Prospective cohort study of referred Malawian children and their survival by hypoxaemia and hypoglycaemia status

Objective

To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression.

Methods

The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji

district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (SpO2) and blood glucose were measured at recruitment and on

arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after

discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between SpO2 and blood

glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching.

Findings

Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (SpO2: 90–93%) in 13.1%

(108/826) and severe (SpO2: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5–4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality.

Conclusion

Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio

observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving

hypoxaemia identification and management are needed.