Analysis of Comorbidities in Children with Severe Acute Malnutrition in Eastern Nepal

Address for correspondence: Dr. Gauri S Shah Professor & Head, Department of Paediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal. Tel: +9779842415770, Fax: +977-25-520251 E-mail: gaurishankarshah@live.com 1Dr. A Thapa, 2Dr. Gaurishankar Shah, Professor, Department of Paediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal, 3Dr. OP Mishra, Professor, Department of Paediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India Abstract


Introduction
G lobally, more than one-third of under-fi ve deaths are a ributed to under nutri on and of these, 10% are severely malnourished 1,2 .To our concern, Nepal also shares this burden of malnutri on with its 29% under 5 children being underweight and 11% severely wasted 3 .Due to lack of knowledge and health resources, malnutri on has been underlooked and most pa ents present at hospital with complica ons rather than malnutri on alone.The mortality rate of children with complicated, severe acute malnutri on (SAM) in hospitalized set-up has remained high 2 .Such high mortality has been a ributed to co-morbidi es such as infec ons and complica ons 4 .There are very reports on comorbidi es in SAM 5,6 .which has evaluated clinical and laboratory profi le in these children especially from this region of the country, Therefore, we analyzed the presence of co-morbidi es and complica ons in children with SAM so that appropriate treatment can be ins tuted promptly in order to improve their survival.

Material and Methods
This was a descrip ve cross-sec onal study carried out at the Department of Paediatrics and Adolescent Medicine, B.P Koirala Ins tute of Health Sciences, Dharan, Nepal during February 2013 to January 2014.All Children of age 1 to 5 years were screened at admission for malnutri on using WHO criteria 7 .Among them, children with Severe Acute Malnutri on (SAM) were enrolled in the study.SAM was defi ned by using WHO criteria 8 .Children with suspected congenital malforma on were excluded.
A er admission, data were collected in a pretested ques onnaire by interview technique.The parents of SAM children were informed about the study and each ques on was explained.The anthropometric parameters such as weight, height, and mid-arm circumference were recorded at admission using standard techniques 9 .Weight was recorded with weighing Secca scale with an accuracy of 50 g and crown to heel length in 1-2 years with infantometer and height using stadiometer in 2-5 years age group, with an accuracy of 0.1 cm.Mid-arm circumference was measured with non-stretch measuring tape with sensi vity of 0.1 cm.
A detailed physical and systemic examina on was performed.The inves ga ons included haemoglobin, total and diff eren al leukocyte counts, platelet counts, blood glucose, serum protein, albumin, urea, crea nine, sodium, potassium, X-ray chest and tuberculin test.Urine microscopy and culture were done, wherever required 7 .The disease classifi ca ons were used as per standard criteria.The children were treated with WHO criteria and followed for complica ons during the stay.

Ethical issues:
The study was started a er the approval of the Ins tu onal Ethical Review Board.A wri en informed consent was obtained from each parent of study subjects.The par cipants had op on to withdraw from the study any me during their hospital stay.

Statistical analysis
Data were analysed with Sta s cal Package for Social Sciences (SPSS) version 20 (Chicago IL).Chisquare test was used to test the signifi cance level for the data of propor ons; with Yates correc on when sample size was less than fi ve.A p-value of < 0.05 was considered as signifi cant.

Results
There were 446 children admi ed in the hospital during the study period; of these 188 (42.2%) were malnourished as per WHO criteria 7 .Among them 77 (17.2%) were diagnosed as SAM.Out of the 188 malnourished children, 95 (85%) were wasted, 20 (10.6%) were stunted and 73 (38.8%) children had both was ng and stun ng.
Thirty children (38.9%) of the study popula on were between 1-2 years (17 males) and 47 (61%) in the age group of 2-5 years (21 males) female.Overall mean age of children with SAM was 23.2 months.Of 77 SAM cases, 71 (92.2%) had their weight for height z-score below -3 SD with no evidence of oedema.The mean weight, height, mid-arm circumference were 8.7±1.6 Kg, (86.6 ±10.cm and 11.9 ±0.8 cm, respec vely. The characteris cs of children with SAM are presented in Table 1.Median age of mothers was 26 years with age of marriage at 19 years and they had shorter birth spacing (median 1.6 years).About 60% of mothers were either illiterate or had basic educa on of primary school level.Around 87% families belonged to lower socio-economic status.Of whom, 46.7 % had joint family, median number of family members was 6 and 64.9% were staying in overcrowding situa on.About 78% of all children were fed with colostrum.The median period of exclusive breas eeding was 4 months.Nearly 90% children were completely immunized and the remaining 10% had par al immuniza on.Pneumonia (50.6%) was the most common co-morbid illness with SAM followed by acute gastroenteri s (20.8%) and bacterial meningi s (7.8%).Children were sub-grouped between 12-24 months and 24-60 months, and it was found that there were no signifi cant diff erences in distribu on of illnesses between the two groups (Table 2).
The laboratory parameters are presented in Table 3. Anaemia, leucocytosis and leucopenia were observed in 59.7%, 37.7% and 7.8% of cases.Other abnormali es were hypalbuminaemia (36.4%), hyponatreamia (31.2%) and hypokalaemia (16.9%).Impaired renal func on was seen in 3 (3.9%)and another 3 (3.9%)children had associated urinary tract infec on.None of the children had hypoglycemia at presenta on.There was no mortality in SAH children.

Discussion
It appears that malnutri on is s ll a common problem in developing country like ours so much so that about 17% of the children belonged to SAM and about 92% had weight for height less than 3 SD.The global prevalence of 16.1% was reported by Casie et al 5 .
In contrast, a study from South-East Nigeria reported lower incidence (4.4%) of SAM in their 616 children 6 .Rela vely higher incidence of SAM in the present study could be because of mul factorial in origin such as younger age of mother and lower educa onal status not having enough awareness regarding feeding prac ces, lower socioeconomic status, lesser dura on of exclusive and total breast feeding than recommended.Keerthiwansa et al 10 found a signifi cant associa on of lower maternal educa on, lower paternal educa on, low family income and mother being a housewife in children with SAM.The gender distribu on of cases was almost equal.The median age of children was 23 months, which was higher than the fi gure (14.3 months) reported by Kumar at al 11 .Further, authors also found that 75.8% of their SAM cases had weight for height Z score less than 3 SD, which was lower than ours fi nding.As such, it appears that the distribu on of SAM pa ents may vary from region to region and accordingly nutri onal rehabilita on should be planned for be er recovery.
Regarding co-morbidi es, pneumonia (50.6%) and acute gastroenteri s (20.8%) were the most common condi ons at presenta on in ore cases.Other studies 6,11,12,13 reported acute gastroenteri s being the most common co-morbid condi on followed by respiratory tract infec ons in their cohort of SAM.
Kumar et al 11 reported other co-morbidi es like tuberculosis, malaria, measles and HIV infec on in their series.We did not fi nd these condi ons except tuberculosis that too in only 2.6% of pa ents.Instead other diseases like bacterial meningi s, congenital heart diseases, febrile convulsions, kalaazar, and urinary tract infec ons were present but in a small propor on of cases.This shows that varia on in spectrum of diseases in SAM can be found.However, two common morbidi es associated with SAM such as pneumonia and acute gastroenteri s should be looked on a priority basis at hospitaliza on and managed appropriately.
Sepsis is another severe condi on, which has been found earlier 11,14 was not present in any of our pa ents.
Increased serum urea, crea nine and electrolyte disturbances are indica ve of acute kidney injury with mul ple complica ons of hospitaliza on.The situa on is further aggravated by anaemia and hypoalbuminaemia, which can lead to, impaired immune status and thus increased chances of infec ons.Presence of leucocytosis and leucopaenia further supports its presence in these children.
These children are o en complicated by respiratory and gastrointes nal infec ons along with biochemical abnormali es at hospitaliza on requiring urgent a en on and therapy.Treatment of condi ons as per WHO guidelines has been advocated for rapid normaliza on of condi ons 15 .A recent report from India on a larger cohort of children with SAM demonstrated that one can achieve higher cure rates in uncomplicated SAM even with community based management of these cases 16 .This is essen al to break the malnutri on-disease vicious cycle phenomenon and improved survival.

Table 1 :
Basic characteris cs of children with severe acute malnutri on (n=77)