Evaluation of Nutritional Rehabilitation Wards in Basrah

Aim: A retrospective descriptive study was carried out to evaluate and address some selected variables of admitted children with severe acute malnutrition to five selected nutritional rehabilitation wards in Basrah, three central Hospitals, and two district hospitals. As well as to assess the extent of implementation of world health organization guidelines for management of severe acute malnutrition. Methods: The data registries of the selected nutritional rehabilitation wards are reviewed from 1 of January till 31 of December 2015. The following information were reviewed: date of birth, sex, Z score (weight for length), weight on admission and discharge, weight gain, oedema, days of hospitalization, clinical diagnosis on admission and the outcome on discharge. Result: Total number of registered patients are 530 with males and females percentage of (53.2% and 46.8%) respectively. Sixty six percent of admitted patients were aged below 12 months. Clinical presentation of admitted patients reveals that more than 50% of patients had diarrhoea followed by pneumonia (21%) and poor weight gain (13%). Facilities of studied hospitals were limited regarding allocated wards, beds and nursing staff, only Basrah General Hospital has isolated nutritional rehabilitation ward with 12 beds and 7 trained staff, other wards are just a room within paediatrics wards with 4-6 beds and only 2 nursing staff. Although high percentage of severe wasting, underweight and stunting reported in nutritional rehabilitation wards with statistically significant result P-value 0.001 still moderate malnutrition reported in (27%) of admitted patients. Poor weight gain was reported in 48% of total studied patients, with higher percentage of good weight gain in nutritional rehabilitation ward of Basrah General Hospital (93.7%) and least recorded percentage was (9.3%) in Al-Zubair Hospital. The outcome of the studied patients reveals that; (56.8%) of patients recovered with improvement of clinical symptoms and weight gain, the higher percentage was in the nutritional rehabilitation ward of Basrah General Hospital(85.5%) and the least one was in Basrah Maternity and Children's Hospital (38.3%). Short hospitalizations period is obvious from registered data approximately 59.4% of patients stayed for (1-5) days and only 4.9% stayed for (11-15) days. Days of hospitalization, weight gain and clinical presentation can be regarded as dependent risk factors associated with good outcome in malnourished patients. Conclusion: This study concludes that management of severe acute malnutrition was not satisfactory and incomplete with faulty recording of the registered data of admitted patients. Current study recommended that the documentation of all data and records seriously will result in better understanding of the reality of nutritional rehabilitation wards.


INTRODUCTION
evere acute malnutrition (SAM) is the major and common cause of morbidity and mortality among children under five years of age worldwide especially in developing countries. [1]Children with severe acute malnutrition have physiological and metabolic changes to conserve energy and preserve essential processes, including reductions in the functional capacity of organs and slowing of cellular activities.In addition to coexisting infections with the difficulty of maintaining metabolic control, severely malnourished children are at risk of death from hypoglycaemia, hypothermia, electrolytes imbalance, heart failure and untreated infection. [2,3]children with SAM are admitted to nutrition rehabilitation wards as the defined admission criteria, where they are managed and provided with medical and nutritional therapeutic care, in order to promote physical and psychosocial growth and build up the capacity of mothers in appropriate feeding practices. [4]World Health Organization (WHO) guidelines for management of children with severe malnutrition (6-59 months) involve ten steps in two phases; an initial stabilization phase, where the actual medical conditions are managed and a longer rehabilitation phase.Standardized case management protocol include appropriate feeding, micronutrient supplementation, antibiotic therapy, intravenous fluid for shock state, use of rehydration solution of malnutrition (ReSoMal) and careful management of complications.Feeding is a critical part in management of severe acute malnutrition should begin as soon as possible with F75 "starter formula" used for 2-7 days, followed by F100"catch up" formula.Therefore S severely malnourished children are prioritized for immediate admission to nutritional rehabilitation wards (NRWs) and with proper case management and follow up care, the case fatality rate can be lowered from over 30% to less than 5%. [5]TERIALS & METHODS This retrospective descriptive study had been carried out to review the registries data of children with severe acute malnutrition (SAM) admitted to the nutritional rehabilitation wards of five hospitals in Basrah governorate from 1 st of January to 31 st of December 2015.Three central hospitals; Basrah Maternity and Children Hospital (BMCH): has 6 beds for severe acute malnutrition within pediatrics wards.Basrah General Hospital (BGH): has isolated nutritional rehabilitation ward consists of 12 beds.Al-Mawani General Hospital (MGH) also has 4 beds for nutritional rehabilitation within paediatrics wards.Two district hospitals which were chosen purposely because they are easily accessible; Al-Zubair General Hospital(ZH); has only a room with 4 beds as nutrition room and Abu-Alkhasib General Hospital (AKH) with 4 beds within paediatrics wards.The Reviewed registered data are: date of birth, sex, Z-scores, weight on admission and discharge, weight gain, oedema, days of hospitalization, clinical diagnosis on admission and their outcome.
The three commonly used anthropometric indices are: weight-for-age (WFA), length-for-age or height-for-age (HFA) and weight-for-length or weight-for-height (WFH), used to identify underweight, stunting and wasting, respectively.Each of these nutritional indicators is expressed in standard deviation units from the median of the reference population and further classification accordingly as moderate (<-2 to >-3 SD) or severe (<-3 SD) malnutrition.Weight gain was expressed as gm/kg/day and classified into; poor less than 5gm/kg/day, moderate 5-10 gm/kg/day and good > 10 gm / kg / day.Admission criteria to NRW as follow: children aged 6 months and above; mid upper arm circumference (MUAC) less than 115 mm, WFH < -3 SD or oedema of both feet, while infants aged up to 6 months and below admission criteria are considered when have visible severe wasting, breast feeding difficulties or oedema of both feet.The basic needs for proper and sufficient milk preparation are: dietary weight scales (minimum 5 gm), measuring jar, electric blender, boiled water, refrigerator, cooking utensils, feeding cups, saucers, spoons and jugs.As well as kitchen, cooker and refrigerator to keep milk after preparation.Preparation of therapeutics milk from available local sources as milk, sugar, oil and minerals solution. [1]udy subjects and Data collection A request was submitted to the research committee at Basrah health directorate to facilitate gathering data from nutritional rehabilitation wards in five hospitals; as well as permission from pediatrics departments authorities was taken to review the registered data of admitted patients over a period of one year.Checklist had been arranged to review the proper practice of standardized case management protocol according to WHO guidelines for management of severe malnutrition includes the following aspects: weight gain, type of therapeutic milk as F75, F100 and diluted F100, choice of antibiotics, vitamin A and mineral supplementation and rehydration with ReSoMal.The diagnosis and registration records follow up were reviewed.

Facilities in the studied nutritional rehabilitation wards (NRWs)
Only BGH has isolated ward with 12 beds and 7 trained nursing staff; while all other nutritional rehabilitation wards were just rooms within paediatric wards with 4-6 beds, had limited nursing staff (only 2).Also insufficient milk preparation facilities were noticed because of the lack of isolated kitchen in nutritional rehabilitation wards of (MH) and (BMCH).

Characteristics of the studied malnourished patients
Total number of malnourished patients admitted to the nutritional rehabilitation wards were 530; their mean ages ranged from (1-48) months, 53.2% were males and 46.8% were females, their mean age was 11.6 ± 1.8 months.(Table -2), shows that the highest percentage of admitted patients were below 12 months (66%).Reviewed data of clinical presentation of admitted children revealed that more than 50% of malnourished patients had diarrhea followed by pneumonia (21%) and only (13.4%) had poor weight gain.5-A); 59.4% of all malnourished patients stayed for (1-5) days and only 4.9% stayed for (11-15) days with higher percentage for patients admitted to MGH and AKH (82.9% and 59.1%) respectively with the lowest percentage in BGH (41.8%).Ten out of the 26 (38.5%) of admitted patients who stayed for (11-15) days were from BGH.The result was statistically significant (P value= 0.001).Good and poor weight gain were recorded in (22.5% and 72.4%) and (74.1% and 15.1%) in children with hospitalization (1-5) and (6-10) days respectively, the result was statistically significant (P value= 0.001), (Table 5-B).6.9% ) respectively and declining to (5.6%) in the year 2014 according to the registered data. [6]ther researchers Hossain et al recorded a case fatality rate of 10.8% in Bangladesh. [17]The current study revealed that management of severe acute malnutrition was not satisfactory in some aspects with a problem of incomplete and faulty recording of the registered data.Ashraf et al has the same conclusion in a study carried out to explore the outcome of standardized case management of SAM in three hospitals in Bangladesh. [9]This study has its'limitation because of retrospectiveness, evidence of faulty case management practices reported; as weight gain records, admission criteria, initial antibiotics therapy, micronutrients, vitamin A supplements and follow up records.Events such as hypoglycemia, hypothermia, dehydration and electrolytes imbalance can't be identified.Same conclusion was reported by Mitulkumar, etal in India. [14]As mentioned earlier; monitoring case management practice retrospectively is difficult because of poor medical reports; common incorrect practices as irrational intravenous fluid prescription, incorrect choice of antibiotics and supplements as; vitamin A, folic acid and multivitamins were not given on regular basis.

Days of hospital stay of registered patients Short hospitalization period was obviously noticed (Table
In conclusion, incomplete and faulty recording system, some unrecorded and inconsistent data were observed in evaluated NRWs.Faulty case management practices was observed as well as absence of follow up, policy and records of discharged patients.Our recommendations are improvement of the knowledge of medical and paramedical staff through training courses on proper practice of case management of severe acute malnutrition and documentation of all data and records seriously and possibly future prospective study will result in better understanding of the reality of NRWs.

1. Distribution of the registered malnourished patients
Higher frequency of admitted malnourished patients to the nutritional rehabilitation wards of ZH and AK H (36.6%, 30.9%) respectively (Table-1).