Childhood malnutrition (ID) remains one of the main causes of mortality among children under 5 years of age.
Malnutrition can be defined as a nutritional deficiency that develops from inadequate consumption of healthy and balanced foods that allow health (Dipasquale and collaborators 2020); This includes severe acute malnutrition, stunting, underweight and wasting.
The effects of ID are devastating and place a heavy burden on low- and middle-income countries as they suffer from unstable economies, lack of access to healthcare, political will, and social inequalities. In 2019, 144 million children under 5 years of age worldwide were reported to be stunted (weight too low for their age) and another 47 million children were wasted (too thin for their height) 1
The highest incidence of ID is found in the continents that are home to the majority of low- and middle-income countries, such as South Asia and sub-Saharan Africa, including South Africa1. Globally, South Asia contributed to half of all wasted children, and sub-Saharan Africa is home to about a quarter of wasted children1. Furthermore, an incidence of 2.2 per 1000 of malnutrition in children under 5 years of age was reported in South Africa for the year 2019.2
Comorbidity is the coexistence of another disease resulting from the direct impact of the primary disease.3 Comorbidities of ID include opportunistic infections such as tuberculosis (TB), pneumonia, and gastroenteritis.4 The impact of ID associated with comorbidities often leads to poor outcomes. undesirable consequences of the treatment of children admitted with malnutrition.5
The cause of mortality in children admitted with malnutrition is usually attributed to ID comorbidities.6 Despite having the World Health Organization’s 10-step malnutrition management guideline,7 the number of ID deaths remain high in low- and middle-income countries. Timely identification and treatment of comorbidities are essential to reduce the risk of mortality.8 However, comorbidities are often missed or diagnosed late despite having guidelines in place.9
Although some countries, such as Ethiopia, have successfully adopted the 10-step guideline, it is still inconclusive whether implementation of the guideline can lead to early detection of comorbidities associated with ID, leading to a desirable prognosis.9 A Despite the successful implementation of treatment and preventive measures for ID, comorbidities associated with CM continue to be one of the main causes of mortality in children under 5 years of age.
| Methods |
> Design and Setting
A systematic review was conducted to retrieve the best available evidence on the prevalence, diagnosis, and treatment outcomes of comorbidities associated with ID in children under 5 years of age in low- and middle-income countries. The review was guided by a search protocol developed for this study.
> Eligibility criteria and search strategy
A clear and focused review question was formulated based on follow-up, where “the population and its problem” were children under 5 years of age with malnutrition, the “exposure” was the comorbidities associated with ID, the “outcomes” were the prevalence, diagnosis and treatment outcomes, and the “place” was low- and middle-income countries. A comprehensive search strategy was developed to retrieve the best evidence on the prevalence, diagnosis, and treatment outcomes of comorbidities associated with ID. Studies that addressed comorbidities of malnutrition in children conducted in low- and middle-income countries that addressed comorbidities associated with malnutrition were included in the review.
The review searched for articles published in Portuguese between 2015 and 2020, in the following databases: EbscoHost (including Academic Search Premier: CAB Abstracts: CINAHL: Electronic journals: Health Source Premium: MasterFile Premier: MED LINE) and Pubmed: Scopus: Publications SAE: Science Direct and Web of Science.
The search terms were as follows: Child or Children or Childhood or child or children or pediatrics or pediatric AND malnutrition or malnutrition or malnutrition or poor diet or poor nutrition or malnutrition or stunting or wasting AND prevalence or incidence or epidemiology or frequency o occurrence AND treatment o intervention o therapy AND comorbidities or comorbidity AND low- and middle-income countries. The search terms were exhaustive, so as not to limit the scope of the bibliographic search.
A search was also conducted to identify relevant studies not yet published, such as theses and dissertations on the PROQUEST database, to avoid publication bias.
The search and selection processes were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart10 The reviewer used the information from Evidence for Policy and Practice: Reviewer Software 411 to manage the process. search and selection of the review.
> Study Selections
The selection phase of the studies to be included in the review was carried out by examining the studies according to the inclusion and exclusion criteria developed for the review and was only completed after critical evaluation. Evaluation with critical appraisal tools is performed to evaluate the methodological quality and rigor of the studies included in the review.12 The validity of the empirical studies included in a secondary study such as a meta-analysis or systematic analysis or review determines the validity of that secondary study in particular.13 Therefore, it is essential to evaluate the empirical studies included in the review.
The Critical Appraisal Skills Program tool was used to evaluate all identified cohort design studies. Additionally, the John’s Hopkins Nursing Evidence-Based Practice was used to evaluate studies with cross-sectional and survey designs.
> Data collection process
The data collection process in this review involves data extraction. Data extraction is a process by which data elements that are relevant to answering the review question under consideration are extracted from the included studies and presented in a single format.
> Risk of bias in individual studies
Two reviewers independently assessed risk of bias in individual studies. Additionally, the use of the PRISMA flowchart provided transparency to the review process. The use of validated critical appraisal tools ensured that only studies of good methodological quality were included in the review.
> Summary of Results
Synthesis of results in this review refers to combining and summarizing the findings of each study included in the review.5
The review had 3 objectives, according to which the data were synthesized. The first objective was to review the best available evidence on the prevalence of comorbidities associated with ID in low- and middle-income countries. Therefore, all ID-associated comorbidities identified in the included studies were grouped according to the human body systems they affect. For the second objective on the best available evidence on the diagnosis of comorbidities associated with ID in populations from low- and middle-income countries, no studies were found.
For the latter aim of the best available evidence on the treatment outcomes of comorbidity-associated ID in low- and middle-income countries, findings from the included studies were grouped under the headings of length of hospitalization/stay, mortality, and recovery. .
> Publication bias
To avoid publication bias, a manual search for unpublished literature was performed during the initial review search.
> Dissemination
The findings of this review will be published in a peer-reviewed journal according to the PRISMA checklist.
> Declaration of Ethics
This study received ethical approval from North-West University with ethical number: NWU-00314-20-A1.
| Results |
The review retrieved a total number of 20,001 studies that were screened against the inclusion and exclusion criteria. Articles judged to address the review question underwent critical appraisal, leaving the review with n = 15 eligible studies.
Some of the n = 15 studies included in the review addressed more than one of the review objectives, while others only addressed 1 objective. The 15 (n = 15) included articles were from low- and middle-income countries (Ethiopia (n = 9/15), Uganda (n = 1/15), Somalia (n = 1/15), South Africa (n = 1 /15), Nigeria (n = 1/15), with Burkina Faso and Mozambique combined (n = 1/15), and multiple low- and middle-income countries (n = 1/15).
The results of this review are discussed according to prevalence, diagnosis, and treatment outcomes.
> Prevalence
Data extracted from studies reporting the "prevalence" of ID comorbidities were grouped according to the human body systems affected, namely the respiratory system (including tuberculosis and pneumonia), the gastrointestinal tract system (including gastroenteritis) and the hematological system (including anemia).
> Respiratory system
The respiratory system includes the lungs and surrounding structures, such as the trachea, bronchi, and bronchioles. The comorbidities identified from the selected articles, which affected the mentioned structures in children with malnutrition, including TB and pneumonia:
• TB . Five studies included in the review reported TB as a comorbidity in malnourished children. Four of these studies16-19 were cohort studies, while 1 study20 was a cross-sectional study. They all took place in Ethiopia. In a retrospective cohort study16 with a selected sample of 423 children under 5 years of age with malnutrition, 5.7% had TB as a common comorbidity. These findings further competed with the results of 1 of the included cohort studies, 17 with a randomly selected sample of 1690 children (under 5 years of age) with malnutrition, of whom 8.22% also had TB. Furthermore, in a retrospective cohort study18 with a random sample of 420 children under 5 years of age with malnutrition, 22% had TB as a common comorbidity.
The prevalence of TB as a comorbidity in ID was also found in a cohort study,19 with a randomly selected sample of 440, of which 15.9% had TB as a comorbidity. Furthermore, the above findings were supported by a cross-sectional study conducted in Ethiopia (20), where TB was reported as a comorbidity in ID in 15.8% of the sample.
• Pneumonia. A total of 8 studies reported on pneumonia as a comorbidity of ID.9,16,18–23 Of these, 5 were cohort studies16,18,19,21,22 2 were survey studies9,23 and 1 was a study cross-sectional.20 One of the included retrospective cohort studies reported that 41.5% of the sample had pneumonia as a comorbidity of ID.18 The results competed with the findings of a cohort study conducted in Ethiopia19 where 20.6% of the randomly selected sample of 416 children under 5 years of age with malnutrition had pneumonia as a comorbidity. Furthermore, pneumonia was identified as a comorbidity of ID in a cohort study conducted in Ethiopia, where 27% of children under 5 years of age with ID had pneumonia.21 Pneumonia is also noted as one of the most prevalent comorbidities. in the findings of several other studies ranging between 25.2% and 54.8% of children under 5 years of age admitted with malnutrition.9,16,20,22,23
> Gastrointestinal tract
The gastrointestinal system includes the stomach and surrounding structures, such as the small and large intestines, appendix, and rectum. The comorbidities identified from selected studies, which affected the mentioned structures in children with malnutrition, are discussed.
• Stomach flu. Findings from 11 of the studies included in the review revealed gastroenteritis as one of the most prevalent comorbidities of ID. Eight of the studies identified were cohort studies,16–18,21,22,24–26 5 of which were conducted in Ethiopia,16–18,21,22 and the remaining 3 studies conducted in South Africa, Nigeria and Uganda, respectively.24–26 The remaining 3 studies were surveys conducted in Ethiopia9,23 and Somalia.27 Findings from a retrospective cohort study from Ethiopia indicated gastroenteritis as one of the most prevalent comorbidities of ID, with 46. 7% of the sample presenting with gastroenteritis as a comorbidity.18 The findings were supported by another cohort study conducted in Ethiopia, where gastroenteritis was reported as one of the most prevalent comorbidities of ID, with 34.02% of the sample with gastroenteritis. .17 Another cohort study26 also found that gastroenteritis is a common comorbidity of ID, with 43% of the sample having gastroenteritis. The findings coincided with multiple studies,16,21–25,28 where the prevalence of gastroenteritis in children under 5 years of age admitted with malnutrition ranged between 11% and 57.6%.
> Hematological System
The hematological system includes blood and blood products or cells; Therefore, the comorbidities identified from the selected studies that affected the mentioned structures in children with malnutrition are discussed.
• Anemia. Six of the articles identified by this review revealed anemia as one of the most prevalent comorbidities of ID. Three of the articles identified were cohort studies,16,18,21 and 2 articles were cross-sectional studies.20,28 One study of the 6 identified was a survey.29
Two of the 3 cohort studies randomly selected their sample,18,21 while the remaining study16 intentionally selected their sample. Furthermore, the 2 cross-sectional studies20,28 and the single survey29 also selected their samples intentionally.
A retrospective cohort study18 with a sample of 420 children under 5 years of age with ID reported anemia as a comorbidity in 74.5% of the sample with a hemoglobin level between 7.0 and 10.9 g/dL. A similar pattern of results was also identified in another cohort study16 where 48.7% of the sample had anemia.
Furthermore, anemia was also revealed as a comorbidity of ID in a cohort study21 where 12.5% of the sample had anemia.
The findings of the aforementioned cohort studies competed with the results of several other studies,18,28,29 where anemia was a common comorbidity ranging between 41.6% and 61.8% of children under 5 years with ID.
> Diagnosis
Although the review identified adequate studies that reported on the prevalence and treatment outcomes of ID comorbidities, no studies reported on the diagnosis of comorbidities based on the established inclusion criteria that can be found with the strategy search. Consequently, there appears to be a paucity of studies on the diagnosis of comorbidities associated with ID.
> Treatment results
Data extracted from studies reporting the outcomes of treatment of comorbidities associated with ID were grouped under the following headings: length of hospitalization/stay, recovery, and mortality.
The findings were further compared to the acceptable values of the Sphere Project standards. The Sphere Project was initiated by a group of international non-governmental organizations to establish acceptable standards in humanitarian aid across all social parameters, including DI.30
The Sphere Project adopts standard values in several studies on the treatment of ID in low- and middle-income countries to compare the results and progress in ensuring quality care for children under 5 years of age with malnutrition.
The Sphere Project’s acceptable standard values for the length of hospitalization/stay of children under 5 years of age with malnutrition are less than 28 days and alarming if they are greater than 42 days; The recovery rate value is acceptable if it is above 75% and alarming if it is below 50%.
> Duration of hospitalization/hospital stay
Five of the studies included in the review reported length of hospitalization/stay in malnourished children. Four of these studies were cohort studies16, 18, 19, 25 and 1 was cross-sectional.2 Three of the 5 cohort studies were conducted in Ethiopia,16, 18, 19 while the remaining cohort study was conducted in Nigeria.25 The cross-sectional study 20 was conducted in Ethiopia.
The retrospective cohort18 reported a mean hospitalization/length of stay and recovery time in children with TB as a comorbidity of ID of 26.1 days. Furthermore, 1 of the cohort studies reported a mean length of hospitalization/stay of 18 days. 19 However, the findings cannot be attributed solely to comorbidities associated with ID, as there were children in the cohort who did not have associated comorbidities. to the DI.
The pattern of findings was also identified in a cohort study conducted in Ethiopia, where the average length of hospitalization/stay among malnourished children was reported to be 15 days for the entire cohort, with 13% of the sample which exceeded the standard period16 of the acceptable 28 days.
The findings of the studies were consistent with the results of one of the included studies,25 where the average duration of hospitalization/stay of the sample was 27 days; however, the findings cannot be attributed to ID-associated comorbidities alone because part of the sample did not have ID-associated comorbidities. Additionally, a study conducted in Ethiopia reported an average hospital stay of 17 days, respectively.20
> Recovery
Similarly, regarding the length of hospitalization/stay, it was difficult to distinguish whether the findings on recovery of malnourished children referred only to malnourished children or children with comorbidities associated with malnutrition. However, the findings of the included studies that report on children with malnutrition and/or associated comorbidities are discussed.
Ten of the included studies reported the recovery rate of children admitted with ID with or without associated comorbidities. Seven of these studies were cohort studies16–19,21,22,25 and 1 study was cross-sectional.20 Two other studies that reported on recovery were surveys.9,23 Five of the cohort studies randomly selected their samples, while 2 They selected their samples intentionally.
One survey study randomly selected its sample, while the other selected its sample intentionally. The cross-sectional study also intentionally selected its sample. The retrospective cohort in Ethiopia reported an overall recovery rate of 69.4% for up to 59 days.18
The overall recovery rate was lower compared to other included studies. However, these findings coincided with the results of one of the included studies, where the recovery rate of 62.13% was reported.17
Furthermore, in contrast to these studies, 1 of the included cohort studies conducted in South Africa24 reported a slightly higher recovery rate (75.6%). One of the included cohort studies conducted in Ethiopia also reported a recovery rate of 69.2%.19
A cohort study conducted in Nigeria reported a high recovery rate of 87.1% among the included studies.26 A similar pattern of results was also identified in a cohort study conducted in Ethiopia, where a recovery rate of 81% was reported. .3%16 lower than ever, those with comorbid conditions such as pneumonia were 24% less likely to recover than those who did not. A cohort study conducted in Ethiopia reported an overall recovery rate of 82%.22
94.3% of those with pneumonia as a comorbidity recovered, while 93.3% and 95.1% of those with anemia and gastroenteritis as comorbidities, respectively, also recovered.22
One cross-sectional study included in the review reported a recovery rate of 77.8%,20 while the 2 survey studies (9,23) reported recovery rates of 55.9% and 75.4%, respectively. A cohort study conducted in Ethiopia with a sample of 545 21 reported a recovery rate of 59.7%, which is disturbing and close to alarming status according to standard Sphere guidelines.
> Mortality
The results of studies reporting the mortality of children with comorbidities associated with malnutrition were also analyzed in relation to the standard Project Sphere guidelines that indicated a mortality rate of less than 10% as acceptable and a mortality rate greater than 15% as alarming.30
The review found 9 studies that reported on mortality, either in children with malnutrition alone or malnutrition and associated comorbidities. Six of the identified studies were cohort studies,18,19,21,22,24,25 one was cross-sectional,20 and 2 studies were survey.9,23
One of the included studies reported a mortality rate of 10.8%, which is slightly above acceptable standard values.18
In another cohort study conducted in Nigeria, a mortality rate of 0.2% was reported, which is low compared to other included studies and acceptable according to standard Sphere guidelines.25 Furthermore, the results of one of the studies in The included cohorts conducted in Ethiopia reported a mortality rate of 9.3%,21 which was consistent with the results of a cohort study conducted in Ethiopia that reported a mortality rate of 3.8%.22 Additionally, reported a mortality rate of 5.7%, 6.7% and 4.9% from pneumonia, anemia and gastroenteritis as comorbidities among people with malnutrition.22 In contrast, one of the included cohort studies conducted in South Africa established a mortality rate of 24.4%,24 which is above Sphere’s acceptable standard values.
One of the included cohort studies conducted in Ethiopia19 reported a mortality rate of 10.8%, which is slightly above the acceptable figure of less than 10% stipulated by Sphere standards. Furthermore, a cross-sectional study conducted in Ethiopia20 reported a mortality rate of 9.3%, which is acceptable according to Sphere standard values, while the 2 surveys9,23 reported a mortality rate of 5.8%. and 3.4%, respectively.
| Discussion |
The review’s findings on prevalent comorbidities associated with ID add knowledge to the World Health Organization treatment guideline currently available for the management of children admitted with severe acute malnutrition.7
One of the steps in the treatment regimen is to treat the infection; However, this step does not necessarily mean that physicians will screen for and treat all possible infections, leading to misdiagnosis or delayed identification of ID-associated comorbidities, leading to mortality. Therefore, this review provides health professionals in low- and middle-income countries with an additional recommendation to screen all children admitted with malnutrition.
Mandatory screening for TB, gastroenteritis, pneumonia and anemia should be performed to reduce mortality caused by late identification and misdiagnoses. Although it would be crucial to identify the 4 most prevalent comorbidities associated with ID, it could also be valuable to consider other comorbidities that are not on the list of the most prevalent, such as developmental delay, and treat them if present.
Diagnosis is an integral part of the management of ID comorbidities, as they are the main causes of mortality in children under 5 years of age with malnutrition.31 However, despite its extensive and comprehensive nature, the review was unable to identify any study that reported on the diagnosis of comorbidities associated with ID. The review’s focus on the diagnosis of comorbidities associated with ID was stimulated by the possible late identification and effect of associated comorbidities. However, no studies were found using the search strategy used.
The Sphere standard values, which are widely used to measure safe performance in the treatment of ID, were adopted as a guide to determine what indices are acceptable in recoveries, mortality and days of hospitalization/stay of children admitted with ID and associated comorbidities.
The review findings on treatment outcomes of CM-associated comorbidities found a generally acceptable recovery rate in all studies involved. Of the studies that reported the recovery rate for ID-associated comorbidities, only 3 reported an acceptable recovery rate according to standard Sphere guidelines.
Some of the reasons for the worrying low recovery rate in these studies could be related to the presence of comorbidities.16 However, issues such as psychosocial inequalities and lack of resources cannot be excluded as factors contributing to the low recovery rate. . Furthermore, findings from the mortality rate review of CM-associated comorbidities established that only 3 of 9 studies reported a mortality rate above the acceptable standard Sphere project guidelines.
Findings from the 2 included studies18,19 indicated a mortality rate of 10.8%, which is only slightly above the acceptable Sphere standard value of less than 10%, indicating that steps should be taken to strengthen interventions to treat DI associated with comorbidities.
In one study, a mortality rate of 24.4%24 was identified, well above acceptable Sphere standards and described as an alarming rate. However, the alarmingly high mortality rate may be linked to a limitation of the study that suggests there could be a layer of internal and external center-based factors that determined treatment outcomes for ID 24 However, the findings of This review indicates that the mortality rate in comorbidities associated with ID is relatively low and acceptable in low- and middle-income countries, suggesting that the measures implemented to treat comorbidities associated with ID are effective, although they are still requires strengthening measures.
The discrepancy between an overall low recovery rate and a low mortality rate should be further investigated, as a low mortality rate generally indicates a high recovery rate. However, factors such as prolonged hospitalization and referral to specialized care units observed in studies with a discrepancy between low mortality and recovery rates could have been contributing factors.
The review established that the most prevalent comorbidities associated with ID in children under 5 years of age are pneumonia, tuberculosis, gastroenteritis and anemia. Furthermore, the length of hospitalization/stay was acceptable in most studies; the recovery rate was relatively low in most studies; and the mortality rate was also acceptable in most of the included studies compared to the established standards of the Sphere project.
| Conclusions |
This review managed to determine the most prevalent comorbidities associated with ID. Although the studies in the review reported many associated comorbidities, only those reported in at least 2 of the included studies were selected as the most common comorbidities of ID.
Some of the studies included in this review reported signs of morbidity such as ID comorbidities. These signs included fever and dehydration, which cannot be considered comorbid conditions. However, gastroenteritis, tuberculosis, pneumonia and anemia were the most prevalent comorbidities of ID reported by the primary studies in the review.
Despite the extensive literature reporting on associated comorbidities, the review could not determine the occurrence of late diagnosis of ID-associated comorbidities and their effects. Research should be conducted on the impact of late diagnosis of CM comorbidities. More research is also needed on the treatment outcomes of comorbidities specifically associated with ID.
Existing management protocols can be strengthened to the extent that algorithms are developed that make it possible to compulsorily rule out comorbidities identified at the admission of children under 5 years of age. Algorithms could help in the early diagnosis and treatment of comorbidities associated with ID.
