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