Severe acute malnutrition (SAM) is a life-threatening condition that affects children under five years of age and is associated with significant morbidity and mortality. According to the World Health Organization (WHO) and UNICEF, SAM in children aged 6–59 months is defined by any of the following: weight-for-height below –3 standard deviations (SD) of the WHO child growth standards median, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper arm circumference (MUAC) less than 11.5 cm [1]. It typically manifests in the form of wasting (marasmus), nutritional oedema (kwashiorkor), or a combination of both (marasmus kwashiorkor) [2].

The National Family Health Survey (NFHS) reports that the prevalence of severe wasting among Indian children, as per WHO child growth standards, is approximately 7.9% [3]. Among the estimated 19 million children affected by SAM worldwide, India alone contributes nearly 8 million cases, which is twice the burden observed in sub-Saharan Africa. The global burden of SAM is immense, affecting an estimated 20 million children under five years of age and contributing to 1 to 2 million preventable child deaths annually [4]. SAM often arises from a prolonged nutritional deficit and is frequently complicated by reduced appetite and concurrent infections [5]. In turn, malnutrition weakens immunity, increasing susceptibility to infections. Diarrhoea, acute respiratory tract infections, and malaria remain the most common causes of death in children with SAM, especially in regions with limited healthcare access [6]. Additionally, micronutrient deficiencies such as anaemia, vitamin B-complex deficiency, vitamin D deficiency, vitamin A deficiency, and scurvy are frequently encountered among children suffering from SAM [7].

The present study was conducted to assess the prevalence of infections and micronutrient deficiencies in children diagnosed with SAM in Koraput district. This hospital-based study was undertaken in the Department of Paediatrics at SLN Medical College and Hospital, Koraput, to understand the clinical profile and associated co-morbidities in this vulnerable population.

This descriptive observational study was carried out in the Department of Paediatric Medicine, SLN Medical College and Hospital, Koraput, Odisha, over a period of one year. The study included children between the ages of 6 to 59 months who were admitted to the paediatric ward with features of severe acute malnutrition. According to WHO and UNICEF criteria, SAM was identified in children who presented with any one of the following features: weight-for-height below –3 standard deviations of the WHO growth reference median, mid-upper arm circumference less than 11.5 cm, presence of bilateral pitting oedema, or visible severe wasting [8].

Children were excluded from the study if consent was not provided by their guardians, if they expired before relevant investigations could be completed, or if they had pre-existing major congenital malformations or chronic systemic diseases such as chronic kidney disease or liver disease. Relevant clinical and demographic information was collected using a pre-tested, structured proforma. This included a detailed history, physical examination, and systemic evaluation. Anthropometric measurements such as weight, height/length, and MUAC were recorded. Socioeconomic status was assessed using the Modified Kuppuswamy scale, which considers parental occupation, education, and family income [9].

The study also assessed tuberculosis exposure based on history of contact with a known case of pulmonary tuberculosis in the recent past, especially within the preceding two years. Immunization status was reviewed against the schedule prescribed by the National Immunization Programme (NIP) [10]. Infectious co-morbidities were evaluated using standard definitions. Diarrhoea was defined as three or more loose stools per day of any duration, while persistent diarrhoea referred to symptoms lasting more than 14 days. Chronic diarrhoea was characterized by a gradual onset lasting more than two weeks. Acute respiratory infections were identified by symptoms of cough or breathing difficulty for less than two weeks, accompanied by age-specific fast breathing or relevant findings on chest auscultation or X-ray.

Urinary tract infections were diagnosed based on clinical signs supported by a positive urine culture. Measles was confirmed by the presence of fever, generalized maculopapular rash for at least three days, and at least one of the following: cough, coryza, or conjunctivitis. Meningitis was diagnosed based on clinical presentation and supported by cerebrospinal fluid analysis and neuroimaging.

Tuberculosis diagnosis was established using the algorithm provided by the Indian Academy of Pediatrics [11]. Anaemia was classified based on WHO reference values for hemoglobin levels in children aged 6 to 59 months: mild (10–10.9 g/dL), moderate (7–9.9 g/dL), and severe (<7 g/dL) [12].Micronutrient deficiencies were identified primarily through clinical evaluation, except for vitamin D, which was assessed biochemically. Vitamin A deficiency was diagnosed based on clinical signs such as night blindness, Bitot’s spots, corneal xerosis, or keratomalacia-induced corneal scars. Vitamin B-complex deficiency was indicated by symptoms like angular stomatitis, cheilosis, glossitis, dermatitis, or peripheral neuropathy. Scurvy was suspected in cases presenting with gum bleeding, joint pains, delayed wound healing, or radiographic changes in long bones.

Vitamin D status was determined using serum 25-hydroxy vitamin D levels measured via chemiluminescence assay with the ADVIA Centaur XP system. A level below 20 ng/mL was considered deficient, while levels between 21 and 29 ng/mL were considered insufficient [13]. Informed written consent was obtained from the parents or guardians of all participants. Ethical clearance was secured from the institutional ethics committee prior to the commencement of the study. Participants were informed of their right to withdraw from the study at any time. All data were entered into Microsoft Excel and cross-verified with patient files to minimize missing data. Descriptive statistics and cross-tabulations were used to analyze associations among various variables.

A total of 240 children diagnosed with severe acute malnutrition (SAM) were included in the study. The mean age of presentation was 19.8 months. The majority of children (54.58%) belonged to the 13–24 months age group, followed by 6–12 months (25.83%) and 25–59 months (19.58%). Males constituted 62.08% of the participants, while females accounted for 37.92%, yielding a male-to-female ratio of 1.64:1.

Regarding immunization status, only 10% of the children were completely immunized, while 27.08% were partially immunized, and 4.17% were not immunized at all. A majority (67.92%) belonged to the upper lower socioeconomic class, with 29.58% from the lower middle class and 2.5% from the upper middle class.

A history of recurrent hospitalization was noted in 64.17% of the children. Exclusive breastfeeding up to 6 months of age was reported by 77.92%, and complementary feeding at 6 months was initiated in 26.67%. Additionally, 15.42% had a history of contact with tuberculosis.

Table 1. Sociodemographic characteristics of study participants (n = 240)

The most common presenting symptom was fever (74.58%), followed by loose motion (44.17%), and cough (40.83%). Decreased oral acceptance, vomiting, and respiratory distress were seen in 25.42%, 22.50%, and 20.00%, respectively. Less common symptoms included irritability (15.42%), swelling (13.75%), seizure (8.75%), and rash (5.00%).

Table 2. Clinical presentation among study participants (n = 240)

Diarrhoea was the most prevalent morbidity, affecting 42.08% of the participants. Acute respiratory infection was the next most common (27.08%), followed by tuberculosis (12.92%), urinary tract infection (9.17%), measles (5.00%), and pyogenic meningitis (4.17%).

Table 3. Nutritional deficiency profile among study participants (n = 240)

Severe acute malnutrition (SAM) represents a critical health condition associated with considerable morbidity and mortality, requiring immediate and comprehensive management. Early initiation of appropriate treatment for complications such as hypoglycemia, hypothermia, dehydration, electrolyte imbalance, and infections, along with nutritional support, can significantly reduce adverse outcomes.

While many studies have focused on infectious co-morbidities in SAM, limited literature explores the micronutrient deficiencies prevalent in these children. The mean age of presentation in our study was comparable to other published studies, with a noticeable male predominance [14]. This pattern may reflect gender-based health-seeking behavior disparities, although no definitive cause could be established. Immunization coverage was found to be suboptimal in our cohort, possibly due to lack of awareness or accessibility issues in the community. Approximately two-thirds of the children in our study had a history of repeated hospitalizations, often for similar or related illnesses. In contrast, a study by Yoann Madec et al. reported a much lower rate (4.7%) of recurrent admissions [15]. Contributing factors in our setting could include poor hygiene, inadequate sanitation, and low socioeconomic status.

Exclusive breastfeeding rates were higher in our population; however, delayed initiation of complementary feeding was common and may have contributed to undernutrition. Diarrhea emerged as the most prevalent co-morbidity in our study, followed by acute respiratory infections and tuberculosis. These findings are consistent with a study from Colombia that reported diarrhea in 68.4% of children and sepsis in 9% at admission [16]. Similarly, African studies have documented diarrhea in 49% and 67% of malnourished children [17,18]. Despite previous literature suggesting pneumonia as a more significant risk factor for malnutrition than diarrhea [19], our findings highlighted diarrhea as the predominant associated illness. Tuberculosis and respiratory infections were also present, in line with another African study reporting both conditions in 18% of SAM cases [20].

A history of measles was more frequently observed in our sample compared to a prior Indian study that noted a 3.8% prevalence [8]. However, in contrast to reports citing malaria and HIV as common co-morbidities with respective rates of 21% and 29.2% [21], we did not detect these infections among our study participants.

The coexistence of protein-energy malnutrition and micronutrient deficiencies is well recognized, with deficiencies often occurring simultaneously [22]. In our study, Anaemia was the most common micronutrient deficiency, affecting 85.8% of the children, with moderate Anaemia being the most frequent (58.3%), followed by severe and mild forms. Vitamin D deficiency was the next most prevalent issue, present in 34.17% of those tested, while 62.92% were found to have insufficiency and only 2.92% had adequate levels. Unlike previous studies that assessed vitamin D status based on clinical or radiological signs, we utilized laboratory investigations, which likely contributed to the higher detection rate [23]. However, limitations such as the absence of a control group and limited biochemical testing for other micronutrients need to be acknowledged. Given that our institution is the primary referral center providing comprehensive pediatric care in this region, our sample may reflect a more severely affected population, introducing a potential selection bias.

Our findings suggest that younger age (less than two years), delayed introduction of complementary foods, history of frequent hospital admissions, consumption of an unbalanced diet, incomplete immunization, and lower socioeconomic background are significant predictors of SAM.

In addition to nutritional therapy, early identification and management of coexisting conditions such as diarrhea, respiratory infections, Anaemia, and micronutrient deficiencies are critical to disrupting the cycle of malnutrition and illness. This approach is essential for reducing mortality and improving recovery outcomes in children with SAM. Given the near-universal inadequacy of vitamin D observed in our study, routine supplementation should be considered in the management of all children diagnosed with severe acute malnutrition.

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