The recovery rate from severe acute malnutrition among under-five years of children remains low in sub-Saharan Africa. A systematic review and meta-analysis of observational studies

BackgroundGlobally, Severe Acute Malnutrition (SAM) has been reduced by only 11% over the past 20 years and continues to be a significant cause of morbidity and mortality. So far, in Sub-Saharan Africa, several primary studies have been conducted on recovery rate and determinants of recovery from SAM in under-five children. However, comprehensive reviews that would have a shred of strong evidence for designing interventions are lacking. So, this review and meta-analysis was conducted to bridge this gap.MethodsA systematic review of observational studies published in the years between 1/1/2000 to 12/31/2018 was conducted following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement. Two reviewers have been searched and extracted data from CINAHL (EBSCO), MEDLINE (via Ovid), Emcare, PubMed databases, and Google scholar. Articles' quality was assessed using the Newcastle-Ottawa Scale by two independent reviewers, and only studies with fair to good quality were included in the final analysis. The review presented the pooled recovery rate from SAM and an odds ratio of risk factors affecting recovery rate after checking for heterogeneity and publication bias. The review has been registered in PROSPERO with protocol number CRD42019122085.ResultChildren with SAM from 54 primary studies (n = 140,148) were included. A pooled rate of recovery was 71.2% (95% CI: 68.5–73.8; I2 = 98.9%). Children who received routine medication (Pooled Odds ratio (POR):1.85;95% CI: 1.49–2.29; I2 = 0.0%), older age (POR: 1.99;95% CI: 1.29–3.08; I2 = 80.6%), and absence of co-morbidity (POR:3.2;95% CI: 2.15–4.76; I2 = 78.7%) had better odds of recovery. This systematic review and meta-analysis suggestes HIV infected children had lower recovery rate from SAM (POR; 0.19; 95% CI: 0.09–0.39; I2 = 42.9%) compared to those non-infected.ConclusionThe meta-analysis deciphers that the pooled recovery rate was below the SPHERE standard, and further works would be needed to improve the recovery rate. So, factors that were identified might help to revise the plan set by the countries, and further research might be required to explore health fascilities fidelity to the WHO SAM management protocol.

研究背景
全球范围内，重度急性营养不良（Severe Acute Malnutrition, SAM）在过去20年间仅降低了11%，仍是导致发病与死亡的重要诱因之一。迄今为止，撒哈拉以南非洲地区已开展多项针对5岁以下儿童SAM康复率及其影响因素的原创研究。然而，目前仍缺乏能够为干预措施制定提供可靠证据支撑的综合性综述研究。为此，本研究开展本次综述与元分析以填补这一研究空白。

研究方法
本研究遵循《流行病学观察性研究元分析规范（Meta-analysis of Observational Studies in Epidemiology, MOOSE）》，对2000年1月1日至2018年12月31日发表的观察性研究开展系统性综述。两名研究者通过CINAHL（EBSCO平台）、MEDLINE（通过Ovid平台）、Emcare、PubMed及Google Scholar数据库检索并提取数据。由两名独立研究者采用纽卡斯尔-渥太华量表（Newcastle-Ottawa Scale, NOS）对纳入文献的质量进行评估，仅将质量尚可及以上的研究纳入最终分析。本综述在检验异质性与发表偏倚后，报告了SAM的合并康复率以及影响康复率的危险因素的比值比。本研究已在PROSPERO平台注册，注册方案编号为CRD42019122085。

研究结果
本研究共纳入54项原创研究中的140148名SAM患儿。合并康复率为71.2%（95%置信区间：68.5%~73.8%；I²=98.9%）。接受常规药物治疗的患儿（合并比值比（Pooled Odds Ratio, POR）=1.85；95%CI：1.49~2.29；I²=0.0%）、年龄较大的患儿（POR=1.99；95%CI：1.29~3.08；I²=80.6%）以及无合并症的患儿康复的概率更高。本次系统性综述与元分析显示，与未感染HIV的患儿相比，HIV感染患儿的SAM康复率更低（POR=0.19；95%CI：0.09~0.39；I²=42.9%）。

研究结论
本次元分析结果显示，合并康复率低于SPHERE标准，仍需开展后续工作以提升康复率。因此，本研究识别的影响因素可协助各国修订现有干预方案，同时还需开展进一步研究以评估医疗机构对世界卫生组织（World Health Organization, WHO）SAM管理规范的执行依从性。