The overall survival time for severely malnourished children was 38 days in the follow up of 7920 days of observation and the cumulative survival rates at the end of 1st, 2nd, 3rd and 4th weeks were 93.5%, 90.6%, 85.4% and 80.2%, respectively. During follow up, 10.54% of children were died of which 37(59.68%) were died with in first week of admission. The mean length of hospital stay was 13.46 days. The average weight gain was 6.16 g/kg/day (0.54 g/kg/day for edematous malnutrition and 13.36 g/kg/day for non-edematous malnutrition). Urban residence, presence of dehydration, presence shock, altered body temperature, failure to take F100 formula milk and oral antibiotics were independent determinants of mortality among children admitted with SAM.
This study revealed that the survival time for SAM children was 38 days in the follow up of 7920 days of observation. It is lower than studies conducted in different parts of Ethiopia Tigray which reported 41.93 days , in Gondar University hospital (69 days) , in DireDawa, (69.28 days) , in Gedeo zone (79.6) , and in Dilla (47 days) . However, it is higher than studies conducted in Lusaka, Zambia (13 days)  in Sekota, north Ethiopia (10days) . This might be due to difference in hospital facilities, difference in study setting; sample size difference, difference in follow up periods, difference skills of professionals, difference in adherence to management protocol, and difference in severity of cases and comorbidity might attribute these variations.
In this study, 10.54% of children were died during follow up period of whom 37(59.68%) were died with in first week of admission during the follow-up period. This is in line with some studies conducted in Ethiopia, Gondar (12.5%)  and Wolaita, (12.4%) . But it is higher than other studies conducted in India 3.5% , in Ethiopia, Woldia (6%) , and Gedeo Zone (9.3%)  Moreover, this result is also higher than acceptable levels of international standards and national protocol set for management of SAM, which describes that it should be less than 10% [30, 36]. However, the result obtained in this study is lower than results of studies conducted in Nigeria (40%) , Zambia Lusaka 40%  and in Seqota hospital (28.67%), north Ethiopia . This variation might be attributed to difference in study setting, adherence to management protocol, sample size, follow up periods and skills of professionals, delay case presentation of mothers /caregivers to treatment, and high comorbidity patterns. The variation also could be attributed to inadequately trained health staff, poor compliance with WHO treatment guidelines, or even faulty practices 
The finding of this study showed that the mean length of hospital stay was 13.46 days. This finding was acceptable when compared with minimum international SPHERE and national standard set for management of SAM, which is less than 30 days . It is also comparable with study done in Zambia, Lusaka (13 days) , Gedeo zone (13 days)  and Woldia (13.2 days), Ethiopia . Nevertheless, it is higher than the results of studies done in Cameron (8.25 days) , in some parts of Ethiopia, DireDawa (10 days)  and Wolaita zone (11 day) . In contrast, it is lower than studies done in India (14.2 days) , Ethiopia, Mekelle (17 days)  and Dilla (15 days . This variation might be due to difference in adherence to management protocol, follow up periods, severity of cases/complication, study setting, and treatment skills of health professionals.
This study also showed that the average weight gain among severely malnourished children aged 0–59 months was 6.16 g/kg/day which represents 13.36 g/kg/day for non-edematous and 0.54 g/kg/day for edematous malnutrition. It was unacceptably low when compared with international and national standards set for management of SAM, which recommends greater than 8 g/kg/day . This finding was also lower than other studies done in Ethiopia including Woldia hospital north Ethiopia 12.03 g/kg/day , Jima university teaching hospital 10.4 g/kg/day , and Dilchora hospital 15.6 g/kg/day . This might be because most of the children included in the current study had edematous malnutrition whereby weight loss is expected rather than weight gain. This low weight gain might be explained by improper therapeutic feeding practice during admission .
The finding of this study revealed that children who were lived in urban area were 2.24 times more likely to die at any given time compared with their counterparts This is congruent with study done in north part of Ethiopia where children from urban settings had an increased hazard of death by 2.73 times . However, this finding contradicts with finding from a previous prospective cohort study done in Ethiopia, which revealed that children living 2 hours far apart from the health facility had high hazards of death than their urban counterparts . This might be due to disparity in soio-economic characteristics
In this study, children who had shock were 4.15 times more likely to die at any given time than their counterparts This finding was comparable with other studies conducted in some parts of Ethiopia like Gondar university hospital, Dilla University specialized hospital, Dilla University specialized hospital Wolaita zone, and Gedeo zone, which have found that shock predicted an increased hazards of death among children admitted with SAM [12, 32–33].This might be due to difference in the typology of shock like, low volume, cardiogenic, obstructive and distributive. However, hypovolemic shock indicates the presence of severe dehydration, fluid and electrolyte imbalance, and low blood circulation in the body contributes to death .
It was also observed that dehydrated children were found to be 4 times more likely to die earlier than those children who were not dehydrated. This is consistent with studies conducted in Cameron where dehydration increased the hazards of death by 29.6% and in Jimma University specialized hospital where double fold hazards of death  were repored. However, it contradicts with other studies, where dehydration had no association with death [12, 40]. This might be due to depleted circulation and electrolyte imbalance with fluid overload, which may be attributed to secondary complication, infection and cardiac failure .
The hazards of death were 2times higher among children with altered body temperature (hypothermia or hyperthermia) when compared with their counterparts. This is supported by studies done in different parts of Ethiopia where the hazards of death due to altered body temperature were higher among children with altered body temperature [11, 20, 18, 32–33 ]. This might be attributed to the effects of hypothermia and hyperthermia, which may affect the biochemical reactions of the body and indicators of altered metabolism suggesting the presence of sepsis and serious infections. In addition, hypothermic child may not have enough calories that keep the body warm and may develop hypoglycemia. Both hypothermia and hypoglycemia are signs acute serious systemic infection, which could lead to death when intervention is delayed .
In this study, children who failed to take F100 formula milk according to SAM treatment protocol had nearly 5 times hazards of death than their counterparts. This finding was in agreement with results of other studies whereby failure to feed on F100 formula milk has increased the hazards of death by three folds  and 26% increased risk of death . However, it contradicts with other studies in Ethiopia  and Uganda , which reported lack of an association. This might be attributed to appropriate use the formula as it contains high calories and protein that hasten recovery, rapid weight gain and growth by rebuilding wasted tissues of the severely malnourished children. [2, 30].
Moreover, the hazards of death were nearly 4 times higher among children who did not take oral antibiotics compared with their counterparts. This finding was consistent with studies conducted among children admitted to three hospitals of Dhaka city in Bangladesh where non- intake of antibiotics has increased the hazards of death  Similarly, according to studies done in Gondar university hospital and Wolaita zone South Ethiopia non- intake of any antibiotics has increased the hazards of death by two folds and four fold respectively [12,33 ]. In the same line, failure to take intravenous antibiotics has increased the hazards of death 3 times among SAM cases admitted to Seqota hospital of North Ethiopia . This might be explained by the rationale behind antibiotic treatment for children with SAM lies in observation that malnourished children may not show sign of clinical infection. Therefore, treatment of infection and small intestine bacterial over growth, prevention of colonizing pathogens, and minimization of nutrient diversion are of paramount importance in increasing recovery rate 
This study could have the following limitations: Firstly, as it was based on record reviews, the chance of capturing all-important risk factors of mortality could be low unlike prospectively capturing the data. Secondly, difference in health professionals’ skill in the management of SAM could have influenced appropriate treatment of cases and record keeping.