Description of bilateral oedema cases among children hospitalized in Mali and the Democratic Republic of Congo
Study design
Quantitative et qualitative study
Background
In Sub-Saharan Africa bilateral oedema is usually associated with Kwashiorkor, a form of severe acute malnutrition (SAM), but the sign can also be indicative of other pathologies. We aimed to describe the children presenting with bilateral oedema, to better understand their evolution and the underlying cause.
Our role
Coordination
Partners
- Ministry of health DRC and Mali
Methods
A prospective study conducted in Rutshuru, Democratic Republic of Congo (DRC) and Koutiala, Mali from October 2016 to December 2017 included children aged 6-59 months admitted with bilateral oedema. Clinical, anthropometric, biological, nutritional, and therapeutic characteristics and outcomes were collected. Description was done according to oedema severity and presence or absence of additional signs of SAM (MUAC<-3Z-score).
The qualitative study aimed to explore the perspectives and lived experiences of health professionals on the diagnosis and management of children with bilateral pitting oedema. Using a participatory approach, we conducted 21 indepth interviews, and 2 focus groups with health professionals at MSF health facilities who had worked in the settings of Koutiala (Mali) and Rutshuru (DRC) for at least 6 months.
Results
Quantitative part
A total of 1611 (488 - DRC; 1123 - Mali) children participated. Overall 98% were ≥12 months of age, 57% had additional signs of SAM while 16% and 49% presented 3+ oedema in DRC and Mali respectively. About half of the children tested were malaria-positive and 57% anaemic. Children with additional signs of SAM were significantly more anaemic (p<0.05) in DRC and more likely to be hypotensive in both sites (p<0.01).
Proteinuria was detected in 45% and 8% in DRC and Mali respectively. Fifty-six percent of Congolese and 91% of Malian children were discharged with no oedema within a median of 2 days [IQR:1-3] and 3 days [2-5] respectively. Seven percent of the children died while hospitalized, with 69% (DRC) and 61% (Mali) of deaths occurring in those with proteinuria and/or anaemia, and 78% and 69%, respectively, in the group with additional signs of SAM.
Qualitative part
The understanding of the bilateral pitting oedema phenomenon is complex. Health workers described clinical obstacles to reducing mortality, including: i) difficulties making the diagnosis due to a lack of specialized staff and insufficient resources, ii) challenges treating complications that may arise due to the complexity of the diseases associated with bilateral pitting oedema, and iii) lack of scientific evidence in the literature explaining the physiopathology of bilateral pitting oedema.
Proteinuria was detected in 45% and 8% in DRC and Mali respectively. Fifty-six percent of Congolese and 91% of Malian children were discharged with no oedema within a median of 2 days [IQR:1-3] and 3 days [2-5] respectively. Seven percent of the children died while hospitalized, with 69% (DRC) and 61% (Mali) of deaths occurring in those with proteinuria and/or anaemia, and 78% and 69%, respectively, in the group with additional signs of SAM. Proteinuria at admission was associated with at least a threefold elevated mortality risk in DRC (aOR 3.0, 95% CI 1.2-7.6; p=0.02) and in Mali (aOR 4.4, 95% CI 1.6-12.2; p=0.01).
Conclusion
This study shows differences in clinical and biological characteristics of children presenting with bilateral oedema, some of which are associated with mortality.
Key recommendations for reducing mortality among children presenting with bilateral pitting oedema included prevention of bilateral pitting oedema at the community level, standardization of the diagnostic process, strengthening of medical training, and better collaboration both within the medical teams and between teams and the children’s families.
