ANALYSIS OF CO-MORBIDITIES

IN CHILDREN
WITH SEVERE ACUTE MALNUTRITION
IN EASTERN NEPAL

Presenter :
Dr. Sulav Shrestha
INTERN
 OBJECTIVES OF PRESENTATION

1. Aim of study 7. Data assessment

2. What we know so 8. Study result
far
9. Discussion
3. Study description
10. Strength
4. Data collection
5. Inclusion criteria 11. Limitations
6. Exclusion criteria 12. Recommendations
 AIM
• To find out the co- morbidities in children with
severe acute malnutrition and analyze them
so as to provide appropriate treatment
promptly in order to improve their survival.
 WHAT WE KNOW SO FAR
• Malnutrition is a common problem in
developing country such as Nepal
• Malnutrition causes dysfunctional immune
system hence the commonly associated co-
morbidities with it.
 STUDY DESCRIPTION
• Type : descriptive cross – sectional study
• Location : Dept. of Pediatrics and Adolescent
medicine, BPKIHS, Dharan
• Duration: February 2013 – January 2014
• Conductors : Dr. Arun Thapa,
Dr. Gaurishankar Shah,
Dr. Om P Mishra
 DATA COLLECTION
• Method: pre- tested questionnaire by
interview technique
• Assessment of malnutrition:
– Weight :- Secca scale
– Crown to heel length :- Infantometer (1-2yr)
– Height :- stadiometer (2-5)
– MUAC :- Non- stretch measuring tape
 INCLUSION CRITERIA
• Children of age 1 to 5 years
• With severe acute malnutrition defined by using
WHO criteria:
• Any of following
i. Weight for height below – 3SD of median WHO
growth preference
ii. Visible severe wasting
iii. Presence of bipedal edema
iv. Mid upper arm circumference below 11.5 cm
 EXCLUSION CRITERIA
• Infants and children above 5 years
• Children with suspected congenital
malformations
 DATA COLLECTION

Flow – chart showing the process of selection of cases for the study
 DATA COLLECTION

Flow – chart showing the process of selection of cases for the study
 DATA ASSESSMENT
• Data assessment was done on 3 basis
1. Maternal characteristics
2. Co- morbidities
3. Laboratory parameters
• Data analysis : Statistical Package for Social
Sciences (SPSS) version 20
• Significance test : chi-square test with yates
correction when sample size was less than five
• p- value <0.05 was considered significant
 STUDY RESULT I
• Total cases admitted in hospital during study
period : 446
• Total malnourished children : 182
• Total sample size : 77
Male Female Total

1-2 year 17 13 30

2-5 year 21 26 47

Total 38 39 77
 STUDY RESULT II
characteristics Value

Median mother’s age 26 yrs.

Median age marriage 19 yrs.

Maternal education : Illiterate 38.9% (30)

Type of family : Nuclear 53.3 % (36)

Overcrowding present 64.9% (50)

Lower socioeconomic status 87.7% (67)

Table : basic characteristics of children with severe acute malnutrition (n=77)

 STUDY RESULTS III
Type of disease n (%) Age groups
12- 24 months 24-60 months (n=47)
(n=30)
Pneumonia 39(50.6) 16 (41.0) 23 (59.0)
Acute gastroenteritis 16 (20.8) 4 (25.0) 12 (75.0)
Bacterial meningitis 6 (7.8) 2 (33.3) 4 (66.7)
Congenital heart disease 3 (3.9) 2 (66.7) 1 (33.3)
Febrile convulsion 3 (3.9) 2 (66.7) 1 (33.3)
Urinary tract infection 3 (3.9) 0 3 (100)
Kaalaazar 2 (2.6) 0 2 (100)
Post- infectious 2 (2.6) 0 2 (100)
glomerulonephritis
Tuberculosis 2 (2.6) 0 2 (100)
Cerebral palsy 1 (1.3) 0 1 (100)

Table : co- morbidities in children with severe acute malnutrition (n=77)

 STUDY RESULTS IV
Abnormalities n (%)
Leukocytosis (TLC >11,000/mm³) 29 (37.7)
Leukopenia (TLC <4,000/mm³) 6 (7.8)
Anaemia (Hb < 11 g/dl) 46 (59.7)
Hypoalbuminemia (se. albumin <2.5 g/dl) 28 (36.4)
Hyponatremia (se. Na <120 mEq/l) 24 (31.2)
Hypokalemia (se. K < 2.5 mEq/l) 13 (16.9)
Raised serum Urea (>35 mg/dl) 3 (3.9)
/creatinine (0.5 mg/dl)
Urine culture positivity 3 (3.9)

Table : Laboratory parameters in severe acute malnutrition


Incidence of SAM
Median age of children in
study
wt/ht z score <3SD
Most common co-
morbidities
Rare co-morbidities in
study
Table: comparison of study with other related study
DISCUSSION
Original research study Related study
17% 16% (casie et al)
4.4% (south- east nigeria
study)
23.2 months 14.3 months ( kumar at al)
92.2 % 75.8%( kumar at al)
Pneumonia AGE ( kumar at al)
AGE Respiratory tract infection
Kaalaazar, Post- infectious TB, malaria, measles and
glomerulonephritis, HIV( kumar at al)
Tuberculosis, Cerebral
palsy
 DISCUSSION
• Increased serum urea, creatinine and
electrolyte disturbance are indicative of AKI
with multiple complications of hospitalization
which is further aggravated by anaemia and
hypoalbuminemia, which can lead to,
impaired immune status and thus increased
chances of infections.
• Presence of leucocytosis and leucopenia
further supports its presence in these children
 STRENGTH
1. Cross- sectional study, so single examination
of cross- section of population at one point in
time can be projected on whole population.
2. Collection of wide array of variables and their
analysis despite small sample size & in small
time duration
3. Comparison with various similar studies of
various geographical location to give
variation of viewpoint on the same topic.
 LIMITATIONS

1. Small sample size as compared to similar studies

kumar et al (n=104), Tarachand et al (n=1082),
Tendai et al (n=9540)
2. Hospital based study which fails to grasp the
actual picture of society
3. Importance of lab parameters in study is not
clear.
4. Inclusion of congenital heart disease despite the
exclusion criteria stating otherwise
 RECOMMENDATIONS
1. Community based approach by survey and
primary collection of data in community itself
rather than hospital based approach.
2. Collaboration with other medical institute for
adequate sample size and longer duration of
study
3. Comparison of incidence of co- morbidities in
SAM with identical disease in normally
nourished children to show association.
4. Appropriate correlation between lab parameters
and co- morbidities or malnutrition.
THANK YOU