{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,3,19]],"date-time":"2025-03-19T04:30:44Z","timestamp":1742358644420,"version":"3.40.1"},"reference-count":49,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2025,3,18]],"date-time":"2025-03-18T00:00:00Z","timestamp":1742256000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000269","name":"Economic and Social Research Council","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100000269","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosglobalpublichealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Glob Public Health"],"abstract":"<jats:p>Severely malnourished patients can present with bilateral pitting oedema, which is a common sign of Kwashiorkor. However, bilateral pitting oedema can also be an expression of other pathologies. In Mali and DRC, the number of children presenting with bilateral pitting oedema at MSF (M\u00e9decins Sans Frontiers\/Doctors Without Borders) hospitals are up to 30% (Mali) and 49% (DRC) higher than in other countries, however, the reasons underlying this trend are unknown. Through this qualitative study, we aimed to explore the perspectives and lived experiences of health professionals on the diagnosis and management of children with bilateral pitting oedema. Using a participatory approach, we conducted 21 in-depth interviews, and 2 focus groups with health professionals at MSF health facilities who had worked in the settings of Koutiala (Mali) and Rutshuru (DRC) for at least 6 months. The understanding of the bilateral pitting oedema phenomenon is complex. Health workers described clinical obstacles to reducing mortality, including: i) difficulties making the diagnosis due to a lack of specialized staff and insufficient resources, ii) challenges treating complications that may arise due to the complexity of the diseases associated with bilateral pitting oedema, and iii) lack of scientific evidence in the literature explaining the physiopathology of bilateral pitting oedema. Study participants shared several key recommendations for reducing mortality among children presenting with bilateral pitting oedema, including prevention of bilateral pitting oedema at the community level, standardization of the diagnostic process, strengthening of medical training, and better collaboration both within the medical teams and between teams and the children\u2019s families.<\/jats:p>","DOI":"10.1371\/journal.pgph.0004125","type":"journal-article","created":{"date-parts":[[2025,3,18]],"date-time":"2025-03-18T17:25:51Z","timestamp":1742318751000},"page":"e0004125","update-policy":"https:\/\/doi.org\/10.1371\/journal.pgph.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Understanding the medical challenges for the diagnosis and treatment of bilateral pitting oedema in children: a qualitative study"],"prefix":"10.1371","volume":"5","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4810-4293","authenticated-orcid":true,"given":"Giulia","family":"Scarpa","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-0285-1412","authenticated-orcid":true,"given":"Joseph","family":"Sagara","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-2960-4786","authenticated-orcid":true,"given":"Christopher","family":"Mambula","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marie-Hortense","family":"Koudika","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-8751-446X","authenticated-orcid":true,"given":"Fabrizio","family":"Loddo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emelie","family":"Yonally-Phillips","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9270-3931","authenticated-orcid":true,"given":"Manal","family":"Shamseldin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5694-6175","authenticated-orcid":true,"given":"M\u00e9trey H.","family":"Tiv","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6811-1351","authenticated-orcid":true,"given":"Emily","family":"Lynch","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-5442-2852","authenticated-orcid":true,"given":"Nana","family":"Nimbu","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4526-5243","authenticated-orcid":true,"given":"Aim\u00e9","family":"Lulebo Mampasi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2046-5836","authenticated-orcid":true,"given":"Nono","family":"Mvuama Mazangama","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Akory","family":"Ag Iknane","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6362-1264","authenticated-orcid":true,"given":"Jihane","family":"Ben-Farhat","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2025,3,18]]},"reference":[{"issue":"21","key":"pgph.0004125.ref001","doi-asserted-by":"crossref","first-page":"2600","DOI":"10.1001\/jama.291.21.2600","article-title":"Estimates of global prevalence of childhood underweight in 1990 and 2015","volume":"291","author":"M de Onis","year":"2004","journal-title":"JAMA"},{"key":"pgph.0004125.ref002","first-page":"S100-4","article-title":"Edema in childhood","volume":"59","author":"S Hisano","year":"1997","journal-title":"Kidney Int Suppl"},{"key":"pgph.0004125.ref003","unstructured":"Alvarez J, Dent N, Browne L, Myatt M, Briend A. Putting child Kwashiorkor on the map. 2016."},{"key":"pgph.0004125.ref004","unstructured":"Ben Farhat J, Hanson K, Shams Eldin M. Description des cas d\u2019\u0153d\u00e8mes bilat\u00e9raux chez les enfants hospitalis\u00e9s dans les structures de M\u00e9decins Sans Fronti\u00e8res (MSF). Epicentre, MSF, 2019."},{"key":"pgph.0004125.ref005","unstructured":"WHO. Management of severe acute malnutrition in children 6\u201359 months of age with oedema 2020 [cited 2020 8 September]."},{"key":"pgph.0004125.ref006","first-page":"120","article-title":"Malnutrition in Sub-Saharan Africa: burden, causes and prospects","volume":"15","author":"LE Bain","year":"2013","journal-title":"Pan Afr Med J"},{"issue":"3","key":"pgph.0004125.ref007","doi-asserted-by":"crossref","first-page":"106","DOI":"10.4314\/mmj.v21i3.45630","article-title":"Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema","volume":"21","author":"MJ Manary","year":"2009","journal-title":"Malawi Med J"},{"issue":"4","key":"pgph.0004125.ref008","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1177\/0379572118794072","article-title":"Lost in Aggregation: The Geographic Distribution of Kwashiorkor in Eastern Democratic Republic of the Congo","volume":"39","author":"M Fitzpatrick","year":"2018","journal-title":"Food Nutr Bull"},{"issue":"7","key":"pgph.0004125.ref009","doi-asserted-by":"crossref","first-page":"1544","DOI":"10.1111\/jan.13555","article-title":"Participatory action as a research method with public health nurses","volume":"74","author":"C Cusack","year":"2018","journal-title":"J Adv Nurs"},{"key":"pgph.0004125.ref010","unstructured":"Stringer ET, Dwyer R. Action research in human services: Prentice Hall; 2005."},{"issue":"1","key":"pgph.0004125.ref011","article-title":"Participatory Research Methods: A Methodological Approach in Motion","volume":"13","author":"J Bergold","year":"2012","journal-title":"Forum Qualitative Sozialforschung \/ Forum: Qualitative Social Research"},{"key":"pgph.0004125.ref012","doi-asserted-by":"crossref","DOI":"10.1177\/16094069211014766","article-title":"Decolonizing Methodologies in Qualitative Research: Creating Spaces for Transformative Praxis","volume":"20","author":"V Thambinathan","year":"2021","journal-title":"International Journal of Qualitative Methods"},{"issue":"1","key":"pgph.0004125.ref013","doi-asserted-by":"crossref","first-page":"3","DOI":"10.4081\/malaria.2012.e3","article-title":"The PASS-model: a model for guiding health-seeking behavior and access to care research","volume":"2","author":"S Hausmann Muela","year":"2012","journal-title":"Malaria Rep"},{"key":"pgph.0004125.ref014","doi-asserted-by":"crossref","unstructured":"UNICEF. Mali Health Thematic Country Report. 2019","DOI":"10.5089\/9781513513362.002"},{"key":"pgph.0004125.ref015","volume-title":"A Threat to Progress: Confronting the Effects of Climate Change on Child Health and Well-Being","author":"UNICEF","year":"2024"},{"key":"pgph.0004125.ref016","unstructured":"USAID. Mali country profile. 2022."},{"issue":"210","key":"pgph.0004125.ref017","first-page":"A001","article-title":"African D. Mali: Selected Issues","author":"International Monetary Fund","year":"2023","journal-title":"IMF Staff Country Reports"},{"key":"pgph.0004125.ref018","article-title":"Prevalence of child malnutrition in North Kivu, DRC: Evidence from Bunyuka Parish","volume":"1","author":"S Barlow","year":"2015","journal-title":"Organization Development Journal"},{"key":"pgph.0004125.ref019","unstructured":"USAID. Democratic Republic of Cong Nutrition profile. 2022."},{"issue":"2","key":"pgph.0004125.ref020","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"V Braun","year":"2006","journal-title":"Qualitative Research in Psychology"},{"issue":"11","key":"pgph.0004125.ref021","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1016\/S2352-4642(23)00214-6","article-title":"The neglect of kwashiorkor","volume":"7","author":"T May","year":"2023","journal-title":"Lancet Child Adolesc Health"},{"key":"pgph.0004125.ref022","doi-asserted-by":"crossref","first-page":"49","DOI":"10.2147\/NDS.S238403","article-title":"Determinants of Nutritional Edema Among Under-Five Children with Severe Acute Malnutrition Admitted to Health Facilities at Gedeo Zone: Unmatched Case\u2013Control Study","volume":"12","author":"R Hussen Kabthymer","year":"2020","journal-title":"Nutrition and Dietary Supplements"},{"issue":"1","key":"pgph.0004125.ref023","doi-asserted-by":"crossref","first-page":"pocj.5000204","DOI":"10.5301\/pocj.5000204","article-title":"Edema in Renal Diseases \u2013 Current View on Pathogenesis","volume":"2","author":"I Bobkova","year":"2016","journal-title":"Nephrology @ Point of Care"},{"issue":"4","key":"pgph.0004125.ref024","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1002\/ehf2.12043","article-title":"Clinical significance of bilateral leg edema and added value of monitoring weight gain during follow-up of patients with established heart failure","volume":"2","author":"H Kataoka","year":"2015","journal-title":"ESC Heart Fail"},{"issue":"4","key":"pgph.0004125.ref025","first-page":"e7609","article-title":"Renal Artery Stenosis As Etiology of Recurrent Flash Pulmonary Edema and Role of Imaging in Timely Diagnosis and Management","volume":"12","author":"PB Bhattad","year":"2020","journal-title":"Cureus"},{"key":"pgph.0004125.ref026","first-page":"199","article-title":"Decolonising research methodologies in the Global South: Experiences of an African social scientist","volume":"12","author":"R Chigevenga","year":"2022","journal-title":"African Journal of Social Work"},{"issue":"1","key":"pgph.0004125.ref027","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1111\/mcn.12198","article-title":"Stigma as a barrier to treatment for child acute malnutrition in Marsabit County, Kenya","volume":"12","author":"JR Bliss","year":"2016","journal-title":"Matern Child Nutr"},{"issue":"11","key":"pgph.0004125.ref028","doi-asserted-by":"crossref","first-page":"e0205688","DOI":"10.1371\/journal.pone.0205688","article-title":"Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India","volume":"13","author":"S Goudet","year":"2018","journal-title":"PLoS One"},{"issue":"3","key":"pgph.0004125.ref029","doi-asserted-by":"crossref","first-page":"e0000144","DOI":"10.1371\/journal.pgph.0000144","article-title":"Socio-economic and environmental factors affecting breastfeeding and complementary feeding practices among Batwa and Bakiga communities in south-western Uganda","volume":"2","author":"G Scarpa","year":"2022","journal-title":"PLOS Glob Public Health"},{"issue":"6","key":"pgph.0004125.ref030","doi-asserted-by":"crossref","first-page":"536","DOI":"10.4037\/ajcc2007.16.6.536","article-title":"Healthy Work Environments, Nurse-Physician Communication, and Patients\u2019 Outcomes","volume":"16","author":"M Manojlovich","year":"2007","journal-title":"American Journal of Critical Care"},{"issue":"1","key":"pgph.0004125.ref031","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1186\/s12875-017-0698-x","article-title":"An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care?","volume":"18","author":"E Matthys","year":"2017","journal-title":"BMC Fam Pract"},{"issue":"2","key":"pgph.0004125.ref032","first-page":"CD001271","article-title":"Substitution of doctors by nurses in primary care","author":"M Laurant","year":"2005","journal-title":"Cochrane Database Syst Rev"},{"key":"pgph.0004125.ref033","doi-asserted-by":"crossref","first-page":"h530","DOI":"10.1136\/bmj.h530","article-title":"Time to deliver patient centred care","volume":"350","author":"T Richards","year":"2015","journal-title":"BMJ"},{"issue":"3","key":"pgph.0004125.ref034","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1038\/sj.jp.7211060","article-title":"Standardization and the practice of medicine","volume":"24","author":"CU Lehmann","year":"2004","journal-title":"J Perinatol"},{"issue":"5 Pt 2","key":"pgph.0004125.ref035","doi-asserted-by":"crossref","first-page":"404","DOI":"10.7326\/0003-4819-158-5-201303051-00007","article-title":"Nurse-patient ratios as a patient safety strategy: a systematic review","volume":"158","author":"PG Shekelle","year":"2013","journal-title":"Ann Intern Med"},{"issue":"12","key":"pgph.0004125.ref036","doi-asserted-by":"crossref","first-page":"e052899","DOI":"10.1136\/bmjopen-2021-052899","article-title":"Patient outcomes and cost savings associated with hospital safe nurse staffing legislation: an observational study","volume":"11","author":"KB Lasater","year":"2021","journal-title":"BMJ Open"},{"issue":"2","key":"pgph.0004125.ref037","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1111\/j.1365-2702.2004.01041.x","article-title":"Child in hospital: family experiences and expectations of how nurses can promote family health","volume":"14","author":"H Hopia","year":"2005","journal-title":"J Clin Nurs"},{"issue":"2","key":"pgph.0004125.ref038","doi-asserted-by":"crossref","first-page":"80","DOI":"10.34172\/jcs.2020.012","article-title":"Family\u2019s Supportive Behaviors in the Care of the Patient Admitted to the Cardiac Care Unit: A Qualitative Study","volume":"9","author":"S Babaei","year":"2020","journal-title":"J Caring Sci"},{"key":"pgph.0004125.ref039","doi-asserted-by":"crossref","first-page":"102356","DOI":"10.1016\/j.evalprogplan.2023.102356","article-title":"Methodological choices for an economic evaluation of a combined psychosocial and nutrition treatment intervention for children with severe acute malnutrition: The FUSAM trial in Nepal","volume":"101","author":"K Le Roch","year":"2023","journal-title":"Eval Program Plann"},{"key":"pgph.0004125.ref040","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1186\/1741-7015-12-19","article-title":"Reliable direct measurement of causes of death in low- and middle-income countries","volume":"12","author":"P Jha","year":"2014","journal-title":"BMC Med"},{"issue":"9600","key":"pgph.0004125.ref041","doi-asserted-by":"crossref","first-page":"1726","DOI":"10.1016\/S0140-6736(07)61309-9","article-title":"Interim measures for meeting needs for health sector data: births, deaths, and causes of death","volume":"370","author":"K Hill","year":"2007","journal-title":"Lancet"},{"issue":"9755","key":"pgph.0004125.ref042","doi-asserted-by":"crossref","first-page":"1853","DOI":"10.1016\/S0140-6736(10)61461-4","article-title":"Causes of neonatal and child mortality in India: a nationally representative mortality survey","volume":"376","author":"Collaborators Million Death Study","year":"2010","journal-title":"Lancet"},{"key":"pgph.0004125.ref043","unstructured":"Briend A, editor. Kwashiorkor: still an enigma\u2013the search must go on. CMAM Forum Technical Brief; 2014: CMAM Forum Copenhagen, Denmark."},{"issue":"1","key":"pgph.0004125.ref044","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1097\/TIN.0b013e318209e3b6","article-title":"Reconsidering Kwashiorkor","volume":"26","author":"SN Osorio","year":"2011","journal-title":"Topics in Clinical Nutrition"},{"key":"pgph.0004125.ref045","doi-asserted-by":"crossref","first-page":"104702","DOI":"10.1016\/j.micpath.2020.104702","article-title":"Difference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment","volume":"150","author":"T-P-T Pham","year":"2021","journal-title":"Microb Pathog"},{"issue":"12","key":"pgph.0004125.ref046","first-page":"94","article-title":"Micronutrients deficiencies vis-a-vis food and nutritional security of India","volume":"10","author":"A Shukla","year":"2014","journal-title":"Indian J Fert"},{"key":"pgph.0004125.ref047","unstructured":"Organization WH. WHO guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years: World Health Organization; 2024."},{"issue":"1","key":"pgph.0004125.ref048","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1111\/jhn.13246","article-title":"Nutrition intervention goals from the perspectives of patients at risk of malnutrition: A qualitative study","volume":"37","author":"L Al-Adili","year":"2024","journal-title":"J Hum Nutr Diet"},{"issue":"8","key":"pgph.0004125.ref049","doi-asserted-by":"crossref","first-page":"301","DOI":"10.1016\/j.paed.2021.05.001","article-title":"Severe acute malnutrition in low- and middle-income countries","volume":"31","author":"MI Otiti","year":"2021","journal-title":"Paediatrics and Child Health"}],"container-title":["PLOS Global Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0004125","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,18]],"date-time":"2025-03-18T17:26:07Z","timestamp":1742318767000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pgph.0004125"}},"subtitle":[],"editor":[{"given":"Gerard Bryan","family":"Gonzales,","sequence":"first","affiliation":[],"role":[{"role":"editor","vocabulary":"crossref"}]}],"short-title":[],"issued":{"date-parts":[[2025,3,18]]},"references-count":49,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2025,3,18]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pgph.0004125","relation":{},"ISSN":["2767-3375"],"issn-type":[{"value":"2767-3375","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,18]]}}}