{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T06:01:13Z","timestamp":1792735273299,"version":"4.5.0"},"reference-count":42,"publisher":"Public Library of Science (PLoS)","issue":"12","license":[{"start":{"date-parts":[[2024,12,26]],"date-time":"2024-12-26T00:00:00Z","timestamp":1735171200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Severe acute malnutrition (SAM) constitutes a substantial burden in African hospitals. Despite adhering to international guidelines, high inpatient mortality rates persist and the underlying contributing factors remain poorly understood.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Objective<\/jats:title>\n<jats:p>We evaluated the 10-year trend (2011\u20132021) in clinical factors and outcomes among children with severe wasting and\/or nutritional edema at Malawi\u2019s largest nutritional rehabilitation unit (NRU).<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Methods<\/jats:title>\n<jats:p>This retrospective study analyzed trends in presentation and outcomes using generalized additive models. The association between clinical characteristics and mortality or readmission was examined and key features were also related to time to either mortality or discharge.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Results<\/jats:title>\n<jats:p>1497 children (53%, females) were included. Median age at admission (23 months, IQR 14, 34) or anthropometry (i.e., weight-for-age, height-for-age and weight-for-height) did not change over the 10-years. But the prevalence of edema decreased by 40% whereas dehydration, difficulty breathing, and pallor became more common. Yearly HIV testing increased but positive-detection remained around 11%. Reporting of complete vaccination dropped by 49%, and no reduction in \u2018watch\u2019 antibiotic usage was detected. Overall admissions declined but mortality remained around 23% [95%CI; 21, 25], and deaths occurred earlier (5.6 days [95%CI; 4.6, 6.9] in 2011 vs. 3.5 days [95%CI; 2.5, 4.7] in 2021; <jats:italic>p<\/jats:italic>&lt;0.001). Duration of hospitalization was shortened and readmissions surged from 4.9% [95%CI; 3.3, 7.4] in 2011 to 25% [95%CI; 18, 33] in 2021 (<jats:italic>p<\/jats:italic>&lt;0.001). Age, wasting, having both dehydration and diarrhea, or having vomiting, cough, or difficulty breathing were associated with mortality but these associations did not show any interaction over time.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Conclusion<\/jats:title>\n<jats:p>Over 10 years, mortality risk remained high among hospitalized children with SAM and coincided with worsened clinical presentation at admission and increased readmission. Longitudinal data from major NRUs can identify shifts in clinical profiles or outcomes, and this information can be leveraged to promote earlier care-seeking, improved risk stratification, and implementation of more patient-centered treatments.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0311534","type":"journal-article","created":{"date-parts":[[2024,12,26]],"date-time":"2024-12-26T18:31:52Z","timestamp":1735237912000},"page":"e0311534","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":2,"title":["Ten-year trends in clinical characteristics and outcome of children hospitalized with severe wasting or nutritional edema in Malawi (2011\u20132021): Declining admissions but worsened clinical profiles"],"prefix":"10.1371","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6233-1532","authenticated-orcid":true,"given":"Mphatso Nancy","family":"Chisala","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6336-0906","authenticated-orcid":true,"given":"Celine","family":"Bourdon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4276-5058","authenticated-orcid":true,"given":"Emmanuel","family":"Chimwezi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1774-1214","authenticated-orcid":true,"given":"Allison I.","family":"Daniel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chikondi","family":"Makwinja","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dominic","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linnea","family":"Weise","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Isabel","family":"Potani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emmie","family":"Mbale","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert J. H.","family":"Bandsma","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5825-2831","authenticated-orcid":true,"given":"Wieger P.","family":"Voskuijl","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,12,26]]},"reference":[{"issue":"9890","key":"pone.0311534.ref001","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/S0140-6736(13)60937-X","article-title":"Maternal and child undernutrition and overweight in low-income and middle-income countries","volume":"382","author":"RE Black","year":"2013","journal-title":"Lancet"},{"key":"pone.0311534.ref002","doi-asserted-by":"crossref","first-page":"17067","DOI":"10.1038\/nrdp.2017.67","article-title":"Severe childhood malnutrition.","volume":"3","author":"ZA Bhutta","year":"2017","journal-title":"Nat Rev Dis 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2009\u20132018.","volume":"8","author":"S Ndlovu","journal-title":"BMC Nutrition. 2022"},{"key":"pone.0311534.ref022","article-title":"Characterising paediatric mortality during and after acute illness in Sub-Saharan Africa and South Asia: a secondary analysis of the CHAIN cohort using a machine learning approach.","author":"AH Diallo","year":"2023","journal-title":"eClinicalMedicine [Internet]."},{"key":"pone.0311534.ref023","volume-title":"Management of severe malnutrition: a manual for physicians and other senior health workers [Internet","author":"World Health Organization","year":"1999"},{"key":"pone.0311534.ref024","unstructured":"Malawi Guidelines for Community-Based Management of Acute Malnutrition | USAID Advancing Nutrition [Internet]. [cited 2024 May 9]. Available from: https:\/\/www.advancingnutrition.org\/resources\/malawi-guidelines-community-based-management-acute-malnutrition"},{"key":"pone.0311534.ref025","doi-asserted-by":"crossref","first-page":"12","DOI":"10.3352\/jeehp.2013.10.12","article-title":"The retrospective chart review: important methodological considerations.","volume":"10","author":"V Matt","year":"2013","journal-title":"J Educ Eval Health Prof."},{"key":"pone.0311534.ref026","unstructured":"WHO Anthro Survey Analyser and other tools [Internet]. [cited 2024 May 9]. Available from: https:\/\/www.who.int\/tools\/child-growth-standards\/software"},{"key":"pone.0311534.ref027","unstructured":"Diarrhoea [Internet]. [cited 2024 May 13]. Available from: https:\/\/www.who.int\/health-topics\/diarrhoea"},{"key":"pone.0311534.ref028","unstructured":"The WHO AWaRe (Access, Watch, Reserve) antibiotic book\u2014Infographics\u2014PAHO\/WHO | Pan American Health Organization [Internet]. 2024 [cited 2024 May 9]. Available from: https:\/\/www.paho.org\/en\/documents\/who-aware-access-watch-reserve-antibiotic-book-infographics"},{"key":"pone.0311534.ref029","doi-asserted-by":"crossref","DOI":"10.1007\/978-0-387-87458-6","article-title":"Mixed Effects Models and Extensions in Ecology With R.","author":"A Zuur","year":"2009"},{"key":"pone.0311534.ref030","article-title":"Trends in severe acute malnutrition admissions, characteristics, and treatment outcomes in Malawi from 2011 through 2019 [Internet].","author":"AI Daniel","year":"2023","journal-title":"medRxiv"},{"key":"pone.0311534.ref031","unstructured":"Applying the Model for Improvement to Strengthen the Care for Children with Severe Acute Malnutrition (SAM) and Medical Complications in Malawi | Food and Nutrition Technical Assistance III Project (FANTA) [Internet]. [cited 2024 May 9]. Available from: https:\/\/www.fantaproject.org\/node\/1795"},{"issue":"1","key":"pone.0311534.ref032","doi-asserted-by":"crossref","first-page":"182","DOI":"10.1186\/s12887-020-02094-w","article-title":"Mortality among children under five years admitted for routine care of severe acute malnutrition: a prospective cohort study from Kampala","volume":"20","author":"D Nalwanga","year":"2020","journal-title":"Uganda. BMC Pediatr"},{"key":"pone.0311534.ref033","article-title":"State of Acute Malnutrition.","author":"Malnutrition S of A"},{"key":"pone.0311534.ref034","article-title":"Kwashiorkor: still an enigma\u2013the search must go on.","author":"MD Andr\u00e9 Briend","year":"2014"},{"issue":"3","key":"pone.0311534.ref035","first-page":"30","article-title":"The impact of HIV infection on the clinical presentation of severe malnutrition in children at QECH.","volume":"13","author":"L Kessler","year":"2001","journal-title":"Malawi Med J."},{"issue":"11","key":"pone.0311534.ref036","doi-asserted-by":"crossref","first-page":"e0002520","DOI":"10.1371\/journal.pgph.0002520","article-title":"The diagnosis and management of dehydration in children with wasting or nutritional edema: A systematic review.","volume":"3","author":"AT Tsegaye","year":"2023","journal-title":"PLOS Glob Public Health"},{"key":"pone.0311534.ref037","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.jpeds.2019.03.014","article-title":"Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda.","volume":"210","author":"B Grenov","year":"2019","journal-title":"J Pediatr"},{"key":"pone.0311534.ref038","article-title":"Predictor of Death in Diarrheal Children Under 5 Years of Age Having Severe Sepsis in an Urban Critical Care Ward in Bangladesh.","volume":"6","author":"M Sarmin","year":"2019","journal-title":"Glob Pediatr Health."},{"issue":"8","key":"pone.0311534.ref039","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1111\/tmi.13446","article-title":"Diarrhoeal children with concurrent severe wasting and stunting compared to severe wasting or severe stunting.","volume":"25","author":"S Nuzhat","year":"2020","journal-title":"Tropical Medicine & International Health."},{"key":"pone.0311534.ref040","unstructured":"Fluid management in severely malnourished children under 5 years of age without shock [Internet]. [cited 2024 May 13]. Available from: https:\/\/www.who.int\/tools\/elena\/interventions\/dehydration-sam"},{"key":"pone.0311534.ref041","unstructured":"WHO guideline on the prevention and management of wasting and nutritional oedema (\u200eacute malnutrition)\u200e in infants and children under 5 years [Internet]. [cited 2024 May 13]. Available from: https:\/\/www.who.int\/publications-detail-redirect\/9789240082830"},{"key":"pone.0311534.ref042","doi-asserted-by":"crossref","first-page":"66","DOI":"10.12688\/wellcomeopenres.12357.3","article-title":"Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review.","volume":"2","author":"KA Houston","year":"2017","journal-title":"Wellcome Open Res."}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0311534","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,26]],"date-time":"2024-12-26T18:32:08Z","timestamp":1735237928000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0311534"}},"subtitle":[],"editor":[{"given":"Nigusie Selomon","family":"Tibebu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2024,12,26]]},"references-count":42,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2024,12,26]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0311534","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,26]]}}}