THE CONTRIBUTION OF MALNUTRITION TO THE IN-HOSPITAL UNDER-FIVE MORTALITY IN RURAL KWAZULU-NATAL

AIM: To determine the contribution of malnutrition to the under-5 mortality in rural KwaZulu-Natal, identify risk factors for malnutrition, and to evaluate the level of care for severe malnourished children. DESIGN: A prospective case-control study, with a retrospective case-control compliance audit. SETTING: the Ngwelezana Hospital, Empangeni, KwaZulu-Natal, South Africa. PARTICIPANTS: 224 patients aged 0 – 5 years METHODS: Detailed anthropometric data and socioeconomic and disease factors were obtained and analyzed using non-parametric and chi-square tests, and risk factors were analyzed using multivariate logistic regression. Malnutrition was defined as moderate, if weight-for-height is between -2 and -3 standard deviations (SD) or height-for-age is between -2 and -3 SD, and severe if weight-for-height is below -3 SD (severe wasting) or if height-for-age is below -3 SD (severe stunting). The level of care was evaluated by an audit on the compliance to the WHO guidelines using de IMCSM Clinical Audit and Compliance Tool. Primary outcome measures were nutritional classification and outcome (discharge or death). RESULTS: In the Ngwelezana Hospital, the under-5 mortality rate was 98 per 1000. 34,4% was severe malnourished. Detailed data on anthropometry showed that in this hospital, 15,6% were moderate wasted, 23,7% were severe wasted, 10,8% was moderate stunted, and 10,8% was severely stunted. Edematous malnutrition was found in 10,2% of all analyzed patient. HIV and Malnutrition are the most contributors to under-5 mortality. Risk of death in the in-hospital population was an positive HIV status (odds ratio, 8.7; 95% CI, 2.9-25.9), being malnourished (odds ratio, 7.0; 95% CI, 1.5-32.8) and being younger than one year old (odds ratio, 3.6; 95% CI, 1.0-13.5). Of all deaths, 61.9% was HIV positive, compared to 13,9% in discharged patients (p=0.000). Of all malnourished children, 29% was HIV positive, versus 7.6% (p=0.000). Risk factors for malnutrition were: coming from a twin pregnancy (odds ratio, 27.1; 95% CI, 3.1-236.6), being HIV positive (odds ratio, 3.9; 95% CI, 1.3-11.7), being younger that one year old (odds ratio, 2.5; 95% CI, 1.1-5.9), not having piped water supply to the house (odds ratio, 2.8; 95% CI, 1.0-7.6), having such a high suspicion for TB that treatment was started (odds ratio, 6.3; 95% CI, 1.8-22.5) and living in an Informal House (odds ratio, 2.5; 95% CI, 1.2-5.4). With 60%, compliance to the WHO Guidelines for the management of severe malnutrition seems to be far from the targeted 100%. Only 38% showed adequate blood glucose testing, 50% an adequate response to a low glucose, only 7% received trace element mix, only 4% received mebendazole of albendazole, 36% received iron supplements, only 14% was referred to a social worker and for 0% of the patients there was any sign of occupational therapist or scheduled playtime. In Ngwelezana Hospital, 76% of all modifiable factors found in audited deaths, were related to the assessment of HIV, whether it was testing, documentation, mother’s HIV status or obtaining the results. These problems mainly occur at site of the Clinics: 62,5%. Delay in seeking care, in one third of deaths in Ngwelezana Hospital, was found to be the major problem, besides recognition of danger signs by the caregivers (14%). CONCLUSIONS: Under-5 mortality remains high in rural KwaZulu-Natal and malnutrition makes children more prone to die. Traditional risk factors for malnutrition like illness, poverty and poor nutrition remain important contributors malnutrition. Compliance to the WHO Guidelines was found to be insufficient in the Ngwelezana Hospital and needs further monitoring throughout rural KwaZulu-Natal. Empowerment of the community, education and feedback to clinics can probably contribute to improving our care for children. Because of its´ contribution to under-5 mortality, prevention, reduction and correct treatment of childhood malnutrition, can help South Africa towards the Millennium Development Goal 4. Successful management of malnutrition needs to encompass all dimensions of the disease: nutritional, socioeconomic and prevention and treatment of HIV and TB.