TREATMENT OUTCOME OF MALNUTRITION AND ITS

DETERMINANT AMONG PEDIATRICS IN WOLLEGA UNIVERSITY

REFERRAL HOSPITAL, WESTERN ETHIOPIA

BY: MEGERSA AYANA

A Research Paper to Be Submitted to Pharmacy Department, Institute of Health

Science, Wollega University in Partial Fulfillment of Requirements for Bachelor
Degree in Pharmacy

February 2021

Nekemte, Ethiopia
 WOLLEGA UNIVERSITY

INSTITUTE OF HEALTH SCIENCE

DEPARTMENT OF PHARMACY

TREATMENT OUTCOME OF MALNUTRITION AND ITS DETERMINANT AMONG

PEDIATRICS IN WOLLEGA UNIVERSITY REFERRAL HOSPITAL, WESTERN
ETHIOPIA

BY: MEGERSA AYANA

ADVISOR: DANIEL MITIKU (B, Pharm)

February 2021

Nekemte, Ethiopia
ACKNOWLEDGEMENT
First of all, I would like to express my thanks to Wollega University, Institute of Health
Science Pharmacy department for selecting and approving my priority topic to be studied.
And also I would like to express my sincere gratitude and deep appreciation to my
advisor Mr Daniel Mitiku as to volunteer and accept his assigned for me and to be my
close advisors throughout proposal development and I would like to say thanks for your
constructive advice and comments and Hopefully your close advice and support will help
me to the end of the proposal.

I
ACRONYMS AND ABBREVIATIONS
CSA Central Statistical Agency

DFID Department of International Development

FMOH Federal Ministry of Health

GAM Global Acute Malnutrition

IFRC International Federation of Red Cross and Red Crescent Societies

MAM Moderate acute malnutrition

MCH Mean Corpuscular Hemoglobin

MUAC Mid Upper Arm Circumference

WUMC Wollega University Medical Center

OPD Outpatient Department

OTP Outpatient Therapeutic Program

SAM Severe Acute Malnutrition

UNICEF United Nation International Children`s Fund

WHO World Health Organization

II
Contents
ACKNOWLEDGEMENT............................................................................................................I

ACRONYMS AND ABBREVIATIONS....................................................................................II

ABSTRACT.................................................................................................................................IV

1. INTRODUCTION......................................................................................................................1

1.1 Background.........................................................................................................................1

1.2 Statement of the Problem...................................................................................................2

1.3 Significance of the Study....................................................................................................3

2. LITERATURE REVIEW........................................................................................................4

2.1 Prevalence of severe acute malnutrition...........................................................................4

2.2 Malnutrition with co-morbidities......................................................................................4

3.RESEARCH OBJECTIVE.......................................................................................................8

3.1 General objective................................................................................................................8

3.2 Specific Objectives..............................................................................................................8

4.METHODS AND MATERIALS..............................................................................................9

4.1 Study Area And Period......................................................................................................9

4.2 Study design........................................................................................................................9

4.3 Source of population...........................................................................................................9

4.4 Study population.................................................................................................................9

4.5 Inclusion and exclusion criteria.........................................................................................9

4.5.1 Inclusion criteria..........................................................................................................9

4.5.2 Exclusion criteria.......................................................................................................10

4.6 Study variables..................................................................................................................10

4.6.1 Independent variables................................................................................................10

4.6.2.Dependent variable....................................................................................................10

4.7 Sample size and Sampling Techniques............................................................................10

4.8 Data Collection Process....................................................................................................11

III
 4.9 Data processing and analysis............................................................................................11

4.10 Ethical Consideration....................................................................................................11

4.11 Operational definitions...................................................................................................11

5. RESULT..................................................................................................................................13

6 14

REFERENCES.............................................................................................................................15

Annex...........................................................................................................................................18

ABSTRACT

Background: Malnutrition is a silent killer that is under reported, under addressed and as
the result, under prioritized. Eventually, every hour and minute of every day, 300 and 5
children die because of malnutrition respectively. It is reported that severe acute
malnutrition (SAM) is the commonest reason for pediatrics hospital admission in many
poor countries; 25 to 30% of children with severe malnutrition die during hospital
admissions. As a step towards treatment outcome, there is need to identify the important
determinants of malnutrition in the specific context.

OBJECTIVE: To determine treatment outcome of sever acute malnutrition and identify

its determinants among pediatrics in Wollega University medical center (WUMC)
pediatrics ward.

METHODS: Data will be collected by using checklist for recording information from
patient card and register book. The cards also recorded follow-up anthropometry
measurements and clinical features, routine medications and outcome status. The
collected data will be interpreted based on the findings, and the association between
dependent & Independent variables will be assessed. The sample size will be 256.

Result: Out of 256 children admitted with SAM, the cure, death, defaulter and
transferred-out rates were 21.25%, 6.64%, 5.86% and 66.25% respectively. Overall,
87.5% of the children were recovered from their disease. The mean length of stay of a
‘recovered’ child in the hospital was 14.57 days. Mean weight gained for recovered

IV
patients were 12.06g/kg/day. Pneumonia, male sex and WFH<70 was significantly
associated with negative treatment outcomes. Immunization, folic acid, deworming were
associated with positive treatment outcomes.

Conclusion: The cure rate in this study was found to be sub-optimal. Immunization, folic
acid, deworming were associated with positive treatment outcomes. Pneumonia, male sex
and WFH<70 were significantly associated with negative treatment outcome.

Keywords: Survival status, Treatment outcome, severe acute malnutrition

LIST OF TABLES

Table 1: Anthropometry of children admitted to therapeutic feeding unit of WURH from

august 2021 to February 2021

Table 2: Types of routine medications for children with severe acute malnutrition
admitted to WURH from august 2021 to February 2021

Table 3: Comparison of the number of recovered, died and defaulted patients according
to the length of Hospital stay of children with SAM admitted to pediatric ward WURH
from august 2021 to February 2021

.
Table 4: Shows anthropometric conditions of children with SAM in WURH from august
2021 to February 2021

Table 5: Results of univariate and multivariate logistic regression analysis for factors
affecting treatment outcome of children with severe acute malnutrition admitted to
WURH from august 2021 to February 2021

V
LIST OF FIGURE
Figure 1: Age and sex distribution of patients admitted with SAM in WURH from august
2021 to February 2021

Figure 2: Clinical conditions of Children with SAM Admitted to Therapeutic Feeding

Unit of WURH from august 2021 to February 2021

Figure 3: Overall status of treatment outcome for children with severe acute malnutrition
admitted to WURH from august 2021 to February 2021

VI
VII
1. INTRODUCTION
1.1 Background
Malnutrition is defined as deficiencies, excesses or “the cellular imbalance between the
supply of nutrients and energy, and the body’s demand for them to ensure growth,
maintenance and specific functions. The term malnutrition covers 2 broad groups of
condition. One is under nutrition which includes stunting (low height for age), wasting
(low weight for height), underweight (low weight for age) and micronutrient deficiencies
or insufficiencies. The other is overweight, obesity and diet related non-communicable
disease (28).

According to the United Nations International Children’s Emergency Fund (UNICEF)

estimates, around 26 million under five children suffer from SAM in developing country
(8). Ethiopia is one of the countries with highest under-five child mortality rate, with
malnutrition underlying to 57% of all children deaths (FMOH, 2011).

The latest Ethiopia mini-Demography and Health Survey stated that stunting, wasting and
underweight among under-five children in Ethiopia are 38 %, 10% and 24 % respectively
and still it is significantly high when compare with the world 22%, 7.7% and 15%
respectively (5).

Malnutrition, which co-exists with diarrhea, can be acute or chronic and can cause
death due to either dehydration or electrolyte imbalance (11). Dehydration must be
differentiated from sepsis, although the two conditions sometimes co-exist.
Dehydration is treated with oral rehydration (rehydration solution for malnutrition)
which has high amount of potassium with low amounts of sodium and is balanced for
better absorption of these minerals (WHO, 2000). Intravenous hydration in severely
malnourished children may lead to over hydration and heart failure because of weak
heart muscles and poor contractility. In Kampala-Uganda, the cause of death in
malnourished children due to excessive infusion was 56.8% and 71% due to
transfusion within 48 hours (15). Intravenous fluids must be used when there is shock
due to dehydration. Half-strength Darrow's solution with 5 percent glucose is
preferred in this situation.

1
Thus, it is very important that the whole guideline is implemented along with the
introduction of the therapeutic products, particularly the diagnosis and management of
the complications during in-patient care and identification of treatments that should
continue until the child’s weight-for-height Zscore is >–1 SD as well as during
discharge, mothers training to continue with care at home and any social problem will
be addressed. So, this study will enhance the treatment outcome of malnutrition and its
determinant among pediatrics in order to provide ongoing counseling for proper diet,
danger signs and address other social problems (3).

1.2 Statement of the Problem

Although the world produces enough food to feed everyone, in 2011 almost 1 billion
children, men and women go to bed hungry every night. Millions of these, particularly
young children, suffer the dire effects of under-nutrition (12). In the world number of
stunted children between 200 and 2016 year were declined from 198 to 155 million. At
the same time, numbers have increased at an alarming rate in west and central Africa
from 229 to 281 million (26).

Ethiopia has been experiencing drought and chronic food insecurity for the last four
decades. The latest Ethiopia mini-Demography and Health Survey stated that stunting,
wasting and underweight among under-five children in Ethiopia are 38 %, 10% and 24 %
respectively and still it is significantly high when compare with the world 22%, 7.7% and
15% respectively (5).

In Oromia region prevalence of child malnutrition indicated that 41 % of the children are
stunted with 21.8 sever stunting, 9.6% of the children are wasted (2.4 % severe wasting)
and 34.4% are underweight with 11% severe underweight (5 & 26). Malnutrition has
severe consequences. Malnutrition reduces functioning of the immune system, wound
healing, increases the chance of developing pressure sores, and impairs the quality of life
and increases mortality. These complications of malnutrition lead to increased length of
stay in hospital with increased use of medication, leading to increased healthcare costs. In
children malnutrition is not only has direct consequences, but, because a child is
developing, it also causes long-term effects such as lower IQ and stunted growth.

2
This research therefore will be aimed at determining the treatment outcome and the
predictors of death among undernourished children admitted to Wollega University
referral hospital where there is paucity of this important data. The findings of this study
will be intended to further aid clinicians to improve the outcome of these children.

This implies that investigating factors that affect improvement of treatment outcome by a
study is important to obtain evidences regarding the program. There is no published study
on Treatment outcome and its determinants among under fourteen children with severe
acute malnutrition treated at pediatric ward of WURH. This indicates that little is known
about the program in pediatric ward and this study will try to identify the factors that
affects treatment outcome and helps for all concerned stake holders to take appropriate
action on the factors and improve the expected outcome of the program.

1.3 Significance of the Study

The findings from this study may contribute its part for clinical pharmacist, local health
office, for the health institution, administrators and other non - governmental
organization working on inpatient department (pediatric ward) service to give great
emphasis to the problem and take appropriate measures to improve their service. In
addition to that all children in the area which are covered by the hospital will be expected
to benefit from the findings of this research at large and it served as base line data for
further study.

3
2. LITERATURE REVIEW
2.1 Prevalence of severe acute malnutrition
In 2017 Study conducted in rural Ethiopia shows 48.5% of children living in rural
Ethiopia were malnourished. From this, 22.7% had single anthropometric failure and
25.9% had multiple anthropometric failures. Malnutrition among rural children in
Ethiopia using the conventional measures was found to be underweight 27%, wasting
9.7%, and stunting 41.2% (19).

In 2017, study conducted in Haramaya district shows the prevalence of stunting, wasting
and underweight were 36.07%, 14.43% and 23.63%, respectively. Prevalence of severe
stunting, wasting and underweight was 11.44%, 6.72% and 6.47% respectively (21).

In 2013 study conducted in Hidabu Abote shows the overall prevalence of malnutrition of
children under five were 47.6% stunted, 30.9% were underweight and 16.8% were
wasted. The highest prevalence of malnutrition was seen in males. Compared with age
group the highest prevalence of stunting was seen in children age between 24-35 months
followed by children aged 12-23 months. However, the lowest prevalence of stunting was
seen in children aged 6-11 months.

The highest prevalence of underweight was seen children aged 48-59 months with
prevalence of 8%. However, the lowest prevalence of underweight seen children aged 6-
11 months with prevalence of 1.7%. The highest prevalence of wasting was seen children
aged 48- 59 months at Hidabu Abote district with 5% prevalence. The lowest prevalence
of wasting was seen in children aged 6-11 months. Anthropometric measurements were
done to determine the level of underweight and wasting. The study revealed that 27.6%
and 9% of children were underweight and wasted respectively (17).

2.2 Malnutrition with co-morbidities

In 2017, study conducted in yirgalem hospital showed that 123(64.4%) children have
diarrhea out of 196 hospitalized children. Diarrhea is common co-morbid disease
according to this finding (14). In 2015 study conducted in Deghabour Hospital eastern
Ethiopia shows, out of total 399 children admitted 64.4% have pneumonia, 38.8%
have fever and 22.6% have vomiting (30).

4
A study conducted in Nigeria showed that 9% of children hospitalized for severe
malnutrition were HIV infected (23). Malnutrition is multi-factorial and HIV can
induce or aggravate it. In sub-Saharan Africa, mortality is higher in HIV infected
children and ranges from 25% to 38% with severe malnutrition than in non-infected
children (Schofield et al., 1996 and Irena et al., 2011). During re-nutrition, mortality
was still found to be higher in HIV positive than HIV negative children in Malawi
(22 & 3)

A study conducted in Yakatit 12 Hospital in Addis Ababa shows that of all the
severely malnourished children (24.3%) have pneumonia, tuberculosis (11%), and
diarrhea (21%) (Tesfaye et al., 2013). Bacteremia in these children is so common.

Organisms commonly isolated in malnourished children in blood, urine and stool

cultures are non-typhoid Salmonella (13%), S. pneumonia (10%), and E. coli (8%).
E. coli accounts for 58% of the urinary isolates, but stool culture most of time has no
growth of pathogens (27).

Malaria is common in severely malnourished children which was 10.2% in Sudanese

children (2). In 2006 a study done at Muhimbili National Hospital (MNH) and Kilifi
District Hospital (KDH) showed that co-morbidity contributed to 86% of deaths in
severe malnutrition at MNH. The common co- morbidities were malaria (46%),
PAIDS (38%), diarrhea (16%), septicemia (8%), and UTI (17%). Also, it showed that
46% of edematous patients with co-infections died compared to only 19% of non-
edematous patients with co-infections. At KDH, septicemia was the most common
cause of death followed by TB and HIV (4).

5
 1.1. Treatment Outcomes of malnutrition

The preferable treatment outcome of malnutrition is to reach normal standard weight

for height / length after the nutritional supplementation in the ward. This outcome can
be achieved by prompt treatment of all infections in these children with appropriate
antibiotics, correction of the electrolytes, hypothermia, hypoglycemia, micronutrients
and macronutrients following WHO criteria.

In India, fatality rates were reported to be 50%, which was reduced to 25% after
following WHO criteria’s (7). Unprofitable outcome include failure to gain weight for
severe marasmic children and failure of reduced weight for the edematous children,
failure of treatment of infected children.

Death due to complications of malnutrition most commonly occur during the first 48
hours of admission (7). In a severely malnourished child who has diarrhea, mortality is
high ranging from 67.3% - 71% and the cause of death is commonly due to
dehydration and electrolytes imbalances.

In 2014 study conducted in Jimma University Specialized Hospital (JUSH) shows

treatment outcome of severe acute malnutrition in under five children were;
152(87.3%) of cases have recovered. Defaulter rate of 12(6.9%) and death rate of
10(5.8%) were recorded. The cause of death was almost sepsis for all of them. The
case fatality rate for marasmic-kwashikor was 2(10.5%) and 4.3% for kwashikor only.

2.3 Factors associated with treatment outcome among children with severe acute
malnutrition.
Factors that are associated with treatment outcome are age, antibiotic given,
presence of edema at admission, sex, presence of associated medical problem and
type of malnutrition. Study conducted in yirgalem hospital shows death and cured
rate of newly admitted patients are 16% and 78% respectively (14). Study conducted
in India shows out of all admitted patients, 72 were below 2 year of age and male to
female ratio was 2.9:1. The mean age of admitted patient was 14.92±7.48 month
(18).

6
In 2015 Study conducted in southwest Ethiopia, kamba district shows Marasmic
children who recovered from SAM had gained an average weight of 5.76
gm/kg/day. However, the rate of weight gain among the children without any
medical complications was 6.09 gm/kg/ day which were higher than those with at
least one medical complication, 4.08 gm./kg/day (24).

A study conducted in Lusaka, Zambia shows that those children for whom data
regarding diarrhea was present (67.1%) had diarrhea on admission. In addition,
(48.0%) reported fever on admission (13).

A study conducted in Khartoum, Sudan showed that children with provision of anti-
biotic (Amoxicillin) were recovery rate and death rate was 70% and 3.9%
respectively (6).

A study conducted in Tigray health facility reported that, (22.1%) of the eligible
children did not receive at least one of the routine medications. The rest of the
children, (77.9%), had received the routine medications partially. The most
administered Medications were amoxicillin (72.13%) and Vitamin A (59.17%)
while the least was Folic acid which was administered to only (5.89%) and variables
showed that taking amoxicillin and de-worming drugs were positive predictors to
recovery rate from SAM. However, having diarrhea, vomiting, loss of appetite were
negative predictors to recovery rate from SAM (11).

The study conducted in Chad on data-analysis revealed that two significant associations
found between fever and diarrhea in the previous two weeks and being a SAM case (22).

7
3.RESEARCH OBJECTIVE
3.1 General objective
To determine treatment outcome of sever acute malnutrition and identify its determinant
factors among pediatrics in Wollega University referral hospital pediatric ward.

3.2 Specific Objectives

 To determine the treatment outcome of SAM in children aged 1 month-14 years

admitted to pediatric ward of Wollega University referral hospital.

 To identify factors associated with treatment outcome severe acute malnutrition

among 1 months-14 years children admitted to pediatric ward of Wollega University
referral hospital.

8
4.METHODS AND MATERIALS
4.1 Study Area and Period
The study was conducted in WURH, East Wollega zone, Oromia Regional State. The
Town is located 331 km away from Addis Ababa to the West. The total population of
town is 123,484 of these 65,002 were male and 62,378 were female (34). There are
different governmental and non-governmental institutions in the town. Currently, there
are two Referral Hospitals, two health centers and one public health research and referral
laboratory in the town that has been serving the communities of the town and districts
found in East Wollega Zones and other communities outside of zones. Nekemte
specialized Hospital, Wollega University Referral Hospital, Nekemte Health center and
Chalalaki Health center has been regularly serving the communities of Nekemte town and
districts located in East Wollega Zone and borders of the zone. From those Public
Heaalth Facilities two facilities WURH selected for study.

4.2 Study design

Retrospective cross-sectional study was applied.

4.3 Source of population

The source population of this study was all malnourished pediatric patients who had been
admitted to inpatient pediatric ward of WURH in 2021 G.C and fulfill inclusion criteria.

9
4.4 Study population

Up to record of 256 malnourished pediatric patients who had been admitted to inpatient
department and fulfilled inclusion criteria during the study period will be randomly
selected.

4.5 Inclusion and exclusion criteria

4.5.1 Inclusion criteria

 The following criteria was satisfied for recruiting a study participant:

 Admitted to nutritional rehabilitation unit of WURH
 Diagnosed with severe acute malnutrition

4.5.2 Exclusion criteria

 Patients aged older than 14 years old

 Incomplete patient chart

4.6 Study variables

4.6.1 Independent variables

 The independent variables of the study will include;

 Socio-demographic variables
 Immunization
 Medical co-morbidities and
 Routine medication

4.6.2. Dependent variable

 Treatment outcome

4.7 Sample size and Sampling Techniques

Sample size of the study calculated using Kish and Lisle formula for cross-sectional
studies (31).

10
 Z 2 p(1−P)
¿=
d2

Where:

Z = Z score for 95% confidence interval CI = 1.96

1. P= Prevalence of undernourished children aged under fifteen. Prevalence of 40%

was taken from 2016 Ethiopian survey shows stunted children in Oromia were
38%≈40% for Nekemte. Central Statistical Agency (CSA) [Ethiopia] and ICF
2016 Ethiopia Demographic and Health Survey 2016 Addis Ababa, Ethiopia, and
Rockville, Maryland, USA: CSA and ICF.

d = tolerable error = 5%

1.96 2 X 0.4 (1−0.4 )

¿= =256
0.052

If N <10,000), the required minimum sample was obtained from the above estimate by
making some adjustment. (nf=n/(1+n/N) . (nf=369/(1+369/720) ꞊256. Simple random
sampling techniques will be used to collect 256 cards from children admitted to patient in
2021 G.C.

4.8 Data Collection Tools and Process

The main data collection instrument for this study was questionnaire. The questionnaire
will be adapted from (16). The data was collected by the principal investigator and a
structured checklist will be used to address the all needed information as a data collection
tool.

4.9 Data processing and analysis

Data was entered to SPSS version 26.0 social packages for further analysis. The results
was presented in the form of tables and graphs. Bivariate analyses will be done using

11
binary logistic regression to see the association between dependent and independent
variables. Odds ratio along with 95% confidence level will be estimated to identify
factors associated with the outcome variable using bivariate logistic regression analysis.
Level of statistical significance was also declared at P- Value levels of 0.5.

4.10 Ethical Consideration

Prior to study ethical clearance or supportive letter was taken from Wollega university
Institutes of Health since, Pharmacy department to selected Health facilities. The
respondents was informed about the objectives and purpose of the study and verbal
consent was obtained from participants. Confidentiality of information by omitting names
and privacy of respondents will be assure

4.11 Operational definitions

Cured: Patient/child that has reached the discharge criteria (1).

Death: patient/child that has died while he was in the inpatient Program the death as to
be confirmed by medical doctors (20). 

Length of stay: is the number of days the patient stayed in the ward starting from the day
of admission to the day of discharge (20). 

Defaulter: when the patient discontinued before recovery (1).

Transferred out: patient transferred out to nearby health center after recovered from
complication (16).

Treatment Outcome: patients/children that have followed their treatment in the pediatric
ward and finally declared as Cured or died (16).

Severe acute malnutrition: weight-for height ratio of less than minus 3 standard
deviations below the median reference population or weight-for-height ratio of below
70% or presence of nutritional edema or visible wasting (16).

12
5. RESULT
5.1 Sociodemography of the patients
From total sample of 256 from children admitted to WURH pediatrics ward with SAM in
2017, (167) 65.23% were males. Their age ranges from 10 days to 14 years with a mean
age of 38.22 months. When we see their age distribution, the most frequent once were
those between 25-60 months with 97 (37.89%) score, followed by 7-24 months with
70(27.34%) score. See (figure-1).

13
 300

250

200

150

100

50

0
0-6 months 7-24 months 25-60 months >60 total

male Column1

Fig-1 Age and sex distribution of patients admitted with WURH from august 2021 to
February 2021 pediatric ward.

5.2 Admission criteria

The percentage of children with MUAC of <11 were 58.98% during admission.
Percentage of children with WFH < 70 AND GRADE (+++) edema were 67.19% and
11.72% respectively. Nearly all admitted children were newly admitted which is (253)
98.83% children and the left (3) 1.17% were re-admitted.

14
Anthropometry At admission
MUAC
>12 37(14.45%)
11-12 68(26.56%)
<11 151(58.98%)
WFH
≥85 10(3.90%)
80-84 24(9.375%)
70-79 50(19.53%)
<70 172(67.19%)
Edema
No edema 129(50.39%)
(+) edema 34(13.28%)
(++) edema 63(24.61%)
(+++)edema 30(11.72%)
Table-1 anthropometry of children admitted to therapeutic feeding unit of JUMC in
2017.

5.3 Presence of Associated Medical Problems

From all cases 239(93.36%)have associated medical problem with SAM at presentation;
out of which the most common were, pneumonia, diarrhea, anemia and TB with rates of
102 (39.84%), 67 (26.17%), 60(23.44%) and 24(9.38%) respectively. The following

15
figure shows medical problem associated with SAM children.

45.00%

40.00%

35.00%

30.00%

25.00%

20.00%

15.00%

10.00%

5.00%

0.00%
pneumonia diarrhea anemia TB athers

Fig-2 Clinical conditions of Children with SAM Admitted to Therapeutic Feeding Unit of
WURH from august 2021 to February 2021.

5.5 Medication given

Ampicillin (documented for N=171), Amoxicillin (documented for N=105) and
Gentamycin (documented for N=89) were the common antibiotics used for treatment and
prevention of bacterial infection among the admitted severely acutely malnourished
children. Mebendazole and Albendazole deworming medicines were documented for 144
and 15 children respectively.

Treatment given at N (%)

16
 admission
Anti-biotic Yes 256(100)
No 0(0)
Vitamin A Yes 187(73.05)
No 69(26.95)
Measles vaccine Yes 139(34.30)
No 117(45.70)
Fully immunized Yes 32(12.50)
No 224(87.50)
Folic acid Yes 175(68.36)
No 81(31.64)
Deworming Yes 159(62.11)
No 96(37.89)
Acetaminophen Yes 119(46.48)
No 137(53.52)
Table-2 Types of routine medications for children with severe acute malnutrition
admitted to JUMC, 2017.

5.6 Outcome of Treatment

Concerning the status of their treatment outcome; 224(87.5%) of cases have recovered.
Defaulter rate of 15 (5.86%) and death rate of 17(6.64%) were recorded. Out of all death,
47.06% were accounted to pneumonia. Recovered rate indicates cured rate and
transferred out rate, which were 21.25 and 66.25% respectively.

17
 defaulter
6%
death
7%

recovered
88%

Fig. 3 Overall status of treatment outcome for children with severe acute malnutrition
admitted to WURH from august 2021 to February 2021

5.6.1 Weight gained for recovered

Out of the total (256) selected and analysis included medical records discharge or
minimum weight of around forty (40) was not documented and the average weight gain
was computed using minimum and discharge weight of only 216 children. The average
weight gained found to be 12.06 g/Kg/day.

5.6.2 Length of stay for recovered

When we see the duration of edema subsided, majority, 99(86.6%) of patients have their
edema subsided with in less than ten days. The median time for edema to subside was 10
days. The duration of stay for the recovery was less than 22 days in 199(77.73%) of
cases. The mean day for recovery was 14.57 days after admission.

Length of hospital Recovered died defaulter

stay
<7days 28 7 0
7-14days 97 2 2

18
15-21days 74 3 1
22-28 6 1 9
>28 19 4 3
Table-3 Comparison of the number of recovered, died and defaulted patients according
to the length of Hospital stay of children with SAM admitted to pediatric ward of WURH
from august 2021 to February 2021

5.6.3 Anthropometry gained for recovered

The percentage of children with MUAC of <11 cm decreased from 58.98% at admission
to 26.56% at discharge. Similarly, WFH measurement indicated that the number of
children with WFH of <70% decreased significantly from 67.19% at admission to
19.92% at discharge. Edema subsided totally during discharge.

Anthropometry At admission At discharge for recovered

MUAC
>12 37(14.45%) 58(22.66%)
11-12 68(26.56%) 98(38.28%)
<11 151(58.98%) 68(26.56%)
WFH
≥85 10(3.90%) 41(16.02%)
80-84 24(9.375%) 52(20.31%)
70-79 50(19.53%) 80(31.25%)
<70 172(67.19%) 51(19.92%)
Edema
No edema 129(50.39%) 224(87.50%)
(+) edema 34(13.28%) 00(0.00%)
(++) edema 63(24.61%) 00(0.00%)
(+++)edema 30(11.72%) 00(0.00%)
Table-4 shows anthropometric conditions of children with SAM in WURH from august
2021 to February 2021 pediatric ward at admission and during discharge.

5.7 Factors associated to treatment outcome

Regarding the overall status of treatment outcome of children with SAM, 87.5% (n =
224) of the patients were recovered from their disease. In addition to this, 21.25%,
6.64%, 5.86% and 66.25% of the patients were cured, died, defaulted their treatment and

19
transferred out to a nearby health centers for continuation of their management
respectively.

Children with >70% of WFH at admission had a better treatment outcome than children
with WFH of ≤ 70% at admission. Edematous patient had doubled (2X) death rate when
compared with non-edematous SAM patients. MUAC during admission had little effect
on the treatment outcome as this research revealed. This was may be due to inclusion of
above five years children.

The odds of being died from SAM for patients with a complication of pneumonia were
1.48 times higher than patients without this complication did. Diarrhea was the highly
associated to death among other comorbidities, which had 6x death rate when compared
with patient without this complication.

Accordingly, the odds of being died from SAM for patients not took folic acid were 47%
more compared to patients took. Likewise, patients who were not fully immunized were
having 60% higher odds of death rate from SAM compared to patients who were fully
immunized. Whereas being male sex was related to death outcome, Folic acid,
anthelmintic, and <5 years age had positive effect on recovered outcome.

Variable Treatment outcome P-value COR

recovered Died
Edema Yes 107 11 0.09 2.00(0.72-
No 117 6
5.61)
MUAC ≤11 135 10 0.01 0.94(0.35-
>11 89 7
2.57)
WFH ≤70 150 13 0.05 1.60(0.51-
>70 74 4
5.09)
Pneumonia Yes 84 8 0.05 1.48(0.55-
No 140 9
3.99)
diarrhea Yes 52 11 0.24 6.06(2.14-
No 172 6
17.19)
deworming Yes 143 9 0.06 0.64(0.24-
No 81 8
1.72)
Folic acid Yes 152 9 0.08 0.53(0.20-
No 72 8
1.44)

20
Fully Yes 30 1 0.06 0.40(0.05-
No 194 16
immunized 3.16)
Age ≤5 years 190 14 0.02 0.84(0.23-
>5years 34 3
3.06)
Sex Male 150 12 0.02 1.18(0.40-
Female 74 5
3.49)
Table-5 Results of bivariate logistic regression analysis for factors affecting treatment
outcome of children with severe acute malnutrition admitted to WURH from august 2021
to February 2021

21
CHAPTER 6 DISCUSSION
In this study, the average length of hospital stay was found to be 14.57 days, which was
lower than reports from studies, conducted in other African countries (a length of stay
varying from 28 to 35 days). This finding indicated that the average length of stay in this
setting was relatively shorter than reports from 13 African countries. This could be
attributable to differences in the health institution setting where the study setting was
referral hospital and supposed to transfer-out recovered patients towards nearby health
institutions.

The average weight gain for recovered SAM patients was 12.06g/kg/day. Study
conducted in south Ethiopia shows average weight gain of recovered SAM patient was
13.7g/kg/day, which is lower than this study.

Moreover, the current study showed that antibiotics were the most commonly prescribed
medications, which was in line with other studies that indicated the inclusion of
antibiotics for children with SAM. These patients are at risk of severe infections and
hence antibiotics could be prescribed customarily as part of their nutritional therapy.

The cure rate, death rate, defaulting rate and transferred out rate were found to be
21.25%, 6.64%, 5.86% and 66.25% respectively. These results was not in line with a
study conducted in Southern Ethiopia that revealed 87% cure rate, 3.6% death rate, 9.1%
defaulting rate. Therefore, cure and defaulter rate in the present study was lower and
death rate was higher. Despite there is no clear justification of these discrepancies,
appropriate utilization of the protocol for management of SAM can maximize the cure
rate and minimize unwanted outcomes of treatment.

The cure rate, unlike the death rate, was found to be less than the standard criteria as per
the SAM management protocol. According to this standard, the death rate is acceptable
but the cure rate is not acceptable that could be attributable to the institution. Because, the
institution is inpatient management, recovered patient transferred to nearby health center.
This finding was congruent with a study done in Gondar University (Ethiopia).

22
The results of bivariate analyses depicted that complication of pneumonia, WFL<70, age
>5 years and male sex was significantly associated with death rate.

Children without the complication of diarrhea were less likely to die from SAM
compared to children with this complication.

In contrary, patients who were not using deworming medications, as part of their
management modality, were less likely to recover from SAM compared to patients who
were using these medications. The use of deworming medications could reduce
gastrointestinal related infections which, in turn, maintain the integrity of the
gastrointestinal tract and hasten absorption of nutrients and thereby recovery from SAM
disease.

23
24
7 .CONCLUSION AND RECOMMENDATION
7.1 conclusion

The cure rate in this study was found to be sub-optimal. Immunization, folic acid,
deworming were associated with positive treatment outcomes. Pneumonia, male sex and
WFH<70 were significantly associated with negative treatment outcome.

7.2 Recommendation
SAM management protocol should be utilized appropriately to maximize the cure rate
and minimize unwanted outcomes of treatment. Emphasis should be given for improving
early detection, immunization and treatment of severely malnourished children.

25
REFERENCES

1. Abeje, A. T., Gudayu, T. W., Malefia, Y. D., & Befftu, B. B. (2016). Analysis of
hospital records on treatment outcome of severe acute malnutrition: the case of
Gondar University Tertiary Hospital. Pediatrics & Therapeutics, 6(2), 1-5.

2. Asayehegn Tekeste, Mekitie Wondafrash, Girma Azene & Kebede Deribe

(2012).Cost effectiveness of community-based and inpatient therapeutic feeding
programs to treat severe acute malnutrition in Ethiopia. Cost Effectiveness and
Resource Allocation

3. Bachou H, Tumwine JK, Mwadime RKN, Tylleskär T. Risk factors in hospital

deaths in severely malnourished children in Kampala, Uganda. BMC pediatrics
2006 Jan;6:7

4. Bangladesh demographic and health survey (2007). National Institute of

Population Research and Training Dhaka, Bangladesh

5. Central Statistical Agency (CSA) [Ethiopia] and ICF 2016 Ethiopia Demographic
and Health Survey 2016 Addis Ababa, Ethiopia, and Rockville, Maryland, USA:
CSA and ICF.

6. Christine Dubray, Salah A. Ibrahim, Mohamed Abdelmutalib, Philippe J. Guerin,

Franc¸ Ois Dantoine, Franc¸ Ois Belanger, Dominique Legros{, Loretxu Pinoges
& Vincent Brown)(2008) Treatment of severe malnutrition with 2-day
intramuscular ceftriaxone vs 5-day amoxicillin.

26
7. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A. Management of
severe acute malnutrition in children. Lancet 2006; 368:1992–2000

8. Esubalew D, Ki flu M, Tessema T (2009) Community Based Emergency

Response to Reduce Acute Malnutrition and Improved Access to Nutritional
Support and Care. Jarcoo consulting

9. FMOH (2011) Decentralization and scale up of outpatient management of SAM

in Ethiopia.

10. Head R. Management of Severe Malnutrition: A Manual for phycians and Other
Seniour Health WHO 2000;6(2):146–7.

11. HG. Yobyo, Kendall C, Nigusse D & Lemma W (2013). Outpatient Therapeutic
Feeding Program Outcomes and Determinants in Treatment of Severe Acute
Malnutrition in Tigray, Northern Ethiopia PLoS ONE 8(6): e65840
doi:10.1371/journal.pone.0065840

12. International Federation of Red Cross and Red Crescent Societies (IFRC) (2011)
World Disasters Report 2011: Focus on hunger and malnutrition. Geneva 19,
Switzerland, 2011. Available at: http://www.ifrc.org/en/publications-and-
reports/world-disasters-report/wdr2011/

13. Irena et al (2011) Diarrhea is a Major killer of Children with Severe Acute
Malnutrition in Lusaka, Zambia Nutrition Journal.

14. Kabeta A, Bekele G (2017) Factors Associated with Treatment Outcomes of

Under-five Children with Severe Acute Malnutrition Admitted to Therapeutic
Feeding Unit of Yirgalem Hospital. Clinics Mother Child Health 14: 261.
doi:10.4172/2090-7214.1000261.

27
15. Matee MI, Msengi AE, Simon E, Lyamuya EF, Mwinula JH, Mbena EC,
Samaranayake LP SF. Nutrition Status of Under-fives Attending Maternal and
Child health Clinics malnutrition in Dar es salaam, Tanzania. East Afr Med J.
1997; 74(6):368–71.

16. Mena, M. B., Dedefo, M. G., & Billoro, B. B. (2018). Treatment outcome of
severe acute malnutrition and its determinants among pediatric patients in West
Ethiopia. International journal of pediatrics, 2018.

17. Mengistu K, Alemu K, Destaw B (2013) Prevalence of Malnutrition and

Associated Factors Among Children Aged 6-59 Months at Hidabu Abote District,
North Shewa, Oromia Regional State. J Nutr Disorders Ther T1:001. doi:

18. Nagar RP, Nagar T, Gupta BD. Treatment outcome in patients with severe acute
malnutrition managed with protocolised care at malnutrition treatment corner in
Rajasthan, India: A prospective observational study (quasi-experimental). Int J
Res Med Sci 2016; 4:238-45.

19. NeimaEndris, Henok Asefa, and Lamessa Dube 2017, Prevalence of Malnutrition
and Associated Factors amongChildren in Rural Ethiopia, Hindawi BioMed
Research International Volume 2017, Article ID 6587853, 6
pages,https://doi.org/10.1155/2017/6587853

20. Rawe, K. (2012). A life free from hunger: tackling child malnutrition. Save the
Children.

21. Redi F, Egata G, Kedir A (2017) Prevalence of Malnutrition among Children

Aged 6-59 in Haramaya District, Oromia, Ethiopia. J Biom Biostat 8: 357. doi:
10.4172/2155-6180.1000357

22. Ruwan Ratnayake, Casie Tesfar & Mark Myatt (2012) Determining predictorsfor
severe acutemalnutrition: Causal analysis with in aSQUEAC assessment in Chad

28
23. Schofield C, Ashworth A. Reviews / Analyses Why have mortality rates for
severe malnutrition remained so high Bulletin of the World Health Organization
1996 74(2):223–9.

24. Shanka NA, Lemma S, Abyu DM (2015) Recovery Rate and

Determinants in Treatment of Children with Severe Acute Malnutrition using
Outpatient Therapeutic Feeding Program in Kamba District, South West Ethiopia.
J Nutr Disorders Ther 5: 155. Doi: 10.4172/2161- 0509.1000155.

25. Tesfaye Taye Gelaw & Amha Mekasha Wondemagegn (2013) Response to
conventional nutritional treatment of severely malnourished hospitalized children
in the context of HIV infection at Yekati 12 hospital, AddisAbaba, Ethiopia
Science Journal of Clinical Medicine 2, 176-182

26. UNICEF (2007) Children and the Millennium Development Goals Progress for
children a report card on nutrition.

27. Uthman OA (2009). Using extended concentration and achievement index to

study socioeconomic in equalities in chronic malnutrition; the case of
Nigeria..Journal for equity in health

28. World Health Organization (1999) Management of severe malnutrition: a manual

for physicians and other senior health workers

29. World Health Organization (2000). The world health report 2000: health
systems: improving performance. World Health Organization.

30. Zinzbu tazeze;(2015) treatment outcome and associated factor among under five
children with severe acute malnutrition treated at outpatient therapeutic feeding
unitin dheghabour Hospital, eastern Ethiopia, dap; public health nutrition.

29
 31. Horumpende, P. G., Said, S. H., Mazuguni, F. S., Antony, M. L., Kumburu, H. H.,
Sonda, T. B., ... & Chilongola, J. O. (2018). Prevalence, determinants and
knowledge of antibacterial self-medication: A cross sectional study in North-
eastern Tanzania. PloS one, 13(10), e0206623.

Annex
WOLLEGA UNIVERSITY

COLLEGE OF HEALTH SCIENCE

DEPARTMENT OF PHARMACY
Dear respondent this questionnaire is prepared to collect relevant information for the
study entitled ‘TREATMENT OUTCOME OF MALNUTRITION AND ITS
DETERMINANT AMONG PEDIATRICS IN WOLLEGA UNIVERSITY
REFERRAL HOSPITAL, WESTERN ETHIOPIA’. Thank you for your willingness
to participate by giving correct and accurate information and personal information will be
confidentially kept

This questionnaire has five parts

PART I: General characteristic of children with SAM treated at WURH

PART II: Anthropometric data

PART III: medical co-morbidities at admission

30
PART IV: Treatment given at admission

PART V: Treatment Outcome

Health facility name _________________

Address of the child
Wereda __________________
Kebele ___________________
Data recorder name____________________ signature ____________ date ___//___//
Child’s Medical record number (MRN) ______________

Part I: General characteristic of children with SAM treated at selected Hospitals.

Particulars Categories of response remark

code

101 Age of the child (month

1.male
102 Sex of the child
2.female

1 Yes
103 Breast feeding on admission
2 No

1. urban
104 Place of residence
2.rural

Part II: Anthropometric data.

31
 Particulars Categories of response remark
code

201 Weight at admission (kg )

202 Weight at discharge (kg )

203 Height /length (cm)

204 MUAC at admission(mm)

205 MUAC at discharge (mm)

206 Date of admission

207 Date of discharge

1. new admission
208 Admission type
2. re-admission

1.only edema(kwashiorkor)

2. only wasting (W/H )(marasmus)

209 Admission criteria
3. both edema and wasting

4. MUAC

210 If oedema is present, what 1. Grade 1

grade? 2. Grade 2

32
 3.Grade 3

1. Hospital

2. Outreach

211 Child is referred from 3. SFC

4. spontaneous(self)

5. other

212 Lowest weight during the stay (kg)

Part III: Medical co-morbidities at admission

301. 1.Present
co-morbidities remark
2.Absent
1. present

302. Fever ( temp >37.5) 2. absent

3.not checked
1. present
2. absent
303. Hypothermia (<35.0)
3. not checked

1. Good
304. Appetite at admission
2. Poor

1. present
305. pneumonia
2.absent

33
 1. present
306. Vomiting
2.absent

1. present
307. Diarrhea
2.absent

1. watery diarrhoea

308. If diarrhea, which type? 2. dysentery

3. other specify)___________

309.
Duration of diarrhea (days)

1. positive

310. HIV status of the child 2. Negative

3. Un know
1. Yes

311. Does the child have TB? 2. No

3. Un know
Presence of malaria? 1.yes Presence of malaria? 1.yes
312.

Part IV: Treatment given at admission

401. I.V Fluid given 1. Yes, 2. No

remark

402. I.V Anti-biotic given 1. Yes, 2. No

403. Amoxicillin 1. Yes, 2. No

34
 404. Vitamin A 1. Yes, 2. No

405. Measles vaccine 1. Yes, 2. No 3. Not applicable

406. Fully immunized 1. Yes, 2. No 3. Not applicable

407. Folic acid 1. Yes, 2. No

408. Albendazole/ Mebendazole 1. Yes, 2. No 3Not applicable

1. Yes
409. Paracetamol Tab/syrup
2. No

Part V: Treatment Outcome

1.Cure/Recovered
Treatment response of the 2.Defaulter
501.
child? 3.Non-responder remark
4. Died
Weight gain(g/kg/week)_______
Treatment response for those
502. Length of stay (weeks)________
who had been cured
MUAC gain (mm|week

35