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Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya^1,2,3,5

¹ From the Kenyan Medical Research Institute (KEMRI) Centre for Geographic Medicine Research (coast), Kilifi, Kenya (PB, SM, IM, SHA, FO, NP, KM, CRN, and JAB); the Nuffield Department of Medicine, Centre for Clinical Vaccinology and Tropical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom, (PB, SHA, and JAB); the Department of Paediatrics and Wellcome Trust Centre for Clinical Tropical Medicine, Imperial College, London, United Kingdom (KM); and the Institute of Child Health, University College, London, United Kingdom (CRN)

² This paper is published with the permission of the director of the Kenya Medical Research Institute (KEMRI).

³ Supported by KEMRI and the Wellcome Trust. JB, CRN, and PB are supported by the Wellcome Trust.

⁵ Reprints not available. Address correspondence to P Bejon, KEMRI Centre for Geographic Medicine Research, PO Box 230, Kilifi 80108, Kenya. E-mail: pbejon{at}kilifi.kemri-wellcome.org.

Background: Malnutrition is common in the developing world and associated with disease and mortality. Because malnutrition frequently occurs among children in the community as well as those with acute illness, and because anthropometric indicators of nutritional status are continuous variables that preclude a single definition of malnutrition, malnutrition-attributable fractions of admissions and deaths cannot be calculated by simply enumerating individual children.

Objective: We determined the malnutrition-attributable fractions among children admitted to a rural district hospital in Kenya, among inpatient deaths and among children with the major causes of severe disease.

Design: We analyzed data from children between 6 and 60 mo of age, comprising 13 307 admissions, 674 deaths, 3068 admissions with severe disease, and 562 community controls by logistic regression, using anthropometric z scores as the independent variable and admission or death as the outcome, to calculate the probability of admission as a result of "true malnutrition" for individual cases. Probabilities were averaged to calculate attributable fractions.

Results: Z scores < –3 were insensitive for malnutrition-attributable deaths and admissions, and no single threshold was both specific and sensitive. The overall malnutrition-attributable fraction for in-hospital deaths was 51% (95% CI: 42%, 61%) with midupper arm circumference. Similar malnutrition-attributable fractions were seen for the major causes of severe disease (severe malaria, gastroenteritis, lower respiratory tract infection, HIV, and invasive bacterial disease).

Conclusions: Despite global improvements, malnutrition still underlies half of the inpatient morbidity and mortality rates among children in rural Kenya. This contribution is underestimated by using conventional clinical definitions of severe malnutrition.