ABSTRACT Objective The aim of the present study is to assess the burden of severe acute malnutrition (SAM) and other malnutrition in a tertiary care hospital in Delhi. Methods All patients aged 2–59 months admitted from August 2012 to July 2014 were screened for malnutrition by anthropometry using standard techniques, and SAM was diagnosed as per guidelines [1, 2]. Results During the study period, 4520 children of age 2–59 months were admitted and complete data of 4354 children were available, which were analysed. Of these, 50.4% were underweight, 44.6% were stunted, 33.5% were wasted, 0.76% had oedematous malnutrition and 18.3% had SAM. Of all patients with SAM, 80% were <24 months old, with 54.1% males and 45.9% females. Moderate acute malnutrition was present in 21.4%. Associated co-morbidities were diarrhoea or respiratory infection or both. Conclusion Hospitals of Delhi have a high load of complicated SAM and need adequate infrastructure and facilities for management of these children. wasting, underweight, stunting, SAM INTRODUCTION Malnutrition is a significant factor in approximately one-third of the nearly 8 million under-five deaths worldwide . Severe acute malnutrition (SAM) affects nearly 20 million preschool-age children all over the world mainly from south-east Asia and Africa . In India, prevalence of SAM is 6.4% in children <5 years as per National Family Health Survey 3 (NFHS-3) and is home to 8 million children with SAM (31.2% of the world’s severely wasted children) . If the United Nations Millennium Development Goals of reducing children malnutrition and mortality by 50% by 2015 are to be met, SAM needs to be prevented and treated effectively . The children with SAM usually come to the hospital with complains like diarrhoea, pneumonia or other medical problems and they are known as complicated SAM. As management of these patients is different since the time of admission, to reduce mortality and morbidity, it is required that cases of SAM are identified earliest, triaged and managed accordingly. The aim of the present study is to assess the burden of complicated SAM and other malnutrition in a tertiary care hospital in Delhi to facilitate planning of the facilities available for them. MATERIAL AND METHODS All patients aged 2–59 months admitted in paediatric wards of Hindu Rao Hospital, a tertiary care hospital of Delhi, from 1 August 2012 to 31 July 2014 were screened for malnutrition by anthropometry, i.e. weight, height/length and Mid Upper arm Circumference (MUAC). Weight was measured using digital weighing scale weighing to a precision of 0.01 kg. In children ≥24 months, height was measured using Wall Mounted Stadiometer to the last completed 0.1 cm, and in children <24 months of age, length was measured using infantometer up to 0.1 cm. MUAC tape was used for measurement of MUAC (>6 months of age) up to 0.1 cm. The children having weight for height/length Z score < −3 SD and/or MUAC < 115 mm (6–59 months) and/or bilateral pedal oedema (other causes ruled out) were classified as SAM as per Government of India (GOI) guidelines . All the data were entered in the World Health Organization (WHO) anthropometry software version 3.2.2 to get Weight for Age (WAZ), Weight for Height (WHZ) and Height for Age (HAZ) scores. RESULTS From August 2012 to July 2014, 4520 children (42% of the total paediatric admissions) of age 2–59 months were admitted. Complete anthropometric measurements were available for 97.2% children. Data of these 4354 children were further analysed and included in this study. Of 4354 children, 58.84% (n = 2562) were males and 41.16% (n = 1792) females. Table 1 shows the varying degree of malnutrition in these patients. Table 1 Nutritional status of the study group < −2 SD < −3 SD WAZ score 50.4% (underweight) 28.1 (severe underweight) HAZ score 44.6% (stunting) 24% (severe stunting) MAM (WHZ < −2 SD to − 3 SD and/or MUAC* 115 mm to < 125 mm) SAM (WHZ < −3 SD and/or MUAC *<115 mm and or B/L oedema) 21.4% (MAM) 18.3% (SAM) < −2 SD < −3 SD WAZ score 50.4% (underweight) 28.1 (severe underweight) HAZ score 44.6% (stunting) 24% (severe stunting) MAM (WHZ < −2 SD to − 3 SD and/or MUAC* 115 mm to < 125 mm) SAM (WHZ < −3 SD and/or MUAC *<115 mm and or B/L oedema) 21.4% (MAM) 18.3% (SAM) * In children ≥6 months. B/L = Bilateral In our study group, 50.4% of the patients were underweight (WAZ score < −2 SD), 44.6% were stunted (HAZ score < −2 SD) and 33.5% were wasted (WHZ score < −2 SD). Using the criteria recommended in GOI guidelines [1, 2] for facility-based care of SAM, 18.3% (n = 795) had SAM. In children >6 months of age, SAM was diagnosed by WHZ score <−3 SD in 64.8% of the patients and by MUAC <115 mm in 85.2% of the patients. Both these criteria were present in 50.7% of the SAM patients (Fig. 1). Only 0.76% (n = 5) of all patients with SAM had oedematous malnutrition, i.e. 0.11% of the total study group. Fig. 1. View largeDownload slide Criteria for diagnosis of SAM. Fig. 1. View largeDownload slide Criteria for diagnosis of SAM. Of all patients of SAM, 80% were <24 months (Fig. 2) and 17.1% (n = 136) were <6 months of age (as depicted in Table 2). There were 54.1% males and 45.9% females (as shown in Fig. 3). Although among all the SAM patients number of males (n = 430) was more than females (n = 365), the percentage of SAM in all admitted female children was more than in males. This is because the total number of males (n = 2562) admitted in the hospital was more as compared with females (n = 1792). Table 2 Stunting in all admitted children and in SAM children All admissions 2–59 months SAM children 2–59 months Age group Number of children Stunting Severe stunting Number of children Stunting Severe stunting 2–59 months 4354 44.6% (1943) 24% (1046) 795 69.4% (552) 46.6% (371) 2–23 months 2934 39.4% (1169) 13.9% (409) 634 66.2% (420) 43.2% (274) 24–59 months 1420 54.5% (774) 44.8% (637) 160 82.5% (132) 60.6% (97) All admissions 2–59 months SAM children 2–59 months Age group Number of children Stunting Severe stunting Number of children Stunting Severe stunting 2–59 months 4354 44.6% (1943) 24% (1046) 795 69.4% (552) 46.6% (371) 2–23 months 2934 39.4% (1169) 13.9% (409) 634 66.2% (420) 43.2% (274) 24–59 months 1420 54.5% (774) 44.8% (637) 160 82.5% (132) 60.6% (97) Fig. 2. View largeDownload slide Age-wise distribution of admitted SAM cases. Fig. 2. View largeDownload slide Age-wise distribution of admitted SAM cases. Fig. 3. View largeDownload slide Gender wise distribution of patients with SAM. Fig. 3. View largeDownload slide Gender wise distribution of patients with SAM. Stunting was much higher (1.5 times) in children with SAM and prevalence of severe stunting was approximately twice in children having associated SAM as compared with all admitted children (Table 2). There was a seasonal variation in the number of children admitted with SAM, with a peak from May to October (Fig. 4). During the months of November to February, not only the total number of SAM patients was reduced but also the percentage of patients with SAM among all admitted patients was reduced. In peak months, >20%–25% of the admissions were having associated SAM, whereas in December and January, it was <10%. Moderate acute malnutrition (MAM), defined as weight-for-height Z score of −3 SD to <−2 SD and/or MUAC of 115 to <125 mm, was there in 21.4% of the study group. MAM percentage was high in all age groups. Fig. 4. View largeDownload slide Seasonal variation of children admitted with SAM. Fig. 4. View largeDownload slide Seasonal variation of children admitted with SAM. More than 70% of the children presented with either diarrhoea or respiratory complaints or both. Rest presented with complaints of fever (7.2%), seizures (5.1%), signs and symptoms of severe anaemia (5.4%) or septicaemia (4.2%) and 7.2% of the children presented with other different symptoms and diagnosis. DISCUSSION Child undernutrition contributes to more than one-third of the deaths. Undernourished children who survive may get trapped in a vicious cycle of recurring illness and faltering growth, with irreversible damage to their development and cognitive abilities. Owing to high prevalence of malnutrition and high population, India contributes largely to global malnutrition. According to NFHS-3, the prevalence of underweight, stunting and wasting in India is 42.5%, 48% and 19.8% and in Delhi it is reported as 26.1%, 42.2% and 15.4%, respectively . In the present study on admitted under-five children, 50.4% of the patients were underweight, 44.6% were stunted and 33.5% were wasted. Though malnutrition is rampant in India, we need to identify patients with SAM at the time of admission in a facility because they need to be triaged and managed differently and hospitals need to be equipped in all ways to deal with these cases. At present, every hospital in India does not have Nutritional Rehabilitation Centre (NRC) and facilities for management of SAM patients with complications. The GOI has developed technical and operational guidelines for establishment of NRCs. The efforts are in progress for establishment of these facilities in various states. As per NFHS-3, prevalence of SAM is 6.4% in India, and in Delhi it is 7.0% . There are not many studies from India to show prevalence of SAM in hospital-admitted under-five children. In a study on prevalence of undernutrition among under-five children attending paediatric Out Patient Department (OPD) in a tertiary care hospital of north-east India, the prevalence of underweight, stunting and wasting was 19.7%, 35.5% and 8.5%, respectively . Yellanthoor et al. reported 54.9% of the admitted under-five children with ARI to have malnutrition . Kaushik et al. also reported a high level of malnutrition (78.6%) in children admitted with acute respiratory tract infection . In our study spread over 2 years, prevalence in hospital-admitted children was 18.3%. At present, the policy of the hospital is to admit SAM patients with medical complication and treat SAM without complication on OPD basis and admit them only if the child is not improving with counselling on follow up or excessive parental concern. In our study, 91.2% SAM patients were with medical complications and 7.8% of SAM patients were without any medical complication. These cases need to be admitted for a longer duration, i.e. at least 14–21 days; therefore, emergency and paediatric wards need to be strengthened by including sensitization and training of the health personnel to deliver appropriate care to these children to reduce mortality and morbidity. The latest update on management of SAM by WHO mentions that only about 40% of the children are classified as having SAM using both WHZ score and MUAC . In the present study, 50.7% children had both the criteria. Singh et al. in their experience of management of children with SAM at NRCs in Uttar Pradesh found that 70.7% had both the criteria . As per NFHS-3, both girls and boys are about equally undernourished . According to HUNGaMA survey, there is little gender difference for all three indicators . In the present study on hospital-admitted patients, however, SAM prevalence was higher in females (20.4%) as compared with males (16.7%). Stunting, an indicator of chronic malnutrition, was much higher (1.5 times) in children with SAM in our study as compared with all admitted under-five children. The prevalence of severe stunting (HAZ < −3 SD) was approximately twice in children having associated SAM. This shows that majority of the SAM patients had chronic malnutrition, and an acute insult like infection would have led to wasting. By using chi-square test, it was found that there was a strong association between SAM and stunting (p value < 0.00001). Chi-square value was 242.2309. In our study, presence of oedematous malnutrition was low (0.76% of all SAM and 0.11% of all admissions aged 2–59 months). As per National Nutrition Monitoring Bureau, Technical Report prevalence of oedematous malnutrition was 0.0% in 2012 all over India and in Uttar Pradesh 0.2% in 1–5-year-old boys.  Singh et al. reported that 8.1% of the patients admitted in NRCs in Uttar Pradesh had oedematous malnutrition . Maurya et al. reported 17% oedematous malnutrition in their admitted SAM children . Kumar et al. in their study on co-morbidities in hospitalized children with SAM reported high incidence of oedematous malnutrition (27%) . Of all our patients with SAM, 80% were <2 years. Singh et al. in their cohort of 1229 SAM children from 12 NRCs in Uttar Pradesh also reported 80% were <2 years . In a study of clinical profile of patients with SAM in Rajasthan, 96% of the patients were <2 years . In a report from Government Tertiary Treatment Facility in Bangladesh, nearly 66% of the admitted children were aged <2 years . Admission pattern showed a seasonal variation. Majority of the patients (81%) with SAM were admitted in the months of April to October. This has programmatic implications, as hospitals need to be prepared with a high load in summer months to provide appropriate care to these patients. This can be attributed to associated co-morbidities like diarrhoea that themselves have seasonal variation. Md. Iqbal Hossain et al. also found seasonal variation in admission rate of children with SAM . Almost all cases of SAM in this study were medically complicated cases. Majority of the patients with SAM came with diarrhoea or pneumonia as the presenting complaints. Choudhary et al. also reported acute diarrhoea and bronchopneumonia as the most common diseases at admission in patients with SAM . Kumar et al. in a study of 104 children have also reported diarrhoea (54%) to be the most common co-morbid disease associated with SAM and acute respiratory tract infections second most common (27.9%) . Gastroenteritis (38.6%) and Respiratory Tract Infection (20.4%) have also been the main clinical diagnosis on admission as reported by Anne-Laure Page in Niger in a cohort of 311 admitted complicated SAM children aged 6–59 months . Additional one-fifth (21.4%) of all the under-five admitted patients had underlying MAM in our study. The prevalence of moderate wasting as per NFHS-3  is 13.4%. MAM itself has a high morbidity and mortality and there is an additional high risk of SAM with illness and continued faulty diet. These patients need to be counselled for appropriate feeding practices besides treating acute illness. CONCLUSION Hospitals of Delhi have a significant number of SAM cases with medical complications and need adequate infrastructure and trained manpower for management of these children, as they need special line of management since the time of admission. REFERENCES 1 Aguayo VM, Jacob S, Badgaiyan N, et al. Providing care for children with severe acute malnutrition in India: new evidence from Jharkhand. Public Health Nutr 2012; 17: 206– 11. Google Scholar CrossRef Search ADS PubMed 2 Uauy R, Desjeux JF, Ahmed T, et al. Global efforts to address severe acute malnutrition. J Pediatr Gastroenterol Nutr 2012; 55: 476– 81. Google Scholar CrossRef Search ADS PubMed 3 International Institute for Population Sciences (IIPS) and Macro International. 2007 National Family Health Survey 3 (NFHS-3), 2005-06, Volume 2. Mumbai: IIPS, India, 1– 168. 4 United Nations. The Millenium goals development report. 2010. http://www.un.org/millenniumgoals/pdf/ (16 May 2015, date last accessed). 5 Facility based management of children with severe acute malnutrition. Ministry of Health & Family Welfare, Government of India, 2011. 6 Durarah S, Bisai S, Barman H. Prevalence of undernutrition among preschool children under five attending pediatric OPD in a tertiary care hospital of northeastern India. 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Google Scholar CrossRef Search ADS 11 HUNGaMA fight for hunger and malnutrition, the HUNGaMA survey report, 2011. http://hungamaforchange.org/hungamBKDec11LR.pdf (20 February 2015, date last accessed). 12 National Nutrition Monitoring Bureau. NNMB Technical Report No. 26.Hyderabad: NIN Hyderabad Press, 2012 13 Maurya M, Singh DK, Rai R, et al. An experience of facility-based management of severe acute malnutrition in children aged between 6-59 months adopting the World Health Organization recommendation. Indian Pediatr 2014; 51: 481– 3. Google Scholar CrossRef Search ADS PubMed 14 Kumar R, Singh J, Joshi K, et al. Comorbidities in hospitalized children with severe acute malnutrition. Indian Pediatr 2014; 51: 125– 7. Google Scholar CrossRef Search ADS PubMed 15 Choudhary M, Sharma D, Nagar RP, et al. Clinical profile of severe acute malnutrition in Western Rajasthan: a prospective observational study from India. J Pediatr Neonatal Care 2015; 2: 00057. () DOI: 10.15406/jnmr.2015.02.00057 16 Hossain MI, Dodd NS, Ahmed T, et al. Experience in managing severe malnutrition in a government tertiary treatment facility in Bangladesh. J Health Popul Nutr 2009; 27: 72– 80. Google Scholar CrossRef Search ADS PubMed 17 Page AL, Rekeneire ND, Sayadi S, et al. Infections in children admitted with complicated severe acute malnutrition in Niger: ed Lorenz von Seidlein. Plos One 2013. http:// dx.doi.org/10.1371/journal.pone.0068699 (23 May 2015, date last accessed) © The Author . Published by Oxford University Press. All rights reserved. For Permissions, please email: firstname.lastname@example.org
Journal of Tropical Pediatrics – Oxford University Press
Published: Feb 1, 2018
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