Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi

Paediatr Int Child Health. 2020 Aug;40(3):148-157. doi: 10.1080/20469047.2020.1747003. Epub 2020 Apr 3.


Background: Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood.

Methods: Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression.

Results: Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44).

Conclusion: HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.

Keywords: Malawi; Mortality; clinical risk factors; quality of care; severe acute malnutrition.

MeSH terms

  • Blood Glucose
  • Child Nutrition Disorders / epidemiology
  • Child Nutrition Disorders / mortality*
  • Child Nutrition Disorders / pathology
  • Child Nutrition Disorders / therapy*
  • Child, Preschool
  • Female
  • HIV Infections / complications
  • HIV-1
  • Humans
  • Infant
  • Malawi / epidemiology
  • Male
  • Odds Ratio
  • Risk Factors
  • Severe Acute Malnutrition / epidemiology
  • Severe Acute Malnutrition / mortality*
  • Severe Acute Malnutrition / pathology
  • Severe Acute Malnutrition / therapy*
  • Shock
  • Tertiary Care Centers


  • Blood Glucose