Moderate to severe acute malnutrition (SAM/MAM) and severe anaemia are important and associated co-morbidities in children aged less than five years. Independently, these two morbidities are responsible for high risk of in-hospital and post-discharge deaths and hospital readmissions. The primary objective of this study is to investigate the risk of death among severely anaemic children with moderate to severe acute malnutrition compared to children with severe anaemia alone.
This was a retrospective analysis of data collected from a large prospective study that was investigating severe anaemia in children aged less than 5 years old. The study was conducted at Queen Elizabeth Central Hospital in Blantyre and Chikhwawa district hospital in southern Malawi. Children aged less than five years old; with severe anaemia were screened and enrolled. Each child was followed up for eighteen months at one, three, six, twelve and eighteen months after enrolment. Data were analysed using STATA 15.
Between July 2002 and July 2004, 382 severely anaemic children were enrolled in the main study. A total of 52 children were excluded due to missing anthropometric data. Out of the 330 included, 53 children were moderately to severely malnourished and 277 were not. At the end of the 18-month follow period, 28.3% of children with MAM/SAM died compared to 13% of children without MAM/SAM (RR 2.1, CI 0.9–4.2, p = 0.03). Similarly, children with moderate to severe malnutrition reported a significantly higher number of malaria infection cases (33.9%) compared to children with severe anaemia alone (27.9%, p = 0.02). However, the number of hospitalizations and recurrence of severe anaemia was similar and not statistically significant between the two groups (RR 0.8 (0.4–1.4), p = 0.6 and RR 1.1 (0.3–2.8), p = 0.8).
Among children with severe anaemia, those who also had moderate to severe malnutrition had a twofold higher risk of dying compared to those who did not. It is therefore crucial to investigate acute malnutrition among severely anaemic children, as this might be treatable factor associated with high mortality.
All data can be accessed at:
Malnutrition is a complex and multifactorial condition that results from deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients and presents in two broad forms; undernutrition which includes wasting, stunting and underweight; and micronutrient deficiencies and obesity [
Severe anaemia is one of the most common causes of admissions and mortality in Sub-Saharan Africa (SSA) and annually affects 9.6 million children globally [
Severe anaemia and any form of malnutrition are common and associated co-morbidities. Anaemia is the most common manifestation of micronutrient deficiency in malnourished children under 5 years old [
Severe anaemia is an important co-morbidity and determinant in the recovery of children with malnutrition, so much so that WHO recommends that children with kwashiorkor or marasmus should be assumed to be severely anaemic [
This study was approved by the ethics committees of the College of Medicine, University of Malawi and the Liverpool School of Tropical Medicine, United Kingdom. In the SEVANA cohort study, children with severe anaemia and aged less than five years old were enrolled from Queen Elizabeth Central hospital and Chikhwawa district hospital in southern Malawi. Enrolment procedures have been extensively described elsewhere [
In the present study, verbal and written informed consent was obtained from the legal guardians and children with severe anaemia who had a recorded weight, length and met the WHO classification of moderate to severe malnutrition defined as a child whose weight-for-length is less than <2 of the Z-scores and weight for age less that -2 of the z-scores [
Information about the child’s age, sex, residence, number of living and dead siblings, 24-hour dietary recall, family history of sickle cell disease (SCD), jaundice, bloody stool and urine, blood transfusion in the last two months, being on any medication, HIV infection and other previous medical history were obtained from the legal guardians at enrolment. Additional information included guardian’s age, occupation and education level.
Other data points collected include physical examination findings at enrolment and laboratory records, which included parasitology, microbiology, haematology and biochemistry.
We did a power calculation to evaluate the statistical power of our study due to the limited sample size. Using open EPI version 3 (
Data were coded, entered and analysed using STATA 15 (StataCorp, College Station, Texas, USA). Categorical variables have been summarized as frequencies and proportions, while continuous variables as means with standard deviations and medians with the interquartile ranges (IQR) reported. Death was our primary outcome. We examined risk of dying by calculating mortality rates in the children with moderate to severe acute malnutrition and those without. We measured time to death by survival analysis, using Kaplan-Meier curves to compare the probability of death between the two groups over the 18-month study period. Significance was calculated with a log-rank test. Incidence rates for the composite outcomes i.e. re-hospitalization, malaria and severe anaemia recurrence were also calculated for each group. For the malaria incidence rate, the time at risk was calculated by subtracting 14 days from the child-years follow-up with each case of clinical malaria treated with Lumefantrine-Artemether (AL). P values and 95% confidence intervals have also been included.
Of the 1141 under-5 children enrolled in the SEVANA study between July 2002 and July 2004, 382 were severe anaemic cases admitted to the paediatric wards of QECH and Chikhwawa district hospital and 759 were hospital or community controls without severe anaemia. Of the 382 children, 330 had their weight and heights measured and were included in the final analysis. A total of 53 children had a weight for height z-scores ≤ -2 (moderate to severe acute malnutrition) and 277 had a weight for height z-scores > -2 (not malnourished). During the follow up period, twenty children were lost to follow up, 51 died and 259 children completed the study (
The baseline characteristics and examination findings of study participants was comparable between the two groups (
Characteristic | Moderate to severe malnutrition | Severe anaemia alone | P-value |
---|---|---|---|
n (%) | n (%) | ||
Mean days in hospital n (SD) | 4.9 (8.2) | 3.9 (4.1) | 0.18 |
Male gender | 23 (43.4) | 129 (46.6) | 0.67 |
Rural location | 24 (45.3) | 145 (52.4) | 0.35 |
Educated father | 35 (66.0) | 172 (62.1) | 0.72 |
Teenage mother | 8 (15.1) | 71 (25.6) | 0.15 |
One dead parent | 5 (9.4) | 18 (6.5) | 0.72 |
Previous blood transfusion | 9 (17.0 | 38 (13.7) | 0.53 |
Recent antimalarial use | 31 (58.5) | 175 (63.2) | 0.72 |
History of bloody stool | 6 (11.3) | 19 (6.9) | 0.45 |
History of bloody urine | 1 (1.9) | 5 (1.8) | 0.97 |
Splenomegaly | 33 (62.3) | 178 (64.3) | 0.49 |
Raised CRP (≥10Mg/L) | 44 (83.0) | 229 (82.7) | 0.96 |
Median CRP n (IQR) | 111.6 (65.2–183.2) | 93.6 (37.8–150.5) | 0.27 |
Mean Haemoglobin n (SD) | 3.6 (0.8) | 3.4 (1.0) | 0.13 |
Low Vitamin B12 (<118pmol/L) | 13 (24.5) | 71 (25.6) | 0.97 |
Iron deficiency | 14 (26.4) | 76 (27.4) | 0.99 |
Malaria infection at enrolment | 32 (60.4) | 164 (59.2) | 0.87 |
HIV infected | 7 (13.2) | 29 (10.5) | 0.30 |
CMV infection | 3 (1.1) | 0 (0.0) | 0.52 |
EBV infection | 11 (20.8) | 63 (22.7) | 0.66 |
Bacteraemia | 4 (7.6) | 36 (13.0) | 0.48 |
Sickle cell disease | 1 (1.9) | 3 (1.1) | 0.88 |
a P-value which are significant at alpha = 0.05
A total of 196 children (59.4%) had a positive blood smear for
During the 18-month study period, the mean observation days was 383 in the severely anaemic children with MAM/SAM and 456 days in the severely anaemic alone group respectively (
Event | Moderate to severe malnutrition | Severe anaemia alone | ||||
---|---|---|---|---|---|---|
Total events | Incidence rate (1000 person- days) | Total events | Incidence rate (1000 person- days) | Rate ratio | p-value | |
n (CI) | ||||||
N = 53 | N = 277 | |||||
15 (28.3) | 5.4 | 36 (13.0) | 2.6 | 2.1 (0.9, 4.2) | 0.03 | |
9 (3.5) | 1.5 | 76 (4.4) | 1.8 | 0.8 (0.4, 1.7) | 0.62 | |
106 (40.8) | 17.3 | 573 (32.3) | 13.0 | 1.3 (1.04, 1.6) | 0.02 | |
5 (1.6) | 0.8 | 32 (1.6) | 0.7 | 1.1 (0.3, 2.8) | 0.81 |
a P-value which are significant at alpha = 0.05
The cumulative proportions of children who died during the entire 18 month study period was 51 (15.4%) with 27 (8.2%) dying within one month of admission. Of the 51 deaths, 15 (28.3%) occurred in children with MAM/SAM compared to 36 (13.0%) who did not. The overall incidence rate of death with the 95% CI was 3.0 (2.2,4.0) children per 1000 person days observed. The incidence rates for death were 5.4 (3.0,9.8) and 2.6 (1.9,3.7) among children with MAS/SAM and those without respectively. This shows that children with MAM/SAM had a twofold risk of dying compared to children who has severe anaemia without MAM/SAM (RR 2.1; CI 0.9–4.2,p = 0.03). Similarly, severely anaemic children who were underweight had almost a 3-fold risk of dying compared to those with severe anaemia alone (RR 2.8; CI 1.5–5.2, p = 0.0006).
The survival curves for the two groups showed a statistically non-significant difference in the two mortality rates (log rank = 2.9, p = 0.098) (
During the follow up period, there were a total of 679 confirmed malaria cases, 16 of which were complicated malaria. There were significantly more children who reported malaria infection among those with MAM/SAM 106 (40.8%) compared to 573 (32.3%) (p = 0.01) with severe anaemia alone (IRR 1.3; CI 1.04–1.6, p = 0.02). There were more hospital readmissions among children who had severe anaemia alone compared to those with moderate to severe acute malnutrition (4.4% versus 3.5%), (IRR 0.8; CI 0.4–1.7,p = 0.62), but this was not statistically significant. In addition, the recurrence of severe anaemia was similarly low between children with moderate to severe malnutrition compared to those who had severe anaemia alone (IRR 1.1, CI 0.3–2.8, p = 0.8) over the entire study period.
To our knowledge, no cohort studies investigating mortality outcomes in children with both severe anaemia and MAM/SAM have been conducted in SSA. We found that severely anaemic children with MAM/SAM are two times more likely to die compared to severely anaemic children without MAM/SAM during 18 months follow-up. High mortality rates have been reported among hospitalized children with severe anaemia and MAM/SAM separately in other African countries [
There are few cohort studies that have investigated mortality outcomes in children with both severe anaemia and MAM/SAM. Most of these have reported varying ranges of the burden of these two co-morbidities but there is limited data on impact. One study in Ethiopia reported that there was no significant difference in recovery among severe malnourished children with anaemia compared to those without anaemia [
The interplay between MAM/SAM, severe anaemia and the risk of mortality is multifactorial. It is believed that malnutrition lowers immunity, which leads to susceptibility to infections [
Compared to other studies among children with severe anaemia or malnutrition, we did not find significant differences in hospital re admissions or recurrent severe anaemia. We had few fewer re-hospitalisations to detect meaningful differences. Although we did not make associations with other risk factors, our findings are important for exploring interventions that may reduce the additional burden that exists among severely anaemic children with malnutrition.
Our study had limitations. Our sample size was limited and we collected data from existing data that are now 16 to 18 years old. This might have an effect on the findings and their interpretation within the current context. Considering that mortality is a relatively rare outcome and the number of deaths was small, the confidence intervals for the mortality risks are relatively wide. However, we were able to detect significant and meaningful differences in mortality between the two groups of children.
Severe anaemic children who also have moderate to severe malnutrition have a higher risk of death than those with severe anaemia alone, even after discharge from hospital. It is therefore crucial to carefully screen for acute malnutrition in children admitted with severe anaemia, as this may be a treatable factor associated with high mortality. Prospective cohort studies may be utilised to evaluate effects of interventions that may be used to reduce mortality among severely anaemic children with moderate to severe acute malnutrition.
We wish to acknowledge the immense contributions of the entire SEVANA team for the data and the children who participated in the main trial.
PONE-D-20-12989
A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi
PLOS ONE
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Reviewer #1: PLOS ONE article review; Manuscript Number: PONE-D-20-12989
Title: A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi
Comments
There are several places where it is not clear whether you are talking about malnutrition in general or MAM/SAM. Such statements should be made more explicit to avoid confusing a reader should your paper be published.
Abstract
Line#41: correct this typo” theses”
Line#44: “Add company name and location for “STATA 15”
Line#48-50: These two sentences should be made clearer. So 15 out of 53 SAM children died vs. 36 out of 275 severely anemic children? 53+275=328, but you had weight and height data for 330 children. 28.3% is a cumulative value across 18 months. What does 53 represent? Is this a cumulative value or the number of SAM children with anemia throughout the study period?
Introduction
After reference 2, “correct the typo in “It”
After reference 3, “…nearly half of all children under five years are
Malnourished…" Given the broad definition of malnutrition in your first sentence, be specific with what malnutrition represents here. For instance, stunting, Stunting + anemia?
Just before reference 8, are community controls here non-anemic healthy children? Anemic children, that are managed at the community level?
Just before reference 16, “… severely malnourished children…”, are these SAM children?
Statistical analysis
First sentence, see comments above under abstract.
The penultimate sentence, what is "AL"? Write the full name on the first appearance.
Page 8: second paragraph, 196 children out of 330? If so, 60.4% (n=118???). Is the total number of malnourished children, not 53?
Discussion
First sentence, does “… our setting ..” here mean Malawi? Sub-Saharan Africa?
The second sentence, add "are" between "malnutrition" and "two."
After reference 19, correct they typo “…higher mortality rate than that…" "that" to "those": Also recheck the references. Reference 21 is the Gambia, not Nigeria.
Page 13: penultimate sentence, correct typo in “Children”.
Second paragraph, “Unpublished, T. Kwambai”.
Check this study from Ethiopia, Int J Pediatr. 2020; 2020: 8406597.
doi: 10.1155/2020/8406597
References
Recheck your all to ensure consistent formatting and style.
Figure 1: Flowchart
52+(53+275) =380. You have not accounted for 2 children.
Figure 2 and Figure 3: Kaplan-Meier plots
The axes should be properly labelled.
Reviewer #2: The authors use old data (2002-2004) from a small sample (n=330) of hospitalized children under five years old in Malawi. Following these children for 18 months, they compare the death rate in children with severe anaemia to the death rate in children with severe anaemia plus at least moderate acute malnutrition (WHZ < -2). Compared to children with severe anaemia alone, children with severe anaemia plus MAM/SAM were twice as likely to die. The authors conclude by recommending that children who are hospitalized with severe anaemia should also be screened for MAM/SAM.
My primary concern is that the findings are not relevant in today’s context. I may be wrong, but it is hard to believe that hospitalized children are not screened for MAM/SAM. I would guess that weight and height are among the first things to be measured when any child is hospitalized. If a child presents with both MAM/SAM and anaemia, they will receive food and iron supplements, two different treatments. A child who presents with MAM/SAM may also be screened for anaemia. It is hard to believe that MAM/SAM would go completely unnoticed by doctors in today’s context. The authors need to address this and justify the relevance of the study using recent evidence. Other minor comments are below.
Abstract
The following sentence is unclear: “Under-five children with severe anaemia were screened and enrolled and of theses children with moderate to severe acute malnutrition; defined as weight-for-height Z-score <-2 were included.” Enrolled and included are distinct? Do you mean included in the analysis? And of course there is a bad typo, “theses”.
Don’t use acronym SAM for moderate to severe malnutrition. SAM is severe (HAZ < -3) and does not include moderate. You could say 53 children were identified as having MAM or SAM.
Introduction
The manuscript is missing line numbers.
The first sentence of the introduction is incorrect. Malnutrition goes much beyond intake. Inadequate or excess intake among other factors can lead to malnutrition.
Change ‘commonest’ to most common.
Methods
Power calculation: can you clarify what the study groups were and what the sample size was for each group? Is it the 53 with MAM/SAM and 275 without MAM/SAM?
What is the acronym AL? Albendazole?
Results
Table 1 – groups need to be labeled better. Severe anaemia + MAM/SAM vs. Severe anaemia alone
Discussion
Do not abbreviate severe anaemia as SA. Avoid abbreviations whenever possible.
The data are 16-18 years old, not 16 years old.
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Dear PLOS ONE,
Thank you for reviewing our manuscript titled “A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi” for consideration for publication in your esteemed journal. We have revised our manuscript with considerations to the comments and suggestions from the reviewers and ensured that it meets PLOS ONE’s style requirements. We would like to confirm that informed verbal and written consent were obtained from the guardians of all the children who participated in the study and a statement regarding ethical considerations has been added under the methods section. In addition, there are no ethical or legal restrictions on sharing of our data set. The anonymized data set can be found on:
Please kindly update our Data availability statement to reflect the availability of data.
Responses to reviewers
Below are point by point responses to each comment raised by the reviewers. Responses are highlighted in bold.
1. There are several places where it is not clear whether you are talking about malnutrition in general or MAM/SAM. Such statements should be made more explicit to avoid confusing a reader should your paper be published.
It is correct that we are referring to MAM/SAM and we have made corrections throughout the manuscript.
2. Abstract
Line#41: correct this typo” theses”
This has been corrected.
3. Line#44: “Add company name and location for “STATA 15”
We have added the company name and location for “STATA 15”.
4. Line#48-50: These two sentences should be made clearer. So 15 out of 53 SAM children died vs. 36 out of 275 severely anemic children? 53+275=328, but you had weight and height data for 330 children. 28.3% is a cumulative value across 18 months. What does 53 represent? Is this a cumulative value or the number of SAM children with anemia throughout the study period?
This has been revised. The correct number of children without MAM/SAM was 277. Revisions to the text and the study flow chart (Figure 1) have been made accordingly.
5. Introduction
After reference 2, “correct the typo in “It”
This has been corrected.
6. After reference 3, “…nearly half of all children under five years are
Malnourished…" Given the broad definition of malnutrition in your first sentence, be specific with what malnutrition represents here. For instance, stunting, Stunting + anemia?
We have revised this in line 81-84. We have defined malnutrition as follow: it is a complex and multifactorial condition that results from deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients and presents in two broad forms; undernutrition which includes wasting, stunting and underweight; and micronutrient deficiencies and obesity.
7. Just before reference 8, are community controls here non-anemic healthy children? Anemic children, that are managed at the community level?
Thank you very much. Community controls were children matched for age and sex from the community and hospital who did not have severe anemia. A revision has been made in live 94 to make it clearer.
8. Just before reference 16, “… severely malnourished children…”, are these SAM children?
This is correct. We have revised this to make it clearer.
9. Statistical analysis
First sentence, see comments above under abstract.
We have revised this with a full name of the company and location in line 180-181 under statistical analyses.
10. The penultimate sentence, what is "AL"? Write the full name on the first appearance.
AL is the abbreviation for Artemether-Lumefantrine and it has been written in full in line 192-193.
11. Page 8: second paragraph, 196 children out of 330? If so, 60.4% (n=118???). Is the total number of malnourished children, not 53?
This was 196 out of 330, representing 59.4% with a positive blood smear for P. Falciparum malaria infection on admission, and out of these, 32 ( 60.4%) were children with MAM/SAM and 164 (59.2 %) were children without MAM/SAM. Revisions have been made in line 216-218 to make it clearer.
12. Discussion
First sentence, does “… our setting ..” here mean Malawi? Sub-Saharan Africa?
“Our setting” means Sub-Saharan Africa. We have revised this to reflect the same in line 287.
13. The second sentence, add "are" between "malnutrition" and "two."
This has been corrected in line 288.
14. After reference 19, correct they typo “…higher mortality rate than that…" "that" to "those": Also recheck the references. Reference 21 is the Gambia, not Nigeria.
This has been corrected in line 291. The references have also been corrected in line 292.
15. Page 13: penultimate sentence, correct typo in “Children”.
This has been corrected.
16. Second paragraph, “Unpublished, T. Kwambai”.
Check this study from Ethiopia, Int J Pediatr. 2020; 2020: 8406597.
doi: 10.1155/2020/8406597
Thank you very much. We have reviewed this reference and included it in our text.
17. References.
Recheck your all to ensure consistent formatting and style.
All references have been checked and formatted according to Plos one guidelines
18. Figure 1: Flowchart
52+(53+275) =380. You have not accounted for 2 children.
The flow chart has been revised. The 2 children who were initially omitted had died on admission.
19. Figure 2 and Figure 3: Kaplan-Meier plots
The axes should be properly labelled.
The Kaplan Meier plots have been revised.
20. Reviewer #2: The authors use old data (2002-2004) from a small sample (n=330) of hospitalized children under five years old in Malawi. Following these children for 18 months, they compare the death rate in children with severe anaemia to the death rate in children with severe anaemia plus at least moderate acute malnutrition (WHZ < -2). Compared to children with severe anaemia alone, children with severe anaemia plus MAM/SAM were twice as likely to die. The authors conclude by recommending that children who are hospitalized with severe anaemia should also be screened for MAM/SAM.
My primary concern is that the findings are not relevant in today’s context. I may be wrong, but it is hard to believe that hospitalized children are not screened for MAM/SAM. I would guess that weight and height are among the first things to be measured when any child is hospitalized. If a child presents with both MAM/SAM and anaemia, they will receive food and iron supplements, two different treatments. A child who presents with MAM/SAM may also be screened for anaemia. It is hard to believe that MAM/SAM would go completely unnoticed by doctors in today’s context. The authors need to address this and justify the relevance of the study using recent evidence. Other minor comments are below.
Thank you very much for your comment. We acknowledge that the data are from 16 to 18 years ago and the concern that the findings are not relevant in today’s context. However, our study was done for that particular reason. There are no studies, recent or old that have explored survival of children who have both severe anemia and moderate to severe malnutrition despite that these two conditions are often found together. Our study findings are very relevant even in today’s context, because the burden of these two comorbidities remains high and therefore the mortality risk is still very present. We have made revisions in lines 141-142 to make our rationale clearer. However, we agree that the sample size was limited and therefore we have highlighted that this was a limitation in our study and a larger prospective study should be conducted to confirm our findings. This has been highlighted in the discussion section.
21. Abstract
The following sentence is unclear: “Under-five children with severe anaemia were screened and enrolled and of theses children with moderate to severe acute malnutrition; defined as weight-for-height Z-score <-2 were included.” Enrolled and included are distinct? Do you mean included in the analysis? And of course there is a bad typo, “theses”.
This has been revised extensively to be clearer.
22. Don’t use acronym SAM for moderate to severe malnutrition. SAM is severe (HAZ < -3) and does not include moderate. You could say 53 children were identified as having MAM or SAM.
We have revised the manuscript throughout. Moderate to severe malnutrition have been identified as having MAM/SAM.
23. Introduction
The manuscript is missing line numbers.
We have inserted line numbers.
24. The first sentence of the introduction is incorrect. Malnutrition goes much beyond intake. Inadequate or excess intake among other factors can lead to malnutrition.
This is correct. We have revised the definition of malnutrition to “Malnutrition is a complex and multifactorial condition that results from deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients and presents in two broad forms; undernutrition which includes wasting, stunting and underweight; and micronutrient deficiencies and obesity.” in lines 81-84.
25. Change ‘commonest’ to most common.
This has been revised in line 99.
26. Methods
Power calculation: can you clarify what the study groups were and what the sample size was for each group? Is it the 53 with MAM/SAM and 275 without MAM/SAM?
We sampled 53 children who had MAM/SAM and 275 children without MAM/SAM. We have revised the section to make it clearer in lines 177-178.
27. What is the acronym AL? Albendazole?
AL is an acronym for Lumefantrine-Artemether. We have made the correction in line 192-193.
28. Results
Table 1 – groups need to be labeled better. Severe anaemia + MAM/SAM vs. Severe anaemia alone.
Table 1 and 2 has been revised with better labels.
29. Discussion
Do not abbreviate severe anaemia as SA. Avoid abbreviations whenever possible.
We have revised this and spelled severe anemia in full throughout the manuscript.
30. The data are 16-18 years old, not 16 years old.
This is correct. We have made a revision in line 371.
Submitted filename:
Click here for additional data file.
A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi
PONE-D-20-12989R1
Dear Dr. Gondwe,
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Reviewer #1: Line# 31; SAM/MAM, most part of the manuscript, MAM/SAM was used. See line#118 and other parts. Keep it consistent.
Line#48; correct to follow-up instead of follow.
Line#81; use lower case for haemoglobin
Line#150; 28.2%, remove space
Line# 155; 10mg/L, use lower case for M.
Line# 168; MAS/SAM?
Lines#189, 191, 193; IRR?
Line#218; “However, this study did not have a comparison group.” It is unclear which study this statement refers to, your study or one of the references?
Line#236, re-admissions
References # 4 and 9 are incomplete.
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PONE-D-20-12989R1
A cohort analysis of survival and outcomes in severely anaemic children with moderate to severe acute malnutrition in Malawi
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