title: Risk factors for death in children during inpatient treatment of severe acute malnutrition: a prospective cohort study.
abstract: Children who receive in-hospital treatment of severe acute malnutrition often have high mortality rates, and the reasons are not well understood.
  
  
  
  We assessed risk factors for death in children who were treated for malnutrition in a hospital.
  
  
  
  In a prospective observational study of 120 children who were receiving in-hospital treatment of severe acute malnutrition in Uganda with therapeutic formulas F-75 and F-100, we collected data on symptoms, clinical findings, plasma markers of refeeding syndrome (electrolytes and phosphate), and acute phase reactants, and recorded the nutritional therapy given in hospital.
  
  
  
  Seventeen children (14%) died. Clinical risk factors for death were the presence of oral thrush (HR: 5.0; 95% CI: 1.6, 15.2), a caretaker-reported severity of illness on a visual analog scale (HR: 1.7; 95% CI: 1.1, 2.6), impaired consciousness (HR: 16.7; 95% CI: 3.1, 90.4), and a capillary refill time >2 s (HR: 3.9; 95% CI: 1.4, 11.3). HIV infection was not associated with mortality (HR: 3.0; 95% CI: 0.7, 12.4), which was most likely due to low power. Biochemical risk factors were a plasma C-reactive protein concentration >15 mg/L on admission and low plasma phosphate that was measured on day 2 (HR: 8.7; 95% CI: 2.5, 30.1), particularly in edematous children. The replacement of F-75 with unfortified rice porridge to ameliorate diarrhea was associated with a higher risk of death, particularly if given during the first 2 d (HR: 5.0; 95% CI: 1.9, 13.3), which was an association that remained after adjustment for potential confounders (HR: 69.5; 95% CI: 7.0, 694.6).
  
  
  
  Refeeding syndrome may occur in children who are treated for malnutrition, even with moderately low plasma phosphate, and, in particular, in children with edematous malnutrition. The replacement of F-75 with unfortified rice porridge is associated with increased risk of death, which is possibly mediated by lowering plasma phosphate. The identified clinical risk factors may potentially improve the triage of children with malnutrition. This trial was registered at www.isrctn.com as ISRCTN55092738.
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark; marenrytter@hotmail.com.
authors.forename: Maren Jh
authors.identifier: 0000-0002-9490-9586
authors.initials: MJ
authors.lastname: Rytter
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.|Mwanamugimu Nutrition Unit, Directorate of Pediatrics, Mulago Tertiary Teaching Hospital, Kampala, Uganda.
authors.forename: Esther
authors.identifier: 0000-0001-7754-0089
authors.initials: E
authors.lastname: Babirekere-Iriso
authors.affiliation: Mwanamugimu Nutrition Unit, Directorate of Pediatrics, Mulago Tertiary Teaching Hospital, Kampala, Uganda.
authors.forename: Hanifa
authors.identifier: 0000-0003-1490-3158
authors.initials: H
authors.lastname: Namusoke
authors.affiliation: Department of Pediatrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; and.
authors.forename: Vibeke B
authors.identifier: 0000-0002-0890-3832
authors.initials: VB
authors.lastname: Christensen
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Kim F
authors.identifier: 0000-0003-0449-0839
authors.initials: KF
authors.lastname: Michaelsen
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Christian
authors.identifier: 0000-0002-5095-0624
authors.initials: C
authors.lastname: Ritz
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Charlotte G
authors.identifier: 0000-0002-4582-9491
authors.initials: CG
authors.lastname: Mortensen
authors.affiliation: Department of Pediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda.
authors.forename: Ezekiel
authors.identifier: 0000-0002-8746-9009
authors.initials: E
authors.lastname: Mupere
authors.affiliation: Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Henrik
authors.identifier: 0000-0002-2848-2940
authors.initials: H
authors.lastname: Friis
mesh_terms: D002097:C-Reactive Protein / Q000378:metabolism; D002675:Child, Preschool; D003967:Diarrhea / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D019648:Foods, Specialized; D015658:HIV Infections / Q000401:mortality / Q000628:therapy; D006801:Humans; D007223:Infant; D007297:Inpatients; D008297:Male; D010710:Phosphates / Q000008:administration & dosage / Q000097:blood; D011446:Prospective Studies; D055677:Refeeding Syndrome / Q000401:mortality / Q000628:therapy; D012307:Risk Factors; D000067011:Severe Acute Malnutrition / Q000401:mortality* / Q000628:therapy*; D014454:Uganda
chemical_list: D010710:Phosphates; D002097:C-Reactive Protein
keywords: HIV; edema; electrolytes; hypophosphatemia; infections; kwashiorkor; malnutrition; marasmus; mortality; refeeding syndrome