharge growth in children with SM. Using SomaScanTM assay, 7335 human plasma proteins were quantified. Linear mixed models identified HIV-associated biological processes and their associations with post-discharge growth. Using structural equation modelling, we examined directed paths explaining how HIV influences post-discharge growth. Here, we show that at baseline, HIV is associated with lower anthropometry. Additionally, HIV is associated with protein profiles indicating increased complement activation and decreased insulin-like growth factor signalling and bone mineralisation. HIV indirectly affects post-discharge growth by influencing baseline anthropometry and modulating proteins involved in bone mineralisation and humoral immune responses. These findings suggest specific biological pathways linking HIV to poor growth, offering insights for targeted interventions in this vulnerable population.

Convalescing from SAM: The pitfalls and possibilities of caring for vulnerable children in Harare's high-density neighbourhoods

It is widely recognised that children recovering from Severe Acute Malnutrition (SAM), remain vulnerable to risk of death following hospital discharge due to a wide range of biological and social factors. In light of this heightened risk, we report here on a qualitative study which aimed to better understand the caring contexts that children recovering from SAM were recuperating in within the high density urban and suburban districts of Harare, Zimbabwe. Undertaken with the mothers and other primary caregivers of 10 children enrolled on a large observational cohort study (HOPE-SAM), this paper identifies several dimensions of the women's lives that impede their caring capabilities. Given the country's status as a global 'hunger hotspot' (FAO/WFP, 2022), it should not be surprising that food insecurity featured prominently amongst these. Beyond this, the paper highlights the women's uneven access to informal social protection, experiences that are reflective of what recent scholarship refers to as examples of 'uncaring' or 'noncaring,' as well as their responses to discourses of shame and stigma within the community and hospital settings. The paper concludes by considering what this means for understanding of, and responses to, the bodies encountered in the place of global health research and interventions.

Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort

Background

Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia.

Methods

This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission.

Findings

Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission.

Interpretation

Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care.

Funding

The Bill & Melinda Gates Foundation (OPP1131320).

Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Background

Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods

We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings

We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation

Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding

Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Inflammation and epithelial repair predict mortality, hospital readmission, and growth recovery in complicated severe acute malnutrition

Severe acute malnutrition (SAM) is the most high-risk form of undernutrition, particularly when children require hospitalization for complications. Complicated SAM is a multisystem disease with high inpatient and postdischarge mortality, especially in children with comorbidities such as HIV; however, the underlying pathogenesis of complicated SAM is poorly understood. Targeted multiplex biomarker analysis in children hospitalized with SAM (n = 264) was conducted on plasma samples, and inflammatory markers were assessed on stool samples taken at recruitment, discharge, and 12 to 24 and 48 weeks after discharge from three hospitals in Zimbabwe and Zambia. Compared with adequately nourished controls (n = 173), we found that at baseline, complicated SAM was characterized by systemic, endothelial, and intestinal inflammation, which was exacerbated by HIV infection. This persisted over 48 weeks despite nutritional recovery and was associated with children's outcomes. Baseline plasma concentrations of vascular endothelial growth factor, glucagon-like peptide-2, and intestinal fatty acid-binding protein were independently associated with lower mortality or hospital readmission over the following 48 weeks. Following principal components analysis of baseline biomarkers, higher scores of a component representing growth factors was associated with greater weight-for-height z score recovery and lower mortality or hospital readmission over the 48 weeks. Conversely, components representing higher gut and systemic inflammation were associated with higher mortality or hospital readmission. These findings highlight the interplay between inflammation, which damages tissues, and growth factors, which mediate endothelial and epithelial regeneration, and support further studies investigating interventions to reduce inflammation and promote epithelial repair as an approach to reducing mortality and improving nutritional recovery.

Survival Analysis of Patients with Severe Acute Malnutrition Admitted at the In-patient Therapeutic Care of the Bicol Regional Training and Teaching Hospital

Background

Severe acute malnutrition (SAM) in children under five years remains a major global health concern. It carries a burden to the overall health of a child, contributes to mortality, and adds financial strain to the family and the hospital. The Philippine Integrated Management of Acute Malnutrition was established to address acute malnutrition in Filipino children.

Objective

This study aimed to determine the factors affecting survival of patients admitted at Bicol Regional Training and Teaching Hospital (BRTTH) In-patient Therapeutic Care (ITC).

Methods

This is a retrospective cohort study design utilizing survival analysis. Accrual period was from January 1, 2018 to December 31, 2018. Follow-up ended on March 31, 2019. There were 154 admissions and excluded 17 missing charts. Survival analysis was done utilizing STATA 14.

Results

The prevalence of SAM requiring ITC admission was 3.0 percent. Majority belonged to 6-59 months of age (63%), with equal predilection for both sexes (1:1) and 71% came from the home province, Albay. Most of patients' caretakers had middle educational attainment. Sixty-eight percent (68%) were new patients, 16% readmitted, 15% transferred from the Out-patient Therapeutic Care (OTC) and <1% relapsed. The top three most common complications and co-morbidities include: pneumonia, low electrolytes, and fever. Sixty-three percent (63%) of patients at the ITC had a desirable treatment outcome, of which, 8% were cured and 55% transferred to OTC. Undesirable outcomes accounted for 37% of the cases which included non-cured, defaulter, and died at 12%, 8%, and 17%, respectively. The risk of dying was higher in SAM patients with parents having middle and low educational attainment as compared to those with high educational attainment (2-5 folds to 100-200 folds). SAM patients presenting with hypovolemic shock were likely to die by 1.5-19 times (1.5-19x) as compared to those without. SAM patients with malignancy were more likely to die 4-44 folds as compared to patients without malignancy.

Conclusion and Recommendations

Educational attainment of parents, malignancy, and hypovolemic shock were significant predictors of mortality. We recommend prompt intervention by educating families, strengthen policies targeting socio-economic determinants, capacitate medical staff, refine current clinical practice guidelines and treatment pathways to reduce the number of children who die from severe acute malnutrition.

Pediatric post-discharge mortality in resource-poor countries: a systematic review and meta-analysis

Background

Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness.

Methods

Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan-Meier survival curves. PROSPERO study registration: #CRD42022350975.

Findings

Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%-5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%-7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%-19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%-9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity.

Interpretation

Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation.

Funding

No specific funding was received.

Inflammation: the driver of poor outcomes among children with severe acute malnutrition?

Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.

Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells

Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.

Fat and lean mass predict time to hospital readmission or mortality in children treated for complicated severe acute malnutrition in Zimbabwe and Zambia

HIV and severe wasting are associated with post-discharge mortality and hospital readmission among children with complicated severe acute malnutrition (SAM); however, the reasons remain unclear. We assessed body composition at hospital discharge, stratified by HIV and oedema status, in a cohort of children with complicated SAM in three hospitals in Zambia and Zimbabwe. We measured skinfold thicknesses and bioelectrical impedance analysis (BIA) to investigate whether fat and lean mass were independent predictors of time to death or readmission. Cox proportional hazards models were used to estimate the association between death/readmission and discharge body composition. Mixed effects models were fitted to compare longitudinal changes in body composition over 1 year. At discharge, 284 and 546 children had complete BIA and skinfold measurements, respectively. Low discharge lean and peripheral fat mass were independently associated with death/hospital readmission. Each unit Z-score increase in impedance index and triceps skinfolds was associated with 48 % (adjusted hazard ratio 0·52, 95 % CI (0·30, 0·90)) and 17 % (adjusted hazard ratio 0·83, 95 % CI (0·71, 0·96)) lower hazard of death/readmission, respectively. HIV-positive v. HIV-negative children had lower gains in sum of skinfolds (mean difference -1·49, 95 % CI (-2·01, -0·97)) and impedance index Z-scores (-0·13, 95 % CI (-0·24, -0·01)) over 52 weeks. Children with non-oedematous v. oedematous SAM had lower mean changes in the sum of skinfolds (-1·47, 95 % CI (-1·97, -0·97)) and impedance index Z-scores (-0·23, 95 % CI (-0·36, -0·09)). Risk stratification to identify children at risk for mortality or readmission, and interventions to increase lean and peripheral fat mass, should be considered in the post-discharge care of these children.

Time to Discharge and its Predictors among Children Aged 1-60 Months with Severe Acute Malnutrition Admitted to the Therapeutic Feeding Center in A Tertiary Hospital, North West Ethiopia

Background

Standard treatment of severe acute malnutrition with medical complication and/or failed appetite test is admission in therapeutic feeding centers for stabilization. Once stabilized, patients will be linked to Outpatient treatment program for rehabilitation. Information regarding time to discharge from inpatient therapeutic feeding centers is limited in Ethiopia. The main objective of this study was to assess the time to discharge and its predictors among children 1-60 months with Severe Acute Malnutrition admitted to University of Gondar Hospital.

Methods

Hospital Based retrospective follow up study was conducted in Gondar University Hospital among 282 children aged 1-60 months admitted to inpatient Therapeutic Feeding Center from June 2018 to December 2020. Participants were selected by Simple random sampling technique. Time to discharge from inpatient treatment was estimated using Kaplan-Meir procedure and Log Rank test was used to test observed difference between covariates. Identification of predictors for time to discharge was done by Stratified cox regression model.

Results

Overall 282 children were studied; 242 (85.8%) were discharged improved and 40 (14.2%) were censored. The median time to Discharge was 13 days (IQR: 9-18) and the Incidence of discharge was found to be 6.4 (95% CI: 5.6-7.2) per 100 person- day observations. Kwash-dermatosis (AHR=2.4, 95% CI: 1.17-4.8), Anemia (AHR=1.7, 95% CI: 1.1-2.6), pneumonia at admission (AHR=1.6, 95% CI: 1.01-2.63) and Hospital acquired infection (AHR=4.4, 95% CI: 2.4-8.2) were predictors of time to discharge.

Conclusion

Hospital stay at the stabilization center was prolonged. Pneumonia, anemia, kwash dermatosis and Nosocomial infections were significant predictors of time to discharge.