The adherence to current available treatment guidelines is expected to contribute to improved survival by achieving a high cure rate and reducing death rate among severely malnourished children. The present study assessed the treatment outcome in 251 severely malnourished children aged 3–59 months admitted at St. Mary’s hospital Lacor in Uganda within a one year period. Our main findings show that hypothermia and HIV infection seems to contribute significantly to poor outcome.
The high mortality rate as found in the present study accords with previous findings of high case fatality rate in hospitalized severely malnourished children in other African countries [6, 12, 19, 20]. However, our findings show a much higher mortality rate than that reported in studies in Ethiopia [5] and Niger [18], but much lower than that reported in another Ugandan and other studies [12, 21, 22]. This difference could be attributed to the fact that most children in our study setting are brought to the hospital at critical stages of their illnesses as a result both of late referrals as well as late health care seeking. In addition, differences in the level of health care could also be the other possible factors for the contrasting variation in outcomes.
Hypothermia was significantly associated with an increased risk of mortality among severely malnourished children in the present study. The negative consequence of hypothermia in relation to mortality among severely malnourished children has been documented in previous studies [12, 21], and may be explained by the fact that hypothermia in these children is an indicator of serious infections as well as hypoglycaemia – two common causes of death among severely malnourished children. Similarly, children who were HIV infected were significantly more likely to die during treatment compared to their HIV negative counterparts who were more likely to have a successful outcome. HIV infection as a risk factor for poor outcome among severely malnourished children as found in the present study agrees with findings previously reported by other authors [12, 23], but contrasts with results from another Ugandan study which found no adequate association between HIV positive status and death – attributed to the effect of HIV being overshadowed by the prominent effect of fluid overload [12]. However, the findings in the present study may not be surprising since both HIV and malnutrition tend to accelerate the progression of each other, a phenomenon that could have been compounded in this case by the increased risk of concurrent opportunistic infections given that majority of the HIV infected children in the current study were ART naïve.
Though IV infusions, either in the form of an I.V fluid infusion or blood transfusion were associated with an increased risk of mortality, these were not statistically significant at multivariate analysis. This finding, however, compares well with that from previous studies [10, 12, 21], and could be due to the fact that the use of IV fluids/blood transfusion serve as markers of severity of malnutrition. In addition, the fact that most of these deaths occurred soon after transfusion or infusion means that fluid overload could also be a plausible consequence of IV infusion/blood transfusion contributing to mortality, and corroborates the general recommendation to restrict transfusions or infusions of severely malnourished children [24, 25].
Whereas children with non-oedematous malnutrition (severe wasting) were more likely to die than those with oedematous malnutrition, this was not statistically significant. These findings, however, mirror that reported by Moges et al. (2009) in Ethiopia [22], but contrasts with that reported by Bachou et al. [12], and could be explained by the fact that malnourished children with severe wasting in the current study were more likely to be HIV positive (39.1 %) compared to those with oedematous malnutrition (25.4 %), thus increasing their vulnerability to death. There was no significant difference in treatment outcome with regard to the patients’ age, though younger infants aged 3–12 months were more likely to die compared to children above one year of age. This finding agrees with that by Teferi et al. in Ethiopia [5], and could reflect the fact that majority of the severely malnourished children in the current study were in the younger age group 3–24 months, coupled with the fact that complications and mortality due to infectious diseases are generally higher in young infants, exacerbated in this case by severe acute malnutrition.
Limitations of the study
Being a retrospective study, other factors that could have important bearing on treatment outcome, including biochemical laboratory parameters and health system factors (diagnostic capacity, knowledge and skills, referral system, and patient monitoring) among others could not be analyzed because they were either not done or not documented.