Associations of admission- and transfer criteria with clinical outcomes of children (24 — 59 months) treated for severe acute malnutrition in Ghanaian referral hospitals — the SAMAC study
Introduction: Severe acute malnutrition (SAM) affects more than 50 million children worldwide of which more than a quarter resides in Africa. A patient presenting with indices of SAM who experiences medical complications requires admission to in-patient treatment as their mortality risk is increased by almost 12 times in comparison to non-wasted children. Thus, the World Health Organisation (WHO) developed a guideline for the treatment of in-patients, which includes the criteria for admission and transfer of SAM patients. SAM is diagnosed in children aged 6 - 59 months as a weight-for-length/height (WLZ/WHZ) below the -3 standard deviation (SD) of the WHO child growth standards or a mid-upper arm circumference (MUAC) of less than 115mm and/or the presence of bilateral pitting oedema. The transfer from in-patient to community-based management is not recommended to be based on anthropometric assessments, but rather on clinical improvement. The WHO guideline is however based on low or very low-quality evidence, as research remains limited. The WHO identified the admission- and transfer criteria as an area that requires significant evaluation to improve clinical outcomes, especially in different age groups. Further, the implementation of the criterion used to diagnose and transfer Ghanaian patients remains, as yet, unknown. It is envisaged that this study will contribute to a better understanding of the clinical practices in terms of whether Ghanaian children are admitted early enough and transferred timeously to Community-based Management of Acute Malnutrition (CMAM). Methods: Secondary data of the Severe Acute Malnutrition in African Children (SAMAC) larger study was used for this mini-dissertation. The SAMAC study is a multi-country, multi-hospital study which is based on a retrospective case-control design, and data are collected from medical records only. Data collection for the purpose of this sub-study took place at three referral hospitals in Ghana and included records of children aged 24 - 59 months, admitted for SAM between January 2013 and June 2018. Data was captured into Microsoft Access and analysed using version 9.4 of Statistical Analysis System (SAS). Results: Medical records of 135 children aged 24 - 59 months were included for analysis. The age group 24 — 35 months presented 70% of the study sample. Tamale Teaching Hospital (TTH) had almost three times the amount of admissions compared to Komfo Anokye Teaching Hospital (KATH) and Princess Marie Louise (PML) Children's Hospital. Weight is the most reported anthropometry measurement on admission. The results will also be discussed as per hospital. Considering the indices of SAM, MUAC were reported in 48% (n=65) of medical records (median = 110mm and interquartile range (IQR): 103.0; 120.0), while WHZ was reported in 12.5% (n=17) of medical records with a median of -4.14 (IQR: -5.37; -2.53). Visible signs of emaciation and oedema occurred in 56% and 46% of patients, respectively. The median length of hospital stay (LOS) was 11 days with an IQR between 8 and 18, while a median weight gain of 0.03kg (IQR: -0.02; 0.08) was observed. Seventy-five percent (n=103) of patients were discharged from in-patient treatment, while 1% (n=2) were referred to CMAM. A 19% (n=25) mortality rate was observed of which TTH had the highest rate (24%; n=21). Discussion: The occurrence of malnutrition differs from region to region in Ghana as TTH remains burden with higher malnutrition rates than KATH and PML. The majority of MUAC and WHZ were unreported at admission, while visible signs of emaciation remain the diagnostic criteria for diagnosis of SAM. The high percentage of oedema occurring, as well as the low MUAC and WHZ values on admission indicates the severity of SAM within our study sample. No other association could be found between anthropometric measurements on admission and clinical outcomes. Since no readmissions occurred, associations between transfer criteria and clinical outcomes could not be evaluated. Conclusion: The practice for admitting a SAM patient is not occurring as per WHO protocol. Further research is thus required to understand poor compliance of these guidelines in Ghanaian hospitals. Furthermore, more focus is required on CMAM to ensure children are admitted early enough to prevent complications, as well as transferred for follow-up treatment.
- Health Sciences