Abstract

Introduction: Severe Acute Malnutrition remains a major public health problem among children under 5 years in Niger. The objective of this work was to study biological abnormalities in Severe Acute Malnutrition at the National Hospital of Niamey. Materials and Methods: This was a descriptive and analytical cross-sectional study conducted from January 2023 to December 2024 at the National Hospital of Niamey. The study covered children aged 1 to 59 months admitted for Severe Acute Malnutrition. The variables studied were related to blood count abnormalities, blood ionogram disturbances, and microbiological abnormalities. Data analysis was performed using Sphinx Plus Version 5.0 software. Results: Of 5439 children hospitalized, 300 children (5.5%) with Severe Acute Malnutrition were recorded. The mean age of patients was 14.48 months ± 9.08 [1 - 59 months]. Fever (79.3%) and diarrhea (72.7%) were observed. Blood count analysis showed anemia in 97.3% of patients. Moderate anemia was present in 51.4% of cases and severe anemia in 29.8% of patients. In white blood cell count, hyperleukocytosis was found in 63.7%. Thrombocytosis was found in 25.7%. Blood ionogram abnormalities included hyponatremia (62.9%) and hypokalemia (50.6%). Hypoglycemia was present in 66% of patients. Urinalysis was positive in 36% of cases. The main germ found was Escherichia coli in 5.3%. Stool culture was positive in two (2) patients. Conclusion: Blood count abnormalities such as anemia, hyperleukocytosis, and thrombocytosis are frequent. Hypoglycemia, hyponatremia, and hypokalemia are also common. Biological disturbances must be systematically screened for the adequate management of the patients.

Keywords

Severe Acute Malnutrition, Anemia, Hypoglycemia, Hyponatremia, Niger

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1. Introduction

Severe Acute Malnutrition remains a major public health problem among children under 5 years of age worldwide [1] [2]. In Niger, it was one of the causes of morbidity and mortality in children [3] [4]. It is responsible for several clinical and paraclinical abnormalities. Indeed, metabolic disorders and secondary hematological abnormalities have been reported as a result of nutritional deficiency or associated complications. These abnormalities are a major cause of morbidity and often worsen the child’s prognosis [5] [6]. In our context, few studies have been conducted on these morbid entities. The objective of this work was to study biological abnormalities in Severe Acute Malnutrition at the National Hospital of Niamey.

2. Materials and Methods

2.1. Type and Period of Study

This was a descriptive and analytical cross-sectional study conducted over a one-year period, from January to December 2024.

2.2. Study Population

The study covered children aged 1 to 59 months admitted for Severe Acute Malnutrition to the Internal Nutritional Recovery Center (INRC) at the National Hospital of Niamey.

2.2.1. Inclusion Criteria

Children admitted for whom biological tests were performed, including at least a complete blood count, blood ionogram (sodium and potassium levels), bacteriological cultures (cytobacteriological examination of urine [CBEU] and stool culture), and thick smear, were included.

2.2.2. Exclusion Criteria

Children transferred to other departments before the end of treatment and those who left the hospital were excluded from the study.

2.2.3. Sampling Method and Sample Size

The minimum sample size was calculated using the SCHWARTZ formula:

n = Ɛὰ² × pq ÷ xi²

where p is the prevalence of acute malnutrition, q = 1 − p; ὰ = the accepted risk of error (5%), Ɛ = reduced deviation at alpha risk (ὰ) = 1.96 and 95% precision, i = desired precision (0.01). With a prevalence of 51.2% according to a hospital study in Niger [7], an error risk ὰ of 5%, a reduced deviation at risk ὰ of 1.96 and the desired precision i of 0.01, the minimum sample size was approximately 240 cases. For convenience, 300 patients meeting the inclusion criteria were studied.

2.3. Variables Studied

The variables studied were related to the general characteristics of the children (age, sex, clinical signs, treatment). Next, blood count abnormalities (presence of anemia, leukocytosis, and platelets) and ionogram disturbances (hyponatremia, hypokalemia) were explored. Finally, microbiological abnormalities (urinalysis, stool culture), variables related to associated diagnoses, and evolutionary aspects were studied.

2.4. Diagnostic Criteria and Operational Definition of Variables

Severe Acute Malnutrition was diagnosed according to WHO methods [8]. Anemia was defined as a hemoglobin level below 10 g/dL (moderate between 10 g/dL and 5 g/dL, and severe if <5 g/dL). Hyperleukocytosis was defined as a white blood cell count > 10,000 cells/mm³, and leukopenia as <5000 cells/mm³. For platelets, thrombocytosis was defined as a platelet count > 450,000 cells/mm³, and thrombocytopenia as < 150,000 cells/mm³. Hypoglycemia was defined as a venous blood glucose level below 3.3 mmol/L, hyponatremia as a serum sodium level < 130 mmol/L, and hypokalemia as a serum potassium level < 3 mmol/L.

2.5. Data Collection and Analysis

Data were collected from patient medical records and patient monitoring forms. Data entry and analysis were performed using Sphinx Plus Version 5.0 software. Data were expressed as numbers and proportions for the descriptive part. Pearson’s chi-square test or Fisher’s exact test was used to investigate the relationship between qualitative variables. The test was non-significant if the p-value (p) was less than 0.05.

3. Results

3.1. Characteristics of the Study Population

A total of 300 children (5.5%) were included out of the 5439 children hospitalized in the department during the study period. The 12- to 24-month age group was the most represented (46.3%). The mean age of patients was 14.48 months ± 9.08 [1 - 59 months]. The sex ratio was 1.41. Fever, diarrhea, and vomiting were the main reasons for consultation, with 79.3%, 72.7%, and 66.7% respectively. Physical examination revealed severe weight loss, moderate skin and mucosal pallor, and dehydration in 85.3%, 48.7%, and 11.4%, respectively. Lethargy was also found in 70% of patients. Marasmus was the most common clinical form (77.3%). Nutritional treatment based on therapeutic milk was instituted in all patients. Antibiotic therapy, antimalarial treatment, and oral rehydration were administered in 96.7%, 40.7%, and 33.7% of cases, respectively.

3.2. Blood Count and Biochemical Abnormalities

Blood count data are shown in Table 1. Blood count analysis showed anemia in 97.3% of patients. It was moderate anemia in 51.4% of cases and severe in 29.8% of patients. In the white blood cell count, hyperleukocytosis was found in 63.7%. Thrombocytosis and thrombocytopenia were the abnormalities found in platelets, with 25.7% and 7.7% respectively. Blood ionogram abnormalities (Table 2) included hyponatremia (62.9%) and hypokalemia (50.6%). Hypoglycemia was present in 66% of patients.

Table 1. Blood count results.

Table 2. Blood ionogram and sugar level.

3.3. Microbiological Abnormalities

Table 3 shows the results of microbiological and serological tests (urinalysis, stool culture, thick smear, and human immunodeficiency virus [HIV] serology). Stool culture was performed in 34.7% of cases (N = 104), with only two (2) positive results (Escherichia coli). Urinalysis was performed in 43.3% of patients, with a positive culture in 7.8% of cases. The main germ found was Escherichia coli in 5.3% of the samples tested. HIV serology was requested for all patients, with only one (1) positive result (0.3%).

Table 3. Microbiological results.

3.4. Associated Pathologies and Evolutionary Aspects

The main associated pathologies were malaria (38.7%), and suspected urinary tract infection (34.6%) or digestive tract infection (43.3%). Seven (7) deaths were reported (2.3%). No links were found between blood count abnormalities (anemia, leukocytosis, and platelet abnormalities), ionogram disturbances (hyponatremia, hypokalemia), hypoglycemia, and deaths (p > 0.05).

4. Discussion

Based on the results obtained, this study found a high frequency of biological disturbances associated with Severe Acute Malnutrition. The limitations of this study were mainly related to the non-exhaustiveness of the biological tests, in particular the exploration of micronutrients such as iron, vitamins, and other nutritional markers. In addition, antibiotic therapy, which is almost systematic in children suffering from Severe Acute Malnutrition, also probably limited the positivity of microbiological tests. Another limitation of the study is the relatively small sample size, which may affect the power of the statistical tests used to detect significant associations between biological abnormalities and mortality.

Blood count abnormalities such as anemia have been reported by other authors, with varying proportions [8]-[12]. The data found in this study regarding anemia differed from those reported by Traore et al. in Mali [13], where the authors found a higher proportion of severe anemia, with 19% of cases. Mikolele-Bilombo et al. [10] in Congo Brazzaville also reported a different profile, with varying degrees of anemia in all patients. Anemia during Severe Acute Malnutrition has multiple causes [5] [6] [14]. On the one hand, it is a deficiency anemia. In severe acute malnutrition, there is a quantitative deficiency of micronutrients in the body, some of which are essential for hematopoiesis. These include iron, folic acid, and vitamin B12. Unlike the present study, some authors have been able to measure the levels of these micronutrients. Panda et al. reported a frequency of hypoferritinemia, indicating iron deficiency, in 31.6% of malnourished children [15]. Another study on microcytic anemia, conducted by Malam-Abdou et al., found that 32% of children were malnourished and 9% had iron deficiency anemia [16]. On the other hand, malnourished children have compromised immune systems, which predisposes them to infections and therefore to inflammatory anemia [14]. To combat anemia and micronutrient deficiencies in general, the WHO has developed enriched milk formulas for the treatment of nutritional deficiencies [17]. Furthermore, these observations suggest regular monitoring of the status of the micronutrients concerned in order to implement a supplementation strategy with a view to reducing the associated morbidity.

The hyperleukocytosis or leukopenia found in this study has also been reported by other authors [15] [18]. The leukocytosis observed during severe acute malnutrition is thought to be secondary to micronutrient deficiencies responsible for immune system dysfunction [18] [19]. These disorders expose children to repeated bacterial, viral, or parasitic infections, complicating the clinical picture. These infectious diseases are sometimes obvious, but more often than not, active investigation is required, as recommended by the management protocol [17]. Infections are screened for by performing bacterial cultures (blood cultures, stool cultures, and urine cultures).

In this study, bacterial cultures performed on patients were mostly negative, raising the issue of routine antibiotic therapy in children suffering from severe acute malnutrition. HIV screening is also routine according to the national protocol for the prevention and management of acute malnutrition in Niger [20]. This was found in one case in the present study. This result differs from those of Traore et al. and Nkumisongo et al., who reported 12.90% and 19.3% of cases positive for HIV [13] [21]. The increased susceptibility to infection in children suffering from severe acute malnutrition also explains the high frequency of malaria found in this study. Malaria infection was also reported in a study in the Democratic Republic of Congo with a lower frequency (16.1%) [21].

Glycemic regulation disorders, particularly hypoglycemia, were present in about one-third of patients. This result is similar to that of Traore et al. [13], who found hypoglycemia in 45% of cases. This frequency of hypoglycemia is probably correlated with the frequency of lethargy found in the majority of patients on admission. Hypoglycemia is quite common in malnourished children due to oxidative stress [22]. This predisposition to hypoglycemia has led the national protocol for the prevention and management of acute malnutrition to systematically recommend a glucose bolus, either through hypertonic glucose serum or therapeutic milk [20]. Ionic disorders such as hyponatremia and hypokalemia reported could be explained by the high frequency of fluid loss, particularly diarrhea and vomiting. This leads to dehydration, which has been reported in other studies with varying frequencies [7] [23]. These abnormalities must be actively screened for and adequately managed, as they are a source of morbidity and mortality.

5. Conclusion

Biological abnormalities are common in cases of Severe Acute Malnutrition in our context. The main blood count abnormalities were anemia, hyperleukocytosis, and thrombocytosis, suggesting systematic screening in malnourished children. The ionogram revealed hyponatremia and hypokalemia in patients that are often secondary to dehydration. Hypoglycemia, a feared complication, was also common. Bacterial infections were weakly positive, with Escherichia coli being the most commonly found germ. These biological disturbances must be systematically screened for and lead to a rigorous diagnostic approach and adequate management.

Conflicts of Interest

There are no conflicts of interest.

References