Retrospective analysis of concurrently wasted and stunted children 6-59 months in the outpatient therapeutic feeding programme in Karamoja: burden, characteristics, detection, response to treatment and outcomes

Abstract

Background: Children with wasting and stunting at the same time (WaSt) are an emerging public health priority group. They have a comparable risk of death to children with severe wasting. However, evidence is needed to inform prevention and treatment strategies for WaSt children. We assessed the burden, characteristics and detection of WaSt children aged 6-59 months, their treatment response and outcomes in outpatient therapeutic feeding programme (TFP) in the Karamoja region. Methods: We carried out three sub-studies (I-III). We conducted secondary analysis of the Karamoja 2015-2018 food security and nutrition assessment (FSNA) cross-sectional survey datasets to assess WaSt prevalence and characteristics; and overlaps between wasted, stunted, underweight and low mid-upper arm circumference (MUAC). We also determined optimal weight-for-age (WAZ) and MUAC thresholds for detecting WaSt among children aged 6-59 months (I.a). Additionally, we examined data for 33,054 children aged 6-59 months using the FSNA dataset to assess factors associated with WaSt (I.b). We conducted a retrospective cohort study to assess the prevalence of WaSt children, their characteristics, treatment outcomes and response; and factors associated with time to recovery among children aged 6-59 months admitted to nine outpatient therapeutic care (OTC) centres from January 2016 to October 2017 (II). Lastly, in an exploratory qualitative study, we described caregivers’ perceptions of severe acute malnutrition (SAM) among children aged 6-59 months admitted to outpatient TFP in Karamoja (III). Data analysis involved descriptive statistics, receiver operator curves (ROC) analysis and regression models (I-II) while inductive thematic method was used for the qualitative data (III). Results: Sub-study I: The pooled datasets contained data on 32,962 children aged 6-59 months. About 49.67% of the sample were males and the median age was 26 months. WaSt prevalence was 4.96% (95% CI; 4.64-5.29). WaSt was more prevalent in lean than in harvest season (5.21% vs. 4.53%; p = 0.018). About half (53.92%) of WaSt children had low MUAC and all were underweight. Younger children aged < 36 months and particularly males had more WaSt. A WAZ < -2.60 threshold detected WaSt with excellent sensitivity (99.02%) and high specificity (90.71%). MUAC threshold <13.20 cm had good sensitivity (81.58%) and moderate specificity (76.15%) to detect WaSt (sub-study I a). In the multivariate analysis, WaSt was more prevalent among males (aOR= 1.79; 95%CI; 1.60-2.00), and children with age 12-23 months (aOR= 2.25; 95%CI; 1.85-2.74), acute respiratory infection (aOR= 1.30; 95%CI; 1.15-1.48) and diarrhoea (aOR =1.25; 95%CI; 1.06-1.48). WaSt was significantly associated with poor maternal nutritional status, high fertility and households without livestock (sub-study Ib). Sub-study II: Out of 788 eligible children included in the analysis; 52.3% were males and the median age was 15 months. The prevalence of WaSt was 48.7% (95% CI; 45.2-52.2) in the study sample. . WaSt was common among males; 56.3% (95% CI; 51.3-61.3). Median age was 18 months in WaSt versus 12 months in non-WaSt children (p < 0.001). All WaSt children were underweight; and more severely wasted than non-WaSt children. During recovery, WaSt children gained weight more rapidly than non-WaSt children (2.2g/kg/day vs. 1.7g/kg/day). WaSt children had lower recovery rate (58.0% vs. 65.4%; p= 0.037). The probability of recovery was significantly higher among children with age 24-59 months, MUAC ≥ 10.5 cm at admission and those living in Moroto and Nakapiripirit districts. Sub-study III: A total of 58 caregivers (14 in the in-depth interviews (IDIs) and 44 in the focus group discussions (FGDs)) with children with SAM aged 6-59 months receiving therapeutic feeding care participated in this study. The mean age of the caregivers in the IDIs was 34 years and 32 years in the FGDs. The caregivers were mainly mothers of children with SAM. Hunger, food scarcity, poor feeding practices, diseases especially diarrhoea, child neglect due to caregivers’ frequent absence from home in search of food were perceived causes of SAM. Caregivers also believed SAM and other childhood illnesses have supernatural causes requiring traditional healing and cleansing. Treatment seeking for illnesses and SAM was delayed and pluralistic with a combination of conventional and traditional medicine. Ready to use therapeutic foods (RUTF) were used as treatment for diarrhoea and as alternative food for children. Inappropriate feeding and repeated episodes of diarrhoea however prolonged SAM treatment. Conclusion: WaSt prevalence of 5% is a public health concern, given its high mortality risk. All children with WaSt were underweight and half had low MUAC.WAZ and MUAC could be useful tools for detecting WaSt. Preventing the occurrence of WaSt through pragmatic and joint approaches are recommended. The magnitude of children with WaSt in OTC shows that existing therapeutic feeding protocols could be used to detect and treat WaSt children. Our findings illustrate the need to incorporate local disease concept and cultural beliefs about SAM causality and treatment into health education and TFPs to improve programme uptake and treatment outcomes.