Changing mortality amongst hospitalised children with Severe Acute Malnutrition in KwaZulu-Natal, South Africa, 2009 – 2018

Abstract

Background The under-five mortality rates of children in South Africa (SA) remain high despite successful HIV prevention and treatment programs. The in-hospital mortality of children with severe acute malnutrition remains a key obstacle. This study identifies and describes changes in the mortality of under-five children with severe acute malnutrition (SAM) following the implementation of HIV and malnutrition prevention and treatment programmes. Methods This was a retrospective review of in-hospital mortality records and databases. The study was based at a large referral hospital in KwaZulu-Natal (KZN), where HIV and malnutrition rates are high, and SAM children are managed with standard WHO guidelines. Records of children under five years old who died from 2009 to 2018 were analysed. Results Of the 698 under-five children who died in this period, 285 (40, 8% of all under-5 deaths) were classified as having SAM. The number of HIV-infected SAM deaths dropped significantly, especially those below six months of age, mirroring the expansion of HIV treatment and prevention programmes. Despite this and a significant drop in the proportion of SAM admissions identified, there was no change in SAM case fatality rates over the ten years. Septicaemia remained the most common cause of death in children with SAM. Conclusions Despite significant decreases in HIV-related malnutrition deaths over ten years, the lack of change in SAM case fatality rates is a concern at this referral hospital. Standardised WHO inpatient management protocols, may require review, especially where underlying medical conditions may contribute to SAM deaths in HIV-negative children.

A retrospective cohort analysis of factors associated with the development of refeeding syndrome in children 0–59 months diagnosed with severe acute malnutrition in a South African setting

“…In 2018, the reported mortality rate of children under the age of five years with SAM in South Africa was 30.9 % [ 4 ]. Furthermore, varying mortality rates have been reported in children under five years with SAM in South African public hospital settings, ranging from 6.5 % to 40.8 % [ 5 , 6 ]. Mbethe and Mda [ 15 ] reported a mortality rate of 9.5 % and noted that most of the children in their study who died had developed RFS.…”

“…However, in 2018 South Africa still had a high case fatality rate of 30.9 % of children under five years dying from SAM [ 4 ]. Furthermore, there seems to be a vast difference in mortality rates reported between different provinces in South Africa ranging from 6.5 % to 40.8 % of children under five years dying from SAM, despite following standardized WHO treatment protocols [ 5 , 6 ]. A factor that may affect the outcome of children treated for SAM is that these children are at risk of developing refeeding syndrome (RFS) as a life-threatening complication [ [7] , [8] , [9] ].…”

“…Fluid retention may also increase the extracellular fluid volume [ 11 ]. Thus, the syndrome is mainly characterized by a drop in blood phosphate to below-normal levels (hypophosphatemia) within five days of initiating nutritional therapy [ 3 , 6 ]. Clinical symptoms range from mild to severe and may be associated with cardiac arrhythmias, cardiac failure, renal failure, and death [ 10 ].…”

Risk factors for inpatient mortality among children with severe acute malnutrition in Zimbabwe and Zambia

“…The causes of death among children hospitalised with SAM are dominated by symptomatic infections such as septicaemia, lower respiratory tract infection, and diarrhoea [ 10 ]. However, limited diagnostics in many settings with a high burden of SAM mean the cause of death is often not ascertained, and asymptomatic pathogen carriage is common among both adequately-nourished and undernourished children in low-income, high-pathogen environments [ 11 ].…”