This study was conducted on 304 severely malnourished children 6–59 months old with complicated SAM admitted to Yekatit 12 teaching hospital from 2013- 2016 and it shows that the cure, death and defaulter rate was 70.4%,12.2% and 8.2% respectively also the rate of weight gain was 8.13g/kg/day and 16 days was the average length of hospital stay. The median nutritional recovery time of the entire cohort was found out to be 17 days (95 % CI: 15.615–18.385). The greatest number and proportion of terminal events occur within the first 7 days. Sepsis and HIV antibody positive cases were also found out to be independent predictors of undesirable outcome hence, diminishing the survival probability of children with SAM. Such a similar effect was also identified in other studies (11,18).
The study revealed that 12.2% children died during the period of follow up which was higher than the minimum SPHERE standard recommendation of 10% mortality rate (9). On the other hand it was significantly less as compared to findings of a similar study conducted in Zambia with 46% mortality rate(19). The result can also be compared to exemplary studies conducted in a relatively similar context. A study carried out at Hawassa university referral hospital depicts a 15.2% death rate which is again above the value reviled in this study (20). On the contrast a couple of similar studies carried out in Gedo in southern Ethiopia and in Jimma depict an observed mortality rate of 9.3% and 12.6% respectively (18,21). This study reported a higher mortality rate than that of the case of Gedo and Jimma. This increase could be due to differences in treatment setup or patient load (patient clinical profile).
The recovery rate of SAM children cases admitted at Yekatit 12 hospital (70.4%) is below the minimum recovery rate recommended in the SPHERE standard which is 75%. This could be due to issues of institutional capacity or for the fact that the hospital is a referral health institution and cases arrive at a later stage of the illness which in turn results in a greater proportion of terminal events to occur within the first 7 days of admission. Some institutional factors which are likely to contribute to diminished recovery rate include high stuff turnover, unbalanced case load, lack of training, lack of quality assurance procedures, availability of medical supplies and incomplete ward setup (for example, lack of isolated rooms for malnourished children) (22,23).
In this study, the defaulter rate was 8.2% this finding was consistent with the minimum international standard set for management of severe acute malnutrition which is <15%. This is consistent with other studies in the country (21,24) It is unclear what factors contribute to the defaulter rate observed in this study. The outcomes for these patients are unknown and limit a complete interpretation of the data.
The average length of hospital stay of the SAM cases was found out to be 16 days which is consistent with the minimum international standard set for management of severe acute malnutrition. The standard recommends an average length of stay of less than 30 days (9) the finding of the study in this regard is also in line with other analogous studies conducted in Ethiopia (11,18,21).
An average weight gain of 8.13g/kg/day for children with non-edematous malnutrition was computed for the study sample. This value is in line with the minimum international standard set for the management of SAM, which is 8g/kg/day(9). The average weight gain computed in this study is similar to other studies as well (18,21,25). Average weight gain for edematous malnutrition cases was difficult to compute for the reason that there was no documentation regarding when the edema was lost and when weight gain was noticed.
In the study sepsis and HIV antibody positive cases were found to be independent predictors of undesirable outcomes. Adjusting other variables, children with sepsis were 7.7 times more likely to have undesirable outcome than children admitted without sepsis. This was in agreement with other reports (19,26,27). Although sepsis was less common in this study (only 8.4%), compared to other comorbidities, it was found to be an independent predictor of undesirable outcome. Malnutrition and infection/sepsis have a synergistic relationship, through which malnutrition inhibits immune response and infectious diseases can exacerbate malnutrition which in turn increases the severity, duration and frequency of infection (28). In addition to this, the diagnosis of infection in malnourished children is difficult because clinical manifestations of infection such as fever may not be apparent (14). The intertwined effects of malnutrition and infection eventually lead to higher risk of mortality. Similarly, the risk of undesirable outcome in children with SAM that are HIV antibody positive was 3.2 times higher than those cases that are HIV antibody negative. Other similar studies also found out that HIV antibody positive children were 3 times more like to die (3,10,11).
We compared the excluded group of children with that of children included in this study and found no significant differences in their ages or sex (for those with available information) or admission characteristics (mean MUAC, mean WHZ, type of comorbidity) and household characteristics (family size) of the children. Thus, selection bias was less likely to occur.
Strength and limitation of the study
A major strength of the study was that all the data collection and screening was carried out by the principal investigator which eliminates problems that might arise from lack of scientific judgment. Records have been thoroughly evaluated and only those deemed fit have been included in the study. Regarding the methodology adopted, the process of finding out comorbidities with significant influence on treatment outcomes involved two levels of investigation. First, all the recorded comorbidities were independently run in bivariate cox regression and those with P-value <0.25 were used for the multivariate regression at a later stage.
On the contrary, since the study is retrospective in nature, it completely relied on secondary data source in the form of medical records. Such data source could have incomplete records and missing information. Another drawback common to survival analysis in general is the situation where the treatment outcomes of defaulters and those referred to another institution could not be traced. These groups were simply left out from the analysis resulting in reduced sample size.