treatment of severe acute malnutrition experience from developmental context jimma, ethiopia tsinuel...

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