Association between admission and transfer criteria and clinical outcomes of infants and children (0-59 months) treated for severe acute malnutrition in Botswana

Abstract

Background: Complicated severe acute malnutrition (SAM) in children under 59 months demonstrates an increase on a country’s economic burden and higher child mortality rates. Despite focussed efforts, 17 million children remain affected by SAM, with a quarter of them residing in Africa. High in-patient mortalities up to 46% have been reported within sub-Sahara Africa. Very few studies have verified the efficacy of the current World Health Organization (WHO) in-patient hospital admission and transfer criteria against clinical outcomes such as recovery, hospital stay (LOS) and mortality. In Botswana, the updated WHO SAM management guidelines have been taken into consideration when drafting the more recent ‘integrated management of acute malnutrition and underweight in children and adolescents (IMAMU)’ guidelines. However, since these guidelines are still in draft format, the current WHO admission and transfer criteria serve only as a reference. Furthermore, the association between the admission and transfer criteria with clinical outcomes are yet to be established. The aim of this study was to determine the association between SAM in-patient admission and transfer criteria and clinical outcomes of children aged 0 - 59 months in Botswana. Objectives: To achieve the study aim, the following objectives were set: to describe basic demographic profiles of those represented on the data extraction forms, to describe admission and transfer criteria, to describe basic clinical outcomes (recovery, LOS and mortality) and to identify associations between admission and transfer criteria and clinical outcomes. Methods: Data was extracted from medical records of children aged 0 – 59 months admitted for the in-patient treatment of SAM in a referral hospital from January 2013 - May 2018. Data extracted included demographic and anthropometric profiles and clinical presentations on both admission and transfer. Data were analysed using SAS version 9.4. and logistic regressions were conducted to test for associations between admission and transfer criteria and clinical outcomes (LOS, weight gain and mortality). Results: All available, relevant files in the hospital were idendified. A total of 101 medical records were included in the study. Admission and transfer practices observed were not in line with the current WHO recommendations. Weight-for-height z-scores (WHZ) were measured in 54% of children at admission and in none on transfer. The mid-upper-arm-circumference (MUAC) was poorly measured. Only 17% and 1% of children had a MUAC measurement at admission and transfer respectively. Results revealed a LOS of 17 days, average daily weight gain of 5.4 g/kg/day, and a mortality rate of 28%. Oedema at admission was associated with an increased risk of mortality (P = 0.045). Neither a WHZ < -3 SD or a MUAC ≤ 115 mm at admission or transfer had any associations on the LOS (P = 0.998 and P = 0.906), weight gain (P = 0.914 and P = 0.218) and mortality (P = 0.377 and P = 0.265) respectively. Conclusion: Adherence to the recommended WHO admission and transfer criteria was poorly conducted. Daily weight gain and mortality were below and above the acceptable global SPHERE levels respectively. Oedema on admission was associated with an increased risk of mortality. The lack of association between other admission and transfer criteria and clinical outcomes of interest could have been due to the poor compliance of anthropometric measures.