Severe Acute Malnutrition affects nearly twenty million under-five children, and contributes to one million child deaths yearly　[1]. The mortality rate of children with complicated SAM that receive treatment in inpatient set ups has remained unacceptably high [2]. Such high mortality in in-patient units has been attributed to co-morbidities such as infections and micronutrient deficiencies [3].

There is a lack of systematic reporting of clinical and laboratory data on admission or during hospital stay to identify baseline risk factors that allow comparative studies of the burden, spectrum and outcome of co-morbidities of severe malnutrition. Here we present a description of co-morbid findings in children admitted to a tertiary level hospital in central India.

This descriptive study was carried out in the Department of Pediatrics, Gandhi Memorial Hospital, Rewa from August 2011 to July 2012. All children between six to sixty months of age with severe acute malnutrition (SAM) admitted in the Nutritional Rehabilitation Ward were included. WHO criteria were used to define severe acute malnutrition [4]. Children suspected to have congenital malformation and diseases were excluded.

Detailed history and systemic examination were done and the clinical signs of micronutrient deficiencies were assessed. Frequencies of various co morbid conditions in study population were recorded.

Ethical issues: A written, informed consent was obtained from parents. Clearance from Departmental Ethics Committee was taken prior to the start of the study. All participants had the option to withdraw from the study anytime during their hospital stay.

Out of 104 SAM children (51.9% females), 59.6% were in age group six to twelve months. Mean age of presentation was 14.3 months. 75.8% cases had their weight for height below -3SD, 24.03% cases had severe visible wasting, and 27% had bilateral pitting edema. Around 75% families belonged to lower socio-economic status, 6% of babies were exclusive breastfed while breast feeding was not at all initiated in 24.3% of children. 42.3% children were completely immunized and 52 % had partial immunization. 72.1% children had achieved normal milestones for the age.

TABLE I Distribution of Co-morbidities in the Study Population

Diarrhea was found to be the most common co morbid disease associated with SAM. 54% SAM children had diarrhea and 27.9% of children suffered acute respiratory tract infections (Table I). Nutritional deficiencies are detailed in Table II. 11.5% children had normal hemoglobin level, 7.6% mild anemia, 55.7 % had moderate anemia and 24% had severe anemia.

TABLE II Nutritional Deficiencies in Study Subjects  

Mean age of children reporting with malnutrition was similar to other studies and there was no significant sex predominance in malnourished children [5]. Diarrhea and acute respiratory infection were the two most common co morbid diseases followed closely by tuberculosis. Previous studies have also reported that malnourished children suffer in greater proportion from bacterial gastrointestinal and respiratory infections [6]. Absence of a comparative group, no biochemical evaluation for micronutrient deficiencies and non-assessment of contributing factors for these deficiencies were the main lacunae of the study.

In a Colombian study, 68.4% of malnourished children were suffering from diarrhea and 9% had sepsis at the time of admission [7]. Two African studies also showed high incidence of diarrhea in SAM children of 49% and 67% [8,9]. Though previous reports have described malnutrition as an important risk factor for pneumonia than for diarrhea [10], diarrhea was the major co-morbid condition found in our study. A study from Africa [11] also reported a comparable incidence of respiratory illness and tuberculosis (18% each) in admitted SAM children. Measles has severe consequences on the nutritional status. A previous Indian study [12] showed only 3- 4% of children with past history of measles but we found a higher proportion. Malaria and HIV infection were previously reported as major co-morbidities with total prevalence of 21% and 29.2%, respectively [11] but data from our hospital showed a comparatively lesser incidence.

Overlapping nature of protein–energy malnutrition and micronutrient deficiencies were well understood and it is seen that lack of one micronutrient is typically associated with deficiency of others [13]. Anemia and vitamin D deficiency were the two most common micronutrient deficiencies associated with malnutrition in our study, and this is consistent with the previous reports [14]. The high incidence of anemia in these children could be due to nutritional factors as well as incidental helminthic infections. Other micronutrient deficiencies seen in this study have also been previously reported [15].

Apart from nutritional rehabilitation, timely identification and treatment of co-morbidities like diarrhea, acute respiratory tract infection, anemia and micronutrient deficiencies is vital in malnourished children, so as to break undernutrition-disease cycle, and to decrease mortality and to improve outcome.

Contributors: RK: collected the data and conducted the study; KJ: supervised the study; HPS and JS: conceived the study and finalized the manuscript and will be the guarantors.

Funding: None; Competing interests: None stated.

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