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

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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.

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Most cited references 22

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Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya.

Newton Opiyo, Mike English, Grace Irimu … (2008)

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Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network

Philip Ayieko, Morris Ogero, Boniface Makone … (2015)

Background Lack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data collection and use, informing wider health system development in time, but are rare in LIC. We report baseline data from a new Clinical Information Network (CIN) in Kenya seeking to promote data-informed improvement and learning. Methods Data from 13 hospitals engaged in the Kenyan CIN between April 2014 and March 2015 were captured from medical and laboratory records. We use these data to characterise clinical care and outcomes of hospital admission. Results Data were available for a total of 30 042 children aged between 2 months and 15 years. Malaria (in five hospitals), pneumonia and diarrhoea/dehydration (all hospitals) accounted for the majority of diagnoses and comorbidity was found in 17 710 (59%) patients. Overall, 1808 deaths (6%) occurred (range per hospital 2.5%–11.1%) with 1037 deaths (57.4%) occurring by day 2 of admission (range 41%–67.8%). While malaria investigations are commonly done, clinical health workers rarely investigate for other possible causes of fever, test for blood glucose in severe illness or ascertain HIV status of admissions. Adherence to clinical guideline-recommended treatment for malaria, pneumonia, meningitis and acute severe malnutrition varied widely across hospitals. Conclusion Developing clinical networks is feasible with appropriate support. Early data demonstrate that hospital mortality remains high in Kenya, that resources to investigate severe illness are limited, that care provided and outcomes vary widely and that adoption of effective interventions remains slow. Findings suggest considerable scope for improving care within and across sites.

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Mortality and morbidity patterns in under-five children with severe acute malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based records (2009–2013)

Tendai Munthali, Choolwe Jacobs, Lungowe Sitali … (2015)

Background Severe acute malnutrition has continued to be growing problem in Sub Saharan Africa. We investigated the factors associated with morbidity and mortality of under-five children admitted and managed in hospital for severe acute malnutrition. Methods It was a retrospective quantitative review of hospital based records using patient files, ward death and discharge registers. It was conducted focussing on demographic, clinical and mortality data which was extracted on all children aged 0–60 months admitted to the University Teaching Hospital in Zambia from 2009 to 2013. Cox proportional Hazards regression was used to identify predictors of mortality and Kaplan Meier curves where used to predict the length of stay on the ward. Results Overall (n = 9540) under-five children with severe acute malnutrition were admitted during the period under review, comprising 5148 (54%) males and 4386 (46%) females. Kwashiorkor was the most common type of severe acute malnutrition (62%) while diarrhoea and pneumonia were the most common co-morbidities. Overall mortality was at 46% with children with marasmus having the lowest survival rates on Kaplan Meier graphs. HIV infected children were 80% more likely to die compared to HIV uninfected children (HR = 1.8; 95%CI: 1.6-1.2). However, over time (2009–2013), admissions and mortality rates declined significantly (mortality 51% vs. 35%, P < 0.0001). Conclusions We find evidence of declining mortality among the core morbid nutritional conditions, namely kwashiorkor, marasmus and marasmic-kwashiorkor among under-five children admitted at this hospital. The reasons for this are unclear or could be beyond the scope of this study. This decline in numbers could be either be associated with declining admissions or due to the interventions that have been implemented at community level to combat malnutrition such as provision of “Ready to Use therapeutic food” and prevention of mother to child transmission of HIV at health centre level. Strategies that enhance and expand growth monitoring interventions at community level to detect malnutrition early to reduce incidence of severe cases and mortality need to be strengthened.

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Author and article information

Contributors

Susan Gachau:

ORCID: http://orcid.org/0000-0002-2167-857X

Role: ConceptualizationRole: Formal analysisRole: Writing – original draft

Grace Irimu: Role: MethodologyRole: Writing – review & editing

Philip Ayieko: Role: ConceptualizationRole: MethodologyRole: Writing – review & editing

Samuel Akech: Role: MethodologyRole: Writing – review & editing

Ambrose Agweyu: Role: MethodologyRole: Writing – review & editing

Mike English: Role: MethodologyRole: Writing – review & editing

Frank Wieringa: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 17 May 2018

Publication date Collection: 2018

Volume: 13

Issue: 5

Electronic Location Identifier: e0197607

Affiliations

[1 ] Kenya Medical Research Institute -Wellcome Trust Research Programme, Nairobi, Kenya

[2 ] Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya

[3 ] Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom

Institut de recherche pour le developpement, FRANCE

Author notes

Competing Interests: The authors have declared that no competing interests exist.

¶ Membership of the Clinical Information Network Author Group is provided in the Acknowledgments

* E-mail: sgachau@ 123456kemri-wellcome.org

Author information

Susan Gachau http://orcid.org/0000-0002-2167-857X

Article

Publisher ID: PONE-D-17-27164

DOI: 10.1371/journal.pone.0197607

PMC ID: 5957373

PubMed ID: 29771994

SO-VID: 32096b31-0161-498f-8eab-6b6445d259c2

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 20 July 2017

Date accepted : 4 May 2018

Page count

Figures: 3, Tables: 5, Pages: 17

Funding

Funded by: funder-id http://dx.doi.org/10.13039/100004440, Wellcome Trust;

Award ID: 097170

Award Recipient : Mike English

Funded by: funder-id http://dx.doi.org/10.13039/100004440, Wellcome Trust;

Award ID: 092654

Award Recipient : Mike English

Funds from the Wellcome Trust (#097170) awarded to ME as a senior Fellowship together with additional funds from a Wellcome Trust core grant awarded to the KEMRI-Wellcome Trust Research Programme (#092654) supported this work. Funders had no role in drafting or submitting this manuscript.

Custom metadata

Data Availability Scientific and ethical clearance to establish the Clinical Information Network and conduct the study was obtained from the Scientific and Ethics Review Unit of the Kenya Medical Research Institute that approved the use of de-identified patient data obtained through retrospective review of medical records without individual patient consent. In brief, all data were anonymized at point of abstraction by trained data clerk where by each hospital in the network was assigned a unique double digit code and all records were assigned a 7 digit unique code auto generated in redcap. Patient names or any other information that would lead to identification of individual patients were not abstracted from medical records into redcap. Since data was collected after patients' discharge, it was not possible to have their consent. Instead consent was obtained at hospital level before data collection began in 2013. An anonymized dataset has been uploaded as required.

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

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Most cited references 22

Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya.

Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network

Mortality and morbidity patterns in under-five children with severe acute malnutrition (SAM) in Zambia: a five-year retrospective review of hospital-based records (2009–2013)

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