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Published on: February 2, 2017
Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?
Kathryn Maitland1, James A Berkley, Mohammed Shebbe
1Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya. kmaitland@kilifi.kemri-wellcome.org
Insights
High in-hospital mortality from severe malnutrition can be reduced by identifying at-risk children using specific clinical signs. Early identification of danger signs improves patient outcomes and resource allocation in pediatric care.
Area of Science:
- Pediatric critical care
- Infectious disease epidemiology
- Global child health
Background:
- Severe malnutrition poses a significant mortality risk, with African hospitals reporting fatality rates up to 20%, far exceeding the recommended <5%.
- Current management challenges in severe malnutrition are often linked to inadequate training and flawed case management protocols.
- Effective resource allocation necessitates identifying high-risk pediatric patients for timely and targeted interventions.
Purpose of the Study:
- To retrospectively analyze risk factors for early (<48 hours) and late in-hospital mortality in children with severe malnutrition.
- To identify specific admission clinical features that can reliably distinguish high-risk patients according to World Health Organization (WHO) guidelines.
Main Methods:
- Retrospective analysis of 920 children admitted with severe malnutrition.
- Evaluation of WHO-recommended danger signs (lethargy, hypothermia, hypoglycemia) for predicting early mortality.
- Assessment of additional bedside clinical features (bradycardia, capillary refill time, pulse volume, consciousness level) and their association with early fatality.
Main Results:
- Overall in-hospital mortality was 19% (176/920), with 33% of deaths occurring within 48 hours.
- WHO danger signs showed 52% sensitivity and 84% specificity for early mortality prediction.
- The presence of two or more of four specific bedside features (bradycardia, prolonged capillary refill, weak pulse, impaired consciousness) significantly increased early fatality risk (OR=9.6; P<0.0001); children lacking these and other specific signs had a 7% fatality rate.
Conclusions:
- Specific clinical features at admission can effectively identify children with severe malnutrition at high risk of early death.
- Formal assessment and integration of these features into triage protocols can optimize resource allocation and improve patient outcomes.
- Further clinical research is needed to develop and validate appropriate supportive treatments for high-risk pediatric malnutrition cases.
Background:
With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (<48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines.
Methods And Findings:
Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended "danger signs" (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%).
Conclusions:
Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments.
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