Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals

Abstract

BackgroundDespite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas.ObjectiveTo explore health care workers’ perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa.MethodsAn explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis.FindingsMost respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians.ConclusionFindings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings.

Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study

“…We found that mortality among children with SAM in Limpopo was higher than the target outlined in the WHO SAM management guidelines (<10%) [1]. Mortality among children under five years with SAM in our study (25.9%) is comparable with figures reported in health facilities in rural Eastern Cape province (24.4%) [21]. This increased mortality could be due to delays in seeking treatment in the hospitals, leading to complications [21].…”

“…These high mortality figures suggest possible unexplored factors that contribute to mortality among children with SAM. While studies on the causes of SAM [20] and implementation of WHO SAM management guidelines [8,10,21] have been conducted in South Africa, few have examined factors for mortality. This study aimed to determine factors associated with mortality in children under five years hospitalized for SAM in public hospitals of Limpopo province.…”

Predictors of in-hospital mortality among under-five children with severe acute malnutrition in South-Western Uganda

“…without edema and SAM with edema [27], despite the fact that mortality is linked directly to the degree of oedema [28,29] and hypoalbuminemia [30,31] The WHO recognized danger signs of lethargy, hypothermia and hypoglycemia as well as other clinical signs that pointed to shock, like weak pulse volume, temperature gradient and altered consciousness were not independently associated with mortality as has been reported in other studies [10,20,24] nor was age less than twenty four months [35]. This could be because the proportions of patients with these features in the above studies [10,34,35] were significantly greater than in our study causing them to register more outcomes than we did.…”

“…Of these, 71 (58.2%) were males with a median age [IQR] of 15 months [11][12][13][14][15][16][17][18][19][20][21][22][23][24]. A total of 91 (74.6%) children were less than 24 months.…”

“…These features would be considered by pediatric life-support providers as constituting a very advanced state of shock, when outcome is generally poor [23]. Indeed a study done in South Africa noted that the WHO guidelines, though relatively simple to implement do not make much difference among severe acute malnutrition cases admitted in critical condition [24]. In our study, most of the patients came to hospital having been ill for more than two weeks with almost half of them having been referred from peripheral health facilities.…”