Children are vulnerable to malnutrition and infectious diseases which can be effectively prevented. Malnutrition in children is a major global health problem associated with childhood morbidity and mortality, impaired intellectual development and increased likelihood of diseases in adulthood.1 According to World Health Organization (WHO), there are three broad groups of malnutrition that is, undernutrition [wasting (low weight-for-height), stunting (low height-for-age) and underweight (low weight-for-age)]; micronutrient-related malnutrition (lack or excess of important vitamins and minerals) and finally overweight [obesity and diet-related noncommunicable diseases (such as heart disease, stroke, diabetes and some cancers)].2,3 According to WHO and United Nations International Children's Emergency Fund (UNICEF) severe acute malnutrition (SAM) in children aged six months to five years of age is diagnosed based on the any one of the three criterion that is, weight-for-height/length less than three standard deviation (<−3 SD) on WHO Growth Standards OR presence of bipedal oedema (excluding non-nutritional causes) OR Mid-upper arm circumference (MUAC) below 11.5 cms.4,5 Malnutrition in India is a major concern as some of the highest rates of childhood malnutrition and mortality in under five age group are seen here.5,6 According to the National family health survey five (NFHS-5) (2019-21),7 nearly one-third (32.10%) of the children under five years of age are underweight (low weight-for-age), 35.5% stunted (low height-for-age) and nearly one-fifth (19.30%) are wasted (low weight-for-height). Among those with wasting, 7.70% of these children are severely wasted (weight-for-height/length <−3 SD). Since ‘wasting’ denotes acute malnutrition, these children are said to have SAM.7 Treatment of children with SAM is divided in three phases; stabilization, transition and rehabilitation. The goal is first to stabilize, treat life-threatening complications and then to feed the child intensively to allow for catch-up growth.8,9 Nutritional Rehabilitation Centre (NRC) is a unit in the health facility where SAM children are admitted as per the defined admission criteria and provided medical and therapeutic nutritional care as well as capacity building of mothers and other caregivers regarding appropriate feeding and caring practices for infants and young children as per SAM management guidelines by the WHO and Indian Academy of Pediatrics.9 The NRC model not only envisages the short term aim to reduce mortality due to SAM but with a community linkage and effective follow up, it is aimed at a comprehensive and long term improvement in quality of life in undernourished children. During the stay in NRC, along with medical and nutritional therapeutic care, mothers/caregivers are also provided counselling and support to address the reasons for poor nutrition and health in their child. As per WHO guidelines, SAM children are treated with a starter F-75 diet (containing 75 calories) initially for three to seven days and later with a catch-up F-100 diet (containing 100 calories) from locally available ingredients containing 300 mL and 900 mL of skimmed milk per 1000 mL of F-75 and F-100 diets, respectively.10,11 After discharge, the child is followed up in to avoid relapse. However, the data on clinical presentation of SAM and its outcome in the study area is limited. Hence, the present study was planned to evaluate the clinical profile and outcome of children admitted with SAM.

A hospital-based cross-sectional study of children with SAM admitted to the NRC were enrolled in the study. The study was conducted at the Maternity & child Care Hospital (MCCH) associated GMC Anantnag from April 2019 TO 2022. Children with SAM in the age of one month to five years from the outpatient department or emergency were admitted and enrolled. The Institutional Ethical Approval was obtained, and informed consent was taken from the parents or caregivers. A pre-designed pro forma was used for data collection. After proper history taken from mothers/caregivers. Nutritional status by anthropometric assessment using standard methods was done. Classification of malnutrition was made according to the WHO guidelines. Anthropometric measurements including weight in kg and length/height in cm, weight for height Z score, mid-upper arm circumference, and oedema were used to classify the grades of malnutrition. The data after collection and compilation were analysed by Statistical Package for the Social Sciences (SPSS). Data were entered and analysed using SPSS version 21. Categorical data were analysed as proportions and percentages.

In the present study, a total of 306 SAM cases were studied during the study period. Table 1 shows age wise distribution of admitted cases in which maximum no. of cases were in the age group of 7 months to one year of life (n=91,29.73%) followed by 13 months to 24 months of life (n=67,21.89%). Out of total number of patients admitted 127(41.50%) patients were males and 176(57.5%) were females. Majority of the children (n=186, 60.78%) belong to nuclear families. SAM was common in lower class(N=152,49.67%) followed by upper lower class(n=136,44.44%) according to Kupuswamy’s socio-economic status scale. SAM was seen least in lower middle class (N=18,5.8%). whereas there was no SAM patient in middle class and upper class. SAM was seen more in children with low literacy rate in parents (n=215, 70.26%) with skilled – semiskilled profession. SAM was more common in children with birth order of more than 03 and spacing between two children less than 24 months in mothers. (Table 2). Preponderance of SAM was noted among the children who resided in rural area (n=217, 69.28%) compared to urban area (n=94, 30.71%). The analysis for weight for height on admission showed that 68.62%of cases had z score of <-3SD, while 16.99 had < -4SD z score. Majority of children (n=156, 50.98%) fulfilled the WHO MUAC cut-off of less than 11.5cm. while (n=117, 38.23%) had MUAC between 11.5-12.5cm. The present study showed that (n=119, 38.88%) had good weight gain while maximum children (n=136, 44.44%) had moderate weight gain. only 51 children (16.66%) had poor weight gain after NRC counselling (Table 2). Adequate exclusive breastfeeding was seen in (n=126), faulty feeding with bottle was given in (n=180 children) with formula milk (n=110) or over diluted cow’s milk (n =70). Most of the children were started on complementary feeding by the end of 6 months of life, but 128 children had late complementary feeding which precipitates to malnutrition in children. Table 4 depicts the clinical profile of children presented with SAM. Most of the children presented with acute gastroenteritis (n=206, 67.32%) followed by acute respiratory tract infection (n=158, 51.63%) and anaemia was found in (n=170, 55.55%) children followed by vitamin deficiencies in (n=56,178.30%) children. During the hospital stay, most common electrolyte imbalance was hypoglycaemia (n=183) followed by hypokalaemia (n=56). Out of 306 children admitted during the three years of the study period, 276 children were discharged and 27 children were referred to the tertiary care centre for further management (Table 5). Table I. Age and gender distribution of children Variable Subgroups Year: 2019, (n=106) Year: 2020, (n=86) Year: 2021, (n=111) Total (n=303) Age (months) 1–6 24 (22.64%) 15 (17.44%) 20 (18.02%) 59 (19.47%) 7–12 30 (28.30%) 27 (31.40%) 34 (30.63%) 91 (30.03%) 13–24 28 (26.42%) 17 (19.77%) 22 (19.82%) 67 (22.11%) 25–36 15 (14.15%) 20 (23.26%) 18 (16.22%) 53 (17.49%) 37–<60 09 (8.49%) 07 (8.14%) 17 (15.32%) 33 (10.89%) Gender Boys 48 (45.28%) 35 (40.70%) 44 (39.64%) 127 (41.91%) Girls 58 (54.72%) 51 (59.30%) 67 (60.36%) 176 (58.09%) Table II. Admission and outcome of children Parameters Year 2019 Year 2020 Year 2021 Total Total admissions 106 86 111 303 Transferred 09 06 12 27 Death 0 0 0 0 Discharged 97 80 99 276 Table III. Socio-demographic characteristics Characteristics Subgroups Number Percentage Family Type Joint 120 39.21 Nuclear 186 60.75 Socio Economic Status Upper Class 0 0.00 Upper middle class 0 0.00 Lower middle class 18 5.88 Upper lower class 136 44.44 Lower class 152 49.67 Educational Status of parents Literate 91 29.73 Illiterate 215 70.26 Occupation of father Professional / Semi Professional 12 3.92 Skilled / Unskilled 294 96.07 Immunization status Unimmunised 18 3.92 Partially immunised 62 20.26 Completely immunised 226 73.85 Feeding pattern Adequate feeding 126 41.17 Faulty feeding 180 58.8 Late complementary feeding 128 41.83 Spacing between 2 children < 24 months 114 37.25 Place of residence Urban 94 30.71 Rural 212 69.28 Weight gain per day Good (≥10) 119 38.88 Moderate (5–<10) 136 44.44 Poor (<5) 51 16.66 Weight/height on admission (Z score) < -2SD 44 14.37 < -3SD 210 68.12 < -4SD 52 16.99 MUAC at admission (cms) <11.5 156 50.98 11.5-12.5 117 38.23 >12.5 30 9.80 Table IV. Clinical Profile of SAM patients. Clinical manifestations Number percentage Acute Gastroenteritis 206 67.32 Acute respiratory infection 158 51.6 Urinary tract infection 15 4.90 Sepsis 48 15.65 Acute otitis media 28 9.1 Tuberculosis 5 1.633 Skin infection 10 3.26 Anaemia 170 55.55 Vitamin deficiencies 56 18.30 Metabolic derangements Hypoglycaemia 183 59.80 Hypokalaemia 56 18.30 Hyperkalaemia 2 0.65 Hypernatremia 18 5.88 Hypernatremia 5 1.633 Hypomagnesaemia 6 1.96 Table V. Distribution of children according to the weight gain Parameters Year 2019 Year 2020 Year 2021 Total Total admissions 106 86 111 303 Transferred 09 06 12 27 Death 0 0 0 0 Discharged 97 80 99 276

The majority of the cases in this study shows female preponderance which is similar with the study by Joshi S. et al.12 (2004) Shah R. et al.13 (2014) also reported the extent of malnutrition significantly increased in female gender. In the present study, maximum number of children belong to 6 to 12 months of age group followed by 12 to 24 months of life. These findings were comparable with the study done by Bhandari B. et al.15 (2013). Prevalence of SAM was seen more in nuclear familes than joint families in our study which is similar with the studies reported by Rehan A. et al.16 (2020). Also the incidence was seen more in children with birth order more than two or more. Different studies16,17 reported higher incidence of SAM in lower socioeconomic status. In this study based on class of kupuswamy socioeconomic status scale, none of the child in upper class had SAM which is comparable with other studies done by Rehan A. et al.16 (2020). In this study, SAM was more in lower with birth order. In the studies done by Rehan A. et al.16 (2020), Meshram II et al.18 (2016) and Bhandari B. et al.15 (2013), SAM was significantly high in illiterate and unskilled parents than literate and professionals which is similar with the findings in our study. In the present study, SAM was more in children with faulty feeding due to overdiluted formula feed or cow’s milk and late starting of complementary feeding which leads to inadequate nutritional requirements and SAM in children. The most common presenting disease in this study was AGE (n=206,67.32) followed by ARTI (n=158,51.63%), sepsis (n=48,15.68%), acute otites media (n=28,9.15%), UTI (n=15,4.90). Other studies done by Choudhary P. et al.19 (2019) and Bernal C et al.20 (2008) reported incidence of gastroenteritis 60% and 68.4% respectively. The present study shows significant rise of number of anemia (n=170,55.55) and vitamin deficiency among SAM patient (n=56,18.30). In this study, most common electrolyte derangement was hypoglycaemia (n=183, 59.80) followed by hypokalemia (n=56, 18.30) which is comparable to studies by Choudhury M. et al.21 (2015). In this study 27 children were transferred to other tertiary care centre and 276 patients were discharged and follow up was done in all children, among them (n=119, 38.88%) children had good weight gain (10mg/kg/day), 136 (44.44%) had moderated weight gain (5-10 gm/kg/day) and 51 (16.66%) had poor weight gain. This is similarly found in other studies done by Shah R. et al.13 (2014). The present study does not include the follow-up data which was an important limitation of this study.

Malnutrition in under five children is very high and multifactorial. Hospital based management of SAM is an important step in reducing the mortality among such children by improving the quality of care and follow-up of such patients. Besides this early detection of moderate malnutrition and timely intervention prevents them to go to SAM.

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