Treatment Outcomes and Predictors of Nutritional recovery among Children with severe Acute Malnutrition attending the Outpatient Therapeutic Clinic in Mulago Hospital

Abstract

Background: Initially, all children with Severe Acute Malnutrition (SAM) used to be treated with inpatient care. The Outpatient Therapeutic Clinic (OTC) is an innovation for treating children with SAM with no medical complications as outpatients within their communities. Although OTC based care of SAM in Mwanamugimu Nutrition Unit (MNU) has been in practice for the past 10 years, there is no information on treatment outcomes and predictors of nutritional recovery. Despite its unique attributes, such as being located in Mulago National Regional Referral Hospital with high patient volume, some children are referrals travelling long distances to attend OTC and others initially admitted in the In-patient Therapeutic Centre (severely ill). Objectives: To determine treatment outcomes (Recovered, Defaulter, Non-responder, Transferred-in and Died) of children with SAM enrolled in the MNU OTC and predictors of nutritional recovery. Methodology: This was a prospective longitudinal study involving both quantitative and qualitative components. The study involved children aged 6-59 months with uncomplicated SAM attending OTC. A pre-tested questionnaire was used at enrollment to extract information on baseline child characteristics, caregiver characteristics and caregiver feeding practices and knowledge. Follow up was a maximum of 8 weeks and follow up data extracted with a tool guide from OTC record books. All participants who defaulted were contacted by phone to determine those who had died. The qualitative component involved Focus Group Discussions (FGDs) with selected caregivers who had attended OTC for at least one visit and key informant interviews with health workers at the clinic to obtain an in-depth understanding of predictors of recovery in OTC. Results: Among the 198 children that participated in the study only N=98 (49.5%), recovered from SAM by 8 weeks. Of those who did not recover, N=74 (37.4%) defaulted, N=18 (9.1%) were nonresponders, N=4 (2%) were Transfer-in’s and N=4 (2%) of the children died. The predictors of recovery were age >1 year (AHR-1.61, CI: 1.09-2.82, p=0.04), breast feeding (AHR0.49, CI:0.30-0.82, p=0.01), SAM with edema (AHR-1.95, CI:1.22-3.12, p=0.01), married (AHR-2.03, CI:1.07-3.82, p=0.03) and increased meal frequency (AHR-1.86, CI:1.06-3.25, p=0.03). From the qualitative part, facilitators to nutritional recovery were family support, availability of RUTF, good health worker attitudes and availability of multidisciplinary services. Barriers to recovery included high cost of preparing “kitoobero”, co-morbidities, long distances, care-giver occupation, lack of home visits, staff shortage, negative culture beliefs, occupation of caregiver, changing of caregiver, discontinuation of care and stigma. Conclusion: Nutritional recovery rate at the OTC in MNU was far below the accepted minimum international standards because of the unique nature of the OTC. Therefore, efforts should be strengthened to facilitate early recovery of children by; paying special attention to infants below 1 year, children with non-edematous SAM, provision of household supplementary food, emphasis and support of quality young infant feeding practices, establish social support structures for unmarried caregivers and referring children to OTCs closest to home if available.