Time to recovery from severe acute malnutrition and its predictors: a multicentre retrospective follow-up study in Amhara region, north-west Ethiopia

Effect of ready-to-use therapeutic foods on time to recovery among children with severe acute malnutrition in Ethiopia: a prospective cohort study

BACKGROUND

The therapeutic feeding unit (TFU) provides comprehensive inpatient clinical care for children suffering from severe acute malnutrition (SAM) in three stages: stabilization, transition, and rehabilitation. During the transitional and rehabilitation phases, children receive either F-100 or ready-to-use therapeutic food (RUTF). Although both promote weight gain, RUTF is more energy dense than F-100. There is limited and contrasting evidence regarding their effect on recovery time. Therefore, this study aimed to assess the effect of RUTF on time to recovery among SAM children aged 6-59 months admitted to the TFU in Ethiopia.

METHODS

Health Facility-based prospective cohort study was conducted among 476 children treated in three hospitals and four health centers in the Sidama region from September 2021 to January 2022. A structured questionnaire adopted from the Ethiopian national protocol for the management of SAM was used for data collection. Data were entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. The Kaplan-Meir curve and log-rank test were used to compare time to recovery between children who received RUTF and F-100. Multivariable Cox proportional hazard analysis was conducted to assess the association between time to recovery and the type of therapeutic food, controlling for the confounding variables.

RESULTS

The median recovery time was significantly shorter in children receiving RUTF (7 days; 95% CI: 6.62-7.38) compared to F-100 (10 days; 95% CI: 8.94-11.06). Children below 24 months (AHR = 0.54, 95% CI: 0.42-0.69), dehydrated (AHR = 1.34, 95% CI: 1.07-1.75), edematous malnutrition (AHR = 1.29, 95% CI: 1.03-1.61), and anemic (AHR = 2.57, 95% CI: 1.90-3.48) during admission were associated with time to recovery.

CONCLUSIONS

Children who received RUTF recovered faster than children who received F-100. Administering RUTF to children below 24 months, who present with anemia and dehydration can improve their recovery rate and shorten their stay in the health facility.

Time to recovery from severe acute malnutrition and its predictors among under five children admitted to therapeutic feeding units of general and referral hospitals in Tigray, Ethiopia, 2020: a prospective cohort study

BACKGROUND

Across the globe, an estimated 16 million children under the age of 5 are affected by severe acute malnutrition. Children with severe acute malnutrition are nine times more likely to die than well-nourished children. In Ethiopia, 7% of children under five are wasted, and 1% of these are severely wasted. A prolonged hospital stay increases the incidence of hospital-acquired infections. The aim of this study was to assess the time to recovery and its predictors among children 6-59 months old with severe acute malnutrition admitted to therapeutic feeding units of selected general and referral hospitals in Tigray, Ethiopia.

METHODS

A prospective cohort study design was conducted among children aged 6-59 months admitted with severe acute malnutrition in selected hospitals in Tigray that have therapeutic feeding units. The data were cleaned, coded, entered into Epi-data Manager, and exported to STATA 14 for analysis.

RESULT

Among 232 children followed in the study, 176 have recovered from severe acute malnutrition with a recovery rate of 54 per 1000 person-days observation and the median time to recovery was 16 days with an inter-quartile range of 8. In a multivariable Cox Regression, feeding plumpy nut [AHR 0.49 (95% CI 0.2717216-0.8893736)] and failing to gain 5 gr/kg/day for three successive days after feeding freely on F-100 [AHR 3.58 (95% CI 1.78837-7.160047)] were found to have an association with time to recovery.

CONCLUSION

Despite the median time to recovery is shorter than what has been reported in a few studies, we can conclude that this could not let children avoid any possible hospital-acquired infections. The impact of staying in a hospital may also extend to the mother/caregiver in terms of the infection that they may acquire or the costs imposed on them.

Achievement of adequate weight gain among infants and children with complicated severe acute malnutrition receiving treatment in therapeutic feeding centers of South Sudanese refugee camps in Ethiopia

Objectives

This study aimed to assess achievement of adequate weight gain and identify its associated factors among infants and children with complicated severe acute malnutrition admitted in Kule and Tierkidi refugee camps in Gambella, Southwest Ethiopia.

Methods

Records of 332 infants and children with complicated severe acute malnutrition were selected by systematic random sampling. Weight gain was calculated for all participants. Patients who achieved weight gain of >5 g/kg/day were regarded as achieving adequate weight gain. Sociodemographic characteristics, season of admission, patients' anthropometry at admission, source of admission, clinical conditions at admission, types of medications used, length of stay at the centers, and the centers of the treatment were considered as covariates. The adjusted odds ratio and its 95% confidence interval were used to identify factors associated with adequate average weight gain in the multivariable logistic regression.

Results

In total, 72% of the treated patients achieved adequate weight gain. Treatment at Tierkidi center Adjusted Odds Ratio = 5.9, 95% Confidence Interval: (2.0,16.9), treatment with amoxicillin-clavulanate Adjusted Odds Ratio = 4.1, 95% Confidence Interval: (1.7, 10.0), WFH z-score < -3 Adjusted Odds Ratio = 4.1, 95% Confidence Interval: (1.9, 9.0) and length of stay of ⩽7 days Adjusted Odds Ratio = 2.5, 95% Confidence Interval: (1.4, 4.4) were significantly associated with achievement of adequate weight gain.

Conclusion

Seven in ten of treated patients achieved adequate weight gain. However, significant proportion of patients still failed to achieve recommended weight gain in refugee camps. Anthropometric indices, type of antibiotics used for treatment, short length of stay, and the treatment center were associated with achievement of adequate weight gain. We recommend that the local antibiotic sensitivity pattern be studied in order to recommend an appropriate treatment regimen for infants and children. Children requiring longer duration have to be given due focus. Inter-center variations have to be narrowed by strengthening follow-up and supervisory supports.

Predictors of time to recovery from uncomplicated severe acute malnutrition among 6-59 months children treated in out patient treatment in health posts of Nagele Arsi district: a retrospective cohort study

BACKGROUND

Access to outpatient therapeutic feeding programs (OTP) for all children who have uncomplicated severe acute malnutrition (SAM) remains a global public health priority. Identifying predictors that determine time-to-recovery from severe acute malnutrition optimize therapeutic success. However, reliable evidence on the determinants of time to recovery at health posts was not available in Nagele Arsi district of South Ethiopia.

OBJECTIVE

This study was aimed to identify determinants of time-to-recovery from uncomplicated SAM among children aged (6-59) months treated at an OTP in health posts of Nagele Arsi district, Southern Ethiopia.

METHODS

Institutional based retrospective cohort study was conducted among 357 children treated in Negele Arsi district from July1, 2018 to June 30, 2020. The children were selected using simple random sampling from 20 health posts. SAM treatment outcomes were compared against international SPHERE standards. The average time-to-recovery was estimated using Kaplan-Meier survival curve and the independent predictors of time to recovery were determined using multivariable Cox-proportional hazard model. The strength of the association was done using adjusted hazard ratio (AHR) with 95% confidence intervals. Statistical significance was declared at p value < 0.05. The results were presented by text, tables and figures.

RESULT

A total of 284 (79.6%) children recovered during follow up. The mean weight gain for recovered children was 4.7 + 2.4 g/kg/day. The median time-to-recovery was 44 days 95% CI (42.7-45.3). Children who received Amoxicillin, AHR =2.574, 95% CI (1.879-3.525); de-wormed, AHR = 1.519, 95% CI (1.137-2.031); received Vitamin A, AHR = 2.518, 95% CI, (1.921-3.301) and new admissions, AHR = 1.823, 95%CI, (1.224-2.715) were more likely to recover. However, those who admitted with non-edema, AHR = 0.256, 95% CI, (0.189-0.346); had cough at admission, AHR = 0.513, 95 CI, (0.366-0.719) and had diarrhea at admission AHR = 0.5, 95% CI, 0.5 (0.350-0.712) were less likely to recover.

CONCLUSION AND RECOMMENDATION

The recovery rate was within the acceptable ranges of International Sphere Standards. Those children who had cough and diarrhea should be given due attention from health extension workers and program planners. Appropriate provision of routine medication and timely intervention of co-morbidity are needed to increase chance of early recovery.

Incidence and predictors of attrition rate after children started inpatient treatments for complicated severe acute malnutrition in North West Ethiopia

BACKGROUND

Retaining children for inpatient treatment of complicated severe acute malnutrition (SAM) is a growing challenge until achieved the reference weight of a child. In Ethiopia, there is limited information regarding the time to be lost from the stabilizing centers after initiation of treatment. Thus, this study aimed to identify incidence and predictors of attrition for children suffering from SAM after started inpatient treatment in North West Ethiopia.

METHODS

A retrospective cohort study was conducted among under-five children admitted and started inpatient treatment for complicated SAM from 2015/2016 to 2020/2021. Data were entered using Epi-data version 4.2 and then exported to STATA (SE) version R-14 software for further analysis. The analysis was computed using Cox proportional hazard regression model after checking all proportional hazard assumptions. Covariates having < 0.2 of P values in the bi-variable analysis were candidates transferred to the multivariable Cox proportional hazard regression model. Finally, a statistical significance was declared at a P value of < 0.05.

RESULT

Overall, 760 files of under-five children were analyzed with a mean (± SD) age of participants 27.8 (± 16.5) months. About 6944 child-days of treatment observation were recorded with the crude incidence of attrition rate of 9.7% (95% CI 7.9-12.6). The overall median time of attrition and half-life time S(t_1/2) of survival rates was determined as 14 (IQR =  ± 7) days and 91.6% (95% CI 88.2-93.1), respectively. The attrition rate was significantly associated with cases living in rural residents (AHR = 6.03; 95% CI 2.2; 25.2), being re-admitted SAM cases (AHR = 2.99; 95% CI 1.62; 5.5), and caregivers did not have formal education (AHR = :5.6, 95% CI 2.7; 11.7) were all independent predictors for attrition from inpatient treatment.

CONCLUSIONS

Nearly one in every ten severely acute malnourished under-five children defaulted at the end of treatment observation with a median time of 14 (IQR =  ± 7) days. Living in a rural residence, being re-admitted cases, caregivers who did not have a formal education were significantly associated with the attrition rate. Hence, it is crucial to detect and control the identified causes of defaulting from treatment observation promptly. Furthermore, serious counseling during admission and nutritional provision strategies are essential for virtuous treatment outcomes.

Comorbidities of Child Malnutrition in Low- and Medium-Income Countries: A Systematic Review

The study intended to review the best evidence on prevalence, diagnosis, and treatment outcomes of comorbidities associated with child malnutrition. The study design was a systematic review of quantitative studies. Critical appraisal tools were used to assess the methodological quality of the studies. Data were extracted according to the predetermined data extraction table. Data were further analyzed narratively according to the set study objectives and main concepts. Fifteen studies were eligible to include in the review. All 15 studies reported on the prevalence of 4 child malnutrition-associated comorbidities. Five (n = 5/15) studies reported on length of hospitalization/stay, 10 (n = 10) studies on recovery rate, and 9 (n = 9/15) studies on mortality rate as treatment outcomes of child malnutrition associated comorbidities. The most prevalent child malnutrition associated comorbidities were tuberculosis, pneumonia, gastroenteritis, and anemia. The treatment outcomes identified included the length of hospitalization/stay, recovery rate, and mortality rate. Screening of prevalent comorbidities in children admitted with malnutrition should be standard procedure in practice. More research needs to be done on the diagnosis of under-5 child malnutrition associated comorbidities.

Time to recovery from severe acute malnutrition and its predictors among children aged 6–59 months at Asosa general hospital, Northwest Ethiopia. A retrospective follow up study

Background

Severe Acute Malnutrition (SAM) has become a major public health challenge in developing countries including Ethiopia, especially among the underprivileged population. Ethiopia is among the developing countries with the highest burden of acute malnutrition among under-five children. Though, plenty of studies were done on the magnitude of acute malnutrition among under-five children in Ethiopia, there is a limited evidence on time to recovery from SAM and its predictors among children aged 6–59 months in Ethiopia, particularly in the study area.

Objectives

The study was aimed to assess the time to recovery from SAM and its predictors among children aged 6–59 months at Asosa general hospital (AGH), Benishangul Gumuz, Ethiopia.

Methods

A Five years retrospective follow-up study design was employed among 454 children admitted with SAM in AGH from January 2015 to December 2019. The data were extracted from the patient medical records using checklist. The data were coded and entered into Epi-Data 3.1; then exported to STATA/SE-14 for analysis. Proportional Cox regression was performed to identify predictors of recovery time. A proportional hazard assumption was checked. Variables with AHR at 95% CI and P-value less than 0.05 in the multivariable Cox proportional regression was considered as significant predictors of recovery time.

Findings

Among the 454 included records of children with SAM, 65.4% (95%CI: 50.1, 69.2) of them were recovered at the end of the follow-up with a median recovery time of 15 IQR(11–18)days. The incidence rate of recovery was 5.28 per 100 child days’ observations. Being HIV Negative (AHR = 2.19: 95% CI 1.28, 3.73), Marasmic (AHR = 1.69: 95% CI 1.18, 2.42), and marasmic-kwashiorkor child (AHR = 1.60: 95% CI (1.09, 2.37) independently predicted recovery time.

Conclusions

Though the time to recovery from severe acute malnutrition was in the acceptable range, the proportion of recovery was found to be low in the study area compared to sphere standard. The prognosis of children with severe acute malnutrition was determined by the HIV status of the child and the type of malnutrition experienced. Further strengthening of malnutrition therapeutic centers and routine checkup of the nutritional status of HIV positive children should be emphasized to reduce child mortality and morbidity from under-nutrition.

Predictors of time to recovery and non-response during outpatient treatment of severe acute malnutrition

Background

Every year, over 4 million children are treated for severe acute malnutrition with varying program performance. This study sought to explore the predictors of time to recovery from and non-response to outpatient treatment of SAM.

Methods

Children with weight-for-height z-score (WHZ) <-3 and/or mid-upper arm circumference (MUAC) <115 mm, without medical complications were enrolled in a trial (called MANGO) from outpatient clinics in Burkina Faso. Treatment included a weekly ration of ready-to-use therapeutic foods. Recovery was declared with WHZ ≥-2 and/or MUAC ≥125 mm, for two weeks without illness. Children not recovered by 16 weeks were considered as non-response to treatment. Predictors studied included admission characteristics, morbidity and compliance during treatment and household characteristics. Cox proportional hazard models were fitted and restricted mean time to recovery calculated. Logistic regression was used to analyse non-response to treatment.

Results

Fifty-five percent of children recovered and mean time to recovery was eight weeks while 13% ended as non-response to treatment. Independent predictors of longer time to recovery or non-response included low age, being admitted with WHZ <-3, no illness nor anaemia at admission, illness episodes during treatment, skipped or missed visits, low maternal age and not practising open defecation. Eighty-four percent of children had at least one and 59% at least two illness episodes during treatment. This increased treatment duration by 1 to 4 weeks. Thirty-five percent of children missed at least one treatment visit. One missed visit predicted 3 weeks longer and two or more missed visits 5 weeks longer treatment duration.

Conclusions

Both longer time to recovery and higher non-response to treatment seem most strongly associated with illness episodes and missed visits during treatment. This indicates that prevention of illnesses would be key to shortening the treatment duration and that there is a need to seek ways to facilitate adherence.