Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya

Philip Bejon, Shebe Mohammed, Isaiah Mwangi, Sarah H Atkinson, Faith Osier, Norbert Peshu, Charles R Newton, Kathryn Maitland, and James A Berkley

Data among children from Kenya have shown that malnutrition is a common predisposing factor to death from malaria, Lower Respiratory Tract Infections, diarrhoeal deseases and gastroenteritis and interventions that reduce malnutrition will reduce deaths from all these causes.

Background Malnutrition remains one of the most significant public health problems in developing countries, and it is associated with more than half of all deaths of children. Because malnutrition is the most global risk factor that accompanies illness and death, estimates of the true burden of malnutrition are difficult to determine accurately. “Attributable fraction” indicates the percentage of all cases linked to a risk factor under study and is widely used to determine the proportion of disease occurrence that would potentially be eliminated if exposure were prevented. Using data collected in a rural hospital in Kenya, Bejon and colleagues examined the contribution malnutrition makes to all admissions and inpatient death relative to severe malaria, lower respiratory tract infection (LRTI), gastroenteritis, and invasive bacterial disease. An attributable fraction logistic regression approach was applied to indicate the risk of death or hospital admission secondary to malnutrition. Study results are published in the December 2008 issue of The American Journal of Clinical Nutrition.

Study Design Standardized clinical, anthropometric, and laboratory data were collected on all children between 6 and 60 mo of age admitted to the pediatric wards. The study sample comprised 13,307 admissions, 674 deaths, 3069 admissions with severe disease, and 600 community controls. Severe disease was defined as coma, respiratory distress, severe anemia, prostration, or seizures. LRTI was defined by the clinician’s diagnosis, whereas loose stools defined gastroenteritis. Meningitis and bacteremia were defined by laboratory studies, and severe malaria required >2500 parasites/µL blood with one of the features of severe disease. An age- and location-matched community control was found for each child admitted with bacteremia. Logistic regression, using anthropometric z scores as the independent variable and admission or death as the outcome, was used to calculate the probability of admission as a result of “true malnutrition” for individual cases.

Results Although the malnutrition-attributable fractions vary depending on the anthropometric marker used, the overall malnutrition-attributable fraction for in-hospital deaths was 51% using the commonly accepted malnutrition marker of mid-upper arm circumference. Similar malnutrition-attributable fractions were seen for the major causes of severe disease (severe malaria, gastroenteritis, LRTI, and invasive bacterial disease). Overall, the attributable fractions for malnutrition were 11–41% for admissions and 28–51% for deaths. The malnutrition-attributable fractions for deaths, but not for admissions, appeared to be lower among older children (>24 mo).

Conclusions The results indicate that malnutrition is still a chief contributor to the major causes of childhood death in rural Kenya and that it accounts for half of the inpatient morbidity and mortality rates. Furthermore, the contribution of malnutrition is underestimated when conventional clinical definitions of severe malnutrition are used. Most of the direct causes for admission that were attributable to malnutrition were infectious diseases, which were recorded as the primary diagnoses by clinicians. This study also suggests that malnutrition is a common predisposing factor, and interventions that reduce malnutrition will reduce deaths from all of these causes.

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