This was a descriptive cross-sectional study on children aged between 6 and 59 months hospitalized in the pediatric ward of the Kalaban Coro Reference Health Center for severe acute malnutrition.

The Koulikoro region, Mali’s 2nd administrative region, comprises 08 health districts. The Kalaban Coro health district, which is the 3rd, had a reference health center, which is the 2nd level of contact for local populations, and 27 community health centers (CHC), which are the first level of contact for communities in Mali’s health pyramid.

This study took place from January 1, 2020 to December 31, 2021, in the pediatrics department of the Kalaban Coro Reference Health Center.

The source population consisted of malnourished children aged 6-59 months from the Kalaban Coro health district. The target population consisted of malnourished children of the same age admitted to the Kalaban Coro referral health center for severe acute malnutrition during the study period.

All children aged 6 to 59 months admitted to the pediatric unit with a weight/height ratio < −3 Zscore or MUAC < 115 mm with or without nutritional edema were included in this study. Not included in this study, children whose files could not be used, those whose names did not appear in the hospitalization register, children aged over 5 years; children with chronic malnutrition and children with moderate acute malnutrition.

Given the objective of the study, we carried out an exhaustive sampling of all eligible cases registered during the study period.

Data were collected from medical records and hospital registers, using a questionnaire designed for this purpose. In addition to the questionnaires, the other tools used were:

The variables collected were:

After manual processing, checking and correction of outliers, the data were entered into Microsoft Excel and analyzed using SPSS version 20.

The analysis plan comprised two stages. First, we carried out a descriptive analysis of the study sample. Quantitative variables were described in terms of mean and extremes, and qualitative variables in terms of percentage. Secondly, an association was sought between the indicators of care performance (cure, death, abandonment and referral) and certain potential explanatory variables. The analysis was limited to univariate analysis, and the Chi-Squared Test was used for this purpose. The significance level was set at 5%.

The purpose of the study was explained to the parents (father, guardian or mother) of each child, and their verbal agreement to the use of their children’s medical data to help enrich the scientific data was obtained. Anonymity and confidentiality were respected throughout the study process.

According to the IMAM (Integrated Management of Acute Malnutrition) approach in Mali, there are three malnutrition management units ( Figure 1 ):

URENAM: Moderate Outpatient Nutritional Recovery and Education Unit in Community Health Worker Sites (CWS).

A total of 534 children aged 6 to 59 months meeting the inclusion criteria were enrolled. The mean age was 25.75 ± 48 months, with extremes of 9 and 48 months. The age range most represented was 12 to 23 months, and females were most affected. In terms of vaccination status, almost half (49.4%) of the children had received all the vaccines according to their age, 35.6% incompletely vaccinated and 15% were never vaccinated ( Table 1 ).

M ± SD*: Means Standard deviation.

The most represented age group was 20 - 40, with 77.5% (n = 414) of fathers and 63.1% (n = 337) of mothers. The majority of parents (31.8%; n = 170) of fathers and 38.6% (n = 206) of mothers were illiterate. The majority of fathers were married (95.9%; n = 512), with polygamy the most common matrimonial regime (89.0%; n = 475).

Approximately 96.1% (n = 513) mothers were married, 71.7% (n = 383) were housewives and 43.3% (n = 231) were primiparous, 41.4% (n = 221) were multiparous and 15.5% (n = 82) were large multiparous. The majority of the children’s parents (83.18%) came from the urban commune of Kalaban Coro.

The average income of children’s mothers was respectively 2.500 FCFA (less than 10 US Dollars) per month for housewives and 85.000 FCFA (less than 200 US Dollars) for civil servant mothers and those with income-generating activities. The average income of fathers was 45,000 FCFA (approximately 76.5 US Dollars) for workers and 150.000 FCFA (approximately 255 US Dollars) for state employees.

The clinical and nutritional profile of the children are described in Table 2 . With regard to clinical data, diarrhea/vomiting (30.3%; n = 162), fever (18.4%; n = 98), cough (15.5%; n = 83) and anorexia (15%; n = 80) were the main reasons for consultation; 68.5% (n = 365) of children were admitted spontaneously. Thirty-five patients (6.5%) had a history of malnutrition. The main clinical signs included hypothermia in 60.9% (n = 325) of case, hypoglycemia in 56.2% (n = 300) of case, candidiasis (49.1%; n = 262), bilateral oedema (22.1%; n = 118), dehydration folds /denutrition folds (12.5%; n = 76), conjunctival pallor (6.7%; n = 36) and a prominent abdomen (5.4%; n = 29).

Nutritional inclusion criteria included weight/height ratio < −3 Z-Score in 38.9% (n = 208), brachial perimeter (BP < 115mm) in 38.6% (n = 206) and bilateral oedema in 22.5% (n = 120). Marasmus was the most frequent form of malnutrition with 77.9% (n = 416) of cases, followed by Kwashiorkor (17%; n = 91) and the mixed form (5.1%; n = 27).

Breastfeeding was not exclusive in 82.2% (n = 439), artificial in 3.7% (n = 20) and mixed in 8.2% (n = 44). Supplementary feeding had been introduced before the 6th month of life in 44.4% (n = 237), between 6 and 12 months in 43.4% (n = 232) and beyond 12 months in 12.2% (n = 65). The weaning age was less than 6 months in 3.6% (n = 19), between 6 to 12 months in 8.2% (n = 44), between 13 to 18 months in 9.6% (n = 51) and more than 18 months in 31.6% (n = 166). The type of withdrawal was gradual in 37.8% (n = 202) and abrupt in 15.2% (n = 81). The causes of weaning were the required age according to the mothers (65%; n = 184), close pregnancy (20.5%; n = 58) and illnesses of the child and/or the mother (7.5 %; n = 20).

The length of hospital stay was between 8 and 14 days in 49.8% of cases, with an average of 8.5 ± 10.1 days.

The highest admission frequencies were observed in September (15%), July (14.4%) and October (14.2%), with extremes in August and September (4.5%-15%). These periods are known as the hunger gap in Mali ( Figure 2 ).

Digestive disorders (39.3%; n = 210), malaria (35.4%; n = 189), acute respiratory infections (14.2%; n = 76), measles (3.6%; n = 19), HIV/AIDS (2.4%; n = 13) and meningitis (1.9%; n = 10) were the associated pathologies encountered ( Table 3 ).

Indicator performance was marked by recovery (82.3%), drop-out (2.1%), transfer (6.4%) and death (9.2%). Monitoring was done once a week during the first month and once every two weeks during the 2nd and 3rd months. The causes of death were severe dehydration (42.9%; n = 21), malaria (34.7%; n = 17) and respiratory conditions (18.4%; n = 9) ( Figure 3 ).

In univariate analysis, the factors statistically associated with performance indicators (cure, drop-out, death) were gastroenteritis (P-value < 0.01), malaria (P-value < 0.01) and acute respiratory infections (P < 0.01). Type of admission and length of hospital stay were not statistically associated with child outcome (p > 0.05) ( Table 4 ).

>=*: greater than or equal to; ARI*: Acute Respiratory Infections.

The aim of this study was to describe the epidemioclinical profile and determinants of performance indicators for the management of severe acute malnutrition in children aged 06-59 months in the pediatric ward of the Kalaban Coro referral health center in the Koulikoro region.

The 12 - 23 months age bracket and the female sex were the most affected, as in several studies reported in the literature [4] [10] - [14] . From a sociological point of view, this predominance of females is a major advantage in terms of the quality of care given to children and the quality of nutritional advice given. The predominance of the 12 - 24 months age group has been reported by several other authors [11] [13] - [15] . Malnutrition at this age could be explained by inadequate dietary diversification, done early or late or with unsuitable complementary foods, or early ablactation following the onset of a new pregnancy. It could also be the result of insufficient food consumption, poor practice of food hygiene rules and/or poor attendance at health services. In our context, one of the root causes of the occurrence of malnutrition in the 12 - 23 months age group is the poor knowledge of populations about good nutritional practices.

Vaccination is an intervention that protects children against many diseases and strengthens their immune systems in the face of numerous aggressions. Despite these facts, many African children do not benefit from this intervention, which is one of their fundamental rights. In our study, less than half (49.4%) of the children included had the correct immunization status for their age. However, the proportion of fully vaccinated children in our study considered low is higher than the 44% reported by Bire and Shifeta in a study carried out in Ethiopia. The low proportion of vaccination coverage observed in our series could be explained on the one hand, by the non-compliance with the vaccination schedule by the parents of children and on the other hand, by the low effectiveness of advanced and mobile strategies which were largely impacted. by the security crisis. This unfortunate observation requires the implementation of local strategies to achieve vaccination targets in a context of insecurity.

As for the parents’ characteristics, most of them were illiterate and had no stable source of income. Indeed, the average income of children’s mothers was respectively 2.500 FCFA (less than 10 US Dollars) per month for housewives and 85.000 FCFA (less than 200 US Dollars) for civil servant mothers and those with income-generating activities. The average income of fathers was 45,000 FCFA (approximately 76.5 US Dollars) for workers and 150.000 FCFA (approximately 255 US Dollars) for state employees. In addition to this, there are in our context, demographic factors that influence the nutrition and health of children in particular. In fact, 89.0% of fathers were polygamous and 15.5% of mothers were multiparous. Our data corroborate those reported in the literature series [15] [16] . As a result, families with low or unstable incomes and large families are more exposed to malnutrition. This exposure manifests itself at the family level in chronic undernourishment, which in turn leads to malnutrition.

Five hundred and thirty-four severely acutely malnourished children out of two thousand eight hundred and thirty-six hospitalized in the department were enrolled, representing a frequency of 18.8%. Although this frequency is lower than that reported by some authors [17] [18] , it remains very high for a pathology considered avoidable through the adoption of simple measures such as exclusive breastfeeding, vaccination and good nutritional practice. The root cause of the non-application of these measures is the illiteracy or low level of education of the population in general. The highest admission frequencies were observed in September (15%), July (14.4%), and October (14.2%). These periods are known as lean times in Mali, when many households are unable to provide the three meals of the day. These periods are also times of high frequency of certain pathologies such as malaria and gastroenteritis which are part of the immediate causes of malnutrition.

In terms of clinical features, diarrhea/vomiting, fever, cough and anorexia were, in order of frequency, the main reasons for consultation. Thirty-five patients (6.5%) had a history of malnutrition. This situation would reflect a system problem due to the poverty of families in terms of their monthly income and the low level of knowledge of the populations. The main signs on physical examination included candidiasis (49.1%), bilateral oedema (22.1%), dehydration/denutrition folds (12.5%), conjunctival pallor (6.7%) and a prominent abdomen (5.4%). A similar trend was reported in work by SANOGO M Y [19] . These signs are fairly frequent in malnourished children, and can be explained by the fact that their immune system is weakened, making them more vulnerable than others to comorbidities. Poor individual and collective hygiene practices, combined with incomplete immunization status according to age, encourage the recrudescence of these signs in malnourished children.

From a nutritional point of view, admission or hospitalization criteria were based on the results of anthropometric measurements such as weight/height ratio, brachial perimeter (BP) and the search for edema of the lower limbs. Weight/height ratio < −3 Z-Score and brachial perimeter (BP) < 115 mm accounted for 38.9% and 38.6% respectively. These data were lower than the 56.1% reported by Nguefack et al. [20] and the 58.8% reported by Kahinda et al. [21] .

Marasmus was the most frequent form of malnutrition with 77.9% of cases, followed by Kwashiorkor (17%) and the mixed form (5.1%). Our results are clearly inferior to those reported in studies conducted by Coulibaly AT [15] , but close to those of this author [22] . The predominance of the slump in our study could partly be explained by the deterioration of the food situation and poverty which are aggravated by the multidimensional crisis that our populations are experiencing.

Despite sufficient advice being given during antenatal and postnatal consultations on the benefits of early breastfeeding, exclusive breastfeeding and nutrition plans during pregnancy, breastfeeding and infant and young child feeding, beliefs cultural, low level of education of parents and poverty prevent them from correctly following all the advice received and remains a challenge in our communities, as confirmed by our study. Indeed 82.2% of children were not exclusively breastfed until the 6th month of life and weaning was abrupt in 15.2% of cases. As for weaning, it is not carried out under the right conditions. Weaning is usually decided abruptly, without taking the minimum food diversification measures necessary for the child. According to the standards, diversification must take place from 6 months. In our context, the common fact is that this weaning is generally done suddenly without diversification beforehand. It occurs during a new pregnancy or an illness, which makes it difficult for the child to overcome, thus leading to a breakdown in nutritional balance and an immune deficiency. In addition, illiteracy promotes traditional beliefs about food taboos. According to these beliefs, children’s consumption of certain foods such as fish, meat and eggs would lead them to theft. In our contexts, children were essentially given family dishes as a substitute food, and even if the opposite occurred, mothers were generally unaware of when and how to diversify or ablactate.

As in the study conducted by Maïga M et al. [23] , the main causes of withdrawal cited in the study were age as defined by the mothers (65.0%), close pregnancy (20.5%) and illness of mother and/or child (7.4%). This reflects a problem with the adoption of modern contraceptive methods by parents which remains a very sensitive phenomenon in many environments.

The diagnosis of underlying pathologies was made after screening for severe acute malnutrition in subjects aged 6-59 months admitted to the Kalaban Coro reference health center for various reasons. Gastroenteritis followed by malaria, acute respiratory infections and HIV/AIDS were the main pathologies associated with malnutrition in our study. This same trend was reported in a study carried out in Mali in 2019 [23] but different from that reported in the studies conducted by Bire and Shifeta where anemia followed by pneumonia and gastroenteritis predominated [24] . The proportion of patients infected with HIV (2.4%) observed in our study was close to that (2.2%) reported in a study carried out in Uganda in 2021 [25] but much lower than those reported in the work of several other series in the literature [20] [21] [26] [27] . This difference could be explained by the non-systematization of HIV screening in our malnutrition treatment units, even though they can be the gateway to entry. Malaria represented 35.4% in our study and was the second comorbidity. This could be explained by the endemicity of this pathology and the inadequacy of non-compliance with preventive measures. This proportion is lower than 39.1% reported by Odikro et al. [23] but higher than the 19% and 20% reported in work carried out respectively in Cameroon [24] and Niger [28] .

In this study, we did not look for the pathologies causing malnutrition in our hospitalized children. However, the high frequency of underlying diseases strongly directs us towards causality or the contribution of these pathologies in the occurrence of malnutrition in our patients given that these underlying pathologies are considered as immediate causes of malnutrition according to the literature [29] .

The evolution of patients was marked by cure (82.3%) for a reference threshold above 75%, death (9.2%) versus a reference below 10% in URNAS and URENI, and abandonment (2.1%) for a reference value below 15% in URENAS and URENI. We recorded 6.4% referrals to a higher structure, including 1.9% for lack of space and 4.5% for medical transfer. All these performance indicators are acceptable according to IMAM standards in Mali [30] . This performance could be explained by the very low frequency of input shortages, the capacity-building of IMAM providers and the close follow-up of patients.

The drop-out rate observed in our series could be explained mainly by the parents’ lack of financial means for the management of associated pathologies, or their desire to return home for other family problems. As for the deaths that did occur, they could be caused, on the one hand, by an alteration in the immune system associated with malnutrition, making the children highly vulnerable, and on the other hand, by a late consultation and/or referral of malnourished patients, which usually takes place after the onset of complications.

The length of hospitalization generally depends on the course of the disease. In our study, the majority of patients (49.8%) had a hospital stay of between 8 and 14 days, which is lower than the reference value (˂ 4 weeks) indicated in the integrated management of acute malnutrition, but close to the WHO standards, which indicate a length of stay of 7 - 10 days at the URENI [14] .

In view of these findings, strengthening communication for development (C4D) activities is one of the communication approaches needed to help reduce this rate. This communication, focused on behavioral change, is an “interactive process for the development of specific messages and approaches using various communication channels with the aim of encouraging and supporting appropriate positive behaviors”. These desired behaviors include adherence to treatment, and respect for therapeutic follow-up. Other approaches, such as the use of community relays and community platforms, could play an important role in raising community awareness.

Associated pathologies can be either a direct cause of the occurrence of malnutrition, or a consequence of malnutrition due to the vulnerability of the state of health of persons in case of malnutrition or vice versa. In our study, the factors statistically associated with performance indicators (cure, abandonment, death) were gastroenteritis (P-value < 0.01), malaria (P-value < 0.01) and acute respiratory infections (P < 0.01). These results confirm data from the literature, where these pathologies have been identified as independent factors associated with the occurrence of death in children under five years of age [31] - [34] .

Contrary to the literature, type of admission and length of hospital stay were not statistically associated with outcome in our study (p > 0.05).