Case fatality in severe acute malnutrition: Determinants and modifiable factors in hospitalised children in Vhembe district, South Africa

Background. In 2019, one-quarter of child deaths in South African (SA) hospitals were attributed to severe acute malnutrition (SAM). Objectives. To identify demographic, clinical, case management and health system factors contributing to mortality in children aged <5 years with SAM admitted to three hospitals in Vhembe district, Limpopo, SA. Methods. A retrospective record review was conducted for children aged 6 - 59 months admitted with SAM over a 30-month period. Bivariable and multivariable regression analyses were used to determine mortality factors. Results. A total of 245 children with SAM were identified, with a median (interquartile range) age of 14 (10 - 18) months. The overall SAM case-fatality rate was 26.9% (66/245), significantly higher than routine data estimates. Key clinical factors associated with mortality included diarrhoea at presentation (odds ratio (OR) 3.34, 95% confidence interval (CI) 1.38 - 8.10), anaemia (OR 3.30, 95% CI 1.28 - 8.50), raised C-reactive protein (OR 9.29, 95% CI 2.81 - 30.76) and hyponatraemia (OR 6.64, 95% CI 2.70 - 16.31). Additional contributors included late presentation, self-referral, limited triage, poor recognition and management of comorbidities and inadequate compliance with SAM guidelines. HIV status and shock were not significant determinants of mortality. Conclusion. SAM mortality was alarmingly high, particularly in the context of a high middle-income country setting with established treatment protocols. The striking discrepancy between the observed case fatality rate and routine district health information system data highlights the need for review of data quality and reporting systems. Targeted interventions addressing both clinical risk factors and systemic gaps are essential to reduce mortality and improve outcomes for children with SAM.