Skip to main content

A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia



Severe forms of malnutrition have drastic effects on childhood morbidity and mortality in sub-Saharan countries, including Ethiopia. Although few studies have previously estimated treatment outcomes of severe acute malnutrition (SAM) in Ethiopia, the findings were widely varied and inconsistent. This study thus aimed to pool estimates of treatment outcomes and identify predictors of mortality among children with SAM in Ethiopia.


A systematic review was carried out to select 21 eligible articles from identified 1013 studies (dating from 2000 to 2018) that estimated treatment outcomes and predictors of mortality among SAM children. Databases including PubMed, CINHAL, Web of Sciences; Cochrane, Psych INFO and Google Scholar were comprehensively reviewed using medical subject headings (MESH) and a priori set criteria PRISMA guideline was used to systematically review and meta-analyze eligible studies. Details of sample size, magnitude of effect sizes, including Hazard Ratio (HRs) and standard errors were extracted. Random-effects model was used to calculate pooled estimates in Stata/se version-14. Cochran’s Q, I2, and meta-bias statistics were assessed for heterogeneity and Egger’s test for publication bias.


Twenty-one studies were included in the final analysis, which comprised 8057 under-five children with SAM in Ethiopia. The pooled estimates of treatment outcomes, in terms of death, recovery, defaulter and transfer out and non-response rates were 10.3% (95% CI: 8.3, 12.3), 70.5% (95% CI: 65.7, 72.2), 13.8% (95% CI: 10.8, 16.9) and 5.1% (95% CI: 3.3, 6.9), respectively. Diarrhea (HR: 1.5, 95% CI: 1.1, 2.2), dehydration (HR: 3.1, 95% CI: 2.3, 4.2) and anemia (HR: 2.2, 95% CI: 1.5, 3.3) were statistically significant predictors of mortality among these children. No publication bias was detected.


Treatment outcomes in under-five children with SAM are lower than the World Health Organization (WHO) standard, where mortality is being predicted by comorbidities at admission. Children with SAM need to be treated for diarrhea, dehydration and anemia at the primary point of care to reduce mortality.

Peer Review reports


Globally, an estimated 20 million under-five children suffer from severe acute malnutrition (SAM) contributing to 1 million deaths every year, mainly attributable to comorbid and/or consequent infections [1, 2]. SAM is characterized by two clinical parameters: (1) severe wasting; that is, marasmus, defined as middle upper arm circumference (MUAC) < 115 mm for children aged > 6 months or a weight-for-height < − 3 z-scores according to WHO’s growth standards for under-five children; and (2) nutritional edema with kwashiorkor; that is, the presence of clinically confirmed bilateral, pitting edema [2,3,4].

Acute malnutrition is a major challenge for achieving sustainable development goals (e.g., Goals 2 and 3–Zero Hunger and Good Health and Wellbeing) as it is associated with major causes of under-five mortality. Moreover, it leads to adverse maternal and child health consequences including retarded school performance and aggravating maternal related problems [5, 6] especially in poorer settings. For instance, 2% of children (nearly 13 million) suffer from SAM in developing countries [7] of which over 90% live in South- East Asia and sub-Saharan Africa [8]. Indeed, SAM is a common indication for pediatric hospital admission and inpatient treatment in these countries. Thus, mortality of children from SAM in inpatient set-ups in sub-Saharan Africa still remains significantly high, with ten-folds higher the risk of death than well-nourished children [9].

Ethiopia has a long history of food insecurity and nutritional disorders aggravated by larger population size, land degradation, and droughts affecting a larger proportion of population [4, 10, 11]. Consequently, the country has been experiencing malnutrition related problems, although both community- and facility-based interventions are in place. For instance, children with SAM had conventionally been managed according to WHO standard in facility set-ups encompassing admission and comprehensive inpatient clinical treatment, although this protocol was first published in 1999 [12] and has guided only inpatient care of complicated SAM patients. Recently (2013 to date), there has been a paradigm shift for treating SAM, using updated WHO treatment guideline published in 2013, with compressive approaches [13]. This includes inpatient, outpatient, and community-based management of acute malnutrition (CMAM) and also provides training for health workers. The main aim of this approach is to decrease over crowdedness by treating non-complicated SAM cases at outpatient treatment programmes (OTP) without admitting to a hospital [7]. Adhering to this protocol has enhanced desired treatment outcomes [14, 15].

In Ethiopia, the health sector has attempted to upgrade nutritional intervention and improve treatment outcomes through health promotion, effective treatment strategy and supplementation of essential micronutrients for children and mothers. Different small scale fragmented studies have been conducted to determine treatment outcomes of children with SAM. However, the evidence base from previous studies on the treatment outcomes of, and factors associated with, SAM are inconsistent, and remain inconclusive. That is, under-five mortality rate in children with SAM ranges from 3.5% [16] to 29% [17] in Ethiopia, depicting a 26% variation between studies. Similarly, recovery rate ranges from 43.5% [16] to 87.6 [18] in different facilities of the country. This suggests that prevention and management of SAM are not uniform and unfinished agendas across the country may be because of lack of access to relevant healthcare, inconsistence use of SAM treatment protocol, etc. In addition, predictors of treatment outcome, particularly mortality, have not been well addressed, although anemia, HIV/AIDS, tuberculosis and diarrhea are reported to be some predictors of time to death [16, 19,20,21,22,23].

The main aim of the current meta-analysis is to determine treatment outcomes and predictors of mortality among under-five children with SAM in Ethiopia. This will assist decision makers and/or other stakeholders to practice effective and efficient SAM management.



This is a systematic review and mata-analysis of published articles on SAM in Ethiopia using a priori criteria.

Search strategies

To identify relevant articles, four authors (FW, GD, HM, and AAA) systematically searched for studies published in English from 2000 to 2018 in PubMed, Web of Science, Cochrane library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Google scholar. Reference lists and grey literature such as programme reports were also retrieved. We used medical subject headings (MESH), adding terms and keywords from a primary search to formulate search strategy in these databases. In all databases, we utilized an interactive process to improve the search strategy through checking numerous search terms and including new search terms as new relevant citations were identified. The keywords included: ‘epidemiology’, ‘treatment outcome’, ‘inpatient severe acute malnutrition’, ‘under-five’, ‘children’, ‘predictors’, ‘associated factors’ and ‘Ethiopia’. Boolean operators – ‘OR’ or ‘AND’ – were used. Endnote reference manager software was used to collect and organize search outcomes and for removal of duplicate and /or irrelevant articles.

Eligibility criteria

Studies conducted in Ethiopia, reporting inpatient treatment outcomes of SAM among under-five children, all published and unpublished observational study designs (i.e., cross-sectional, case-control and cohort) were included. Included studies were within the PICO framework (P = under-five children with SAM; I = SAM management; C = under-five children with no selected SAM treatment outcomes; O = under-five children with selected SAM treatment outcomes). Articles with no full text, after email contact with the primary author, and those studies reporting outcomes above the age of 5 were excluded.

Measurement of outcome variables

The outcomes of interest included the proportion of treatment outcomes of SAM, and predictors of mortality among under-five children with SAM. For predictors, Hazard Ratio (HR) was calculated for dichotomous outcomes from the primary studies. Those predictors included in this study were: sex (‘male’ versus ‘female’), diarrhea (‘no’ versus ‘yes’), dehydration (‘no’ versus ‘yes’), and anemia (‘no’ versus ‘yes’).

Data extraction

Data extraction format was constructed and pilot-tested with a subset of eligible studies, and then summarized using a table. Two reviewers (FW, HM) independently extracted necessary information from relevant articles. Discrepancies were adjudicated or discussed with a third reviewer (AN), whenever appropriate. We made some efforts to communicate the authors whenever further information was required. Numerator and denominator data and beta coefficients and their standard errors (if given) were used to compute HRs, where HRs with 95% CI were not reported. For dichotomous data, we extracted the number of participants with the outcome and the total sample size. The following study characteristics were extracted: region of the study area, year of publication, participant characteristics, study design, types of hospitals and treatment outcomes.

Risk of bias

The risk of bias for each relevant article was assessed by two authors (FW and AAA) independently using risk of bias assessment tool. We used the Hoy 2012 addressing internal and external validity tool using 10 criteria [24]. Accordingly, each item has either low or high risk of bias; unclear was categorized as high risk of bias. Overall score of risk of bias was then classified into low, moderate, and high for each eligible study (Additional file 3: Table S1).

Data processing and analysis

Information about the study design, study sample and country were summarized by Microsoft Excel and then exported to STATA/se version 14 for analysis. Meta-analysis of a pooled proportion of treatment outcomes was carried out using a random-effects model, generating a pooled proportion with 95% CIs. Heterogeneity across studies was estimated using the Cochran’s Q and I2 statistics [25]. The I2 statistic estimates the percentage of total variations across studies that are due to factual between-study differences rather than chance. We also scrutinized forest plots of summary estimates of each study to determine whether we could identify any heterogeneity between studies. For meta-analyses with a minimum of 10 studies, publication bias was determined based on the visual assessment of the funnel plot [26] and Egger’s test [27].


Overview of the search

This systematic review and meta-analysis has been reported in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement [28]. First, 1013 articles related to the treatment outcomes of children with SAM were found. Of these, 535 duplications and 667 unrelated articles were excluded. Second, from the remaining 39 potential articles, 21 met eligibility for the review and included in the analysis. Eighteen full-text articles were excluded for the following reasons: 8 articles [29,30,31,32,33,34,35,36] due to unmet outcomes of interest or location and 10 studies [37,38,39,40,41,42,43,44,45,46] as they focused on outpatient treatment outcomes (Fig. 1).

Fig. 1

Flowchart diagram describing selection of studies for a meta-analysis of SAM treatment outcomes among inpatient under-five children in Ethiopia

Kappa statistic was used to measure agreement between reviewers to determine the uniformity of those potentially eligible full-text articles using the guidelines proposed by Landis and Koch [47]: < 0.20 as slight agreement, 0.21–0.40 fair agreement, 0.41–0.60 moderate agreement, 0.61–0.80 substantial agreement and > 0.80 almost perfect agreement. Finally, the kappa coefficient which revealed the agreement rate between the two reviewers for the included papers was 0.803.

Descriptive characteristics of the included studies

We identified and included 21 articles with 8057 participants which offered original data on the treatment outcomes of SAM among under-five children in Ethiopia. Main characteristics of the included studies are described in Table 1. These primary studies used different study designs to examine the magnitude of treatment outcomes of SAM. Thirteen out of 21 (61%) studies were retrospective cohort and the remaining 8 (39%) were cross-sectional in design. Sample size ranged from 151 [43] to 947 [48]. Reported under-five mortality rate ranged from 3.5% [16] to 29% [17]. Similarly, the recovery rate ranged from 43.5% [16] to 87.6% [18]. Defaulter rate ranged from 2.6% [49] to 43.6% [16] (Table 1).

Table 1 Descriptive summary of 21 included studies on treatment outcomes of SAM among under-five children admitted to a stabilization center in Ethiopia

Risk of bias assessment

The risk of bias for each original study was evaluated using toy risk of bias assessment tool which incorporated ten different items [24]. Accordingly, four studies [50,51,52,53] had high risk of bias while ten studies [16,17,18,19,20,21,22,23, 48, 49, 54,55,56,57,58] had low risk of bias and the remaining two studies [43, 59] had medium risk of bias (Additional file 3: Table S1). The funnel plot and overall Egger’s test for publication bias revealed no statistically significant evidence, p-value = 0.23(Additional file 1: Figure S1).

Treatment outcomes of under-five children with SAM

The pooled mortality rate in 8057 under-five children admitted with SAM was 10.3% (95% CI: 8.3, 12.3%) (Fig. 2). On sensitivity analysis, Kebede et al.,2015 [17], and Tirore et al., 2017 [16] had shown an impact on the overall estimation (Additional file 2: Figure S2).

Fig. 2

Forest Plot of the 21 studies estimating the mortality rate of under-five children with SAM in Ethiopia

The pooled estimate of recovery rate, representing 7608 participants admitted to stabilization centers was 70.5% (95% CI: 65.7, 72.2) (Fig. 3).

Fig. 3

Forest Plot of 20 studies that assessed recovery rate of under-five children with SAM in Ethiopia

The pooled estimate of defaulter rate, for 21 studies representing 7943 SAM children admitted to stabilization centers was 13.8% (95% CI: 10.8, 16.9) (Fig. 4).

Fig. 4

Forest Plot for 21 studies that reported defaulter rate among under-five SAM children in Ethiopia

Finally, the pooled estimate for transfer out and non-response for 13 studies, representing 5098 participants was 5.1% (95% CI: 3.3, 6.9) (Fig. 5).

Fig. 5

Forest Plot of 13 studies reporting the proportion of non-recovery and transfer out among under-five SAM children in Ethiopia

Predictors of SAM treatment outcomes

Five studies examined the predictors of time to death among SAM children using adjusted statistical models. Statistically significant factors (p < 0.05) associated with time to death were reported. In this analysis, diarrhea, dehydration and anemia were significant predictors of mortality among SAM children. As shown in Fig. 6, the risk of mortality was 1.5 times higher for patients with diarrheal comorbidity as compared to those without diarrheal comorbidity (HR: 1.5 (95% CI: 1.1, 2.2)). Similarly, the likelihood of death was significantly higher in dehydrated patients as compared with those without dehydration (HR: 3.1(95% CI: 2.3, 4.2)).Finally, the risk of death for SAM children with anemia was more than two times higher than those children without anemia (HR: 2.2(95% CI: 1.5, 3.3)) (Fig. 6).

Fig. 6

Predictors of mortality among under-five SAM children in Ethiopia


This meta-analysis examined treatment outcomes – death, recovery, defaulter and transfer out plus non-response rates – in under-five children admitted to SAM stabilization centers in Ethiopia. The proportion of children that died and recovered does not achieve the minimum SPHERE standard and WHO management protocol for SAM (i.e., < 10% death rate and > 75%) [60]. This high death rate and low recovery rate could be a result of delay at presentation to a stabilization center, the occurrence of recurrent infections, presence of co-morbidities and non-adherence (by healthcare providers) to the current SAM treatment guideline. The finding was also lower than the previous retrospective review done by Teferi et al. (n = 11,335 children) that revealed 87% cure rate and 3.6% (n = 468) death rate [15]. Likewise, a study from SierraLeone (n = 1987 children) reported 83% recovery rate [61]. This discrepancy might be because of the study characteristics. For instance, previous studies included both moderate and severe forms of acute malnutrition, which might potentially be associated with good treatment outcomes. However, the current analysis reported a recovery rate higher than that reported in Indian study (1130 SAM children) where 51.7% children were discharged from the program upon meeting discharge criteria [62]. Interestingly, the defaulter rate was in parallel with SPHERE report standard stating that the defaulter rate should be less than 15% [60]. By contrast, this finding was lower than a finding in India (47.2% children did not complete their treatment course – defaulters) [62]. The observed variation might be due to sociodemographic characteristics, study period and provision of quality of care, or inefficient use of resources including manpower. Moreover, uncomplicated SAM has occasionally been admitted to Asian stabilization centers [63].

In terms of predictors of mortality in SAM children, the association of diarrhea and SAM is a well-recognized fact [64, 65], although, to the best of our knowledge, the management of children presenting with diarrhea and SAM is limited [66]. This could have a vital role for treatment outcomes. This is supported by several studies [67,68,69,70,71] that have shown increased mortality rates in children who have both diarrhea and SAM comorbidities. This possibly is attributed by the fact that children with diarrhea have concurrent clinical features including severe dehydration, impaired perfusion, and severe metabolic acidosis that would raise mortality. Moreover, gram-negative bacteremia is normally allied with diarrhea and is the major risk factor for death, nonetheless of HIV or anthropometric status [72].

Furthermore, higher mortality rates amongst dehydrated children is likely to be related to the fact that children develop metabolic disturbance and volume deficit with the high prevalence of bacterial disease. Furthermore, the urgent correction of hypotension by speedy volume expansion may attribute to potential sodium and fluid overload that could be a plausible subsidizing factor to death [73,74,75]. We also found that anemia is one of the predictors responsible for increased mortality in SAM children. Consistently, the risk of earlier death for anemic children is reported to be significantly higher than for children without anemia [14, 76, 77]. The higher risk of mortality is because of an increased prevalence of infection and increased probability of heart failure [78].

Enhancing management of inpatient SAM remains an important approach for reducing malnutrition-related complications including mortality. As such, rendering comprehensive outpatient treatment for most SAM patients may diminish inpatient caseloads, decreases the risks of hospital-acquired infections, and thus, leave staff time to inpatient care. This strategy may reduce case-fatality rates, with cost-effective techniques. Indeed, this is recommended by updated WHO SAM management guideline which is meant to be adhered and implemented in respective set ups.

In general, our findings have policy implications for the management of children with SAM. Policymakers should be cognizant of this to strengthen health systems for appropriate management of SAM. Accordingly, in a bid to improve treatment outcomes for children with SAM, the WHO developed a-ten steps guideline for effective management of SAM, which is a widely accepted standard [79]. Indeed, few studies have reported the feasibility and sustainability of the implementation of this guideline in district hospitals with insufficient resources [80, 81]. Thus, further evaluation studies may fill this gap.

However, the findings need to be considered in the context of some important limitations. These included less control for possible confounders as crude hazard ratios were used to estimate some factors associated with treatment outcomes as opposed to adjusted analyses due to scarcity of data. Moreover, although Egger’s test did not show any risk of publication bias, few studies (e.g., Kebede et al., 2015 and Tirore et al., 2017)) showed high heterogeneity that needs to be considered while interpreting these findings.


Desired treatment outcomes in under-five children with SAM are lower than the WHO standard, where mortality is being predicted by comorbidities at admission. Healthcare facilities and providers are strongly advised to adhere to and implement based on the up-to-date inpatient SAM treatment and management protocol.

Availability of data and materials

All data generated or analyzed during this study are included within the manuscript [and its supplementary information files].



Human Immune deficiency virus/Acquired Immune-deficiency Syndrome


Hazard Ratio


Severe Acute Malnutrition


World Health Organization


  1. 1.

    Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, De Onis M, Ezzati M, Grantham-McGregor S, Katz J, Martorell R. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427–51.

    PubMed  PubMed Central  Article  Google Scholar 

  2. 2.

    Organization WH. Pocket book of hospital care for children: guidelines for the management of common childhood illnesses: World Health Organization; 2013.

  3. 3.

    Organization WH. Guideline: updates on the management of severe acute malnutrition in infants and children: World Health Organization; 2013.

  4. 4.

    Organization WH, UNICEF: community-based management of severe acute malnutrition: a joint statement by the World Health Organization, the world food Programme, the United Nations system standing committee on nutrition and the United Nations Children's fund. 2007.

    Google Scholar 

  5. 5.

    Senbanjo IO, Oshikoya KA, Odusanya OO, Njokanma OF. Prevalence of and risk factors for stunting among school children and adolescents in Abeokuta, Southwest Nigeria. J Health Popul Nutr. 2011;29(4):364.

    PubMed  PubMed Central  Article  Google Scholar 

  6. 6.

    UNICEF. The state of the world's children 2008: Child survival, vol. 8: UNICEF; 2007.

  7. 7.

    Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A. Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull. 2006;27(3_suppl3):S49–82.

    PubMed  Article  Google Scholar 

  8. 8.

    UNICEF WaWBG. Levels and trends in child malnutrition, joint malnutrition estimates 2012 edition. Washington, DC; 2012.

  9. 9.

    Black RE, Allen LH, Bhutta ZA, Caulfield LE, De Onis M, Ezzati M, Mathers C, Rivera J. Maternal, group CUS: maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371(9608):243–60.

    PubMed  Article  Google Scholar 

  10. 10.

    IFPRI. The world food situation: new driving forces and required actions. Beijing: Bi-Annual Overview of the World Food Situation presented to the CGIAR Annual General Meeting; 2007.

    Google Scholar 

  11. 11.

    Korthals M. Ethics of food production and consumption. In: The Oxford Handbook of Food, Politics, and Society; 2015. p. 1–15.

    Google Scholar 

  12. 12.

    WHO. Management of severe malnutrition: a manual for physicians and other health workers. Geneva; 1999.

  13. 13.

    WHO. Guideline: updates on the management of severe acute malnutrition in infants and children: World Health Organization; 2013.

  14. 14.

    Ashworth A, Chopra M, McCoy D, Sanders D, Jackson D, Karaolis N, Sogaula N, Schofield C. WHO guidelines for management of severe malnutrition in rural south African hospitals: effect on case fatality and the influence of operational factors. Lancet. 2004;363(9415):1110–5.

    PubMed  Article  Google Scholar 

  15. 15.

    Teferi E, Lera M, Sita S, Bogale Z, Datiko DG, Yassin MA. Treatment outcome of children with severe acute malnutrition admitted to therapeutic feeding centers in Southern Region of Ethiopia. Ethiop J Health Dev. 2010:24(3).

  16. 16.

    Tirore MG, Atey TM, Mezgebe HB. Survival status and factors associated with treatment outcome of severely malnourished children admitted to Ayder referral hospital: a cross-sectional study. BMC Nutrition. 2017;3(1):66.

    Article  Google Scholar 

  17. 17.

    Desta K. Survival status and predictors of mortality among children aged 0–59 months with severe acute malnutrition admitted to stabilization center at Sekota hospital Waghemra zone. J Nutr Disord Ther. 2015;5:160.

    Google Scholar 

  18. 18.

    Misganaw C, Mesfin M, Tesfaye M, Derese A. Retrospective study on outcome of in-patient treatment of severe acute malnutrition in Jimma University specialized hospital from September 2011-September 2012. J Diagn. 2014;1(2):18–28.

    Article  Google Scholar 

  19. 19.

    Asres DT, Prasad RP, Ayele TA. Recovery time and associated factors of severe acute malnutrition among children in Bahir Dar city, Northwest Ethiopia: an institution based retrospective cohort study. BMC Nutrition. 2018;4(1):17.

    Article  Google Scholar 

  20. 20.

    Gebremichael M, Bezabih AM, Tsadik M. Treatment outcomes and associated risk factors of severely malnourished under five children admitted to therapeutic feeding centers of Mekelle City, Northern Ethiopia. O A Library J. 2014;1(04):1.

    Google Scholar 

  21. 21.

    Girum T, Kote M, Tariku B, Bekele H. Survival status and predictors of mortality among severely acute malnourished children< 5 years of age admitted to stabilization centers in Gedeo zone: a retrospective cohort study. Ther Clin Risk Manag. 2017;13:101.

    PubMed  PubMed Central  Article  Google Scholar 

  22. 22.

    Mekuria G, Derese T, Hailu G. Treatment outcome and associated factors of severe acute malnutrition among 6–59 months old children in Debre Markos and Finote Selam hospitals, Northwest Ethiopia: a retrospective cohort study. BMC Nutrition. 2017;3(1):42.

    Article  Google Scholar 

  23. 23.

    Wagnew F. Survival and predictors of mortality among under-five children with severe acute malnutrition admitted to University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. A retrospective follow-up study; 2017.

    Google Scholar 

  24. 24.

    Hoy D, Brooks P, Woolf A, Blyth F, March L, Bain C, Baker P, Smith E, Buchbinder R. Assessing risk of bias in prevalence studies: modification of an existing tool and evidence of interrater agreement. J Clin Epidemiol. 2012;65(9):934–9.

    Article  PubMed  Google Scholar 

  25. 25.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60.

    PubMed  PubMed Central  Article  Google Scholar 

  26. 26.

    Borenstein M, Hedges LV, Higgins J, Rothstein HR. A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods. 2010;1(2):97–111.

    PubMed  Article  Google Scholar 

  27. 27.

    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  28. 28.

    Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Amberbir A, Woldemichael K, Getachew S, Girma B, Deribe K. Predictors of adherence to antiretroviral therapy among HIV-infected persons: a prospective study in Southwest Ethiopia. BMC Public Health. 2008;8(1):265.

    PubMed  PubMed Central  Article  Google Scholar 

  30. 30.

    Asena TF, Teni DA. Bayesian semi-parametric regression analysis of childhood malnutrition in Gamo Gofa zone: the social and economic impact of child under nutrition. Am J Theor Appl Stat. 2015;4(4):269–76.

    Article  Google Scholar 

  31. 31.

    Banbeta A, Seyoum D, Belachew T, Birlie B, Getachew Y. Modeling time-to-cure from severe acute malnutrition: application of various parametric frailty models. Arch Public Health. 2015;73(1):6.

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Boltena SS. Factors affecting the rehabilitation outcome (of outpatient therapeutic program) of children with severe acute malnutrition in Durame. Southern Ethiopia: UWC; 2008.

    Google Scholar 

  33. 33.

    Briend A, Collins S. Therapeutic nutrition for children with severe acute malnutrition: summary of African experience. Indian Pediatr. 2010;47(8):655–9 Springer.

    PubMed  Article  Google Scholar 

  34. 34.

    Tagar E, Sundaram M, Condliffe K, Matatiyo B, Chimbwandira F, Chilima B, Mwanamanga R, Moyo C, Chitah BM, Nyemazi JP. Multi-country analysis of treatment costs for HIV/AIDS (MATCH): facility-level ART unit cost analysis in Ethiopia, Malawi, Rwanda, South Africa and Zambia. PLoS One. 2014;9(11):e108304.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  35. 35.

    Tekeste A, Wondafrash M, Azene G, Deribe K. Cost effectiveness of community-based and in-patient therapeutic feeding programs to treat severe acute malnutrition in Ethiopia. Cost Eff Resour Alloc. 2012;10(1):4.

    PubMed  PubMed Central  Article  Google Scholar 

  36. 36.

    Wirth JP, Matji J, Woodruff BA, Chamois S, Getahun Z, White JM, Rohner F. Scale up of nutrition and health programs in Ethiopia and their overlap with reductions in child stunting. Matern Child Nutr. 2017;13(2):e12318.

    Article  Google Scholar 

  37. 37.

    Dereje N. Determinants of severe acute malnutrition among under five children in Shashogo Woreda, southern Ethiopia: a community based matched case control study. J Nutr Food Sci. 2014;4(300):2.

    Google Scholar 

  38. 38.

    Kabalo MY, Seifu CN. Treatment outcomes of severe acute malnutrition in children treated within Outpatient Therapeutic Program (OTP) at Wolaita Zone, Southern Ethiopia: retrospective cross-sectional study. J Health Popul Nutr. 2017;36(1):7.

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Massa D, Woldemichael K, Tsehayneh B, Tesfay A. Treatment outcome of severe acute malnutrition and determinants of survival in northern Ethiopia: a prospective cohort study. Int J Nutr and Metab. 2016;8(3):12–23.

    Article  Google Scholar 

  40. 40.

    Mengesha MM, Deyessa N, Tegegne BS, Dessie Y. Treatment outcome and factors affecting time to recovery in children with severe acute malnutrition treated at outpatient therapeutic care program. Glob Health Action. 2016;9(1):30704.

    PubMed  Article  Google Scholar 

  41. 41.

    Saaka M, Osman SM, Amponsem A, Ziem JB, Abdul-Mumin A, Akanbong P, Yirkyio E, Yakubu E, Ervin S. Treatment outcome of severe acute malnutrition cases at the tamale teaching hospital. J Nutr Metab. 2015;2015.

  42. 42.

    Shanka N, Lemma S, Abyu D. Recovery rate and determinants in treatment of children with severe acute malnutrition using outpatient therapeutic feeding program in Kamba District. South West Ethiopia: Journal of Nutritional Disorders & Therapy; 2015.

    Google Scholar 

  43. 43.

    Shiferaw W, Tilahun B, Patrick K, Belachew T. Treatment outcome and predictors of severe acute malnutrition using the WHO guideline at a referral Hospital in Southern Ethiopia. Ethiop J Pediatr Child Health. 2015;11(1):29–37.

    Google Scholar 

  44. 44.

    Tadesse E, Ekström E-C, Berhane Y. Challenges in implementing the integrated community-based outpatient therapeutic program for severely malnourished children in rural southern Ethiopia. Nutrients. 2016;8(5):251.

    PubMed Central  Article  Google Scholar 

  45. 45.

    Yebyo HG, Kendall C, Nigusse D, Lemma W. Outpatient therapeutic feeding program outcomes and determinants in treatment of severe acute malnutrition in Tigray, northern Ethiopia: a retrospective cohort study. PLoS One. 2013;8(6):e65840.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  46. 46.

    Yorra DT, Sagar G: Survival rate and determinants in treatment of children with severe acute malnutrition using outpatient therapeutic feeding program in Sidama zone, South Ethiopia.

  47. 47.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. biometrics. 1977;33(1):159–74.

    CAS  PubMed  Article  Google Scholar 

  48. 48.

    Jarso H, Workicho A, Alemseged F. Survival status and predictors of mortality in severely malnourished children admitted to Jimma University specialized hospital from 2010 to 2012, Jimma, Ethiopia: a retrospective longitudinal study. BMC Pediatr. 2015;15(1):1.

    Article  Google Scholar 

  49. 49.

    Kabeta A, Bekele G. Factors associated with treatment outcomes of under-five children with severe acute malnutrition admitted to therapeutic feeding unit of Yirgalem hospital. Clinics Mother Child Health. 2017;14(261):2.

    Google Scholar 

  50. 50.

    al BTe: co-morbidity and predictors of time to recovery among under-five childen with severe acute malnutrition in Debrebrhan hospital. 2018.

  51. 51.

    Amsalu S, Asnakew G. The outcome of severe malnutrition in Northwest Ethiopia: retrospective analysis of admissions. Ethiop Med J. 2006;44(2):151–7.

    PubMed  Google Scholar 

  52. 52.

    Ashagrie Terefe Abeje1 TWG, Yewunetu Dessalegn Malefia3 and Birhanu Boru Befftu3: Analysis of Hospital Records on Treatment Outcome of Severe Acute Malnutrition: The Case of Gondar University Tertiary Hospital Pediatrics & Therapeutics 2016.

  53. 53.

    M A: Managment outcome of severe acute malnutrition from 6 months to 5 years of age children admitted to yekatit 12 hospital. 2014.

  54. 54.

    Tadele Girum Adal MK, Tariku B. Incidence and predictors of mortality among severe acute malnourished under five children admitted to Dilla University Referal hospital: a retrospective longitudinal study. J Biol, Agriculture and Healthcare. 2016;6(13).

  55. 55.

    Desyibelew HD, Fekadu A, Woldie H. Recovery rate and associated factors of children age 6 to 59 months admitted with severe acute malnutrition at inpatient unit of Bahir Dar Felege Hiwot referral hospital therapeutic feeding unite, Northwest Ethiopia. PLoS One. 2017;12(2):e0171020.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  56. 56.

    Admasu A, Tadesse E, Moshago T, Mekonnen N. Survival status and its associated factors among under-five children admitted with complicated severe acute malnutrition in hospitals of Wolaita zone. South Ethiopia: Retrospective Cohort Study; 2017.

    Google Scholar 

  57. 57.

    Firehiwot M, Abdu O. Survival status and predictors of mortality among children aged 0-59 months admitted with severe acute malnutrition in Dilchora referral hospital, Dire Dawa from September 2011 to 2015: Harmaya University. p. 2016.

  58. 58.

    Gebremichael DY. Predictors of nutritional recovery time and survival status among children with severe acute malnutrition who have been managed in therapeutic feeding centers, southern Ethiopia: retrospective cohort study. BMC Public Health. 2015;15(1):1267.

    PubMed  PubMed Central  Article  Google Scholar 

  59. 59.

    Chane T, Oljira L, Atomesa GE, Agedew E. Treatment outcome and associated factors among under-five children with severe acute malnutrition admitted to therapeutic feeding unit in Woldia hospital, North Ethiopia. J Nutr Food Sci. 2014;4(6):1.

  60. 60.

    SPHERE: Sphere project: humanitarian charter and minimum standards in disaster response. 2011.

    Google Scholar 

  61. 61.

    Maust A, Koroma AS, Abla C, Molokwu N, Ryan KN, Singh L, Manary MJ. Severe and moderate acute malnutrition can be successfully managed with an integrated protocol in Sierra Leone–4. J Nutr. 2015;145(11):2604–9.

    CAS  PubMed  Article  Google Scholar 

  62. 62.

    Singh K, Badgaiyan N, Ranjan A, Dixit H, Kaushik A, Kushwaha K, Aguayo V. Management of children with severe acute malnutrition: experience of nutrition rehabilitation centers in Uttar Pradesh, India. Indian Pediatr. 2014;51(1):21–5.

    CAS  PubMed  Article  Google Scholar 

  63. 63.

    Sanghvi J, Mehta S, Kumar R. Predicators for weight gain in children treated for severe acute malnutrition: a prospective study at nutritional rehabilitation center. ISRN pediatrics. 2014;2014.

  64. 64.

    Irena AH, Mwambazi M, Mulenga V. Diarrhea is a major killer of children with severe acute malnutrition admitted to inpatient set-up in Lusaka, Zambia. Nutr J. 2011;10(1):110.

    PubMed  PubMed Central  Article  Google Scholar 

  65. 65.

    Anand K, Sundaram K, Lobo J, Kapoor S. Are diarrheal incidence and malnutrition related in under five children? A longitudinal study in an area of poor sanitary conditions. Indian Pediatr. 1994;31(8):943–8.

    CAS  PubMed  Google Scholar 

  66. 66.

    Heikens GT, Bunn J, Amadi B, Manary M, Chhagan M, Berkley JA, Rollins N, Kelly P, Adamczick C, Maitland K. Case management of HIV-infected severely malnourished children: challenges in the area of highest prevalence. Lancet. 2008;371(9620):1305–7.

    PubMed  Article  Google Scholar 

  67. 67.

    Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, Berkley JA, Toromo C, Atkinson S, Maitland K. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One. 2012;7(6):e38321.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  68. 68.

    Ahmed T, Ali M, Ullah MM, Choudhury IA, Haque ME, Salam MA, Rabbani GH, Suskind RM, Fuchs GJ. Mortality in severely malnourished children with diarrhoea and use of a standardised management protocol. Lancet. 1999;353(9168):1919–22.

    CAS  PubMed  Article  Google Scholar 

  69. 69.

    Amadi B, Mwiya M, Chomba E, Thomson M, Chintu C, Kelly P, Walker-Smith J. Improved nutritional recovery on an elemental diet in Zambian children with persistent diarrhoea and malnutrition. J Trop Pediatr. 2005;51(1):5–10.

    PubMed  Article  Google Scholar 

  70. 70.

    Maitland K, Berkley JA, Shebbe M, Peshu N, English M, Newton CRC: Children with severe malnutrition: can those at highest risk of death be identified with the WHO protocol?. PLoS med 2006, 3(12):e500.

    PubMed  PubMed Central  Article  Google Scholar 

  71. 71.

    Sunguya B, Koola J, Atkinson S. Infection associated with severe malnutrition among hspitalised children in East Africa. Tanzania J Health Res. 2006;8(3):189.

    CAS  Google Scholar 

  72. 72.

    Micek ST, Welch EC, Khan J, Pervez M, Doherty JA, Reichley RM, Kollef MH. Empiric combination antibiotic therapy is associated with improved outcome against sepsis due to gram-negative bacteria: a retrospective analysis. Antimicrob Agents Chemother. 2010;54(5):1742–8.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  73. 73.

    English M, Esamai F, Wasunna A, Were F, Ogutu B, Wamae A, Snow RW, Peshu N. Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya. Lancet. 2004;363(9425):1948–53.

    PubMed  Article  Google Scholar 

  74. 74.

    Manary M, Brewster D. Intensive nursing care of kwashiorkor in Malawi. Acta Paediatr. 2000;89(2):203–7.

    CAS  PubMed  Article  Google Scholar 

  75. 75.

    Dalwai S, Choudhury P, Bavdekar SB, Dalal R, Kapil U, Dubey A, Ugra D, Agnani M, Sachdev H. Consensus statement of the Indian academy of pediatrics on integrated management of severe acute malnutrition. Indian Pediatr. 2013;50(4):399–404.

    PubMed  Article  Google Scholar 

  76. 76.

    Muoneke VU, Ibekwe RC, Nebe-Agumadu HU, Ibe BC. Factors associated with mortality in under-five children with severe anemia in Ebonyi, Nigeria. Indian Pediatr. 2012;49(2):119–23.

    PubMed  Article  Google Scholar 

  77. 77.

    Bachou H, Tumwine JK, Mwadime RK, Tylleskär T. Risk factors in hospital deaths in severely malnourished children in Kampala, Uganda. BMC Pediatr. 2006;6(1):7.

    PubMed  PubMed Central  Article  Google Scholar 

  78. 78.

    WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children, vol. 2013. Geneva: World Health Organization; 2013. p. 6–54.

    Google Scholar 

  79. 79.

    Argent AC, Balachandran R, Vaidyanathan B, Khan A, Kumar RK. Management of undernutrition and failure to thrive in children with congenital heart disease in low-and middle-income countries. Cardiol Young. 2017;27(S6):S22–30.

    PubMed  Article  Google Scholar 

  80. 80.

    Deen JL, Funk M, Guevara VC, Saloojee H, Doe JY, Palmer A, Weber MW. Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa. Bull World Health Organ. 2003;81:237–45.

    PubMed  PubMed Central  Google Scholar 

  81. 81.

    Wanzira H, Muyinda R, Lochoro P, Putoto G, Segafredo G, Wamani H, Lazzerini M. Quality of care for children with acute malnutrition at health center level in Uganda: a cross sectional study in West Nile region during the refugee crisis. BMC Health Serv Res. 2018;18(1):561.

    PubMed  PubMed Central  Article  Google Scholar 

  82. 82.

    Ahmed M. Managment outcome of severe acute malnutrition from 6 months to 5 years of age children admitted to yekatit 12 hospital; 2014.

    Google Scholar 

Download references


The authors would like to acknowledge the Debre Markos University library for providing us with a wide range of available online databases.


Not applicable

Author information




FW involved in the conception of the research idea; (FW, GD, HM, AAA) undertook data extraction, analysis, interpretation, and manuscript write-up. (FW, SMS, AT, DH, WWT, AN, AAA) interpreted the results, data validation and drafted the manuscript. All authors mentioned in the manuscript approved the final manuscript.

Corresponding author

Correspondence to Fasil Wagnew.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Additional files

Additional file 1:

Figure S1. Funnel plots, exploring publication bias for the analysis of pooled estimate (PNG 456 kb)

Additional file 2:

Figure S2. The sensitivity analysis showed the pooled mortality when the studies omitted step by step (PNG 2054 kb)

Additional file 3:

Table S1. Risk of Bias assessment Tool of Eligible Articles by using the Hoy 2012 tool (XLSX 13 kb)

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wagnew, F., Dessie, G., Takele, W.W. et al. A meta-analysis of inpatient treatment outcomes of severe acute malnutrition and predictors of mortality among under-five children in Ethiopia. BMC Public Health 19, 1175 (2019).

Download citation


  • Severe acute malnutrition
  • Treatment outcomes
  • Meta-analysis
  • And Ethiopia