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Long-term mortality and nutritional status following severe acute malnutrition: a longitudinal cohort study
  1. M Kerac1,,3,
  2. G Chagaluka2,
  3. S Collins1,
  4. P Bahwere1,
  5. A Seal3,
  6. J Bunn2,4
  1. 1Valid International, Oxford, UK
  2. 2Department of Paediatrics, College of Medicine, Blantyre, Malawi
  3. 3Centre for International Health and Development, UCL, London, UK
  4. 4Liverpool School of Tropical Medicine, Liverpool, UK

Abstract

Aims Effectively tackling severe acute malnutrition (SAM) is a global public health priority. Most treatment programmes report short-term outcomes at discharge. There is limited evidence about subsequent mortality and morbidity. The authors aimed to address this research gap by describing longer-term outcomes following SAM treatment.

Methods One year after discharge, the authors attempted to trace all survivors from a large urban, inpatient-based SAM treatment programme. 796/1024 (78%) had been enrolled in a probiotic randomised controlled trial which had no overall effect. Detailed baseline and follow-up data were available.

Results From July 2006 to March 2007, 1024 patients contributed to 1187 admission episodes for SAM treatment. 697/1024 (68.1%) had oedematous malnutrition. 459/1024 (45%) were known HIV seronegative, 445/1024 (43%) known seropositive. Long-term outcomes were determined for 899/1024 (88%). Mortality risk was greatest early in the programme: 238/1024 (23%) children died during initial inpatient treatment, 84/1024 (8%) in the subsequent 90 days and a further 105/1024 (10%) over the subsequent year. Preliminary Cox regression showed that HIV was strongly associated with mortality. Of the total 427 deaths, 274/427 (64%) were known seropositive but only 77/427 (18%) were known seronegative. Low admission weight-for-age, low admission weight-for-height were and age <12 months were also associated with mortality after adjusting for age, sex, height-for-age, mid-upper arm circumference, and admission oedema.

Initial treatment cure (reaching weight-for-height >80% of NCHS median) was associated with long-term survival. Of 471 initial cures, 372/471 (79%) were still alive at 1 year. Total known long-term programme survivors were 472/1024 (46%). At 1 year, mean weight-for-height z-score (WHZ) of those measured was −0.03 (SD 1.2, n=396) compared to baseline WHZ of −2.25 (SD1.3, n=976). Height-for-age (HAZ) remained low: HAZ −3.05 (SD 1.4) at 1 year compared to −3.23 (SD 1.4) at baseline. Putting these in context, mean WHZ of the oldest sibling in the family was −0.23 (SD 0.9, n=59) and HAZ −1.75 (SD 1.7, n=59).

Conclusions In this study, most children who were successfully cured in a SAM treatment programme remained alive 1 year after discharge. Overall mortality was however high. Community-based strategies could play an important role in earlier identification and treatment of high-risk children as well as longer-term support of children discharged from nutrition programmes.

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