Analysis of Risk and Prognostic Factors in a Population of Pediatric Patients Hospitalized for Acute Malnutrition at the Chiulo Hospital, Angola

Analysis of Risk and Prognostic Factors in a Population of Pediatric Patients Hospitalized for Acute Malnutrition at the Chiulo Hospital, Angola | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Analysis of Risk and Prognostic Factors in a Population of Pediatric Patients Hospitalized for Acute Malnutrition at the Chiulo Hospital, Angola Federica Maria Tripoli, Salvatore Accomando, Simona La Placa, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-477173/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: Malnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other. The impact that this disease has on the health of children worldwide is dramatic. Severe acute malnutrition in particular is a disease affecting nearly 20 million preschool children worldwide, most of them in Africa and South East Asia. Objectives: This work aims to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of the disease. Methods: Our study was carried out at the “Hospital da Missão Catolica do Chiulo”, in Angola, where the NGO Doctors with Africa CUAMM has been operating since 2000. In the first part of the study we analyzed the characteristics and clinical evolution of 163 patients hospitalized for acute malnutrition at the UEN (Unidade Especial de Nutrição) of the Chiulo Hospital over a period of six months, in order to identify potential prognostic factors of the disease. The second part of our study was carried out by administering a questionnaire to a group of caregivers of malnourished children and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes, with the aim of identifying potential risk factors for the development of malnutrition. Results and Conclusions: The analysis of prognostic factors revealed that the most relevant are the WHZ (weight for height z-score) at the time of admission, the presence of Stunting and the presence of other pathologies or clinical conditions associated with severe acute malnutrition. The analysis of risk factors has shown that not only food shortages, but also errors in the timing of the suspension of breastfeeding and the timing of the introduction of complementary foods play an important role. Equally important were some family risk factors, including the size of the family unit and the presence of deceased children. It also emerged that the lack of knowledge of what a child needs to grow up healthy often affects the development of malnutrition. It follows that a useful and low-cost tool for preventing child malnutrition would be large-scale nutrition education campaigns. Pediatrics severe acute malnutrition wasting risk factors prognostic factors Sub-Saharan Africa breastfeeding Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Doctors with Africa CUAMM is an NGO that has been working since 1950 to ensuring the right to health and to make access to health services available to everyone. It is active today in eight countries of sub-Saharan Africa with long-term health care projects, including Angola were this study was carried out ( 1 ). Angola is a country with a low population density, with a high fertility rate (5.6 births per woman of childbearing age) and a population growth rate of 2.7% per year ( 2 ). The infant mortality rate is unacceptably high, with 44 deaths under the first year of life for every 1000 live births and under 5 mortality is 68 for every 1000 live births. Life expectancy at birth is 60.2 years. 30% of the Angolan population and 58% of that of rural areas lives below the poverty line ( 3 ). In a context such as the one described, malnutrition among childhood pathologies, is certainly one of the most widespread and causes a high rate of morbidity and mortality. In Angola, according to the 2015–2016 IIMS, the prevalence of moderate chronic malnutrition under the age of 5 is 38% (32% of children in urban areas and 46% in rural areas), the prevalence of severe chronic malnutrition is 15%. The percentage of children under 5 who suffer from moderate acute malnutrition is 5%, the percentage of those who suffer from a severe acute form is 1%. Finally, 19% of children have a low weight for age (<-2 SD), this percentage is 25% in rural areas, 15% in urban areas ( 3 ). The province of Cunene, where this study was carried out, is the one with the highest percentage of acute malnutrition (11% of children under 5 years). It is estimated that only 33% of Angolan children between 6 and 23 months meet the WHO criteria for minimum dietary variety. The same percentage of children between 6 and 23 months receive a minimum frequency of meals. Only 13% of children of this age meet both of these. In the provinces of Luanda Norte and Cunene, only 2% meet the minimum criteria ( 3 ). Our study took place at the “Hospital da Missão Catolica do Chiulo”, founded in 1945, owned by the Catholic diocese of Ondjiva but also supported by the Angolan government and CUAMM. It is located in the municipality of Ombadja, in the province of Cunene, in the south of Angola. Its reference population is about 300,000 people organized in family groups and residing in rural areas without telephone networks, public transport, electricity and water ( 1 ). There are three main forms of malnutrition: undernutrition, hidden hunger and overweight ( 4 ). These conditions constitute different facets of a similar problem, namely that of failing to ensure adequate nutrition for a growing organism, with significant short and long-term consequences ( 5 ). Our work has focused on the study of childhood undernutrition. In the following discussion, for simplicity, the term "malnutrition" will be used to refer to the condition of undernutrition, unless otherwise specified. Malnutrition is both a consequence and one of the main causes of poverty and deprivation, in the context of a vicious circle in which the impairment of the physical and cognitive development of citizens, inevitably, has repercussions on the development of the entire country. A state of malnutrition, especially in the first thousand days, is known to have significant consequences on the development of the individual. In fact, it is a crucial period for the establishment of proper linear growth and adequate neurological development. In the context of undernutrition, we can distinguish at least three different clinical conditions: “Stunting”, term that indicates the state of chronic malnutrition, defined by a height/length for age z-score less than − 2 SD, according to the 2006 WHO growth charts. It is an expression of linear growth retardation. “Wasting”, term that indicate s the state of acute malnutrition, defined by a weight for height/length z-score less than − 2 SD, according to the WHO 2006 growth charts. This index is an expression of body mass in relation to height and describes the current nutritional status. It is further distinguished into SAM (Severe Acute Malnutrition) when the WHZ is <-3SD, and MAM (Moderate Acute Malnutrition) when the WHZ is between − 2 SD and − 3SD. “Underweight ” , a composite index that takes into account both chronic malnutrition and acute malnutrition but does not distinguish between the two and which is defined by a weight for age z-score less than − 2 SD, according to the WHO 2006 growth charts (5). So, it is essential for the diagnosis and clinical management of malnutrition, to get accurate anthropometric measurements and therefore proper tools and specifically trained personnel, this can be a challenge, especially in rural contexts ( 6 ). It is estimated that SAM affects nearly 20 million preschool children around the world, most of them are in Africa and South East Asia ( 7 ). Globally, acute malnutrition triggers more than 50% of childhood mortality in children under 5 years old, which implies that about 3.5 million children die of malnutrition each year ( 8 , 9 ). According to the WHO guidelines of 2013 (the latest published), the diagnosis of Severe Acute Malnutrition is placed in the presence of at least one of the following three criteria: 1) weight for height/lenght z-score < − 3 SD; 2) MUAC (mid-upper arm circumference) < 11,5 cm in children between 6 and 59 months; 3) presence of bilateral pitting edema The diagnosis of SAM imposes the need to include the patient in a program for clinical management and follow-up of malnutrition. First, it will be established whether the patient's condition requires hospitalization and consequent "intensive" treatment or an outpatient management may be sufficient, ideally in the health center closest to home. This decision is based on the presence of associated acute complications (diarrhea, fever, respiratory distress, extensive skin lesions, dehydration, hypothermia, severe anemia, marked asthenia, severe edema) and on passing the appetite test. ( 10 ). OBJECTIVES The objective of this study is to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of this disease, by studying a low-resource hospital setting in a country with poor health indicators. Patients And Methods Our study consists of two parts. In the first one, we analyzed a sample of 163 patients admitted to the UEN (Unidade Especial de Nutrição) of the Chiulo Hospital for acute malnutrition, over a period of six months (November 2018-May 2019). For each patient we collected data on age, sex, anthropometric data at entry (weight, length, MUAC, weight for height z-score, weight for age z-score, height for age z-score), presence or absence of edema, anthropometric data at discharge, outcome (discharged, escaped or deceased), average weight gain (g/Kg/die), length of hospitalization and presence of pathologies or associated clinical conditions. The goal of this first part was to identify possible prognostic factors in the clinical evolution of the disease. The analysis was carried out by dividing the patients into groups on the basis of some variables, considered as potential prognostic factors (age, sex, severity of malnutrition, presence of stunting, presence of associated pathologies), and comparing the different groups in relation to the following clinical outcomes: length of hospitalization, average weight gain, difference between discharge weight and target weight (weight for which WHZ is -2 DS), difference between MUAC at admission and at discharge and mortality. The averages of the parameters evaluated as outcomes, have been calculated without considering the patients who died and escaped, so that these data were not influenced by mortality. In the comparison between the different groups, the evaluation of statistical significance was carried out by applying the Student's T test. The second part of our study was carried out by administering a questionnaire to a group of malnourished children’s caregivers and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes. The questionnaire consisted of a first part with the patient's personal and anthropometric data, a section on perinatal anamnesis, with particular attention to the opportunities of access to health services, then the nutritional anamnesis, the maternal anamnesis and some data relating to socio-economic conditions of the family nucleus (Fig. 1 ). The goal of this second part of the study was to identify possible risk factors for the development of acute malnutrition. The questionnaires were administered to the caregivers with the help of Angolan nurses who acted as interpreters, translating the questions from Portuguese to the local dialect to make them understandable to mothers who did not speak Portuguese (most of them). Each questionnaire took about 20 minutes, making that moment an opportunity to perform nutritional education. Given the time required for administration, and the need for local staff available for translation, the final number of questionnaires was limited (52 mothers of malnourished children and 22 mothers of non-malnourished children interviewed) compared to the size of the sample of the first part of the study (163 malnourished). This is the main limitation of our study, which is why we considered carrying out a simple descriptive work on the questionnaires, which however provides us with a fairly representative picture of the socio-economic and family context in which the malnutrition pathology typically occurs. Results Sample characteristics The 163 patients in our sample ranged in age from 6 to 48 months, the median was 12 months, with most (63.2%) in the 6–12 months range, only three patients were over 2 years. There was no significant prevalence of one sex over the other (48.5% male, 51.5% female). By analyzing the degree of severity of acute malnutrition at admission, indicated by the value of the weight for height z-score (WHZ), it was observed that only 6.8%, showed a moderate acute malnutrition (-3 SD ≤ WHZ <-2 SD), 47.2% had a severe acute malnutrition (-4 SD ≤ WHZ <-3 SD), 46% were suffering from very severe acute malnutrition ("Malnutrição aguda muito severa- MAMS", WHZ <-4 SD). The evaluation of the height for age z-score allowed us to highlight that only 60% of patients had a stunting pattern associated with wasting, in a significant proportion therefore acute malnutrition had arisen in the absence of a previous impairment of linear growth. The diagnosis of SAM was made for the presence of at least one of the three WHO criteria, in particular only in 7 patients all three criteria were satisfied, in 112 patients the criteria met were MUAC < 11.5 cm and WHZ <-3 SD, in 20 patients only the WHZ criterion, in 11 patients only the MUAC criterion, only one patient had MUAC < 11.5 cm associated with edema, only one was diagnosed for the presence of edema only. So not always all three diagnostic criteria were satisfied. Another aspect that we wanted to study is the presence of other pathologies or clinical conditions that can sometimes accompany severe acute malnutrition. We do not clearly refer to those acute intercurrent pathologies but to pre-existing clinical conditions, congenital, chronic or long-lasting pathologies. In our sample, 21 of 163 patients (13%) had the following conditions (Fig. 2 ): Tuberculosis (10 patients), HIV (2 patients), Tuberculosis + HIV (1 patients), sickle cell disease (4 patients), encephalopathy (2 patients), congenital heart disease (1 patients), preterm birth (1 patients). Often these diseases were diagnosed during the hospitalization for SAM and their treatment, where possible, it was essential for the resolution of the SAM itself. The average length of hospitalization of the patients studied was 7.9 days. This, however, was influenced by the deceased and escaped patients whose hospitalizations were generally of shorter duration. If we exclude deaths and runaways, the average length of hospitalization for regularly discharged patients is 8.8 days. The mortality recorded in our sample was 11.7%. In fact, 19 patients died, whose average hospital stay was 3.4 days. In addition, 4 escapes were recorded, a fairly widespread phenomenon that generally concerned very serious patients, for whom the chances of survival outside the hospital were minimal. Combining the two groups (deceased and escaped) we have 14.5% of cases in which there has been a therapeutic failure. Analysis of potential prognostic factors We first divided the population into two groups based on age. The first group (103 patients), was aged between 6 and 12 months and with a similar representation of both sexes, the second group (60 patients) aged > 12 months and higher prevalence of females (55% F, 45% M). Minimal differences emerged between the two groups regarding the outcomes considered. The variable “age” was not related to a statistically significant difference in the severity of malnutrition at admission or to a different prognosis in terms of length of hospitalization, weight gain and mortality. We then divided the population into two groups based on the variable “sex”, we saw that males and females showed slight differences in terms of average age (slightly lower in males, 13.5 months vs 14.6) and severity of malnutrition at admission (average WHZ − 4.3 SD in males, -3.7 SD in females). Even in this case, however, the variable considered (sex) was not significantly associated with a difference in terms of outcomes. Minimal differences emerged, in average weight gain, in the difference between target weight and weight at discharge and in the difference between MUAC at admission and at discharge, but were not statistically significant in the Student's T test. Mortality was also similar in the two groups (11.4% M, 11.9% F). Another variable analyzed, as a potential prognostic factor, is the severity of acute malnutrition at the time of admission, represented by the WHZ. We have divided the population into three severity groups: patients with moderate acute malnutrition or MAM (-3 SD ≤ WHZ <-2 SD); patients with severe acute malnutrition or SAM (-4 SD ≤ WHZ <-3 SD); patients with very severe acute malnutrition or MAMS (WHZ <- 4 SD). (Table 1 ) Table 1 Anlalysis of the variable “Severity of acute malnutrition at the time of admission” Severity of acute malnutrition Average age Associated pathologies Lenght of hospitalization* Average weight gain* Difference target weight/ discharge weight* Difference MUAC at admission/ MUAC at discharge* Mortality Moderate (MAM) 11 patients 12.8 months 27% 6.2 days 12.3 g/Kg/die -30 g 0.3 cm 18% Severe (SAM) 77 patients 14.3 months 8% 8.2 days 14.7 g/Kg/die 180 g 0.4 cm 5.2% Very severe (MAMS) 75 patients 14.3 months 16% 10.3 days 16.3 g/Kg/die 640 g 0.7 cm 17% *Deaths and escapes were excluded from the average As shown in Table 1 , there are some significant differences between these three groups of patients. Specifically, with regard to the presence of pathologies/clinical conditions associated with malnutrition, a significant difference emerges between patients with SAM and those with MAMS. Among the most serious patients, 16% had associated diseases compared to 8% of the less severe patients. Furthermore, observing the analyzed outcomes, as the severity of the pathology at entry increases, the average length of stay increases (Fig. 3 ), but also increases the average weight gain, as well as the difference between the MUAC at admission and at discharge. The comparison between the average length of hospitalization of the three groups of patients, also in this case, was made using the Student's T test. The comparison between the MAMS group and the MAM group allowed us to demonstrate the existence of strong evidence against the hypothesis 0 that the averages are equal (p value 0.01). So, the difference between the average length of hospitalization of the MAMS group and the MAM group is statistically significant. However, this difference was not as significant in the comparison between the SAM group and the MAMS group (p-value 0.53), nor between the SAM group and the MAM group (p-value 0.18). The average weight gain of most patients is concentrated in the range between 0 and 20 g/kg/day, but the cases of greater average weight gain (> 20 g / kg / day) mainly concerned those patients starting from a lower WHZ. The application of Student's T test in this case, however, revealed that the differences in average weight gain are not statistically significant. Probably a greater number of the sample could have confirmed the significance of this difference, especially in the comparison between the MAMS group and the MAM group, which is the one that reported the lowest p value (0.18). Mortality was significantly higher in patients with MAMS (17%) than in patients with SAM (5.2%). This is probably the data that more clearly confirms that the lower is the WHZ, the worse is the prognosis. Mortality in the MAM group is also high (18%) but this assumes little significance in relation to the low number of the sample and the high percentage, in this group, of patients with associated diseases. We also analyzed whether and how the coexistence of a state of chronic malnutrition (stunting) can influence the prognosis of patients suffering from acute malnutrition (Table 2 ). Patients with stunting appear to be on average older (Fig. 4 ) and appear to have a slightly higher severity of acute malnutrition upon admission (WHZ − 4.2 versus − 3.9 SD). The percentage of patients suffering from pathologies associated is significantly higher in the group of patients suffering from stunting (17% versus 6%). No significant differences in the duration of hospitalization emerged between patients with stunting and patients without stunting. The analysis of the outcomes related to growth showed that patients with stunting grow on average more during hospitalization (average weight gain 15.9 vs 13.5 g/kg/ day), but the Student's T test did not give us a value of statistical significance (p-value 0.26). The presence of associated pathologies and mortality were instead significantly higher in the stunting group than in patients without stunting. Table 2 Analysis of the variable “presence of stunting” Lenght for age Average age Average WHZ at admission Associated pathologies Lenght of hospitalization* Average weight gain* Difference target weight/ discharge weight Difference MUAC at admission/ MUAC at discharge* Mortality < -2 SD (Presence of stunting) 98 patients 14.2 months -4.2 SD 17% 8.9 days 15.9 g/Kg/die 260 g 0.6 cm 13.3% ≥-2 SD (Absence of stunting) 65 patients 12.5 months -3.9 SD 6% 8.4 days 13.5 g/Kg/die 460 g 0.4 cm 9.2% *Deaths and escapes were excluded from the average By subdividing the population based on the presence or absence of associated pathologies, substantial differences emerged both in terms of individual characteristics and in prognostic terms (Table 3 ). The average age is 16.7 months for patients with associated pathologies and 12.9 for patients without other pathologies (19.7 and 13.1 respectively if we also consider deceased patients). The application of the Student’s T test allowed us to demonstrate that this difference is statistically significant (p-value 0.007). Table 3 Analysis of the variable “presence of associated pathologies” Average age* Average WHZ at admission Presence of stunting Lenght of hospitalization* Average weight gain* Difference target weight/ discharge weight* Difference MUAC at admission/ MUAC at discharge* Mortality Presence of associated pathologies 21 patients 16.7 months − 4.7 SD 80.9% 14.89 days 7.94 g/Kg/die 490 g 0.6 cm 0 Absence of associated patgologies 142 patients 12.9 months -3.9 SD 55.6% 7.74 days 16.29 g/Kg/die 320 g 0.4 cm 13.4% *Deaths and escapes were excluded from the average Regarding the severity of SAM on admission, patients with associated diseases had a lower average WHZ (-4.7 vs -3.9 SD). The length of hospitalization was on average longer in those with another pathology (14.89 days vs 7.74 days) and the average weight gain was lower in the same group (7.94 vs 16.29 g/kg /die). Also in these cases it has been shown that the difference between the averages is statistically significant, being the p-value 0.007 in the case of the average weight gain, even lower in the case of the duration of hospitalization (< 0.0001). No deaths were recorded in the group of patients with associated diseases. Analysis of potential risk factors We first evaluated the characteristics of the sample of 52 malnourished whose mothers were interviewed, to verify that it was representative of the entire malnourished population. The average age of this group was 12 months, 46.2% were male, 53.8% female. Regarding the severity of SAM at admission, the mean WHZ in the interviewed sample was − 3.9 and the mean MUAC was 10.6. For all these aspects, the sample studied could be considered quite representative of the UEN patient population. The only data that differs is that of mortality, which is lower in the sample of the 52 patients interviewed (5.8%). The average age of the sample of 23 non-malnourished children, whose mothers were interviewed, was 14.6 months, the median of 12 months. 52% were male children, 48% female. Only one of these children died. In perinatal anamnesis, the first aspect that we have analyzed is access to health services, potential opportunities for health and nutrition education. We investigated the place of birth (home or hospital), the execution of antenatal visits and vaccinations. In the malnourished group, most patients were born in hospital or health center, had vaccinations and most mothers had visits during pregnancy. There are no major differences in terms of access to services compared to the group of non-malnourished patients admitted to Pediatrics (Table 4 ). Table 4 Access to health services Groups Place of birth Antenatal visits Vaccinations Home Hospital/ Health center Done Not done Done Not done N. % N. % N. % N. % N. % N. % Patients admitted to UEN 22 42 30 58 45 86.5 7 13.5 48 92 4 8 Patients admitted to pediatrics 11 48 12 52 23 100 0 0 22 96 1 4 Another risk factor analyzed is birth weight, which however cannot always be known precisely. In fact, there is no habit of memorizing the birth weight of children and almost always there is no health document to certify it. As the exact birth weight was often not known, mothers were asked if their baby at birth was very small or normal/large. Although we are aware of the considerable approximation of this data, differences between the two groups emerged in this regard. Among the mothers of malnourished patients, 54% reported that their child was born large or normal, 42% that it was born very small, 4% did not know. Among the mothers of the non-malnourished, 91% reported that their child was born large or normal, 9% that they were born small. Being born small could indicate prematurity or low weight for gestational age and could be a sign of maternal malnutrition ( 11 ). The next part of the questionnaire was based on the patient's eating habits with particular regard to breastfeeding and introduction of complementary foods (Table 5 ). Table 5 Patient’s eating habits Group Age of introduction of water Age of suspension of breastfeeding Interval between suspension of breastfeeding and hospitalization Age of introduction of complementary foods 6 months Not suspended yet 12 months 6 months Not introduced yet 6 months Patients admitted to UEN (malnourished) 65% 35% 35% 4% 27% 33% 42% 11.5% 10% 2% 25% 23% 50% Patients admitted to pediatrics (not malnourished) 70% 30% 70% 0 13% 17% 4% 4% 22% - 13% 39% 48% In the malnourished group in 2 cases (4%) breastfeeding was interrupted before 6 months of life (in one case because the mother was seriously ill, in the other because the mother had died), 1 patient had never been breastfed as he was orphan, in 14 cases (27%) breastfeeding was suspended between 6 and 12 months, in 17 cases (33%) suspended after 12 months, 18 mothers (35%) replied that breastfeeding was still continuing at the time of admission (the mean age of the patients still breastfed was 9.5 months). In the group of malnourished patients, 65% were no longer breastfed at the time of admission and the average age of these patients was 15.2 months. Among the non-malnourished in no case breastfeeding was interrupted before 6 months, in 3 cases (13%) had been suspended between 6 and 12 months, in 4 (17%) suspended after 12 months. Sixteen mothers (70%) answered that breastfeeding was still continuing at the time of admission and the average age of this group of patients was 10.8 months. The mean age of patients who were no longer breastfed was 24 months. One element that we wanted to investigate is the interval between the suspension of breastfeeding and hospitalization for SAM to highlight a potential role of the suspension of breastfeeding as a trigger for acute malnutrition. Among patients admitted to UEN, 42% had stopped breastfeeding less than three months before admission, in these children it is likely that this dietary change was the trigger for SAM. 11.5% had stopped breastfeeding from 3 to 6 months earlier and 10% more than three months earlier. Of the patients admitted to pediatrics (not malnourished), only 4% had stopped breastfeeding less than three months earlier. Another aspect studied is the age of introduction of the water. In the context in which our study was carried out, the administration of water under the age of six months was an extremely widespread practice (65% in malnourished and 79% in non-malnourished). In such contexts, the recommendation not to give water to small infants should be even stronger, considering that water is often unsafe and can seriously endanger the survival of these children. With regard to the introduction of complementary foods, important critical issues emerge especially in the malnourished group. In this group, as much as 25% had started weaning before 3 months of life, this percentage was 13% among non-malnourished patients. The WHO in 2008 published the document "Indicators for assessing infant and young child feeding practices" in which it describes indicators for the evaluation of infant and child nutrition, among these it introduces the concept of minimum acceptable diet - MAD), an index composed of the “minimum dietary diversity” and the “minimum meal frequency” for children aged between 6 and 23 months ( 12 ). The criterion of minimum dietary diversity (intake of foods belonging to at least 4 different groups) in the group of malnourished patients was met in only 33% of cases, on average the patients in this group ate foods belonging to 2.8 different groups. If we consider the availability of food for the family unit, however, it emerges that 79% of the mothers interviewed report having food available at home belonging to at least four different groups. In the group of non-malnourished patients, 65% meet the criterion of minimum dietary diversity, with an average of 3.7 different food groups. Even in this case, however, there is a difference with the percentage of families who have food from at least 4 different groups (83%). Mothers were also interviewed about the type of food their children eat. The foods of the category cereals, roots and tubers are the most widely consumed. Only a few children unfortunately consume foods rich in proteins such as legumes, dairy products, meats and eggs (Table 6 ). Table 6 Percentages of patients who eat the foods of the different categories, in the UEN group and in the Pediatrics group Food category Patients admitted to UEN Patients admitted to Pediatrics Cereals, roots and tubers 96% 91% Legumes and nuts 31% 52% Dairy products 42% 52% Flesh foods 42% 52% Eggs 27% 57% Fruits and vegetables 35% 61% The other parameter that constitutes the "minimum acceptable diet" is the "minimum frequency of meals", which is different in breastfed than in non-breastfed children and in relation to age. For breastfed babies the minimum number of solid/semi-solid meals should be 2 per day between 6 and 8 months, 3 per day between 9 and 23 months. For non-breastfed infants, the minimum frequency of meals (solid/semi-solid and in this group also milk-based meals) is 4 between 6 and 23 months. This criterion was met among the malnourished in only 4 patients out of 52 (7.7%) and all these 4 children were breastfed. In the group of non-malnourished patients, 4 out of 23 met this criterion (17.4%), also in this case they were all children still breastfed. Patients who meet both WHO criteria (minimum frequency of meals and minimum dietary diversity) are 2 out of 52 among the malnourished (3.8%) and 3 out of 23 among the non-malnourished (13%). To conclude our analysis on risk factors for malnutrition, we analyzed family risk factors, with particular regard to maternal ones. First was asked if the child's caregiver was the mother or another figure (usually another female family member such as an aunt, grandmother or older sister). In the malnourished group, 83% of children lived with their mother, 17% with another family member, often because they were orphans. Among the non-malnourished, 95.5% lived with their mother, 4.5% did not. Among the potential maternal risk factors, we considered age, education, BMI and the presence of HIV and Tuberculosis. In the malnourished group, 13.5% of mothers were under the age of 20, 50% were between 20 and 30, 17.3% between 30 and 40 and 19.2% had more than 40 years. The group of mothers of non-malnourished patients did not show great differences in terms of age (13% 40, 4% age not known). Another factor considered is the maternal education, also in this case the two samples were comparable in both cases being constituted by approximately 50% of mothers who had attended the school and 50% of mothers who had never attended the school. Regarding the BMI, among the mothers of malnourished patients, for 4 we were unable to obtain this data because they were not present in hospital, one was underweight (BMI < 18.5), one overweight (BMI between 25 and 30), all the others were normal weight (BMI between 18.5 and 25). Even in the group of mothers of the non-malnourished we were unable to obtain the BMI for one mother, only one was underweight, all the others normal weight. With regard to the presence of associated pathologies and specifically HIV and Tuberculosis, in the malnourished group one of the mothers was infected with HIV and had died, another was suffering from tuberculosis. None of the mothers in the non-malnourished group presented these pathologies. To analyze the characteristics of the family unit, we asked the mothers how many children they had and if all were still alive or, if not, how many of them had died. On this aspect, important differences emerged between the two groups. On average, the mothers of the malnourished had 4.2 live children compared to 2.7 for the mothers of the non-malnourished. Malnourished children therefore seem to belong on average to larger families. However, the even more striking figure concerns the deceased children. Out of 52 mothers of malnourished patients interviewed 23 (44%) had had at least one deceased child (among these the average was two deceased children each). In the other group, however, 3 mothers out of 23 (13%) had lost at least one child. Finally, we tried to analyze some characteristics that could be indicative of the socio-economic level of the family unit. We considered the type of house and the type of kitchen in which the meals were prepared. We asked the mothers if they lived in a hut (71% of the malnourished vs 43% of the non-malnourished), in a house made of sheet metal (17% of the malnourished vs 43% of the non-malnourished) or in a house made of cement (12% of malnourished vs 9% of non-malnourished). With regard to the type of cuisine used, 90.4% of the mothers of the malnourished and 91.3% of those of the non-malnourished cooked with wood, 9.6% of the former and 8.7% of the latter with a gas kitchen. Discussion From the analysis of the characteristics of our sample, it emerged that hospitalizations for acute malnutrition at the Chiulo Hospital, in accordance with the literature data, mainly concern children aged between 6 and 24 months. This is the age group most susceptible to this disease, a period that corresponds with the introduction of complementary foods and unfortunately, very often with an early suspension of breastfeeding ( 13 ). Before six months, breastfeeding plays an important protective role, none of our patients were less than 6 months old. Regarding the diagnostic criteria for SAM, our data confirmed the importance of assessing all the parameters to prevent some cases might escape diagnosis. In fact, not always all three diagnostic criteria were met ( 14 , 15 ). In our sample, 21 patients would have escaped the diagnosis with the sole use of MUAC (a widespread practice especially in peripheral centers). The mortality of our sample was quite high, but similar to that reported in the literature ( 16 ). Most of the deceased were patients who already arrived in extremely serious conditions, and whose death often occurred a few days after hospitalization, as demonstrated by an average length of hospitalization significantly shorter than the rest of the sample. This data is consistent with those reported in similar studies carried out in other countries ( 17 ). The analysis of prognostic factors has shown that the variables “age” and “sex” do not seem to be associated with significant changes in the clinical outcome. Differences in terms of outcome were instead observed among patients with different degrees of severity at the time of hospitalization. In fact, the most serious patients, in terms of WHZ at admission, remain hospitalized longer but seem to grow more both in terms of weight and MUAC (even if the small number of the sample does not allow us to confirm the latter data). Mortality was significantly higher in the group of patients with lower WHZ. Furthermore, among the most serious patients the percentage of those with associated diseases was higher. This leads us to reflect on the importance of always suspecting an associated disease, especially in those with a WHZ <- 4 DS. Another variable considered as a possible prognostic factor is the presence of stunting. It should be emphasized that the height for age z-score, in rural contexts such as Chiulo, has an important limit. Most children are not registered at birth and do not present any documents ( 18 ). Furthermore, the date of birth is not given the importance that we are accustomed to attribute to it, so the mothers often did not remember the date of birth of their children. It follows that the reported age did not always correspond to the real one. Any evaluation on the height for age parameter must take this aspect into account. However, we considered it appropriate to make an assessment of chronic malnutrition, while not ignoring these limits. Regarding the variable “presence of stunting”, we observed that the average age is higher in the stunting group as well as the length of hospitalization; in both cases, the difference is not statistically significant. However, a fact that seems appropriate to emphasize is that the very few cases of long-term hospitalizations (over 30 days) are all concentrated in the stunting group. These are patients suffering from diseases associated with SAM, mainly tuberculosis, which justify the longer length of hospitalization and which typically, also compromise linear growth. Even the average weight gain was greater in patients with stunting but the difference is not statistically significant. We believe that the small number of the sample affects the significance of this data. The presence of associated pathologies and mortality were instead significantly higher in the stunting group. The variable that gave the most significant results is the presence of associated pathologies. Patients with associated pathologies were on average older. Three of these 21 patients were even older than 24 months, and were therefore outside the typical age range for developing SAM. This confirms that in an older patient with SAM it is always important to look for an associated pathology. The “primitive” SAM is typically a pathology of the younger child. In addition, patients with associated pathologies had a WHZ lower at the admission, they more often presented stunting, and this is easily to understood by knowing the impact that chronic diseases have on linear growth ( 19 ). They remained hospitalized longer and had lower average weight gain than patients without associated pathologies. All these differences were statistically significant. A data in contrast with these is that of mortality, no deaths were recorded in the group of patients with associated pathologies. However, it should be considered that the deaths all occurred in the first two-three days and we cannot exclude that among the deceased there were patients with associated diseases that we did not have time to diagnose. The second part of our study focused on identifying potential risk factors for acute malnutrition. Due to the time required for the administration of the questionnaire and the need for local staff to act as interpreters, the final number of questionnaires was quite limited. The very small number of mothers of non-malnourished patients interviewed is sadly linked to the very high prevalence of malnutrition in this geographical area. Often in fact, even patients hospitalized in Pediatrics for other pathologies, presented some degree of malnutrition that did not allow us to include them in the control group. However, despite the limitations linked to the low number of samples, we believe that our data shows a fairly representative picture of the context in which malnutrition occurs. We first evaluated if the sample of malnourished was representative of the entire population of patients admitted to UEN. The two samples were comparable for age, male/female ratio, WHZ and MUAC. Mortality is very different (lower in the group of patients to whom the questionnaire was administered). This is influenced by the fact that we have rarely had time to administer the questionnaire to the mothers of the deceased children. The short time of hospitalization, together with the extremely serious conditions of these patients, did not allow creating the conditions for the administration of the questionnaire. The first aspect we analyzed is access to health services, potential opportunities for health education. In theory, those who have had more opportunities to access services should be more sensitive to certain issues such as malnutrition than those who have never or almost never had recourse to a health facility (quite frequent occurrence in such contexts). Any access to services should be an opportunity to carry out health education with particular reference to nutritional education. Our data did not reveal any significant differences between the two groups, in both there had been occasions of access to services. It therefore emerges that access to health services is likely to be opportunities that are not exploited enough. It would be advisable to carry out awareness campaigns and training of health personnel on this aspect; it is an intervention almost at no cost that could have important implications. At the Chiulo Hospital, patients in the waiting room are entertained with the so-called "gyms", that is short and simple lessons by the staff on certain pathologies and their prevention strategies. This habit should be extended to the other wards and health centers. The analysis of eating habits revealed interesting data, especially on breastfeeding and weaning habits. Breastfeeding is known to be protective against numerous pathologies, for its ideal nutritional characteristics but also for the countless other properties, first of all the immunomodulating ones ( 20 , 21 ). In developing countries, its role becomes even more important as it can really make the difference between the survival and death of children ( 5 , 9 ). It is the only food that is safe in microbiological terms in the first months of life (scarce availability of safe water sources). In many contexts, it is the only one that can guarantee the nutrients necessary for a growing organism, in consideration of the very limited availability of other foods. It is for these reasons that, despite the small number of our samples, substantial differences emerge between the malnourished group and the non-malnourished group regarding breastfeeding. Almost none of both the malnourished and non-malnourished had suspended breastfeeding before six months, but a significant proportion of the malnourished had suspended it between 6 and 12 months. It is also significant that at the time of admission only 35% of the malnourished were still breastfed compared to 70% of the non-malnourished, despite an average age comparable in the two groups, confirming the protective role of breast milk against the development of SAM. The biggest difference concerns the proportion of patients who still continued breastfeeding after the start of weaning. On the other hand, there was a fairly low prevalence of exclusive breastfeeding in the first six months in both groups. In this regard, the analysis of habits related to the weaning revealed critical issues in both groups. Among the malnourished, even 25% had started taking complementary foods before 3 months of life; this percentage was 13% among non-malnourished patients. The extremely early introduction of complementary foods is confirmed to be an important risk factor for the development of malnutrition, as already highlighted by other studies ( 22 ). When other foods are introduced, the intake of breast milk and therefore its production is inevitably reduced. In addition, the risks of administering semi-solid foods to an individual not yet mature enough to take them, together with the poor quality of the foods administered, contribute to the extreme inadequacy of nutrition that these children practice. Therefore, despite the high prevalence of breastfeeding (almost 100% of children have practiced it), are absolutely unsatisfactory the percentages of those who only take breast milk in the first six months of life, introduce complementary foods at the correct times and continue breastfeeding up to 24 months ( 3 ). With regard to the type of food consumed, there was little dietary variability in both groups. An interesting fact is the discrepancy between the availability of food at home and its intake by children. This makes us understand that, often at the basis of inadequate nutrition, there is not only limited food availability but also frequently cultural factors and lack of knowledge of children's needs play a central role ( 23 ). It is clear once again how important it is to carry out nutrition education campaigns to educate families on how to make the most of available resources ( 24 ). The foods in the category of cereals, roots and tubers are the most widely consumed, many families grow various types of cereals to produce flours that they use in the preparation of “funge” (a staple food typical of Angola). There are many children, especially in rural areas, whose diet consists almost exclusively of foods of this group with consequent very serious nutritional deficiencies. They are low-cost, locally produced foods that easily give a sense of satiety, thus allowing, with a minimum expense, to feed very large families. Foods rich in proteins (legumes, dairy products, meats, eggs) are consumed only by small percentages of children, especially among the malnourished. False beliefs also play their role, such as the belief that eggs cannot be taken by children or that legumes cause diarrhea. Furthermore, there is no habit of transforming foods such as meat and fish to prepare baby food that can also be taken by little children. The percentages of those who meet the minimum meal frequency criterion are also very low. In particular, none of the children not breastfed in both groups meets the minimum meal frequency criterion. It once again emerges that breastfeeding is a fundamental resource for guaranteeing children of this age group a diet that is minimally acceptable, even in the presence of extremely limited economic resources. The analysis of family risk factors revealed a greater risk of malnutrition in those who do not live with their mother. This may partly be due to the fact that they are often orphans, who have never been breastfed or have been for a short time. Among the family risk factors, age, educational level and BMI of the mother, according to our data, do not seem to be significantly associated with childhood malnutrition, although the small number of samples does not allow us to exclude a correlation, which has instead been demonstrated in other studies ( 7 , 25 ). The differences in the characteristics of the family unit were significant. On average, the families of the malnourished were more numerous and the percentage of families in which at least one child had died was higher in this group, although even among the non-malnourished this percentage was high. In both cases, these are dramatic numbers, especially when compared with our realities in which, the loss of a child is an exceptional event. However, once the emotional impact of such data has been overcome, it is evident that the presence of deceased children always represents an important alarm bell that should never be underestimated and that must make us consider that patient at high risk. Regarding the two indices of socio-economic level considered, type of house and type of kitchen, the first was different in the two groups (with the vast majority of malnourished people living in a hut), the second was instead comparable in the two groups. We believe that more numerous samples would probably have confirmed a correlation between the risk of malnutrition and the socio-economic level, as already demonstrated in other studies. Conclusions This work, despite the limitations relating to the short period in which the data collection could be carried out and consequently to the small size of the population studied, wanted to provide a picture of the main issues still open in the field of acute malnutrition. In some rural contexts, such as the one examined, the malnutrition rate is so high that the vast majority of children, especially under two years of age, have some degree of malnutrition. So, in the eyes of their parents, those children seem “normal” when compared to others of the same age ( 19 ). The perception of the malnutrition problem often by caregivers is absolutely non-existent, until one acute event occurs that precipitate the delicate balance that had been created, leading to a full-blown picture of severe acute malnutrition. Based on the collected data, some interesting elements emerged regarding the risk factors for the development of the disease, the diagnosis of acute malnutrition, but also regarding potential prognostic factors. Our data have confirmed the importance, in the face of a child with suspected malnutrition, to carry out a global clinical evaluation using all the anthropometric measures available to prevent many cases from escaping diagnosis and treatment. In this regard, staff training programs would be essential for identifying and managing cases of malnutrition, especially in more peripheral contexts ( 26 ). Among the prognostic factors, the most relevant were the WHZ at the time of admission, the presence of stunting and the presence of chronic diseases/clinical conditions associated with SAM. A lower weight for height z-score (WHZ) correlate with longer length of hospitalization, higher mortality, and, in those who survived, a trend towards greater average weight gain. Patients with Stunting were older on average, had associated diseases more often, and had slightly higher mortality. Patients with other associated pathologies/conditions had a higher average age than the others, a longer average length of hospitalization and a lower average weight gain. SAM associated with other pathologies has very different characteristics compared to "primitive" SAM, often the underlying pathology is the main etiological factor of acute malnutrition. While such patients tend to have a more severe disease course, on the other hand if the disease in question is promptly identified and treated (where this is possible as in the case of tuberculosis), the chances of recovery from SAM are much higher. With regard to risk factors, the importance of breastfeeding as a protective factor against malnutrition has emerged in a striking way. Despite the high prevalence of breastfeeding, the percentages of exclusive breastfeeding in the first six months, and the introduction of complementary foods at the correct times with continued breastfeeding (until 24 months), are absolutely unsatisfactory, in accordance with the literature data ( 3 , 5 , 8 ). Even the practice of weaning is often burdened by significant problems and often this is not due solely and simply to the food shortages. Too often, it is in fact the lack of knowledge of what a child needs, which has the greatest impact on the development of malnutrition ( 23 ). Nutritional education campaigns are necessary, they should be based on a deep knowledge of the socio-economic and cultural context in which the patients live, of the available resources and they should be carried out on the territory. Even when these efforts are carried out flawlessly, there are, however, a considerable number of cases in which the basic problem remains the dramatic unavailability of nutrients and the impossibility of obtaining them. So, the best impact is likely to be achieved for those interventions in which the provision of complementary foods is combined with nutrition education ( 13 ). Malnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other. Unfortunately, it is a pathology that is little known in developed countries but which, due to the dramatic impact it has on children's health worldwide, deserves to be known at all latitudes. In today's world, in fact, having a projected look on global health is now necessary for those involved in health care. Opening up to health problems that have historically been considered of exclusive interest to "distant" countries, is a precious opportunity not only for those who want to spend themselves in the field of international cooperation, but also for those involved in child health in our country, always more multi-ethnic and globalized. Abbreviations BMI: Body Mass Index CUAMM: Collegio Universitario Aspiranti Medici Missionari HIV: Human Immunodeficiency Virus IIMS: Inquérito de Indicadores Múltiplos e de Saúde MAM: Moderate Acute Malnutrition MAMS: “Malnutrição aguda muito severa” (Very severe acute malnutrition) MUAC: Mid-upper arm circumference NGO: Non Governmental Organization RUTF: Ready to Use Therapeutic Foods SAM: Severe Acute Malnutrition UEN: “Unidade Especial de Nutrição” (Special Nutrition Unit) WHO: World Health Organization WHZ: Weight for height z-score Declarations Ethics approval and consent to participate: The study was approved by the Mother and Child Department of the University of Palermo (Palermo, Italy). All procedures performed in this report were in accordance with the ethical standards of the institutional and national research committee, and with the 1964 Helsinki declaration and its later amendments, or comparable ethical standards. Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no external funding. Authors' contributions: FMT, SA, SLP and MG: design of the study; FMT and AP: administration of questionnaires to caregivers and data collection; FMT and SA data analysis; GP, GC and MG: supervision; FMT: writing - original draft preparation; SA, GC and MG: writing - review and editing. All Authors approved the final manuscript as submitted. Acknowledgements: We are very grateful to all the nurses of Chiulo Hospital for having acted as interpreters in administering the questionnaires to caregivers and for the deep devotion in every day care for Angolan children. We are grateful to Dr. Giuseppe Carollo for his support in statistical analysis. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Major revision 27 Jun, 2021 Review # 1 received at journal 19 Jun, 2021 Reviews received at journal 09 Jun, 2021 Reviewer # 1 agreed at journal 08 Jun, 2021 Reviewers invited by journal 07 Jun, 2021 Submission checks completed at journal 28 Apr, 2021 Editor invited by journal 28 Apr, 2021 Editor assigned by journal 27 Apr, 2021 First submitted to journal 26 Apr, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-477173","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":24345100,"identity":"535b223e-ad57-40bc-964b-3f3660821b28","order_by":0,"name":"Federica Maria Tripoli","email":"","orcid":"","institution":"Università degli Studi di Palermo","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Federica","middleName":"Maria","lastName":"Tripoli","suffix":""},{"id":24345101,"identity":"6f7938dd-3c3d-4b65-bf0d-06181d67691a","order_by":1,"name":"Salvatore Accomando","email":"","orcid":"","institution":"Università degli Studi di 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SAM","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-477173/v1/2118e34b4f792ede3442fd66.jpg"},{"id":8833532,"identity":"59e9e73a-5096-4286-885d-5d0bdbe70dcc","added_by":"auto","created_at":"2021-05-05 22:24:24","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":70954,"visible":true,"origin":"","legend":"Length of hospitalization in relation to the WHZ value at admission","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-477173/v1/bfa2f19a98f69dad5615c6df.jpg"},{"id":8833627,"identity":"409906d1-09ca-465b-8412-da05d27752cf","added_by":"auto","created_at":"2021-05-05 22:27:24","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":66247,"visible":true,"origin":"","legend":"Age of the patients in relation to height for age z-score","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-477173/v1/c4e2c1001405d00423689b19.jpg"},{"id":13691535,"identity":"c8b92135-09dd-4d8e-bf5a-5c6e7ea9fa05","added_by":"auto","created_at":"2021-09-17 12:39:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":859622,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-477173/v1/48479574-2264-4974-bf81-637855a9f136.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eAnalysis of Risk and Prognostic Factors in a Population of Pediatric Patients Hospitalized for Acute Malnutrition at the Chiulo Hospital, Angola\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDoctors with Africa CUAMM is an NGO that has been working since 1950 to ensuring the right to health and to make access to health services available to everyone. It is active today in eight countries of sub-Saharan Africa with long-term health care projects, including Angola were this study was carried out (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAngola is a country with a low population density, with a high fertility rate (5.6 births per woman of childbearing age) and a population growth rate of 2.7% per year (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e). The infant mortality rate is unacceptably high, with 44 deaths under the first year of life for every 1000 live births and under 5 mortality is 68 for every 1000 live births. Life expectancy at birth is 60.2 years. 30% of the Angolan population and 58% of that of rural areas lives below the poverty line (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e). In a context such as the one described, malnutrition among childhood pathologies, is certainly one of the most widespread and causes a high rate of morbidity and mortality. In Angola, according to the 2015\u0026ndash;2016 IIMS, the prevalence of moderate chronic malnutrition under the age of 5 is 38% (32% of children in urban areas and 46% in rural areas), the prevalence of severe chronic malnutrition is 15%. The percentage of children under 5 who suffer from moderate acute malnutrition is 5%, the percentage of those who suffer from a severe acute form is 1%. Finally, 19% of children have a low weight for age (\u0026lt;-2 SD), this percentage is 25% in rural areas, 15% in urban areas (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe province of Cunene, where this study was carried out, is the one with the highest percentage of acute malnutrition (11% of children under 5 years). It is estimated that only 33% of Angolan children between 6 and 23 months meet the WHO criteria for minimum dietary variety. The same percentage of children between 6 and 23 months receive a minimum frequency of meals. Only 13% of children of this age meet both of these. In the provinces of Luanda Norte and Cunene, only 2% meet the minimum criteria (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOur study took place at the \u0026ldquo;Hospital da Miss\u0026atilde;o Catolica do Chiulo\u0026rdquo;, founded in 1945, owned by the Catholic diocese of Ondjiva but also supported by the Angolan government and CUAMM. It is located in the municipality of Ombadja, in the province of Cunene, in the south of Angola. Its reference population is about 300,000 people organized in family groups and residing in rural areas without telephone networks, public transport, electricity and water (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThere are three main forms of malnutrition: undernutrition, hidden hunger and overweight (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e). These conditions constitute different facets of a similar problem, namely that of failing to ensure adequate nutrition for a growing organism, with significant short and long-term consequences (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eOur work has focused on the study of childhood undernutrition. In the following discussion, for simplicity, the term \"malnutrition\" will be used to refer to the condition of undernutrition, unless otherwise specified.\u003c/p\u003e\n\u003cp\u003eMalnutrition is both a consequence and one of the main causes of poverty and deprivation, in the context of a vicious circle in which the impairment of the physical and cognitive development of citizens, inevitably, has repercussions on the development of the entire country. A state of malnutrition, especially in the first thousand days, is known to have significant consequences on the development of the individual. In fact, it is a crucial period for the establishment of proper linear growth and adequate neurological development.\u003c/p\u003e\n\u003cp\u003eIn the context of undernutrition, we can distinguish at least three different clinical conditions:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u0026ldquo;Stunting\u0026rdquo;, term that indicates the state of chronic malnutrition, defined by a height/length for age z-score less than \u0026minus;\u0026thinsp;2 SD, according to the 2006 WHO growth charts. It is an expression of linear growth retardation.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u0026ldquo;Wasting\u0026rdquo;, term that indicate s the state of acute malnutrition, defined by a weight for height/length z-score less than \u0026minus;\u0026thinsp;2 SD, according to the WHO 2006 growth charts. This index is an expression of body mass in relation to height and describes the current nutritional status. It is further distinguished into SAM (Severe Acute Malnutrition) when the WHZ is \u0026lt;-3SD, and MAM (Moderate Acute Malnutrition) when the WHZ is between \u0026minus;\u0026thinsp;2 SD and \u0026minus;\u0026thinsp;3SD.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u0026ldquo;Underweight\u003cstrong\u003e\u0026rdquo;\u003c/strong\u003e, a composite index that takes into account both chronic malnutrition and acute malnutrition but does not distinguish between the two and which is defined by a weight for age z-score less than \u0026minus;\u0026thinsp;2 SD, according to the WHO 2006 growth charts (5).\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSo, it is essential for the diagnosis and clinical management of malnutrition, to get accurate anthropometric measurements and therefore proper tools and specifically trained personnel, this can be a challenge, especially in rural contexts (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). It is estimated that SAM affects nearly 20\u0026nbsp;million preschool children around the world, most of them are in Africa and South East Asia (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e). Globally, acute malnutrition triggers more than 50% of childhood mortality in children under 5 years old, which implies that about 3.5\u0026nbsp;million children die of malnutrition each year (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAccording to the WHO guidelines of 2013 (the latest published), the diagnosis of Severe Acute Malnutrition is placed in the presence of at least one of the following three criteria: 1) weight for height/lenght z-score\u0026thinsp;\u0026lt;\u0026thinsp;\u0026minus;\u0026thinsp;3 SD; 2) MUAC (mid-upper arm circumference)\u0026thinsp;\u0026lt;\u0026thinsp;11,5 cm in children between 6 and 59 months; 3) presence of bilateral pitting edema\u003c/p\u003e\n\u003cp\u003eThe diagnosis of SAM imposes the need to include the patient in a program for clinical management and follow-up of malnutrition. First, it will be established whether the patient's condition requires hospitalization and consequent \"intensive\" treatment or an outpatient management may be sufficient, ideally in the health center closest to home. This decision is based on the presence of associated acute complications (diarrhea, fever, respiratory distress, extensive skin lesions, dehydration, hypothermia, severe anemia, marked asthenia, severe edema) and on passing the appetite test. (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003ch2\u003eOBJECTIVES\u003c/h2\u003e\n\u003cp\u003eThe objective of this study is to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of this disease, by studying a low-resource hospital setting in a country with poor health indicators.\u003c/p\u003e"},{"header":"Patients And Methods","content":"\u003cp\u003eOur study consists of two parts. In the first one, we analyzed a sample of 163 patients admitted to the UEN (Unidade Especial de Nutri\u0026ccedil;\u0026atilde;o) of the Chiulo Hospital for acute malnutrition, over a period of six months (November 2018-May 2019). For each patient we collected data on age, sex, anthropometric data at entry (weight, length, MUAC, weight for height z-score, weight for age z-score, height for age z-score), presence or absence of edema, anthropometric data at discharge, outcome (discharged, escaped or deceased), average weight gain (g/Kg/die), length of hospitalization and presence of pathologies or associated clinical conditions. The goal of this first part was to identify possible prognostic factors in the clinical evolution of the disease. The analysis was carried out by dividing the patients into groups on the basis of some variables, considered as potential prognostic factors (age, sex, severity of malnutrition, presence of stunting, presence of associated pathologies), and comparing the different groups in relation to the following clinical outcomes: length of hospitalization, average weight gain, difference between discharge weight and target weight (weight for which WHZ is -2 DS), difference between MUAC at admission and at discharge and mortality. The averages of the parameters evaluated as outcomes, have been calculated without considering the patients who died and escaped, so that these data were not influenced by mortality. In the comparison between the different groups, the evaluation of statistical significance was carried out by applying the Student's T test.\u003c/p\u003e\n\u003cp\u003eThe second part of our study was carried out by administering a questionnaire to a group of malnourished children\u0026rsquo;s caregivers and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes. The questionnaire consisted of a first part with the patient's personal and anthropometric data, a section on perinatal anamnesis, with particular attention to the opportunities of access to health services, then the nutritional anamnesis, the maternal anamnesis and some data relating to socio-economic conditions of the family nucleus (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The goal of this second part of the study was to identify possible risk factors for the development of acute malnutrition. The questionnaires were administered to the caregivers with the help of Angolan nurses who acted as interpreters, translating the questions from Portuguese to the local dialect to make them understandable to mothers who did not speak Portuguese (most of them). Each questionnaire took about 20 minutes, making that moment an opportunity to perform nutritional education. Given the time required for administration, and the need for local staff available for translation, the final number of questionnaires was limited (52 mothers of malnourished children and 22 mothers of non-malnourished children interviewed) compared to the size of the sample of the first part of the study (163 malnourished). This is the main limitation of our study, which is why we considered carrying out a simple descriptive work on the questionnaires, which however provides us with a fairly representative picture of the socio-economic and family context in which the malnutrition pathology typically occurs.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eSample characteristics\u003c/h2\u003e\n\u003cp\u003eThe 163 patients in our sample ranged in age from 6 to 48 months, the median was 12 months, with most (63.2%) in the 6\u0026ndash;12 months range, only three patients were over 2 years. There was no significant prevalence of one sex over the other (48.5% male, 51.5% female).\u003c/p\u003e\n\u003cp\u003eBy analyzing the degree of severity of acute malnutrition at admission, indicated by the value of the weight for height z-score (WHZ), it was observed that only 6.8%, showed a moderate acute malnutrition (-3 SD\u0026thinsp;\u0026le;\u0026thinsp;WHZ \u0026lt;-2 SD), 47.2% had a severe acute malnutrition (-4 SD\u0026thinsp;\u0026le;\u0026thinsp;WHZ \u0026lt;-3 SD), 46% were suffering from very severe acute malnutrition (\"Malnutri\u0026ccedil;\u0026atilde;o aguda muito severa- MAMS\", WHZ \u0026lt;-4 SD). The evaluation of the height for age z-score allowed us to highlight that only 60% of patients had a stunting pattern associated with wasting, in a significant proportion therefore acute malnutrition had arisen in the absence of a previous impairment of linear growth.\u003c/p\u003e\n\u003cp\u003eThe diagnosis of SAM was made for the presence of at least one of the three WHO criteria, in particular only in 7 patients all three criteria were satisfied, in 112 patients the criteria met were MUAC\u0026thinsp;\u0026lt;\u0026thinsp;11.5 cm and WHZ \u0026lt;-3 SD, in 20 patients only the WHZ criterion, in 11 patients only the MUAC criterion, only one patient had MUAC\u0026thinsp;\u0026lt;\u0026thinsp;11.5 cm associated with edema, only one was diagnosed for the presence of edema only. So not always all three diagnostic criteria were satisfied.\u003c/p\u003e\n\u003cp\u003eAnother aspect that we wanted to study is the presence of other pathologies or clinical conditions that can sometimes accompany severe acute malnutrition. We do not clearly refer to those acute intercurrent pathologies but to pre-existing clinical conditions, congenital, chronic or long-lasting pathologies.\u003c/p\u003e\n\u003cp\u003eIn our sample, 21 of 163 patients (13%) had the following conditions (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e): Tuberculosis (10 patients), HIV (2 patients), Tuberculosis\u0026thinsp;+\u0026thinsp;HIV (1 patients), sickle cell disease (4 patients), encephalopathy (2 patients), congenital heart disease (1 patients), preterm birth (1 patients). Often these diseases were diagnosed during the hospitalization for SAM and their treatment, where possible, it was essential for the resolution of the SAM itself.\u003c/p\u003e\n\u003cp\u003eThe average length of hospitalization of the patients studied was 7.9 days. This, however, was influenced by the deceased and escaped patients whose hospitalizations were generally of shorter duration. If we exclude deaths and runaways, the average length of hospitalization for regularly discharged patients is 8.8 days.\u003c/p\u003e\n\u003cp\u003eThe mortality recorded in our sample was 11.7%. In fact, 19 patients died, whose average hospital stay was 3.4 days. In addition, 4 escapes were recorded, a fairly widespread phenomenon that generally concerned very serious patients, for whom the chances of survival outside the hospital were minimal. Combining the two groups (deceased and escaped) we have 14.5% of cases in which there has been a therapeutic failure.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eAnalysis of potential prognostic factors\u003c/h2\u003e\n\u003cp\u003eWe first divided the population into two groups based on age. The first group (103 patients), was aged between 6 and 12 months and with a similar representation of both sexes, the second group (60 patients) aged\u0026thinsp;\u0026gt;\u0026thinsp;12 months and higher prevalence of females (55% F, 45% M). Minimal differences emerged between the two groups regarding the outcomes considered. The variable \u0026ldquo;age\u0026rdquo; was not related to a statistically significant difference in the severity of malnutrition at admission or to a different prognosis in terms of length of hospitalization, weight gain and mortality.\u003c/p\u003e\n\u003cp\u003eWe then divided the population into two groups based on the variable \u0026ldquo;sex\u0026rdquo;, we saw that males and females showed slight differences in terms of average age (slightly lower in males, 13.5 months vs 14.6) and severity of malnutrition at admission (average WHZ \u0026minus;\u0026thinsp;4.3 SD in males, -3.7 SD in females). Even in this case, however, the variable considered (sex) was not significantly associated with a difference in terms of outcomes. Minimal differences emerged, in average weight gain, in the difference between target weight and weight at discharge and in the difference between MUAC at admission and at discharge, but were not statistically significant in the Student's T test. Mortality was also similar in the two groups (11.4% M, 11.9% F).\u003c/p\u003e\n\u003cp\u003eAnother variable analyzed, as a potential prognostic factor, is the severity of acute malnutrition at the time of admission, represented by the WHZ. We have divided the population into three severity groups: patients with moderate acute malnutrition or MAM (-3 SD\u0026thinsp;\u0026le;\u0026thinsp;WHZ \u0026lt;-2 SD); patients with severe acute malnutrition or SAM (-4 SD\u0026thinsp;\u0026le;\u0026thinsp;WHZ \u0026lt;-3 SD); patients with very severe acute malnutrition or MAMS (WHZ \u0026lt;- 4 SD). (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAnlalysis of the variable \u0026ldquo;Severity of acute malnutrition at the time of admission\u0026rdquo;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSeverity of acute malnutrition\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage age\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAssociated pathologies\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLenght of hospitalization*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage weight gain*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference target weight/ discharge weight*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference MUAC at admission/ MUAC at discharge*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMortality\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eModerate (MAM)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e11 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.8\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.2 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.3\u003c/p\u003e\n\u003cp\u003eg/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-30 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.3 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSevere (SAM)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e77 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.3\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.2 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.7\u003c/p\u003e\n\u003cp\u003eg/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e180 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVery severe (MAMS)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e75 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.3\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10.3 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.3\u003c/p\u003e\n\u003cp\u003eg/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e640 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003e\u003cem\u003e*Deaths and escapes were excluded from the average\u003c/em\u003e\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, there are some significant differences between these three groups of patients. Specifically, with regard to the presence of pathologies/clinical conditions associated with malnutrition, a significant difference emerges between patients with SAM and those with MAMS. Among the most serious patients, 16% had associated diseases compared to 8% of the less severe patients. Furthermore, observing the analyzed outcomes, as the severity of the pathology at entry increases, the average length of stay increases (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), but also increases the average weight gain, as well as the difference between the MUAC at admission and at discharge.\u003c/p\u003e\n\u003cp\u003eThe comparison between the average length of hospitalization of the three groups of patients, also in this case, was made using the Student's T test. The comparison between the MAMS group and the MAM group allowed us to demonstrate the existence of strong evidence against the hypothesis 0 that the averages are equal (p value 0.01). So, the difference between the average length of hospitalization of the MAMS group and the MAM group is statistically significant. However, this difference was not as significant in the comparison between the SAM group and the MAMS group (p-value 0.53), nor between the SAM group and the MAM group (p-value 0.18).\u003c/p\u003e\n\u003cp\u003eThe average weight gain of most patients is concentrated in the range between 0 and 20 g/kg/day, but the cases of greater average weight gain (\u0026gt;\u0026thinsp;20 g / kg / day) mainly concerned those patients starting from a lower WHZ. The application of Student's T test in this case, however, revealed that the differences in average weight gain are not statistically significant. Probably a greater number of the sample could have confirmed the significance of this difference, especially in the comparison between the MAMS group and the MAM group, which is the one that reported the lowest p value (0.18).\u003c/p\u003e\n\u003cp\u003eMortality was significantly higher in patients with MAMS (17%) than in patients with SAM (5.2%). This is probably the data that more clearly confirms that the lower is the WHZ, the worse is the prognosis. Mortality in the MAM group is also high (18%) but this assumes little significance in relation to the low number of the sample and the high percentage, in this group, of patients with associated diseases.\u003c/p\u003e\n\u003cp\u003eWe also analyzed whether and how the coexistence of a state of chronic malnutrition (stunting) can influence the prognosis of patients suffering from acute malnutrition (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Patients with stunting appear to be on average older (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e) and appear to have a slightly higher severity of acute malnutrition upon admission (WHZ \u0026minus;\u0026thinsp;4.2 versus \u0026minus;\u0026thinsp;3.9 SD). The percentage of patients suffering from pathologies associated is significantly higher in the group of patients suffering from stunting (17% versus 6%). No significant differences in the duration of hospitalization emerged between patients with stunting and patients without stunting. The analysis of the outcomes related to growth showed that patients with stunting grow on average more during hospitalization (average weight gain 15.9 vs 13.5 g/kg/ day), but the Student's T test did not give us a value of statistical significance (p-value 0.26). The presence of associated pathologies and mortality were instead significantly higher in the stunting group than in patients without stunting.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAnalysis of the variable \u0026ldquo;presence of stunting\u0026rdquo;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLenght for age\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage age\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage WHZ at admission\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAssociated pathologies\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLenght of hospitalization*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage weight gain*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference target weight/ discharge weight\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference MUAC at admission/ MUAC at discharge*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMortality\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt; -2 SD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Presence of stunting)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e98 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.2\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-4.2 SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.9 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.9\u003c/p\u003e\n\u003cp\u003eg/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e260 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026ge;-2 SD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Absence of stunting)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e65 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.5\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-3.9 SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.4 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.5\u003c/p\u003e\n\u003cp\u003eg/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e460 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\"\u003e\u003cem\u003e*Deaths and escapes were excluded from the average\u003c/em\u003e\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBy subdividing the population based on the presence or absence of associated pathologies, substantial differences emerged both in terms of individual characteristics and in prognostic terms (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The average age is 16.7 months for patients with associated pathologies and 12.9 for patients without other pathologies (19.7 and 13.1 respectively if we also consider deceased patients). The application of the Student\u0026rsquo;s T test allowed us to demonstrate that this difference is statistically significant (p-value 0.007).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAnalysis of the variable \u0026ldquo;presence of associated pathologies\u0026rdquo;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage age*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage WHZ at admission\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePresence of stunting\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLenght of hospitalization*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAverage weight gain*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference target weight/ discharge weight*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDifference MUAC at admission/ MUAC at discharge*\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMortality\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePresence of associated pathologies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e21 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.7 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026minus;\u0026thinsp;4.7 SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e80.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.89 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.94 g/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e490 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.6 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAbsence of associated patgologies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e142 patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.9 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-3.9 SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55.6%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.74 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.29 g/Kg/die\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e320 g\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.4 cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"9\"\u003e\u003cem\u003e*Deaths and escapes were excluded from the average\u003c/em\u003e\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the severity of SAM on admission, patients with associated diseases had a lower average WHZ (-4.7 vs -3.9 SD). The length of hospitalization was on average longer in those with another pathology (14.89 days vs 7.74 days) and the average weight gain was lower in the same group (7.94 vs 16.29 g/kg /die). Also in these cases it has been shown that the difference between the averages is statistically significant, being the p-value 0.007 in the case of the average weight gain, even lower in the case of the duration of hospitalization (\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e\n\u003cp\u003eNo deaths were recorded in the group of patients with associated diseases.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eAnalysis of potential risk factors\u003c/h2\u003e\n\u003cp\u003eWe first evaluated the characteristics of the sample of 52 malnourished whose mothers were interviewed, to verify that it was representative of the entire malnourished population. The average age of this group was 12 months, 46.2% were male, 53.8% female. Regarding the severity of SAM at admission, the mean WHZ in the interviewed sample was \u0026minus;\u0026thinsp;3.9 and the mean MUAC was 10.6. For all these aspects, the sample studied could be considered quite representative of the UEN patient population. The only data that differs is that of mortality, which is lower in the sample of the 52 patients interviewed (5.8%).\u003c/p\u003e\n\u003cp\u003eThe average age of the sample of 23 non-malnourished children, whose mothers were interviewed, was 14.6 months, the median of 12 months. 52% were male children, 48% female. Only one of these children died.\u003c/p\u003e\n\u003cp\u003eIn perinatal anamnesis, the first aspect that we have analyzed is access to health services, potential opportunities for health and nutrition education. We investigated the place of birth (home or hospital), the execution of antenatal visits and vaccinations. In the malnourished group, most patients were born in hospital or health center, had vaccinations and most mothers had visits during pregnancy. There are no major differences in terms of access to services compared to the group of non-malnourished patients admitted to Pediatrics (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAccess to health services\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eGroups\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003ePlace of birth\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eAntenatal visits\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eVaccinations\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eHome\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eHospital/ Health center\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eDone\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eNot done\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eDone\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eNot done\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatients admitted to UEN\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e42\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e86.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatients admitted to pediatrics\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother risk factor analyzed is birth weight, which however cannot always be known precisely. In fact, there is no habit of memorizing the birth weight of children and almost always there is no health document to certify it. As the exact birth weight was often not known, mothers were asked if their baby at birth was very small or normal/large. Although we are aware of the considerable approximation of this data, differences between the two groups emerged in this regard. Among the mothers of malnourished patients, 54% reported that their child was born large or normal, 42% that it was born very small, 4% did not know. Among the mothers of the non-malnourished, 91% reported that their child was born large or normal, 9% that they were born small. Being born small could indicate prematurity or low weight for gestational age and could be a sign of maternal malnutrition (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe next part of the questionnaire was based on the patient's eating habits with particular regard to breastfeeding and introduction of complementary foods (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab5\" style=\"width: 1025px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient\u0026rsquo;s eating habits\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 147px;\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 114px;\" colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAge of introduction of water\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 220px;\" colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eAge of suspension of breastfeeding\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 243px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eInterval between suspension of breastfeeding and hospitalization\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 213px;\" colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eAge of introduction of complementary foods\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 79px;\" align=\"left\"\u003e\n\u003cp\u003eNot suspended yet\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e6\u0026ndash;12\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e3\u0026ndash;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 72px;\" align=\"left\"\u003e\n\u003cp\u003eNot introduced yet\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;3\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e3\u0026ndash;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;6\u003c/p\u003e\n\u003cp\u003emonths\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 147px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatients admitted to UEN\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(malnourished)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e65%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 79px;\" align=\"left\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e33%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e42%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e11.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e10%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 72px;\" align=\"left\"\u003e\n\u003cp\u003e2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e25%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e23%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e50%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 147px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatients admitted to pediatrics (not\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003emalnourished)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e30%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 79px;\" align=\"left\"\u003e\n\u003cp\u003e70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e17%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 81px;\" align=\"left\"\u003e\n\u003cp\u003e22%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 72px;\" align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e13%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e39%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 47px;\" align=\"left\"\u003e\n\u003cp\u003e48%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the malnourished group in 2 cases (4%) breastfeeding was interrupted before 6 months of life (in one case because the mother was seriously ill, in the other because the mother had died), 1 patient had never been breastfed as he was orphan, in 14 cases (27%) breastfeeding was suspended between 6 and 12 months, in 17 cases (33%) suspended after 12 months, 18 mothers (35%) replied that breastfeeding was still continuing at the time of admission (the mean age of the patients still breastfed was 9.5 months). In the group of malnourished patients, 65% were no longer breastfed at the time of admission and the average age of these patients was 15.2 months.\u003c/p\u003e\n\u003cp\u003eAmong the non-malnourished in no case breastfeeding was interrupted before 6 months, in 3 cases (13%) had been suspended between 6 and 12 months, in 4 (17%) suspended after 12 months. Sixteen mothers (70%) answered that breastfeeding was still continuing at the time of admission and the average age of this group of patients was 10.8 months. The mean age of patients who were no longer breastfed was 24 months.\u003c/p\u003e\n\u003cp\u003eOne element that we wanted to investigate is the interval between the suspension of breastfeeding and hospitalization for SAM to highlight a potential role of the suspension of breastfeeding as a trigger for acute malnutrition. Among patients admitted to UEN, 42% had stopped breastfeeding less than three months before admission, in these children it is likely that this dietary change was the trigger for SAM. 11.5% had stopped breastfeeding from 3 to 6 months earlier and 10% more than three months earlier. Of the patients admitted to pediatrics (not malnourished), only 4% had stopped breastfeeding less than three months earlier.\u003c/p\u003e\n\u003cp\u003eAnother aspect studied is the age of introduction of the water. In the context in which our study was carried out, the administration of water under the age of six months was an extremely widespread practice (65% in malnourished and 79% in non-malnourished). In such contexts, the recommendation not to give water to small infants should be even stronger, considering that water is often unsafe and can seriously endanger the survival of these children.\u003c/p\u003e\n\u003cp\u003eWith regard to the introduction of complementary foods, important critical issues emerge especially in the malnourished group. In this group, as much as 25% had started weaning before 3 months of life, this percentage was 13% among non-malnourished patients.\u003c/p\u003e\n\u003cp\u003eThe WHO in 2008 published the document \"Indicators for assessing infant and young child feeding practices\" in which it describes indicators for the evaluation of infant and child nutrition, among these it introduces the concept of minimum acceptable diet - MAD), an index composed of the \u0026ldquo;minimum dietary diversity\u0026rdquo; and the \u0026ldquo;minimum meal frequency\u0026rdquo; for children aged between 6 and 23 months (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe criterion of minimum dietary diversity (intake of foods belonging to at least 4 different groups) in the group of malnourished patients was met in only 33% of cases, on average the patients in this group ate foods belonging to 2.8 different groups. If we consider the availability of food for the family unit, however, it emerges that 79% of the mothers interviewed report having food available at home belonging to at least four different groups. In the group of non-malnourished patients, 65% meet the criterion of minimum dietary diversity, with an average of 3.7 different food groups. Even in this case, however, there is a difference with the percentage of families who have food from at least 4 different groups (83%). Mothers were also interviewed about the type of food their children eat. The foods of the category cereals, roots and tubers are the most widely consumed. Only a few children unfortunately consume foods rich in proteins such as legumes, dairy products, meats and eggs (Table \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab6\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePercentages of patients who eat the foods of the different categories, in the UEN group and in the Pediatrics group\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFood category\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePatients admitted to UEN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePatients admitted to Pediatrics\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCereals, roots and tubers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e96%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e91%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLegumes and nuts\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDairy products\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFlesh foods\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e42%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEggs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFruits and vegetables\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other parameter that constitutes the \"minimum acceptable diet\" is the \"minimum frequency of meals\", which is different in breastfed than in non-breastfed children and in relation to age. For breastfed babies the minimum number of solid/semi-solid meals should be 2 per day between 6 and 8 months, 3 per day between 9 and 23 months. For non-breastfed infants, the minimum frequency of meals (solid/semi-solid and in this group also milk-based meals) is 4 between 6 and 23 months. This criterion was met among the malnourished in only 4 patients out of 52 (7.7%) and all these 4 children were breastfed. In the group of non-malnourished patients, 4 out of 23 met this criterion (17.4%), also in this case they were all children still breastfed.\u003c/p\u003e\n\u003cp\u003ePatients who meet both WHO criteria (minimum frequency of meals and minimum dietary diversity) are 2 out of 52 among the malnourished (3.8%) and 3 out of 23 among the non-malnourished (13%).\u003c/p\u003e\n\u003cp\u003eTo conclude our analysis on risk factors for malnutrition, we analyzed family risk factors, with particular regard to maternal ones.\u003c/p\u003e\n\u003cp\u003eFirst was asked if the child's caregiver was the mother or another figure (usually another female family member such as an aunt, grandmother or older sister). In the malnourished group, 83% of children lived with their mother, 17% with another family member, often because they were orphans. Among the non-malnourished, 95.5% lived with their mother, 4.5% did not.\u003c/p\u003e\n\u003cp\u003eAmong the potential maternal risk factors, we considered age, education, BMI and the presence of HIV and Tuberculosis.\u003c/p\u003e\n\u003cp\u003eIn the malnourished group, 13.5% of mothers were under the age of 20, 50% were between 20 and 30, 17.3% between 30 and 40 and 19.2% had more than 40 years. The group of mothers of non-malnourished patients did not show great differences in terms of age (13% \u0026lt;20 years, 65% between 20 and 30, 9% between 30 and 40 and 9%\u0026gt; 40, 4% age not known).\u003c/p\u003e\n\u003cp\u003eAnother factor considered is the maternal education, also in this case the two samples were comparable in both cases being constituted by approximately 50% of mothers who had attended the school and 50% of mothers who had never attended the school.\u003c/p\u003e\n\u003cp\u003eRegarding the BMI, among the mothers of malnourished patients, for 4 we were unable to obtain this data because they were not present in hospital, one was underweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5), one overweight (BMI between 25 and 30), all the others were normal weight (BMI between 18.5 and 25). Even in the group of mothers of the non-malnourished we were unable to obtain the BMI for one mother, only one was underweight, all the others normal weight.\u003c/p\u003e\n\u003cp\u003eWith regard to the presence of associated pathologies and specifically HIV and Tuberculosis, in the malnourished group one of the mothers was infected with HIV and had died, another was suffering from tuberculosis. None of the mothers in the non-malnourished group presented these pathologies.\u003c/p\u003e\n\u003cp\u003eTo analyze the characteristics of the family unit, we asked the mothers how many children they had and if all were still alive or, if not, how many of them had died. On this aspect, important differences emerged between the two groups.\u003c/p\u003e\n\u003cp\u003eOn average, the mothers of the malnourished had 4.2 live children compared to 2.7 for the mothers of the non-malnourished. Malnourished children therefore seem to belong on average to larger families. However, the even more striking figure concerns the deceased children. Out of 52 mothers of malnourished patients interviewed 23 (44%) had had at least one deceased child (among these the average was two deceased children each). In the other group, however, 3 mothers out of 23 (13%) had lost at least one child.\u003c/p\u003e\n\u003cp\u003eFinally, we tried to analyze some characteristics that could be indicative of the socio-economic level of the family unit. We considered the type of house and the type of kitchen in which the meals were prepared. We asked the mothers if they lived in a hut (71% of the malnourished vs 43% of the non-malnourished), in a house made of sheet metal (17% of the malnourished vs 43% of the non-malnourished) or in a house made of cement (12% of malnourished vs 9% of non-malnourished). With regard to the type of cuisine used, 90.4% of the mothers of the malnourished and 91.3% of those of the non-malnourished cooked with wood, 9.6% of the former and 8.7% of the latter with a gas kitchen.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFrom the analysis of the characteristics of our sample, it emerged that hospitalizations for acute malnutrition at the Chiulo Hospital, in accordance with the literature data, mainly concern children aged between 6 and 24 months. This is the age group most susceptible to this disease, a period that corresponds with the introduction of complementary foods and unfortunately, very often with an early suspension of breastfeeding (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e). Before six months, breastfeeding plays an important protective role, none of our patients were less than 6 months old.\u003c/p\u003e\n\u003cp\u003eRegarding the diagnostic criteria for SAM, our data confirmed the importance of assessing all the parameters to prevent some cases might escape diagnosis. In fact, not always all three diagnostic criteria were met (\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). In our sample, 21 patients would have escaped the diagnosis with the sole use of MUAC (a widespread practice especially in peripheral centers).\u003c/p\u003e\n\u003cp\u003eThe mortality of our sample was quite high, but similar to that reported in the literature (\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e). Most of the deceased were patients who already arrived in extremely serious conditions, and whose death often occurred a few days after hospitalization, as demonstrated by an average length of hospitalization significantly shorter than the rest of the sample. This data is consistent with those reported in similar studies carried out in other countries (\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe analysis of prognostic factors has shown that the variables \u0026ldquo;age\u0026rdquo; and \u0026ldquo;sex\u0026rdquo; do not seem to be associated with significant changes in the clinical outcome. Differences in terms of outcome were instead observed among patients with different degrees of severity at the time of hospitalization. In fact, the most serious patients, in terms of WHZ at admission, remain hospitalized longer but seem to grow more both in terms of weight and MUAC (even if the small number of the sample does not allow us to confirm the latter data). Mortality was significantly higher in the group of patients with lower WHZ. Furthermore, among the most serious patients the percentage of those with associated diseases was higher. This leads us to reflect on the importance of always suspecting an associated disease, especially in those with a WHZ \u0026lt;- 4 DS.\u003c/p\u003e\n\u003cp\u003eAnother variable considered as a possible prognostic factor is the presence of stunting. It should be emphasized that the height for age z-score, in rural contexts such as Chiulo, has an important limit. Most children are not registered at birth and do not present any documents (\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e). Furthermore, the date of birth is not given the importance that we are accustomed to attribute to it, so the mothers often did not remember the date of birth of their children. It follows that the reported age did not always correspond to the real one. Any evaluation on the height for age parameter must take this aspect into account. However, we considered it appropriate to make an assessment of chronic malnutrition, while not ignoring these limits.\u003c/p\u003e\n\u003cp\u003eRegarding the variable \u0026ldquo;presence of stunting\u0026rdquo;, we observed that the average age is higher in the stunting group as well as the length of hospitalization; in both cases, the difference is not statistically significant. However, a fact that seems appropriate to emphasize is that the very few cases of long-term hospitalizations (over 30 days) are all concentrated in the stunting group. These are patients suffering from diseases associated with SAM, mainly tuberculosis, which justify the longer length of hospitalization and which typically, also compromise linear growth. Even the average weight gain was greater in patients with stunting but the difference is not statistically significant. We believe that the small number of the sample affects the significance of this data. The presence of associated pathologies and mortality were instead significantly higher in the stunting group.\u003c/p\u003e\n\u003cp\u003eThe variable that gave the most significant results is the presence of associated pathologies. Patients with associated pathologies were on average older. Three of these 21 patients were even older than 24 months, and were therefore outside the typical age range for developing SAM. This confirms that in an older patient with SAM it is always important to look for an associated pathology. The \u0026ldquo;primitive\u0026rdquo; SAM is typically a pathology of the younger child.\u003c/p\u003e\n\u003cp\u003eIn addition, patients with associated pathologies had a WHZ lower at the admission, they more often presented stunting, and this is easily to understood by knowing the impact that chronic diseases have on linear growth (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). They remained hospitalized longer and had lower average weight gain than patients without associated pathologies. All these differences were statistically significant. A data in contrast with these is that of mortality, no deaths were recorded in the group of patients with associated pathologies. However, it should be considered that the deaths all occurred in the first two-three days and we cannot exclude that among the deceased there were patients with associated diseases that we did not have time to diagnose.\u003c/p\u003e\n\u003cp\u003eThe second part of our study focused on identifying potential risk factors for acute malnutrition. Due to the time required for the administration of the questionnaire and the need for local staff to act as interpreters, the final number of questionnaires was quite limited. The very small number of mothers of non-malnourished patients interviewed is sadly linked to the very high prevalence of malnutrition in this geographical area. Often in fact, even patients hospitalized in Pediatrics for other pathologies, presented some degree of malnutrition that did not allow us to include them in the control group. However, despite the limitations linked to the low number of samples, we believe that our data shows a fairly representative picture of the context in which malnutrition occurs.\u003c/p\u003e\n\u003cp\u003eWe first evaluated if the sample of malnourished was representative of the entire population of patients admitted to UEN. The two samples were comparable for age, male/female ratio, WHZ and MUAC. Mortality is very different (lower in the group of patients to whom the questionnaire was administered). This is influenced by the fact that we have rarely had time to administer the questionnaire to the mothers of the deceased children. The short time of hospitalization, together with the extremely serious conditions of these patients, did not allow creating the conditions for the administration of the questionnaire.\u003c/p\u003e\n\u003cp\u003eThe first aspect we analyzed is access to health services, potential opportunities for health education. In theory, those who have had more opportunities to access services should be more sensitive to certain issues such as malnutrition than those who have never or almost never had recourse to a health facility (quite frequent occurrence in such contexts). Any access to services should be an opportunity to carry out health education with particular reference to nutritional education. Our data did not reveal any significant differences between the two groups, in both there had been occasions of access to services. It therefore emerges that access to health services is likely to be opportunities that are not exploited enough. It would be advisable to carry out awareness campaigns and training of health personnel on this aspect; it is an intervention almost at no cost that could have important implications. At the Chiulo Hospital, patients in the waiting room are entertained with the so-called \"gyms\", that is short and simple lessons by the staff on certain pathologies and their prevention strategies. This habit should be extended to the other wards and health centers.\u003c/p\u003e\n\u003cp\u003eThe analysis of eating habits revealed interesting data, especially on breastfeeding and weaning habits. Breastfeeding is known to be protective against numerous pathologies, for its ideal nutritional characteristics but also for the countless other properties, first of all the immunomodulating ones (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). In developing countries, its role becomes even more important as it can really make the difference between the survival and death of children (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). It is the only food that is safe in microbiological terms in the first months of life (scarce availability of safe water sources). In many contexts, it is the only one that can guarantee the nutrients necessary for a growing organism, in consideration of the very limited availability of other foods. It is for these reasons that, despite the small number of our samples, substantial differences emerge between the malnourished group and the non-malnourished group regarding breastfeeding.\u003c/p\u003e\n\u003cp\u003eAlmost none of both the malnourished and non-malnourished had suspended breastfeeding before six months, but a significant proportion of the malnourished had suspended it between 6 and 12 months. It is also significant that at the time of admission only 35% of the malnourished were still breastfed compared to 70% of the non-malnourished, despite an average age comparable in the two groups, confirming the protective role of breast milk against the development of SAM. The biggest difference concerns the proportion of patients who still continued breastfeeding after the start of weaning. On the other hand, there was a fairly low prevalence of exclusive breastfeeding in the first six months in both groups. In this regard, the analysis of habits related to the weaning revealed critical issues in both groups. Among the malnourished, even 25% had started taking complementary foods before 3 months of life; this percentage was 13% among non-malnourished patients. The extremely early introduction of complementary foods is confirmed to be an important risk factor for the development of malnutrition, as already highlighted by other studies (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). When other foods are introduced, the intake of breast milk and therefore its production is inevitably reduced. In addition, the risks of administering semi-solid foods to an individual not yet mature enough to take them, together with the poor quality of the foods administered, contribute to the extreme inadequacy of nutrition that these children practice.\u003c/p\u003e\n\u003cp\u003eTherefore, despite the high prevalence of breastfeeding (almost 100% of children have practiced it), are absolutely unsatisfactory the percentages of those who only take breast milk in the first six months of life, introduce complementary foods at the correct times and continue breastfeeding up to 24 months (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eWith regard to the type of food consumed, there was little dietary variability in both groups. An interesting fact is the discrepancy between the availability of food at home and its intake by children. This makes us understand that, often at the basis of inadequate nutrition, there is not only limited food availability but also frequently cultural factors and lack of knowledge of children's needs play a central role (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). It is clear once again how important it is to carry out nutrition education campaigns to educate families on how to make the most of available resources (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e). The foods in the category of cereals, roots and tubers are the most widely consumed, many families grow various types of cereals to produce flours that they use in the preparation of \u0026ldquo;funge\u0026rdquo; (a staple food typical of Angola). There are many children, especially in rural areas, whose diet consists almost exclusively of foods of this group with consequent very serious nutritional deficiencies. They are low-cost, locally produced foods that easily give a sense of satiety, thus allowing, with a minimum expense, to feed very large families. Foods rich in proteins (legumes, dairy products, meats, eggs) are consumed only by small percentages of children, especially among the malnourished. False beliefs also play their role, such as the belief that eggs cannot be taken by children or that legumes cause diarrhea. Furthermore, there is no habit of transforming foods such as meat and fish to prepare baby food that can also be taken by little children. The percentages of those who meet the minimum meal frequency criterion are also very low. In particular, none of the children not breastfed in both groups meets the minimum meal frequency criterion. It once again emerges that breastfeeding is a fundamental resource for guaranteeing children of this age group a diet that is minimally acceptable, even in the presence of extremely limited economic resources.\u003c/p\u003e\n\u003cp\u003eThe analysis of family risk factors revealed a greater risk of malnutrition in those who do not live with their mother. This may partly be due to the fact that they are often orphans, who have never been breastfed or have been for a short time.\u003c/p\u003e\n\u003cp\u003eAmong the family risk factors, age, educational level and BMI of the mother, according to our data, do not seem to be significantly associated with childhood malnutrition, although the small number of samples does not allow us to exclude a correlation, which has instead been demonstrated in other studies (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe differences in the characteristics of the family unit were significant. On average, the families of the malnourished were more numerous and the percentage of families in which at least one child had died was higher in this group, although even among the non-malnourished this percentage was high. In both cases, these are dramatic numbers, especially when compared with our realities in which, the loss of a child is an exceptional event. However, once the emotional impact of such data has been overcome, it is evident that the presence of deceased children always represents an important alarm bell that should never be underestimated and that must make us consider that patient at high risk.\u003c/p\u003e\n\u003cp\u003eRegarding the two indices of socio-economic level considered, type of house and type of kitchen, the first was different in the two groups (with the vast majority of malnourished people living in a hut), the second was instead comparable in the two groups. We believe that more numerous samples would probably have confirmed a correlation between the risk of malnutrition and the socio-economic level, as already demonstrated in other studies.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis work, despite the limitations relating to the short period in which the data collection could be carried out and consequently to the small size of the population studied, wanted to provide a picture of the main issues still open in the field of acute malnutrition.\u003c/p\u003e\n\u003cp\u003eIn some rural contexts, such as the one examined, the malnutrition rate is so high that the vast majority of children, especially under two years of age, have some degree of malnutrition. So, in the eyes of their parents, those children seem \u0026ldquo;normal\u0026rdquo; when compared to others of the same age (\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e). The perception of the malnutrition problem often by caregivers is absolutely non-existent, until one acute event occurs that precipitate the delicate balance that had been created, leading to a full-blown picture of severe acute malnutrition.\u003c/p\u003e\n\u003cp\u003eBased on the collected data, some interesting elements emerged regarding the risk factors for the development of the disease, the diagnosis of acute malnutrition, but also regarding potential prognostic factors. Our data have confirmed the importance, in the face of a child with suspected malnutrition, to carry out a global clinical evaluation using all the anthropometric measures available to prevent many cases from escaping diagnosis and treatment. In this regard, staff training programs would be essential for identifying and managing cases of malnutrition, especially in more peripheral contexts (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eAmong the prognostic factors, the most relevant were the WHZ at the time of admission, the presence of stunting and the presence of chronic diseases/clinical conditions associated with SAM.\u003c/p\u003e\n\u003cp\u003eA lower weight for height z-score (WHZ) correlate with longer length of hospitalization, higher mortality, and, in those who survived, a trend towards greater average weight gain.\u003c/p\u003e\n\u003cp\u003ePatients with Stunting were older on average, had associated diseases more often, and had slightly higher mortality.\u003c/p\u003e\n\u003cp\u003ePatients with other associated pathologies/conditions had a higher average age than the others, a longer average length of hospitalization and a lower average weight gain. SAM associated with other pathologies has very different characteristics compared to \"primitive\" SAM, often the underlying pathology is the main etiological factor of acute malnutrition. While such patients tend to have a more severe disease course, on the other hand if the disease in question is promptly identified and treated (where this is possible as in the case of tuberculosis), the chances of recovery from SAM are much higher.\u003c/p\u003e\n\u003cp\u003eWith regard to risk factors, the importance of breastfeeding as a protective factor against malnutrition has emerged in a striking way. Despite the high prevalence of breastfeeding, the percentages of exclusive breastfeeding in the first six months, and the introduction of complementary foods at the correct times with continued breastfeeding (until 24 months), are absolutely unsatisfactory, in accordance with the literature data (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eEven the practice of weaning is often burdened by significant problems and often this is not due solely and simply to the food shortages. Too often, it is in fact the lack of knowledge of what a child needs, which has the greatest impact on the development of malnutrition (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). Nutritional education campaigns are necessary, they should be based on a deep knowledge of the socio-economic and cultural context in which the patients live, of the available resources and they should be carried out on the territory. Even when these efforts are carried out flawlessly, there are, however, a considerable number of cases in which the basic problem remains the dramatic unavailability of nutrients and the impossibility of obtaining them. So, the best impact is likely to be achieved for those interventions in which the provision of complementary foods is combined with nutrition education (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eMalnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other. Unfortunately, it is a pathology that is little known in developed countries but which, due to the dramatic impact it has on children's health worldwide, deserves to be known at all latitudes. In today's world, in fact, having a projected look on global health is now necessary for those involved in health care. Opening up to health problems that have historically been considered of exclusive interest to \"distant\" countries, is a precious opportunity not only for those who want to spend themselves in the field of international cooperation, but also for those involved in child health in our country, always more multi-ethnic and globalized.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI: Body Mass Index\u003c/p\u003e\n\u003cp\u003eCUAMM: Collegio Universitario Aspiranti Medici Missionari\u003c/p\u003e\n\u003cp\u003eHIV: Human Immunodeficiency Virus\u003c/p\u003e\n\u003cp\u003eIIMS: Inqu\u0026eacute;rito de Indicadores M\u0026uacute;ltiplos e de Sa\u0026uacute;de\u003c/p\u003e\n\u003cp\u003eMAM: Moderate Acute Malnutrition\u003c/p\u003e\n\u003cp\u003eMAMS: \u0026ldquo;Malnutri\u0026ccedil;\u0026atilde;o aguda muito severa\u0026rdquo; (Very severe acute malnutrition)\u003c/p\u003e\n\u003cp\u003eMUAC: Mid-upper arm circumference\u003c/p\u003e\n\u003cp\u003eNGO: Non Governmental Organization\u003c/p\u003e\n\u003cp\u003eRUTF: Ready to Use Therapeutic Foods\u003c/p\u003e\n\u003cp\u003eSAM: Severe Acute Malnutrition\u003c/p\u003e\n\u003cp\u003eUEN: \u0026ldquo;Unidade Especial de Nutri\u0026ccedil;\u0026atilde;o\u0026rdquo; (Special Nutrition Unit)\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization\u003c/p\u003e\n\u003cp\u003eWHZ: Weight for height z-score\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Mother and Child Department of the University of Palermo (Palermo, Italy). All procedures performed in this report were in accordance with the ethical standards of the institutional and national research committee, and with the 1964 Helsinki declaration and its later amendments, or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003eAuthors' contributions:\u003c/p\u003e\n\u003cp\u003eFMT, SA, SLP and MG: design of the study; FMT and AP: administration of questionnaires to caregivers and data collection; FMT and SA data analysis; GP, GC and MG: supervision; FMT: writing - original draft preparation; SA, GC and MG: writing - review and editing. All Authors approved the final manuscript as submitted.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eWe are very grateful to all the nurses of Chiulo Hospital for having acted as interpreters in administering the questionnaires to caregivers and for the deep devotion in every day care for Angolan children.\u003c/p\u003e\n\u003cp\u003eWe are grateful to Dr. Giuseppe Carollo for his support in statistical analysis.\u003c/p\u003e\n\u003cp\u003eWe are grateful to CUAMM for the huge work it does for the right to the health of the children, especially the most marginalized.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDoctors with Africa CUAMM, https://doctorswithafrica.org/en/. Accessed 01 March 2021\u003c/li\u003e\n\u003cli\u003eN\u0026uacute;\u0026ntilde;ez Sabar\u0026iacute;s A, Ruiz R V, Satorras Orriols M, Guillot de la Puente S, Card\u0026uacute;s O, Jos\u0026eacute; Aniceto do Rosario Mario, Formative Evaluation Report CP Angola, https://www.ungm.org. Accessed 17 February 2020\u003c/li\u003e\n\u003cli\u003eInstituto Nacional de Estat\u0026iacute;stica (INE), Minist\u0026eacute;rio da Sa\u0026uacute;de (MINSA), Minist\u0026eacute;rio do Planeamento e do Desenvolvimento Territorial (MINPLAN) e ICF. 2017. Inqu\u0026eacute;rito de Indicadores M\u0026uacute;ltiplos e de Sa\u0026uacute;de em Angola 2015-2016. Luanda, Angola e Rockville, Maryland, EUA: INE, MINSA, MINPLAN e ICF\u003c/li\u003e\n\u003cli\u003eUNICEF, The State of the World\u0026rsquo;s Children 2019. Children, Food and Nutrition: Growing well in a changing world, New York 2019\u003c/li\u003e\n\u003cli\u003eAkombi BJ, Agho KE, Hall JJ, Wali N, Renzaho AMN, Merom D. Stunting, Wasting and Underweight in Sub-Saharan Africa: A Systematic Review. Int J Environ Res Public Health. 2017;14(8):863. doi: 10.3390/ijerph14080863.\u003c/li\u003e\n\u003cli\u003eKok MC, Dieleman M, Taegtmeyer M, Broerse JE, Kane SS, Ormel H, Tijm MM, de Koning KA. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan. 2015;30(9):1207-27. doi: 10.1093/heapol/czu126. Epub 2014 Dec 11. PMID: 25500559; PMCID: PMC4597042.\u003c/li\u003e\n\u003cli\u003ePravana NK, Piryani S, Chaurasiya SP, Kawan R, Thapa RK, Shrestha S. Determinants of severe acute malnutrition among children under 5 years of age in Nepal: a community-based case-control study. BMJ Open. 2017;7(8):e017084. doi: 10.1136/bmjopen-2017-017084.\u003c/li\u003e\n\u003cli\u003ePark SE, Kim S, Ouma C, Loha M, Wierzba TF, Beck NS. Community management of acute malnutrition in the developing world. Pediatr Gastroenterol Hepatol Nutr. 2012;15(4):210-9. doi: 10.5223/pghn.2012.15.4.210.\u003c/li\u003e\n\u003cli\u003eHassen SL, Astatkie A, Mekonnen TC, Bogale GG. Survival Status and Its Determinants among Under-Five Children with Severe Acute Malnutrition Admitted to Inpatient Therapeutic Feeding Centers in South Wollo Zone, Amhara Region, Ethiopia. J Nutr Metab. 2019;2019:2643531. doi: 10.1155/2019/2643531.\u003c/li\u003e\n\u003cli\u003eTickell KD, Denno DM. Inpatient management of children with severe acute malnutrition: a review of WHO guidelines. Bull World Health Organ. 2016;94(9):642-651. doi: 10.2471/BLT.15.162867.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=6603814405\"\u003ePiro E\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=55200193600\"\u003eSerra G\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=57217151319\"\u003eSchierz IAM\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=7005258524\"\u003eGiuffr\u0026egrave; M\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=55139114600\"\u003eCorsello G.\u003c/a\u003e \u003ca href=\"https://www.scopus.com/record/display.uri?eid=2-s2.0-85066981653\u0026amp;origin=resultslist\"\u003eFetal growth restriction: A growth pattern with fetal, neonatal and long-term consequences\u003c/a\u003e. \u003ca href=\"https://www.scopus.com/sourceid/21100239255?origin=resultslist\"\u003eEuroMediterranean Biomedical Journal\u003c/a\u003e 2019;14(9):38\u0026ndash;44. doi: 10.3269/1970-5492.2019.14.09.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Indicators for assessing infant and young child feeding practices: part 1: definitions: conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA. 2008\u003c/li\u003e\n\u003cli\u003eDewey KG, Adu-Afarwuah S. Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008;4(Suppl 1):24-85. doi: 10.1111/j.1740-8709.2007.00124.x. PMID: 18289157; PMCID: PMC6860813.\u003c/li\u003e\n\u003cli\u003eTadesse AW, Tadesse E, Berhane Y, Ekstr\u0026ouml;m EC. Choosing Anthropometric Indicators to Monitor the Response to Treatment for Severe Acute Malnutrition in Rural Southern Ethiopia-Empirical Evidence. Nutrients. 2017;9(12):1339. doi: 10.3390/nu9121339.\u003c/li\u003e\n\u003cli\u003eSchwinger C, Golden MH, Grellety E, Roberfroid D, Guesdon B. Severe acute malnutrition and mortality in children in the community: Comparison of indicators in a multi-country pooled analysis. PLoS One. 2019;14(8):e0219745. doi: 10.1371/journal.pone.0219745\u003c/li\u003e\n\u003cli\u003eWagnew F, Dessie G, Takele WW, Tadesse A, Islam SMS, Mulugeta H, Haile D, Negesse A, Abajobir AA. A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia. BMC Public Health. 2019;19(1):1175. doi: 10.1186/s12889-019-7466-x. PMID: 31455292; PMCID: PMC6712890.\u003c/li\u003e\n\u003cli\u003eKumar D, Rao SK, Kumar A, Singh TB. Risk Factors of Mortality in Hospitalized Children with Severe Acute Malnutrition. Indian J Pediatr. 2019;86(11):1069. doi: 10.1007/s12098-019-03016-0.\u003c/li\u003e\n\u003cli\u003eBhatia A, Krieger N, Beckfield J, Barros AJD, Victora C. Are inequities decreasing? Birth registration for children under five in low-income and middle-income countries, 1999-2016. BMJ Glob Health. 2019;4(6):e001926. doi: 10.1136/bmjgh-2019-001926. PMID: 31908868; PMCID: PMC6936526.\u003c/li\u003e\n\u003cli\u003ede Onis M, Branca F. Childhood stunting: a global perspective. Matern Child Nutr. 2016;12(Suppl 1):12-26. doi: 10.1111/mcn.12231. PMID: 27187907; PMCID: PMC5084763.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=57214316801\"\u003eNotarbartolo V\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=57210699797\"\u003eCarta M\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=56811562500\"\u003eInsinga V\u003c/a\u003e, \u003ca href=\"https://www.scopus.com/authid/detail.uri?authorId=7005258524\"\u003eGiuffr\u0026egrave; M.\u003c/a\u003e \u003ca href=\"https://www.scopus.com/record/display.uri?eid=2-s2.0-85103826044\u0026amp;origin=resultslist\"\u003eHuman milk is not \u0026ldquo;merely nutritious\u0026rdquo;: How its bioactive role can influence child health\u003c/a\u003e. \u003ca href=\"https://www.scopus.com/sourceid/21100239255?origin=resultslist\"\u003eEuroMediterranean Biomedical Journal\u003c/a\u003e 2021,16(5),21\u0026ndash;26. doi: 10.3269/1970-5492.2021.16.5.\u003c/li\u003e\n\u003cli\u003eFerrante G, Carta M, Montante C, Notarbartolo V, Corsello G, Giuffr\u0026egrave; M. \u003ca href=\"https://pubmed.ncbi.nlm.nih.gov/32850557/\"\u003eCurrent Insights on Early Life Nutrition and Prevention of Allergy.\u003c/a\u003e Front Pediatr. 2020;8:448. doi: 10.3389/fped.2020.00448. eCollection 2020.\u003c/li\u003e\n\u003cli\u003eMukuku O, Mutombo AM, Kamona LK, Lubala TK, Mawaw PM, Aloni MN, Wembonyama SO, Luboya ON. Predictive Model for the Risk of Severe Acute Malnutrition in Children. J Nutr Metab. 2019;2019:4740825. doi: 10.1155/2019/4740825.\u0026nbsp;\u003c/li\u003e\n\u003cli\u003eSanghvi J, Mehta S, Kumar R. Predictors for weight gain in children treated for severe acute malnutrition: a prospective study at nutritional rehabilitation center. ISRN Pediatr. 2014;2014:808756. doi: 10.1155/2014/808756\u003c/li\u003e\n\u003cli\u003eImdad A, Yakoob MY, Bhutta ZA. Impact of maternal education about complementary feeding and provision of complementary foods on child growth in developing countries. BMC Public Health. 2011;11(Suppl 3):S25. doi: 10.1186/1471-2458-11-S3-S25. PMID: 21501443; PMCID: PMC3231899.\u003c/li\u003e\n\u003cli\u003eDavid SM, Pricilla RA, Paul SS, George K, Bose A, Prasad JH. Risk factors for severe acute malnutrition among children aged 6-59 months: A community-based case-control study from Vellore, Southern India. J Family Med Prim Care. 2020;9(5):2237-2243. doi: 10.4103/jfmpc.jfmpc_211_20.\u003c/li\u003e\n\u003cli\u003eJackson AA, Ashworth A, Khanum S. Improving child survival: Malnutrition Task Force and the paediatrician's responsibility. Arch Dis Child. 2006;91(8):706-10. doi: 10.1136/adc.2006.095596. PMID: 16861489; PMCID: PMC2083066.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"severe acute malnutrition, wasting, risk factors, prognostic factors, Sub-Saharan Africa, breastfeeding","lastPublishedDoi":"10.21203/rs.3.rs-477173/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-477173/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eMalnutrition is a multifactorial pathology in which genetic, epigenetic, cultural, environmental, socio-economic factors interact with each other.\u003cstrong\u003e \u003c/strong\u003eThe impact that this disease has on the health of children worldwide is dramatic. Severe acute malnutrition in particular is a disease affecting nearly 20 million preschool children worldwide, most of them in Africa and South East Asia.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eObjectives: \u003c/strong\u003eThis work aims to investigate potential prognostic factors in the clinical evolution of acute malnutrition and potential risk factors for the development of the disease.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eOur study was carried out at the “Hospital da Missão Catolica do Chiulo”, in Angola, where the NGO Doctors with Africa CUAMM has been operating since 2000. In the first part of the study we analyzed the characteristics and clinical evolution of 163 patients hospitalized for acute malnutrition at the UEN (Unidade Especial de Nutrição) of the Chiulo Hospital over a period of six months, in order to identify potential prognostic factors of the disease. The second part of our study was carried out by administering a questionnaire to a group of caregivers of malnourished children and to a group of caregivers of non-malnourished children admitted to Pediatrics for other causes, with the aim of identifying potential risk factors for the development of malnutrition. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults and Conclusions: \u003c/strong\u003eThe analysis of prognostic factors revealed that the most relevant are the WHZ (weight for height z-score) at the time of admission, the presence of Stunting and the presence of other pathologies or clinical conditions associated with severe acute malnutrition.\u003c/p\u003e\u003cp\u003eThe analysis of risk factors has shown that not only food shortages, but also errors in the timing of the suspension of breastfeeding and the timing of the introduction of complementary foods play an important role. Equally important were some family risk factors, including the size of the family unit and the presence of deceased children.\u003c/p\u003e\u003cp\u003eIt also emerged that the lack of knowledge of what a child needs to grow up healthy often affects the development of malnutrition. It follows that a useful and low-cost tool for preventing child malnutrition would be large-scale nutrition education campaigns.\u003c/p\u003e","manuscriptTitle":"Analysis of Risk and Prognostic Factors in a Population of Pediatric Patients Hospitalized for Acute Malnutrition at the Chiulo Hospital, Angola","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-05-05 22:24:22","doi":"10.21203/rs.3.rs-477173/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2021-06-28T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-06-20T00:00:00+00:00","index":1,"fulltext":"Recommendation: Reviewer's comments unavailable due to the journal's policy.\n"},{"type":"editorInvitedReview","content":"","date":"2021-06-09T10:41:00+00:00","index":0,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-06-09T00:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-06-08T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-04-28T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-04-28T23:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2021-04-28T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"Italian Journal of Pediatrics","date":"2021-04-26T19:08:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"italian-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"itjp","sideBox":"Learn more about [Italian Journal of Pediatrics](http://ijponline.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ITJP/default.aspx","title":"Italian Journal of Pediatrics","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b61ac1-430a-4e4c-a490-70fa948ebf04","owner":[],"postedDate":"May 5th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":4105011,"name":"Pediatrics"}],"tags":[],"updatedAt":"2021-08-27T06:32:59+00:00","versionOfRecord":[],"versionCreatedAt":"2021-05-05 22:24:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-477173","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-477173","identity":"rs-477173","version":["v1"]},"buildId":"GqpaHPwrfC8PjnIFayRh5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}