Treatment of severe acute malnutrition

Experience from developmental context

Jimma, Ethiopia

Tsinuel GirmaAsst professor of Pediatrics and Child Health

Jimma University Mar 2008 (2000)

Child health indicators

0

20

40

60

80

100

120

140

160

Infant MortalityRate

Under 5 MortalityRate

2000

2005

Target-HSDPIII

Current U5MR trend Vs MDG trend

165153

140

123109

95

165153

140

123

89

54

0

40

80

120

160

1990 1995 2000 2005 2010 2015

Years

Under

5 M

ort

ality

Rat

e

Current Trend MDG Trend

HSDP I II

f

Neonatal, 25%

Malaria, 20%

Pneumonia, 28%

Diarrhea, 20%

AIDS, 1%

Measles, 4%

Other, 2%

500,000 under-5 dying each yearRanking 6th in the world

72 % preventable

Malnutrition57%

HIV/AIDS11%

Nutritional Status of Children Under Age Five

Key interventions selected for targeted condition NATIONAL STRATEGY FOR CHILD SURVIVAL IN ETHIOPIA ,2005

Malnutrition

Prevention/promotion

Clinical care

Breast feeding

Complementary feeding

Nutrition advice and supplementation

Vitamin A supplementation

PMTCT

Measles vaccination

Family Planning

Management of severe acute malnutrition

Vitamin A

Zinc

Nutrition advice

In-patient treatment- hospital based

• Opened as part of pediatric in-patient service (Feb 2004)

• Maximum capacity of 30 patients• Staff : Feeders, nurses ,interns ,residents

and consultants • Implementation of national protocol • Open 24 hrs

Achievements

Disciplined treatment, improved practicum set-up, new outlook about treating SAM and interest in nutrition

related research

• More than 1350 patients treated so far most with co-morbidities (TB/HIV)

• Death Rate < 6%

• ARWG ~ 15g/kg/d

• ALOS 4 weeks

Observed and expected deaths from Jimma TFUusing Prudhon Index

Out- Patient Treatment

• Context • In 5 Health centers using RUTF (Dec 2005)

• Community mobilization and screening

• MOH is primarily responsible

• UNICEF provides RUTF and antibiotics

• Concern – Ethiopia: training• Jimma University- Department of Pediatrics and Child Health

Performance

Post-training follow –up, after 2 months in nine HCs showed

• Implementation within 34days (20-58)• Enthusiastic health workers • Good acceptance by mothers and caregivers (also

demonstrated in another study)

But• Poor adherence to protocol ( one in five)• Poor medical recording• No proper evaluation of appetite – (field tested )

Types of malnutrition on admissionn=324,four health centers

Treatment outcome

Outcome

• RWG for recovered children was 6.0 g/ kg/d and no difference between types of malnutrition

• RWG for defaulters < 5g/kg/d

• Length of stay for all recovered children was 36.0 and 39.0 days, respectively.

different outcome between HCs but not on the type of malnutrition

Malnutrition and HIV/AIDS

• Variable according to implementing agency so NO harmonized and standard care

• Screening for SAM and treatment in adults is practically absent in most programs

• Planned RCT in Jimma on supplementary feeding for patients on HAART

Challenges

• Staff turnover

• Supply breaks

• Sharing/ selling of RUFT

• Poor recording

• Protocol breach

• High defaulter rate

• Payment for drugs

Conclusion • Appropriate treatment of SAM and

integration to routine health care delivery can save many lives

• There is favorable environment: Interest in health service managers at different level, motivation of health workers and mothers by the treatment outcome

• Quality of care has to be improved through constant supportive supervision, in-service training and strengthening pre-service training as long term solution

Conclusion …

• Develop local expertise by working closely with higher learning institutions which is crucial for sustainability of new initiatives, research and development

• There is an urgent need for more operational researches