Purpose: Malnutrition is a leading cause of mortality among children in sub-Saharan Africa. In Malawi, 3% of children under five are severely malnourished. At Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, malnutrition screening is not routinely performed on the pediatric wards. Patients suspected of malnutrition at admission are referred directly to the Nutritional Rehabilitation Unit (NRU), where eligibility is based on National Center for Health Statistics (NCHS) growth reference. In 2006, the World Health Organization (WHO) published growth standards to identify severe acute malnutrition that were intended to replace the NCHS reference. We initiated routine ward-based malnutrition screening to determine whether additional children would be identified meeting NCHS-based NRU admission criteria and we assessed the implications of the WHO 2006 guidelines on inpatient malnutrition prevalence.
Methods: We conducted a prospective observational study implementing routine ward-based malnutrition screening for children ages 6-60 months at KCH from December 2011 – March 2012. Lay malnutrition screeners were trained to perform bedside measurements for weight, height (or length), mid-upper arm circumference (MUAC), and bi-pedal edema assessment. We evaluated patients by WHO guidelines for severe malnutrition (Weight-for-Height (WFH) z-score < -3SD, bipedal edema, or mid-upper arm circumference (MUAC) <115mm) and NCHS based criteria (WFH percentile <70%, bipedal edema, or MUAC <110 mm). Patients meeting NCHS criteria were referred to the NRU. We compared characteristics of screener-identified children using NCHS and WHO 2006 criterion versus those children directly referred to the NRU by clinicians.
Results: Screeners evaluated 2112 children on the ward, identifying 171 meeting NRU admission criteria. There were 369 standard-of-care NRU admissions during the same period. Ward screeners identified 32% of all NRU-eligible patients.
The majority of screener-identified patients (71%) met only one measure for malnutrition. MUAC and edema captured 77% of the children evaluated.
Children detected by ward-based screening were younger (mean age of 19.8 vs. 25.4 months, p<0.001), with a greater percentage of children 6-12 months (32.2% vs. 13.3%, p< 0.001), and had smaller MUAC (112 vs. 116 mm, p<.017). More direct NRU admissions had edema (80.5% vs. 48.0% p<0.001). Mean WFH percentile was comparable between the two groups (75.5 vs. 76.8, p<0.574). The mortality rate was similar (7.4% vs. 8.2%, p< 0.629) suggesting identification of children at similar risk for death.
The prevalence of severe malnutrition on the wards was higher per WHO guidelines at 12% versus 8% per NCHS criterion.
Conclusions: Routine ward-based screening identifies severely malnourished children otherwise missed by direct NRU referral, particularly younger children. Measurement of MUAC and edema assessment can capture most severely malnourished children in settings where height and weight are not feasible. WHO guidelines identified additional children as severely malnourished and would markedly increase NRU admissions, if adopted.