Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya

Abstract

BackgroundGoals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions.ObjectiveThe aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM.DesignThis was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2–59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points.ResultsOver 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥−2, respectively, which, compared with a WHZ <−3, was associated with lower risks of subsequent LTEs [adjusted HRs (95% CIs): 0.50 (0.40, 0.64), 0.30 (0.23, 0.39), and 0.23 (0.16, 0.32), respectively]. However, children with a WHZ ≥−2 at 1, 3, and 6 mo still had 39 (95% CI: 32, 47), 26 (95% CI: 22, 32), and 15 (95% CI: 12, 20) LTEs/100 child-years of observation during the following 6 mo. WHZ at study enrollment predicted subsequent WHZ but not the risk of LTEs. Changes in height-for-age z score did not predict LTEs.ConclusionsAnthropometric response was associated with a rapid and substantial reduction in risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, together with anthropometric assessment, may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery and addressing broader vulnerabilities that complicated SAM indicates may save lives. This trial was registered at www.clinicaltrials.gov as NCT00934492.

Phenotype is sustained during hospital readmissions following treatment for complicated severe malnutrition among Kenyan children: A retrospective cohort study

“…Children with cSAM were actively linked to therapeutic and supplementary feeding programmes upon hospital discharge. Missing follow‐up visits and needing to be traced by a fieldworker making a home visit was associated with readmission (with any condition, not just complicated SAM) and death, as previously published (Berkley et al, ; Ngari et al, a).…”

“…The goal of SAM treatment also includes the reduction of susceptibility to life‐threatening infections, restoration of a healthy body composition, and improvement in neurocognitive status (Ngari et al, a). However, children with SAM remain at risk of developing severe illness and/or infections after treatment of clinical complications and discharged from hospital (Berkley et al, ; Chisti et al, ; Kerac et al, ; Ngari et al, a). A study by Kerac et al () that followed 1,024 children 1 year post‐discharge reported 5% hospital readmissions but 42% deaths, whereas Khanum et al () reported 1.2% emergency hospital readmissions.…”

“…Accounting for multiple hospital readmissions, a previous report recorded 616 nonfatal admissions to hospital and 3,266 nonfatal episodes of illness post‐discharge among 1,778 children in the original randomised trial (Berkley et al, ). A secondary analysis of this data focusing on life‐threatening events reported 823 life‐threatening events (257 fatal and 566 nonfatal events) among 612 children after discharge from the hospital (Ngari et al, a), including a high rate of events in those who had recovered their nutritional status. However, these reports did not focus on the children who specifically readmitted with cSAM.…”

“…A study by Kerac et al (2014) (Berkley et al, 2016). A secondary analysis of this data focusing on life-threatening events reported 823 life-threatening events (257 fatal and 566 nonfatal events) among 612 children after discharge from the hospital (Ngari et al, 2018a), including a high rate of events in those who had recovered their nutritional status. However, these reports did not focus on the children who specifically readmitted with cSAM.…”

Examining Mid‐Upper Arm Circumference Malnutritionz‐Score Thresholds

“…However, when all anthropometric measures (eg, height, weight, BMI, MUAC) in a given population of undernourished children are represented by z-scores, the extent to which each measure deviates from the mean will differ depending on the presence of other confounders such as wasting, stunting, dehydration, and edema. [28][29][30][31] In our cohort, for example, MUACz was 0.4 SD lower than the mean, whereas BMIz or WLz were only 0.1 SD below the mean despite the fact that weight and height, independently, were 0.5 and 0.8 SD below the mean, respectively. Consequently, it is unclear whether the same z-score thresholds should be applied across parameters to classify malnutrition.…”