title: Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): a prospective cohort study.
abstract: BACKGROUND
  Management of Severe Acute Malnutrition (SAM) plays a vital role in achieving global child survival targets. Effective treatment programmes are available but little is known about longer term outcomes following programme discharge.
  
  
  METHODS
  From July 2006 to March 2007, 1024 children (median age 21.5 months, IQR 15-32) contributed 1187 admission episodes to an inpatient-based SAM treatment centre in Blantyre, Malawi. Long term outcomes, were determined in a longitudinal cohort study, a year or more after initial programme discharge. We found information on 88%(899/1024).
  
  
  RESULTS
  In total, 42%(427/1024) children died during or after treatment. 25%(105/427) of deaths occurred after normal programme discharge, >90 days after admission. Mortality was greatest among HIV seropositive children: 62%(274/445). Other risk factors included age <12 months; severity of malnutrition at admission; and disability. In survivors, weight-for-height and weight-for-age improved but height-for-age remained low, mean -2.97 z-scores (SD 1.3).
  
  
  CONCLUSIONS
  Although SAM mortality in this setting was unacceptably high, our findings offer important lessons for future programming, policy and research. First is the need for improved programme evaluation: most routine reporting systems would have missed late deaths and underestimated total mortality due to SAM. Second, a more holistic view of SAM is needed: while treatment will always focus on nutritional interventions, it is vital to also identify and manage underlying clinical conditions such as HIV and disability. Finally early identification and treatment of SAM should be emphasised: our results suggest that this could improve longer term as well as short term outcomes. As international policy and programming becomes increasingly focused on stunting and post-malnutrition chronic disease outcomes, SAM should not be forgotten. Proactive prevention and treatment services are essential, not only to reduce mortality in the short term but also because they have potential to impact on longer term morbidity, growth and development of survivors.
authors.affiliation: Valid International, Oxford, United Kingdom; Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi; Institute for Global Health, University College London, London, United Kingdom; Leonard Cheshire Disability and Inclusive Development Centre, University College London, London, United Kingdom.
authors.forename: Marko
authors.initials: M
authors.lastname: Kerac
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors.forename: James
authors.initials: J
authors.lastname: Bunn
authors.affiliation: Department of Paediatrics and Child Health, College of Medicine, Blantyre, Malawi.
authors.forename: George
authors.initials: G
authors.lastname: Chagaluka
authors.affiliation: Valid International, Oxford, United Kingdom; Centre of Research in Epidemiology, Biostatistics and Clinical Research, Free University of Brussels, Brussels, Belgium.
authors.forename: Paluku
authors.initials: P
authors.lastname: Bahwere
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Tomkins
authors.affiliation: Valid International, Oxford, United Kingdom.
authors.forename: Steve
authors.initials: S
authors.lastname: Collins
authors.affiliation: Institute for Global Health, University College London, London, United Kingdom.
authors.forename: Andrew
authors.initials: A
authors.lastname: Seal
mesh_terms: D000208:Acute Disease; D001827:Body Height; D001835:Body Weight; D016022:Case-Control Studies; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D048788:Growth and Development; D015658:HIV Infections / Q000150:complications; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D053208:Kaplan-Meier Estimate; D008295:Malawi / Q000453:epidemiology; D008297:Male; D044342:Malnutrition / Q000150:complications / Q000401:mortality* / Q000628:therapy*; D010351:Patient Discharge / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D035781:Siblings; D016896:Treatment Outcome