Children with oedema recover better than those with severe wasting in outpatient therapeutic program at Boloso Sore district, Southwest Ethiopia
Kabalo and Yohannes BMC Res Notes
Children with oedema recover better than those with severe wasting in outpatient therapeutic program at Boloso Sore district, Southwest Ethiopia
Mulugeta Yohannis Kabalo 0 2
Bereket Yohannes 0 1 3
0 School of Public Health, Wolaita Sodo University , P.o.box 126, Wolaita Sodo , Ethiopia
1 School of Public and Environmental Health, Hawasa University , Hawasa , Ethiopia
2 Damot Pulasa District , Wolaita Sodo , Ethiopia
3 Centre for International Health, The University of Bergen , Bergen , Norway
Objectives: Severely undernourished young children clinically present with a typical nutritional oedema or noneoedematous. However, research evidence is limited on how these types predict treatment outcomes in Ethiopia. This study was aimed to compare oedematous and none-oedematous children for their treatment outcomes in Boloso Sore district in Southwest Ethiopia. Results: The overall recovery rate was 396 (68%). From oedematous children; 235 (79.9%) recovered, 18 (6.1%) transferred, 6 (2.0%) defaulted, 3 (1.0%) died, and 32 (11%) remained none-respondents. The treatment outcomes among the none-oedematous children were 161 (55.9%), 12 (4.2%), 4 (1.4%), 3 (1.0%), and 108 (37.5%) in similar order. Treatment outcomes of severely undernourished children in the two arms were statistically different (Χ2 = 5.82, P < 0.016). Severely malnourished children with oedema were 2.3 times highly likely to recover as compared to those without it (adjusted hazard ratio = 2.3 at 95% confidence interval: 1.79, 2.82). We documented that oedematous children in the study area had a better likelihood of recovery as compared to those with severe wasting. We recommend targeted community outreach activities on severe acute malnutrition focusing on the types.
Oedema; Severe acute malnutrition; Treatment outcome
Severely malnourished children are about 10 times at
higher risk of death than those not affected [
13 million children aged less than 5 years are affected
with severe acute malnutrition (SAM) in low income
countries; its case fatality rate in this region is of great
]. The ‘Outpatient Therapeutic Program
(OTP)’ has been implemented in many countries in
response to the burden of SAM. The program was
intended to decentralize treatment of severe acute
malnutrition (SAM) [
Based on the existing protocol, severely wasted
children with weight for height ‘z-score’ less than − 3 or mid
upper arm circumference (MUAC) less than 115 mm,
and those children with bilateral pitting oedema to legs
are considered as severely malnourished. Severely
malnourished children with medical complications are
treated as inpatient and those without medical
complications are treated in OTP [
]. The complications
include diarrhoea, coughing, dehydration, vomiting,
anorexia and related medical symptoms.
The SAM affected children in OTP receive ready to use
therapeutic foods (RUTF) and supportive medications
for 2 months. In Ethiopia, this service is given through
community health posts [
]. A recovery from SAM is
declared in either of these conditions: a 15% weight gain
for children with severe wasting and if oedema is lost for
2 consecutive weeks for those with oedema on
]. Oedematous SAM has been a concern in low
income settings resulting in high case fatality.
Noneoedematous SAM also causes mortality in children. Both
forms are common among children less than 5 years of
age in low income settings. Reviews indicate differences
in pathogenesis, and aetiology of oedematous and
noneoedematous SAM. Besides, there is evidence that
caregivers of oedematous children are more concerned for
their child nutritional disorder than caregivers of
noneoedematous children [
The existing SAM management protocol allows both
forms of SAM (oedematous and none-oedematous) to
be treated in OTP through RUTF [
studies indicate the presence of association between
treatment outcomes of SAM and the type of malnutrition [
]. However, the available evidences on treatment
outcomes of SAM by type of malnutrition are very
limited. Therefore, we compared the treatment outcomes of
SAM among oedematous and none-oedematous children
treated in OTP at Boloso Sore district in South Ethiopia.
This study was done at Boloso Sore district in
Southwest Ethiopia. It is located in 300 km distance in south
direction from Addis Ababa. It is a densely populated
area experiencing repeated episodes of severe food
]. The district has a town administration and 30
rural kebeles. The people get health service from a
hospital, 6 health centres and 32 health posts in the area [
Thirty-two OTP sites give treatment to severe
malnutrition children at outpatient in the study area. According
to the local health department reports, 12,000 children
under age 5 were treated at community outpatients at
therapeutic centres in the area during 2014 and 2015.
We did a retrospective cohort study on children OTP
records in the 2 years (2014–2015). All children
admitted to OTP in Boloso sore district with SAM during
the 2 years were the source population. Records were
excluded when the child’s age and sex, and admission
criteria were not registered in OTP cards.
The sample size was calculated assuming an anticipated
proportion of the outcome (a recovery rate of 37.1%), a
95% confidence level, an 80% power, a relative risk by the
type of undernutrition RR = 0.415, a design effect of 2,
and a 10% consideration for missing values [
computed sample size was 642 children records in OTP.
We purposely selected 6 sites from 32 OTP centres based
on higher case load. The required sample was then
allocated for each site proportionally. Children OTP cards
were randomly selected from each sites. The data were
retrieved by trained enumerators using pretested tool.
The study tool was developed from OTP card formats
and was pre-tested in other OTP sites before use.
Data were entered, cleaned, coded and analyzed in
SPSS version 20 [
]. The treatment outcomes were
calculated and compared with sphere standard
yardsticks. The disparity in the treatment outcomes among
oedematous and none-oedematous children were
compared using Chi square (Χ2), and P < 0.05 was used to
state statistical significance. The effect size was estimated
with adjusted hazard ratio (AHR) at 95% CI and the
survival status was reported using Kaplan–Meier survival
Oedematous and none‑oedematous children
Children who were admitted to OTP with the diagnoses
of nutritional oedema were considered as oedematous
and those who were admitted to the program with severe
wasting were categorized as none-oedematous.
If severely wasted children gained 15% of their weight
after admission, and if those oedematous lost the swelling
after 2 consecutive weeks of admission they were
classified as recovered.
Children who were discharged from OTP with any
outcome except recovery were termed as not recovered. A
none-recovered child could be died, defaulted,
noneresponder or medical transfer.
A SAM case absent for 2 consecutive weeks after getting
admitted to OTP and confirmed as alive by home visit
were reported as defaulter.
None‑respondent or none‑responder
A SAM case that did not reach the discharge criteria after
2 months stay in OTP was classified as a none
respondent or none-responder in this study.
Result and discussion
Socio‑demographic characteristics and nutritional status at admission
A total of 582 (90.6%) OTP cards of children were
analysed. Sixty (9.4%) cards were excluded due to
missing main records. Of those included in the analysis, 288
(49.5%) were none-oedematous and 294 (50.5%) had
oedema. Children aged ≤ 24 months were 207 (72%) in
none-oedematous study arm and were 212 (72.1%) in the
oedematous study arm (Additional file 1).
Recovery rate and other treatment outcomes at OTP
The overall recovery rate of children admitted to OTP
was 396 (68%). From oedematous arm 235 (79.9%) with
95% CI 75.5, 84.4 children recovered, 3 (1.0%) died, 6
(2.0%) defaulted, 18 (6.1%) were transferred elsewhere for
medical reason, and 32 (10.9%) were none-respondents.
Conversely, of those with oedema 161 (55.9%) with 95%
CI 50.3, 61.8 recovered, 3 (1.0%) died, 4 (1.4%) defaulted,
12 (4.2%) medically transferred and 108 (37.5%) were
none-respondents (Table 1). None-oedematous children
gained mean (SD) weight of 3.9 (2.23) g/kg/days. Both
weight gain and recovery rate of none-oedematous
children in the study area were intolerable based on
international sphere standard.
Variation in treatment outcomes by type of the SAM
Statistically significant variation in treatment
outcomes was observed between the study arms; the types
of SAM at admission (none-oedematous and
oedematous) (Χ2 = 5.82, P = 0.016). Similar findings were
reported from the south [
] as well as Northern part
of Ethiopia [
]. A study in Southwest Ethiopia at Jima
reported no association between the types and
treatment outcomes of SAM in stabilization centre [
The variations might be explained by the difference in
the study settings and the type of facilities the care was
On overage (SD) oedematous children stayed on
admission for 6.4 (3.2) weeks and it was 8.1 (3.7) weeks
for children admitted due to severe wasting with the
mean difference of 1.7 weeks (95% CI 1.66, 2.04). The
difference in the length of stay among the study arms was
statistically significant (P = 0.001) (Fig. 1). Moreover, the
likelihood of recovery was 2.3 times highly for
oedematous children than none-oedematous ones treated at
OTP (AHR = 2.25 at 95% CI 1.79, 2.82) (Table 2). This
finding was in line with the some evidences arguing that
none-oedematous children had slower response to the
current SAM treatment as compared to the oedematous
]. The likely reason for better recovery
rate and shorter length of stay for children oedema might
be due to relatively better care provided to them by
caregivers and attendants.
Oedema have been recognized as major concern to
caregivers since early years; thus caregivers have more
concern to oedematous malnutrition than that of severe
]. In contrast, the OTP is currently facing
challenges including the commonly practiced sharing of
therapeutic foods with family members [
reasons for sharing were related to perceptions of
caregiver’s on SAM and household food insecurity . Thus
the curious caregivers to the oedematous SAM as they
perceive it would difficult to treat [
] might have less
likelihood of sharing therapeutic foods provided to their
children. Therefore, we would argue that the possible
reason for the better recovery of oedematous SAM could be
better utilization of provided therapeutic foods.
The type of SAM on admission affects the treatment
outcomes of the children in outpatient therapeutic
program in Boloso sore district. Oedematous children
recovered better in time than those severely wasted.
This could be related to better utilization of therapeutic
foods by oedematous children due to caregivers’
perception towards oedema on their children. We recommend
continual awareness creation on the effects of both types
of SAM as they are cause or underlying factors of child
deaths in Ethiopia. Targeted community sensitization on
the severity of none-oedematous SAM might enhance
proper use of therapeutic foods. Furthermore,
monitoring proper usage of RUTF should be strengthened
and should also target caregivers of none-oedematous
Lack of evidence on utilization of provided RUTF on
patient card and presence of missing information in OTP
Additional file 1. Sociodemographic and related characteristics of
children admitted to OTP.
CIH: Centre for International Health; CMAM: Community based Management
of Acute Malnutrition; NORHED: Norwegian Programme for Capacity
Development in Higher Education and Research for Development; OTP: Outpatient
Therapeutic Program; RUTF: ready to use therapeutic food; SAM: severe acute
malnutrition; SC: Stabilization Centre; SENUPH: South Ethiopia Network of
Universities in Public Health; UoB: University of Bergen; WSU: Wolaita Sodo
MYK had a principal role in design, analysis, interpretation of the findings,
and write-up. BY had valuable contributions in design, analysis,
interpretation of the findings, and write-up. Both authors read and approved the final
Authors would like to acknowledge NORHED_SENUPH project, Wolaita Sodo
University, local authorities, data collectors and supervisors involved in this
study. Moreover, authors would like to extend special thanks to Elisabeth
Badie and Yohannes Kabalo for their insight all through the evolution of this
The authors declare that they have no competing interests.
Availability of data and materials
The datasets analyzed for this study were available from the corresponding
author on reasonable request.
Consent for publish
Ethics approval and consent to participate
The ethical clearance for this study was obtained from research ethics
committee of College of Health Sciences and Medicine at Wolaita Sodo University
(WSU) in Ethiopia. We received permission letter from locally relevant health
offices to retrieve data from selected OTP sites. Finally, we used unique
number as anonymous codes and data are kept confidential.
This study was financially supported by the South Ethiopia Network of
Universities in Public Health (SENUPH) project through the Norwegian Programme
for Capacity Development in Higher Education and Research for Development
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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