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ETHIOPIAN JOURNAL OF PEDIATRICS
AND CHILD HEALTH
November 2015, Volume XI, Number 1
ISSN 2413-2640
Original articles
Featuring Article …………………………………………………………………..………….…1
Mulugeta Betre Gebremariam (MD, MPH, DLit et Phil Fellow), Birkneh Tilahun (MD),
Damte Shimelis (MD, Negussie Deyassa (MD, MPH, PHD), Tsinuel Girma(MD, PHD)
Pattern of child sexual abuse among children treated in Tikur Anbessa Specialized
Teaching Hospital 2010-2013…..………………………………………………………………..13
Teferi Elfu (MD), Etsegenet Gedlu (MD),
Magnitude of asymptomatic microscopic hematuria and proteinuria in 7-12 years old
school children in Addis Ababa, Ethiopia…………………………………………………...…..19
Abate Yeshidinber (MD), Damte Shimelis(MD)
Treatment Outcome and Predictors of Severe Acute Malnutrition using the
WHO Guideline at a Referral Hospital in Southern Ethiopia………………………….……….. 29
Wegen Shiferaw (MD), Birkneh Tilahun(MD), Kolsteren Patrick(PhD) , Tefera Belachew (MD)
Quality of Pediatric Prescription Writing at Department of Pediatrics and Child Health,
Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia.………………….……..38
Fitsum W/Gebriel (MD), Damte Shimelis (MD)
Incidence of Low Birth Weight and Its Associated Factors in Jimma University
Specialized Hospital………………………………………….………………………………..…46
Melkamu Berhane (MD), Netsanet Workneh (MD, DTM&H) and Bitiya Admassu ( BSc, MPH)
Instruction to Authors…………………………………………………………………..……..….54
Ethiopian Pediatric Society
Tele: 251-011-466-73-46/011-416-68-79 E-mail: [email protected]
website: www.epseth.og P.O. Box- 14205
Addis Ababa, Ethiopia
Ethiopian Journal of Pediatrics and Child Health
The official organ of Ethiopian Pediatric Society
Tel-251-01-466-73-46/011-416-68-79
E-mail : [email protected] Website : www.epseth.org
Addis Ababa Ethiopia
The Ethiopian Journal of Pediatrics and Child Health aims to contribute towards the improvement
of child health in developing countries, particularly in Ethiopia. The journal publishes original
articles, reviews, case reports pertaining to health problems of children.
Editorial board
Damte Shimelis, MD Editor-in-chief
Kassahun Mitiku, MD , MPH, Member
Nigussie Deyessa, MD, MPH, PhD Member
Birkneh Tilahun ,MD Member
Tsinuel Girma, MD, PhD Member
Mulugeta Betre , MD, MPH, DLit et Phil Fellow
Tigist Bacha, MD, MPH. Member
Rebecca Zewdie ,Secretary
Guest Editor
Prof. Abraham Haileamlak
1
Table of Contents
Original articles
Featuring Article …………………………………………………………………..………….…1
Mulugeta Betre Gebremariam (MD, MPH, DLit et Phil Fellow), Birkneh Tilahun (MD),
Damte Shimelis (MD, Negussie Deyassa (MD, MPH, PHD), Tsinuel Girma(MD, PHD)
Pattern of child sexual abuse among children treated in Tikur Anbessa Specialized
Teaching Hospital 2010-2013…..………………………………………………………………..13
Teferi Elfu (MD), Etsegenet Gedlu (MD),
Magnitude of asymptomatic microscopic hematuria and proteinuria in 7-12 years old
school children in Addis Ababa, Ethiopia…………………………………………………...…..19
Abate Yeshidinber (MD), Damte Shimelis(MD)
Treatment Outcome and Predictors of Severe Acute Malnutrition using the
WHO Guideline at a Referral Hospital in Southern Ethiopia………………………….……….. 29
Wegen Shiferaw (MD), Birkneh Tilahun(MD), Kolsteren Patrick(PhD) , Tefera Belachew (MD)
Quality of Pediatric Prescription Writing at Department of Pediatrics and Child Health,
Tikur Anbessa Specialized Teaching Hospital, Addis Ababa, Ethiopia.………………….……..38
Fitsum W/Gebriel (MD), Damte Shimelis (MD)
Incidence of Low Birth Weight and Its Associated Factors in Jimma University
Specialized Hospital………………………………………….………………………………..…46
Melkamu Berhane (MD), Netsanet Workneh (MD, DTM&H) and Bitiya Admassu ( BSc, MPH)
Instruction to Authors…… .…………………………………………………………..……..….54
2
Key Features of Sub-Sahara Africa‟s…
Vol. 11, No 1
Mulugeta BG. et al 1
ORIGINAL ARTICLE
Key Features of Sub-Sahara Africa’s Selected Child Health Policy
and Program Evidence-base Publications
Mulugeta Betre Gebremariam(MD, MPH, DLit et Phil Fellow)1, Birkneh Tilahun (MD)2, Damte
Shimelis (MD)1, Negussie Deyassa (MD, MPH, PhD)1, Tsinuel Girma(MD, PhD)3
ABSTRACT
Background: Progressive child health care continuum policy and research advancement constitutes
rightful priority in every setting. Nevertheless, given the current reality, countries of Sub-Saharan Africa,
including Ethiopia are expected to improve performance in this respect.
Objective: The given research output aimed at describing the key features of selected child health policy
and programmatic research evidence publications from the Sub-Saharan Africa.
Method: The study implemented a quantitative cross-sectional descriptive methodological framework using
sampled abstracts pool of reference sources which are already published and archived into the Pub Med
between September 2013 through September 2015 limit. Coupled with several sub-themes Child Health
Policy Evidences in Sub-Saharan Africa and Child Health Research in Sub-Saharan Africa were the two
main search strategies. A total of 1,446 abstracts of the published articles were solicited and organized in
alphabetical order on thematic area. Subsequently, with consideration a sample size of one-third (33.9%),
491 abstracts were enrolled for the focused quantitative descriptive analysis.
Result: Majority of the Sub-Saharan countries have two or more published child health related articles
entered in Pub Med during the period. Kenya (12.5%; 60), South Africa (11.0%; 53), Uganda (8.7%; 42),
Ethiopia (8.0%; 38) and Nigeria (8.0%; 38) were the lead countries. Overall, the Eastern Africa Region
was on top with 35.9% share of the articles. From the perspective of design and quality of evidence,
quantitative and cross-sectional descriptive, including exploratory were most commonly used accounting
for 77.6% and 77.2% respectively. Specifically, intervention trials and mixed method designs were below
10.0% each. Pertaining to the child population and child health conditions, the desired proportional due
priority to the newborn and under-five category, of course, without forgetting all other childhood
population and their health conditions, appeared not optimal. Predominance of multiple authorships where
nearly 50% revealed between five and ten authors for an article was encouraging. Publication journal
outlets are quite abundant even by taking the Ethiopian case scenario.
Conclusion & Recommendation: Even if still very modest, efforts made by the majority of the Sub-Saharan
African countries and particularly so by Kenya, South Africa and Uganda should encourage other countries
of the region to advancing the child health research culture cause with increased enterprise. Engagement in
dynamic mapping, analysis, and synthesis of up-to-date child health evidence-base should serve standard
academic, research, policy and program continuum of practice in Sub-Saharan Africa.
INTRODUCTION
No matter from which dimension, i.e., the
promotion-protection, prevention, curative and
rehabilitation domains, child health care
continuum policy and research should be viewed
rightful priority, practically, in every setting for
legitimate reasons (1). However, given the
prevailing myriads of multi-faceted societal
1 College of Health Sciences, Addis Ababa University
2 College of Health Sciences, Hawassa University
3 College of Medicine and Public Health, Jimma University
Correspondence to the Principal: Mulugeta Betre Gebremariam ([email protected]; [email protected])
challenges and factors, in Sub-Saharan Africa
(SSA) in particular, advancement of child health
policy and research „priorities‟ have never been
clear, easy, simple, smooth and straightforward (1-
2 Ethiopian Journal of Pediatrics and Child Health.
5).As a result, in the region, it is not unusual to
witness child health policy and research
„priorities‟ defined with insufficient evidence base
as well as mostly being donor directed with less
holistic and integrative pathway model. Overall,
whereas the Child Survival and the Millennium
Development Goals (MDGs) have certainly been
offering importance in respect to concerted
mobilization of the catalytic global momentum,
however, there were critical gaps which prompted
the ultimate consideration of the Sustainable
Development Goal (SDG) paradigm instead (6-9).
Due to the very fact that civic and vital
registration systems are yet little functioning
within most of the Sub-Saharan Africa settings, it
has been hardly possible to be able to generate
convincingly comprehensive, holistic and optimal
child population based evidence for policy
decision making to date. Likewise, ensuring
effective institutionalization and sustainability of
comprehensive as well as up-to-date child health
information base has remained a daunting
challenge for less developed countries, again, the
majority being in SSA. To date, the child health
research and development culture in SSA settings
has not been commensurate to the demand (4, 913). With an ever growing drive for evidencebased policy and program practice, it is crucial
that the child health research and development
gets strengthened.
Despite the prevailing shortcomings, it still is
worthwhile to duly appreciate that there has really
been ever growing interest on evidence-based
decision making and policy guidance inclusive of
the SSA within the last two to three decades,
partly, in connection with MDGs and closely
associated with global initiatives in particular.
Along the same, it should be encouraging and thus
promising to witness that more and more child
health policy-oriented scientific articles from the
SSA countries have increasingly been appearing
on international journals (9-12). Dynamic
improvements are more than ever desired in light
of the global SDG (6-8), and more specifically,
with the building momentum of “universal health
coverage, universal health access and universal
health equity” drive against the existing wide
disparities (17, 18, 23, 24), including influential
research
outputs.
Also,
increasingly
comprehensive, holistic, transformative and
“business unusual” policy and programmatic
Vol. 11, No. 1
November 2015
guidance models are being sought along the
progressive optimization and sustainability of the
child health and development gain continuum
paradigm in Sub-Saharan Africa, including
Ethiopia (4, 18-22).
Accordingly, as we are rounding up with the
MDGs phase of implementation and already
entering the SDGs era, it was felt worthwhile to
duly characterize the recent trends of child health
policy and program evidence-base in particular.
Such, among others, may form crude launchingpad indicator in order to inform and guide more
refined research enterprises into the future.
Therefore, in order to better guide future educated
practice across the academic, research, policy and
program continuum, the study has aimed at
focused examination and analysis of Pub Med
archived evidence reference resource, specifically,
of the current child health policy and
programmatic evidence base publications in SubSaharan Africa in between September 2013 to
September 2015.
MTHODS
Design, focus, search source, and strategy
The study implemented quantitative crosssectional descriptive methodological framework
with a two-year period focused research analysis.
The research has exclusively relied upon the U. S.
National Library of Medicine of the National
Institute of Health or commonly shortly
designated as Pub Med (ncbi.nlm.nih.gov)
enrolled publications reference source. And the
defining set of criteria for preferred Pub Med
domain choice and thus focus was its comparative
access friendliness, perceived comprehensiveness,
reliability, and up-to-datedness, essentially, on the
basis of the commonly held educated guess.
Search strategy has been made dynamically
double-checked up-to-date with both backward
and forward search track right up until the 25th
September, 2015; the two major search themes
were “Child Health Research in Sub-Saharan
Africa” and “Child Health Policies in Sub-Saharan
Africa” whereas the additional sub-themes of the
search details being as: ("child welfare"[MeSH
Terms]
OR
("child"[All
Fields]
AND
"welfare"[All Fields]) OR "child welfare"[All
Fields] OR ("child"[All Fields] AND "health"[All
Fields]) OR "child health"[All Fields]) AND
("research"[MeSH Terms] OR "research"[All
Key Features of Sub-Sahara Africa‟s…
Fields]) AND ("Africa south of the Sahara"[MeSH
Terms] OR ("Africa"[All Fields] AND "south"[All
Fields] AND "Sahara"[All Fields]) OR "Africa
south of the Sahara"[All Fields] OR ("sub"[All
Fields] AND "Saharan"[All Fields] AND
"Africa"[All Fields]) OR "Sub Saharan
Africa"[All Fields]). For this study, Child Health
Policy and Program were made loosely defined to
make the enrollment as cross-cutting and as
inclusive as possible with the view that every
piece of child health related research will have
some degree of contribution to the dynamic
evidence-based policy and program improvement.
Sample and sampling procedure
Choice of the Pub Med Reference Resource was
rationalized in view of its comparatively
authoritative, comprehensive and current enough
evidence base in particular. Pertaining inclusion
criteria and terms, the research was poised to
enroll all of the child health and pediatrics related
abstracts falling within 26th September, 2013
through 25th September, 2015 included. However,
at the outset, the search was unrestricted by time
range (i.e., it was made all-time inclusive with the
entire panel of abstracts pool with an all-time
aggregate to the very final date of the search
exercise, namely 26th September, 2015). The
forward and backward active search process was
implemented during 26th July through 25th
September, 2015. Accordingly, all in all, it was
possible to identify 12,192 abstracts of the articles
on “Child Health Research in Sub-Saharan Africa”
whilst 1,710 on “Child Health Policy in SubSaharan Africa” of all-period aggregate.
However, the panel of abstracts for “current” per
se pool included articles which were reported
published (and thus posted and archived in Pub
Med) in between 26th September 2013 and 25th
September 2015. The exclusive focus was on
English language-based publications.
The randomly first-appearing abstract firstdownload listing approach was followed right up
to the achievement of the full number set. The
abstracts
were
collated
and
organized
alphabetically title-based. The total number of
articles in the Pub Med for the specific period
were 1,446 abstracts dominantly 2014 & 2015
with few falling onto the 2013 (September –
December 2013) segment. Subsequently, however,
guided by the principle of manageable size in view
of time and hence based on every third abstract
Mulugeta BG. et al
3
enrollment approach, the sub-sample abstracts
panel pool for analysis was set. Accordingly, in
total, 491 (33.96%) abstracts pool of child specific
as well as with cross-cutting nature were sampled
and subjected for the structured rigorous analysis.
To the very effect, all the 1,446 abstracts were
first listed and organized in the dedicated folder
with the thematic-alphabetical order; and based on
which every subsequent third abstract beginning
right from the first to the end in the list to
fulfilling the total 491 was made enrolled and thus
subjected for critical systematic analysis by the
Investigators‟ team. Neither thematic nor country
specific preferential selection was allowable
across the sample enrollment process.
Analysis
Analysis followed the key features of the
descriptive characterization track. Custom-made
template was developed in order to systematically
guide the organization, characterization, analysis
and interpretation processes, namely the year and
month of publication, country, number of authors,
health condition, population category, study
design and type were entered into the structured
template on an excel sheet. Accordingly, based on
the given framework and thus protocol of analysis
– the key attributes of eligible (sampled) abstracts
were analyzed, summarized and presented in pure
descriptive dimension. The key features of the
analysis get presented with judicious mix of
narration, graphic and tabulation tools.
Quality
assurance
and
quality
control
management
Systematic use of structured checklist, streamlined
and uniformity of the standards of practice
coupled with nil inter-observer fallacy are
believed to ensure better quality of the given piece
of scientific work. In connection, the authors
endured full compliance to required strict
adherence to “the first occurrence of the abstract
first enrollment” pathway principle and practice in
specific view of the sampling technique
framework per se. Impartiality and integrity of
authors could have served essential quality
assurance instrumentation.
Ethical responsiveness
The given research did not require institutional
ethical review process since it was analysis
expansion and furtherance enterprise. The entirety
of the research did not involve contact or
interaction with humans; and, as well it did not
4 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
involve links with the potentially identifiable
attributes of the study subjects either case-by-case
or on collective level. Same token, furtherance of
the analysis and interpretation of the given study
relied on next level aggregation and generation of
scientifically sound evidence. Also, authors bear
no conflict of interest and have zero bias either
way, and no preferential or a prior selection other
than purely at random as per the ordered listing
within the corresponding resources. Meaningful
scholarly contribution in the best interest of
addressing the child health research agenda
dynamics, specifically, in Sub-Saharan Africa
comprised the authors‟ singular governing
motivation. No funding was solicited from any
source to undertaking the project.
Country and Articles
(N=491) Distribution
Multi-Country
Kenya
South Africa
Uganda
Ethiopia
Nigeria
Ghana
Tanzania
Malawi
Zambia
Zimbabwe
Burkina Faso
Cameroon
Rwanda
DR Congo
Ivory Coast
Mozambique
The Gambia
Senegal
FINDINGS/RESULTS
Featuring countries and overall characteristics of
abstracts of articles subjected for analysis
A total of 491 sample articles were subjected for
the current research analysis. It is important to
note that quite sizeable number of the articles bear
cross-cutting, i.e., combined child and adult health
related features. In this sample, Kenya, South
Africa, Uganda, Ethiopia, Nigeria, Ghana,
Tanzania, and Malawi with 12.5% (N=60), 11.0%
(N=53), 8.7% (N=42), 8.0% (N=38), 8.0%
(N=38), 5.6% (N=27), 5.6% (N=27) and 4.6%
(N=22) articles, respectively, appeared on the
forefront of child health research evidence
publication which as such actually were only
preceded by the Multi-Country and/or SubSaharan Global cohort (19.0%, N=91) (Table 1).
Based on the given cohort, other than the Northern
(non Sub-Saharan) African cohort per se, there
was little publication information from countries
such as Central African Republic, Djibouti,
Guinea, Liberia, Madagascar, Mali, Mauritania,
Mauritius, Santo me Principe, Seychelles and
Togo in particular.
Table 1: Relative Distribution of SSA Pub Med
Sampled Child Health Research Articles by the
Countries, September 2013 – September 2015.
November 2015
N (%)
91 (19.0)
60(12.5)
53(11.0)
42 (8.7)
38 (8.0)
38 (8.0)
27 (5.6)
27 (5.6)
22 (4.6)
17 (3.5)
17 (3.5)
12 (2.5)
10 (2.1)
9 (1.9)
8 (1.7)
6 (1.2)
5 (1.0)
5 (1.0)
4 (1.0)
The Eastern Africa Region was having largest and
the leading (35.9%) share of all the sampled
articles and as already exhibited in Table 1, the
most notable leading countries being Kenya,
Uganda, Ethiopia and Tanzania in order. In the
given sample there were no child health related
published articles representing Central and
Northern Africa in particular (Figure 1).
Figure 1: Relative Regional Bulk Share of SSA
Pub Med Source Sampled Child Health Articles,
September 2013 – September 2015
Characteristics of study designs and types
In the current sample, the descriptive and
quantitative study domains bear the lions‟ share
with 77.2% (N=363) and 76.6% (N=360)
respectively.
Observational analytical and
Key Features of Sub-Sahara Africa‟s…
randomized controlled trials of any form carried
less than 10.0% each. Again, with just 3.6%
Mulugeta BG. et al
5
(N=17) the share of mixed method application
may be stated negligible enough (Table 2).
Table 2: Relative Distribution of SSA Pub Med Sampled Child Health Articles by the Study Design
and Method, September 2013 – September 2015.
Publications (N=470) by Design and Method
Design
N (%)
Cross-Sectional Descriptive
269 (57.2)
Exploratory Descriptive
94 (20.0)
Cohort and Case-Control Group
46 (9.8)
Randomized Controlled Trials (all forms)
41 (8.7)
All other forms, including Quasi-Experimental and evaluative
22 (4.7)
Method Quantitative only
Qualitative only
Mixed Method
Spectrum of child health issues and most researched thematic domain
In the context of this analysis, HIV and AIDS
related (127; 20.5%) and all the other child health
conditions combined together (249; 40.2%) were
found to carry sizable share. Expanded Program of
Immunization (EPI)/vaccination (17; 2.8%),
under-five childhood ARI-pneumonia and diarrhea
360 (76.6)
93 (19.8)
17 (3.6)
(28; 4.5%) and tuberculosis (14; 2.3%) were found
to fall in the comparatively lower range. With the
particular focus to the childhood population
category, published respective research outputs
pertaining newborns were 63 (11.4%) and that of
the under-five children were 92 (16.6%) (Table 3).
Table 3: Relative Distribution of SSA Pub Med Sampled Child Health Articles by the Major Health
Conditions/Issues of Research, September 2013 – September 2015
Major Features
Health Conditions
Childhood
population
Characteristics
Neonatal conditions (any)
Expanded program of immunization/vaccination
Growth-Development & Malnutrition
Under-Five Childhood ARI-Pneumonia & Diarrhea
Malaria related
HIV and AIDS related
Tuberculosis
All the others
Neonates focused
Under-Five Children focused**
Five Years and Above focused and/or cross-cutting
N (%)*
63 (10.2)
17 (2.8)
65 (10.5)
28 (4.5)
56 (9.1)
127 (20.5)
14 (2.3)
249 (40.2)
63 (11.4)
92 (16.6)
400 (72.1)
* [1] Due to the co-morbidity, multiple entity
study features and overlap related factors within a single article, encounters of simultaneous counts (i.e., falling) to
more than one category was not rare; and, therefore, the denominator gets inflated to 619. [2] Again, for the same
reason, pertaining childhood population segment per se, the denominator was 555 in this particular instance.
** This is with the exclusion of studies where there was a specific mention of “neonates”.
Overall authorship model and publication journal
characteristics
6 Ethiopian Journal of Pediatrics and Child Health.
Authorship membership mix with five to ten
persons category on a given article was nearly half
of the present sample (N=233; 48.6%). The two to
four and the over ten categories revealed more or
less comparable size, 122 (25.5%) and 110
(23.0%), respectively. Single authorship style was
the rarest occurrence (14; 2.9%) (Figure 2).
Vol. 11, No. 1
November 2015
Whilst the authorship mix has ranged wide,
between single to over three hundred (with
inclusion of the collaborative consortiums), the
commonest encounters were four (65; 13.6%), five
(53; 11.1%), eight (48; 10.0%), six (42; 8.8%) and
seven (37; 7.7%) (not depicted in Figure 2).
250
200
150
Counts
Proportion
100
50
0
Single
Two - Four
Five - Ten
Over Ten
Figure 2: Relative Authorship Size Profile of SSA Pub Med Source Sampled Child Health Articles
(N=479), September 2013 – September 2015
majority (35; 92.1%) of articles were crossEthiopia’s relative share and the specific features
sectional descriptive and quantitative (32; 84.2%)
of published articles
domains. Authorship mix with two to four (14;
Based on the given Ethiopian cohort, no article
36.8%) and five to ten (15; 39.5%) authors were
was found pertaining expanded program of
the dominating feature (Table 4).
immunization/vaccination,
malaria
and
tuberculosis whereas “all the other conditions”
exhibited approximately half (21; 52.5%) of all the
articles. Articles focusing on Neonatal and UnderFive Childhood segments took 3(7.9%) and
13(34.2%), respectively. The overwhelming
Key Features of Sub-Sahara Africa‟s…
Mulugeta BG. et al
7
Table 4: Focused Characterization of Ethiopia‟s Pub Med Sampled Child Health Articles by the Major
Features, September 2013 – September 2015.
Major Features
Characteristics
Neonatal conditions
Expanded program of immunization/vaccination
Growth-Development & Malnutrition
Under-Five Childhood ARI-Pneumonia & Diarrhea
Malaria related
HIV and AIDS related
Tuberculosis
All the others
N (%)*
3 (7.5)
--7 (17.5)
6 (15.0)
--3 (7.5)
--21 (52.5)
Childhood Population
Categories
Newborns
Under-Five Childhood
All others and/or cross-cutting
3 (7.9)
13 (34.2)
22 (57.9)
Study Design & Type
Randomized controlled trial (any)
Observational: cohort and/or case-controlled
Cross-sectional descriptive
1 (2.6)
2 (5.3)
35 (92.1)
Quantitative
Qualitative
Mixed
32 (84.2)
4 (10.5)
2 (5.3)
Single
Two to Four
Five to Ten
More than Ten***
2(5.3)
14 (36.8)
15 (39.5)
7 (18.4)
Health Issues*
Authorship mix
* As already highlighted for Table 3 case, a given article could address a combination of two or more
entities
*** Also includes the collaborative consortiums
outlets. All of the Ethiopian based health journals
In this sample, the commonest encounter (mode)
but the Ethiopian Medical Journal (2; 5.3%) were
pertaining number of articles against the listed
not enrolled within the given sample of Pub Med
journals was 1 which covered in the nine out of
source. Also, in the given Ethiopian sample, no
the 26 journal titles. In comparison, BMC Public
article was revealed in some of the would be
Health (7; 18.4%), BMC Research Notes (4;
common reference sources such as the American
10.5%), PLOS One (4; 10.5%), BMC Pregnancy
Academy of Pediatrics, International Child Health,
and Child Birth (3; 7.9%) and Global Health
Journal of Tropical Pediatrics, The Lancet and The
Action (7.9%) appeared the dominant publication
New England Journal of Medicine (Table 5).
8 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
Table 5: Journals‟ Profile and Relative Distribution of Ethiopia‟s Pub Med Sampled Child Health Articles
by the Major Features, September 2013 – September 2015.
Journal Title
American Academy of Pediatrics J.
BMC International Health and Human Rights
British Medical Journal
BMC Pregnancy and Child Birth
BMC Public Health
BMC Research Notes
Ethiopian Journal of Health Development
Ethiopian Journal of Health Sciences
Ethiopian Journal of Pediatrics and Child Health
Ethiopian Medical Journal
Food and Nutrition Bulletin
Global Health Action
Human Resources for Health
International Child Health J.
Journal of Epidemiology and Global Health
Journal of Midwifery and Women‟s Health
Journal of Pediatrics Infectious Diseases
Journal of Trauma Stress
Journal of Tropical Pediatrics
Lancet (The)
New England Journal of Medicine (The)
Pan African Medical Journal
PLOS One
Social Science Medicine
Tropical Medicine and International Health
Vaccine
DISCUSSION
This study has endeavored to examine the key
features of selected child health policy and
programmatic evidence base publications from
Sub-Saharan Africa, specifically, within the Pub
Med reference source framework during
September 2013 through September 2015 in
particular. It, certainly, was not within the scope
of this research to be able to determine on how
much of the research endeavors of the SubSaharan African countries have actually been
guided by the pertinently designed priority
specific policies and programs.
Guided by the soundly formulated standards of
methodological procedure and corresponding
template, 491 abstracts of the published articles
were sampled and subjected to the focused
analysis. In gross terms, it would be fair to state
that in spite of the fact that majority of the Sub-
N (%)
--1 (2.6)
1 (2.6)
3 (7.9)
7 (18.4)
4 (10.5)
------2 (5.3)
2 (5.3)
3 (7.9)
1 (2.6)
--1 (2.6)
1 (2.6)
2 (5.3)
2 (5.3)
------1 (2.6)
4 (10.5)
1 (2.6)
1 (2.6)
1 (2.6)
Saharan African countries have registered two or
more published articles in the Pub Med reference
source during the past two years, it was evident
that the representation was not even enough by
several parameters (1, 4, 6) and, also, few
countries could not get reflected within the given
sample per se. Of course, among others, the
working language factor, specifically, such that
the predominant use of Arabic, French and
Portuguese in some of these unrepresented SubSaharan countries could have played certain role
in respect. The prevailing feature calls for more
expanded, comprehensive, and robust research in
order to be able to consolidate reliable and equally
sustainable evidence based policy and program
along the high demand for progressive child health
and development care optimization across the
Sub-Saharan Africa forward (4, 5, 7, 9, 10, & 12).
Everything else of the Sub-Saharan African
countries considered equal, it could have been
Key Features of Sub-Sahara Africa‟s…
assumed that Nigeria and Ethiopia featuring
productive first and second given the simple
theoretical logical rationalization of the per capita
proportional distribution child health research
publication outputs in the Pub Med reference
source inclusive. However, based on the findings
of this given study, it actually was Kenya, South
Africa and Uganda in the order placed from first
to third whereas Ethiopia and Nigeria ranked the
fourth and fifth instead. At the same time, though,
the largest child health research publication output
aggregate volume of approximately 36%
contributed by Eastern Africa inclusive of
Ethiopia as compared to all the other sub-regions
of the Sub-Saharan Africa; this is something to get
inspired by other sub-regions of Sub-Saharan
Africa in future.
Further looking into the featuring study designs,
types and evidence quality aspects of the sampled
child health policy and programmatic research
publication outputs of the Sub-Saharan African
countries within the Pub Med during the period, it
was revealed that the relative contribution of
intervention trials, observational analytical (cohort
and case-control), evaluative and mixed method
was somewhat marginal. Factors, such as the
“business as usual” mode of operation, crisis
response framework, capacity limitations, cost and
donor driven research enterprises could have
possibly played critical role to the prevailing
manifestation (10-12).
Specifically, when it comes to the category of
child population and respectively the child health
conditions covered in the sample research
publication outputs, as a whole, it looked that duly
the proportional emphasis on the newborn, underfive childhood population and the respective
conditions across the Sub-Saharan countries was
not optimal. HIV and AIDS related publication
outputs was the dominant feature probably in view
of the uniqueness of the HIV and AIDS pandemic
and as a result of donor-based interests per se.
More or less the same feature was evident with the
focused analysis on the Ethiopian set as well.
Nonetheless, tailor-made prioritization across the
continuum of care with rightful focus on optimal
quality of survival and development cannot be an
overemphasis (1-3, 5, 7, 8, 12, 13 & 22).
Furthermore, the yet highly widespread shortfall
backlogs, disparities and inequities coupled with
the future aspirations of the Sub-Saharan African
Mulugeta BG. et al
9
countries should warrant increasingly maximized
and multiplied responsiveness of child health
research outputs in multi-faceted dimensions to
the future (7-9, 14-17& 20-24). For both Ethiopia
and the Sub-Saharan African countries, the
comparatively better engagement of more authors
in the two and above membership for an article
category and where nearly 50% had fallen in the
five to ten authors‟ membership for an article
category should be highly encouraging. Potential
publication journal outlets may rightfully be
claimed abundant.
Overall, this fairly expeditious analysis provides
useful picture about the contemporary dynamic to
duly informing the future practice. Also, it comes
at no better right time as we get to conclude with
the popular MDGs (1-3, 5) and prepared to
commence the SDGs (6-10) and, also, equally that
professional societies are expected to undertake
the corresponding strategic up-dates to anytime
soon. Systematic guidance of the Child Health
Research Practice both in wider Sub-Saharan and
in the Ethiopian contexts will have paramount
significance (4, 11-13). Such kind of periodic
profiling is believed to facilitate increased trend
monitoring, adaptation research prioritization
guidance and focused policy dialogue practices for
both Ethiopia and the Sub-Saharan Africa at large.
Equally importantly, the mapping can serve
dynamic academic discourse purposes. Periodical
systematic
analysis,
consolidation
and
dissemination of something like the Contemporary
Child Health Research Compendium will play
vital evidence-informed academic, research,
policy and program practices. The precise format
and time range may get deliberated and finalized
at the earliest possibilities.
Scope and limitations of the given study
As stated, the analysis was exclusively focusing
on the abstracts of already published and, also,
those exclusively appearing in Pub Med.
Systematic appraisal of the full publication could
have been highly desired had it not been to the
already set objective and time considerations of
the current endeavor. Also, it may likely be the
case that Pub Med could not have catered to all of
published materials be it for the specific period of
interest or else. It as well will be worthwhile to
further note that many more yet unpublished
pertinent research resources are believed to have
existed across the Sub-Saharan African countries
10 Ethiopian Journal of Pediatrics and Child Health.
at the time of this research. Future research efforts
may attempt to offset such constraints.
Nonetheless, it is the presumption of the authors
that it still could have the greater share and thus
the given profile can inform sound enough.
Conclusion and Recommendations
Having robust enough Child Health Research
Priority Framework is viewed fundamental. Even
if still very modest, efforts being made by the SubSaharan Africa countries should be a reason for
enthusiasm which should bolster further
motivation to advancing the child health research
cause with increased enterprise by all pertinent.
The comparatively vigorous Child Health
Research culture of some Sub-Saharan African
countries, namely Kenya, South Africa, and
Uganda may be worth emulating, particularly, in
light of the per capita consideration. In view of the
present sample, Ethiopia‟s share was not
negligible and, in fact, may be viewed
increasingly promising to the future. Engagement
in dynamic mapping, analysis, and synthesis of
up-to-date child health evidence-base should serve
standard academic, research policy and
programming continuum of practice. To this very
noble effect of which, therefore, the pertinent
Pediatrics Society like that of Ethiopia and
respectively the African Chapter may have to take
the rightful lead-leap role pursuance whilst the
collaboration to the cause with all the other salient
actors and stakeholders cannot be an
overemphasis.
Vol. 11, No. 1
November 2015
Key Features of Sub-Sahara Africa‟s…
Mulugeta BG. et al
11
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Pattern of Child Sexual Abuse …
Teferi E. et al
13
ORIGINAL ARTICLE
Pattern of child sexual abuse among children treated in Tikur
Anbessa Specialized Teaching Hospital 2010-2013
Teferi Elfu (MD)1, Etsegenet Gedlu (MD)2,
ABSTRACT
Background: sexual abuse is a worldwide problem affecting all segments of the society including children.
It has a profound impact on the physical and mental health of the victims and their families. In Ethiopia
sexual abuse of children has been under reported and prevalence reported were wide range and impact on
the individual and society level not known.
Objective: To assess the prevalence of child sexual abuse and predisposing conditions among children
treated in Tikur Anbessa Specialized Teaching Hospital in three years period from September 2010-2013.
Methods: During the three year study period, 544 children under 18 years were treated for sexual abuse
out of them 300 charts were selected after systematic random sampling and sociodemographic variables,
possible risk factors and family structure were analyzed.
Results: During the three years period a total of 97,682 children were seen at the Outpatient Department
(OPD) of Tikur Anbessa Specialized Teaching Hospitalout of them 544 were children treated for sexual
abuse. Among 300 selected children 64.7% (194) of them were females. 59% were aged between 6-11
years. 203 of the children were living with their both biologic parents and reported no family problem.
41% and 23.3% of the children were victimized at their neighbourhood and their own house respectively.
Almost all perpetrators (90%) were males and majority of them were known to the child and used physical
force as means. Drug and weapons used rarely. Late presentation to health institution and absence of
abnormal physical findings in more than half of the victims were observed.
Conclusion: all children are at risk of sexual abuse irrespective of their age, gender, degree of relationship
to the perpetrators. Females are more affected than males. Living with both parents was not found
protective and children were abused in the environment considered safe. There is a need of more research
to understand the whole dynamics of child sexual abuse
Keywords: child sexual abuse, perpetrator, victim
INTRODUCTION
Child sexual abuse is complex starting from the
definition.
According to World Health
Organization (WHO) child sexual abuse (CSA)
defined as „the involvement of a child in sexual
activity that he or she does not fully comprehend,
is unable to give informed consent to, or for which
the child is not developmentally prepared and
cannot give consent, or that violates the laws or
social taboos of society (1). It is a worldwide
problem affecting all segments of the society and
has a profound impact on the physical and
1
psychosocial and mental health of its victims and
that of their families, communities and the society
at large. According to WHO estimate 150 million
girls and 73 million boys under the age of 18
worldwide experienced sexual abuse ( 2). The
current data on Africa from the World Health
Organization Global School-based Student Health
Survey estimated lifetime prevalence of sexual
abuse among primary students aged between 13–
15 years ranged from 9% to 33% (3). A south
African study done among 414 secondary school
students; 54% of them
reported to have
College of Health Sciences, Addis Ababa University
College of Health Sciences, Addis Ababa University (corresponding author)
2
14
Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
experienced contact sexual abuse before the age of
18 yrs (4,5 ). A study done in Ethiopia in one of
the schools in South West Ethiopia among 323 9th
grade female students found out that 68.7% of
them experienced sexual abuse (6).
Children are victimized at any age, by
individuals known to them in a place perceived
safe including their own home and at schools. This
problem has
short and long term social,
psychological, behavioral consequences beyond
physical damage (7-10). Thus the extent of CSA
and the socio-cultural impact and factors
associated with victimization and perpetration has
to be known clearly to establish comprehensive
holistic prevention and treatment program.
Although it is a hospital data this study may
help create awareness and also generates well
designed research questions for study r and
interventions.
Among them 544 children were cases of child
sexual abuse (CSA) and accounted for 0.56% of
the OPD visit. Data from 300 systematically
sampled victims analyzed. Females accounted for
64.6% (194 /300) and males 35.3 % (106/300).
The age distribution of abused children showed
that children in age group 6-11 were the most
affected followed by age group 12-18; 59.3% and
20% respectively .The mean age of the victims
were 8.5 years. When we look into the caretaker
profile 67.7% of the children were living with
their biological parents 15% (47) of them were
living with single parent. The rest live with
adopting parents, relatives or alone (Table1).
Variable
Frequency
SUBJECTS AND METHODS
percen
t
Gender
Male
Female
106
194
35.3
64.6
32
268
10.7
89.3
3
59
178
60
1.0
19.7
59.3
20.0
50
179
9
1
61
16.7
59.7
3.0
0.3
20.7
203
14
67.7
4.7
38
9
4
11
12.7
3.0
1.3
3.7
The study was done at Tikur Anbessa Specialized
Teaching Hospital outpatient department. The
medical records of all children less than 18 years,
who presented to the outpatient department as a
case of sexual abuse were retrieved .A sample size
of 272 children obtained by calculating using
single population proportion with 95% confidence
level (z=1.96) margin of error of 5%, and
estimated prevalence of child sexual abuse 23%
taken from one of the study done on child sexual
abuse (CSA) in Addis Abeba (13).10% was added
for incomplete records. 300 cards were selected by
systematic sampling method. The study variables
which include the socio-demographic variables,
the relationship of victim with perpetrator, family
status and circumstance related to the abuse were
analysed. Data were analyzed using a computer
with latest SPSS version 20.0 software.
Ethical clearance was obtained from Department
of Paediatrics and Child Health Research and
Publication Committee (DRCP) and from
Institutional Review Board (IRB) of College of
Health Sciences. To keep the confidentiality data
were entered anonymously.
RESULTS
Total of 97,682 children under 18years of age
were seen at TASH during the study period.
Table 1. Sociodemographic variable of Sexually
Abused children September 2010-1013.
Address
Rural
Urban
*Age (year)
<3
3-5
6-11
12-18
Educational Level
Kindergarten
Elementary
Secondary
Collage
Not attending school
Care Taker
Both biological
parents
Adopted parents
Mother only
Father only
Relative
live alone
*The mean age of the victim was 8.5 years, with SD of
3.45 years
(Minimum age 1.67yr and maximum age max 17 years)
Pattern of Child Sexual Abuse …
Teferi E. et al
As shown in table 2 the majority of the children
139 (46.3%) were abused in neighbor's house 47.4
%( 145) their own home 23.7% (71) and at school
15.7 %( 47). The majority of perpetrators were
persons known to the child including their
neighbors, own family members and teachers.
Strangers accounted only 16.3% (49). Almost all
15
victims 91.3 (274) were sexually abused by single
perpetrator and in 8.7% (26) of cases more than
one perpetrators were involved. The mean age of
the abusers was 22.6yrs the youngest being 11
years and oldest 73 years old. There were only two
females reported as perpetrators.
Table 2. Circumstances associated with Child Sexual abuse.
Variable
Frequency
Relation of Victim with perpetrator
Neighbors
Family members
Acquaints
Teachers
Employer
Stranger
Location of sexual abuse
Victims own Home
Neighbor house
School
Street
Other (car, workplace etc.)
Time of the attack
Day time
Night time
Day and night time
Number of perpetrators
Single
More than one
Total
Percentage (%)
139
41
31
14
4
49
46.3
7.3
10.3
4.7
1.3
16.3
71
145
47
6
31
23.7
47.4
15.7
2.0
10.3
267
30
3
89
10
1.0
274
26
300
91.3
8.7
100
Most of the attack took place at day time 89 %(
267), 10% (30) at night and the rest three cases
both day and night. Majority of children were
attacked by one perpetrator 91.3% (274) and 8.7%
(26) children were abused by more than one
perpetrator.
Figure 1 Family problem of Sexually
Abused children
Alcholic
1%
Divorced
Alcholic
Unknown
19%
Divorced
10%
Parental
Death
12%
Parental Death
parent'smental illness
No family problem
Unknown
No family
problem
57%
parent'sment
al illness
1%
16
Ethiopian Journal of Pediatrics and Child Health.
Family problem identified among the abused
children isillustrated in Figure 1. The majority of
the abusers (67%) used physical force, 8% used
weapon 2.7 % them used drug and alcohol and the
mean time of presentation to the health facility
Vol. 11, No. 1
November 2015
were 38 days with minimum of two hours and
maximum of six years. Physical findings at
presentation to health institution shown in Figure
2.
Figure 2 physical findings at presentation
0.30%
4%
6.70%
Normal
minor mucosal laceration
8%
old torn hymen
major bleeding
9.30%
anal laceration
52%
skin bruise
discharge only
16.70%
DISCUSSION
Among 97,682 children seen over the three year
period, 544 cases of children with sexual abuse
were identified, and this accounted for 0.54% of
outpatient visits during the study period. This
result is similar to study done by Girgira etal (13)
but is much lower than most prevalence studies
reported worldwide. The recent meta-analysis of
global sexual abuse indicated a prevalence of 11.8
%(14) Whereas data pooled from Sub-Saharan
African countries based on the global school based
student health survey data, reported prevalence of
23%, ranging from 9-33% (3). The Ethiopian,
data showed higher prevalence and wider range
from 16-68% (6,15,-19).The difference in this
study can be explained by difference in
methodology such as sampling, definition of CSA
and the sociodemography of the studied
population. Studies conducted in clinical setups
and data from police records often have been
found to report lower prevalence rates than
population based studies .The main reason for this
was the selective nature of the purpose of the
visits to higher health institution usually is referral
for better management for those with severe
trauma, or for getting legal certificate for court
cases (18).
Therefore all these evidences indicate that we
don't have exact estimation of the burden of CSA
in Ethiopia. There is need for representative
population based study.
The proportion of assaulted children was 35%
(106) male and 64.6% (194) female. This finding
is similar with other studies which consistently
show that victims of child sexual abuse are
overwhelmingly females with estimated risk of 2.5
to 3 times higher than males (10, 19, 20).
Several investigators have tried to explain
why it is lower in males. Possible potential
reasons suggested were wider screening of
females, societal norms such as the expectation
that boys should be dominant and self-reliant; the
notion that early sexual experiences are a normal
part of boys‟ lives; and reluctance to report or
disclose due to pressure
not to express,
helplessness or vulnerability, or don't know what
to do (21,22,23 ). Therefore; further research has
to be done to look into magnitude of male child
sexual abuse and possible causes of under
reporting in the community with different cultural
back ground.
Pattern of Child Sexual Abuse …
The average age of victims in our study was
8.5years; the majority of them were in the age
group 6-11yr.This finding is similar to other
studies done in USA which showed the
vulnerability of children age group of 7-12 years
for sexual abuse (10, 19).
In this study the majority of the sexually
abused children were living with their biological
parents (67.7%) and more than half of the victims
(57%) reported not to have any family problem.
Several literatures indicated that living with
biological parents is protective factor for CSA (5,
7, 9). Family problem identified as one of the
predisposing factor CSA. The reasons for this
discrepancy in our case might be poor
documentation, as in the case of missing
information due to the retrospective nature of data
collection. Most of the children brought to the
hospital were accompanied by the parents and or
family members who may be reluctant to disclose
the family problem to the health worker,
policemen who brought the children may not
know the exact family history of the child.
Therefore further researches to understand why
children who are living with their parents and
those with reported no family problem are at risk
for CSA in our study.
In the majority of cases the perpetrators were
known to the child includes neighbors, family
members, friends and teachers.The abuse took
place mostly in neighbor‟s house, victim's home,
and at school. Most of the victimization occurred
during the day time. These finding are similar to
several studies in the literature (4, 5, 11) Therefore
educating parents and other caretakers that
strangers on the streets are not the only ones as
perceived by the society, responsible for sexual
abuse. Health professionals also have to be aware
of this fact and keep in mind during their enquiry.
Our series showed a delayed reporting of CSA to
health institution which is similar to report by
Girgira et al (13 )and longer than reported by
Lakew .(18). The delay of reporting is almost
universal in most of studies across different parts
of the world. Delayed disclosure due to fear of
repercussions, intimidation by the abuser, young
age, cultural beliefs such as respect for older
person, lack of information what to do, access to
health care , are some of the reasons mentioned in
the literatures ( 9, l13, 23 ).Therefore, issues
Teferi E. et al
17
related to delayed disclosure have to be addressed
in the Ethiopian perspective.
In our study almost two thirds of the
perpetrators used physical force; whereas weapons
and drugs used rarely. Several literatures
mentioned as unique for CSA is use of bribes in
the form of gifts, favour and or grooming as the
usual technique (5, 20). This apparent difference
with the literature could be because of a sampling
bias, cultural differences or methodology used.
The finding nevertheless calls for a well-designed
study to understand the reasons behind the more
frequent use of physical force in our case.
The majority of children were reported to have
normal physical findings, only few of them did
have major bleeding and anal laceration. The
absence of suggestive physical findings may be
due to delayed presentation of victims in which
lesions might heal completely within few days.
This finding is not unique for this study, multiple
research studies worldwide demonstrated a low
prevalence of definitive physical findings among
victims of sexual abuse and clearly emphasized
absence of definitive physical findings can't rule
out CSA. (9, 10, 24).
The study has limitations of being a retrospective
hospital based study which can't reflect fully on
the spectrum of child sexual abuse in the country.
In conclusion, all children are at risk of
sexual abuse irrespective of their age, gender,
degree of relationship to the perpetrators, females
are more affected than males. Living with both
parents was not found to be protective and
children were abused in the environment
considered safe. Most of the perpetrators used
force (physical violence) during the abuse,
weapons and drugs rarely used. The victims
presented to health institution late and the majority
of them did not have abnormal findings upon
physical examination.
Creating social awareness and educating parents
and care takers about CSA is prudent. There is a
need of more research to understand the whole
dynamics of child sexual abuse in Ethiopian
context so develop effective targeted preventive
and treatment intervention strategies.
ACKNOWLEDGMENT
For Tikur Anbessa specialized hospital record
room staffs and for all staffs of the hospital
involved in the care of the children and their
Family.
18
Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
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Magnitude of Assymptomatic …
Abate Y. et al
19
ORIGINAL ARTICLE
Magnitude of asymptomatic microscopic hematuria and proteinuria
in 7-12 years old school children in Addis Ababa, Ethiopia
Abate Yeshidinber (MD)1, Damte Shimelis(MD)2
ABSTRACT
Background: Hematuria or proteinuria or mixed hematuria and proteinuria are one of the most important
signs of renal or bladder disease in children and it can represent a process that is simple and benign or
complex and life threatening. There is no research done in this country pertaining to this problem in
pediatric practice and this study will assess the magnitude of asymptomatic microscopic hematuria and
proteinuria in apparently healthy school children in Addis Ababa, Ethiopia.
Objective: To assess the prevalence of asymptomatic microscopic hematuria and proteinuria in apparently
healthy school children between the ages of 7-12 years in Addis Ababa, Ethiopia.
Materials and Methods: This is a cross sectional survey done in apparently healthy school children (7-12
years of age) from the beginning of April 2014 to the end of May 2014 over a period of 8 weeks. After
obtaining written consent from parents, a labeled urine collection cup was given for each student with
written instruction to the parents to take midstream early morning fresh urine to the level of the mark on
the cup and send the cup to the child after proper sealing. The urine samples were received by the data
collector and dipstick urinalysis was done within 1 hour of collection. A dipstick test (Multistix, Bayer
Diagnostics, Miles Inc., USA) was performed on the un spun urine specimen by trained laboratory
technician, with reagent strip designed to react progressively producing color changes at given intervals.
The results were decided by visual comparison of the test strip with a color chart provided on the bottle. All
positive hematuria results were screened for the second time after 2 weeks to check for persistence of
hematuria. This time the positive dipstick results were confirmed by microscopy after centrifugation of 10ml
of fresh urine and 5 or more RBC/HPF confirms hematuria.
Results: In the first screening out of 382 school children 32 (8.4 %) tested positive for hematuria. Among
these 7 (1.8%) were males and 25 (6.5%) were females. The difference between males and females was
statistically significant (p=0.009). When compared with the three age groups (7-8, 9-10, 11-12 years) the
prevalence of hematuria was higher in the 7-8 age group (19%) as compared to 11-12 year old children
(5.7%) and this is statistically significant (p=0.013). 75 students (19.6%) were tested positive for
proteinuria. Among the children with proteinuria 32 (8.4%) were males and 43 (11.3%) were females and
the difference was not statistically significant. 32 students (8.4%) were positive for leukocyte esterase all of
which were females. Glycosuria and nitrituria was present in less than 1%.
In the second screening, 14 children (3.7%) had isolated hematuria and 2 children (0.5%) mixed hematuria
and proteinuria making the prevalence of hematuria and proteinuria 4.2% and 0.5% respectively. Age and
sex differences in the prevalence of hematuria and proteinuria were not demonstrated. Among the 16
children with hematuria 6 children (37.5%) had red blood cell (RBC) casts in their urine suggesting
glomerulonephritis as the possible cause of hematuria.
Conclusions: The study demonstrated that the prevalence of hematuria (4.2%) and proteinuria (0.5%) is
higher in Ethiopian children than most other African children and worldwide but nitrituria and glycosuria
were rare.
1
Pediatrician, Department of pediatrics and Child Health, Saint Paul Hospital Millenium Medical College, Addis
Ababa, Ethiopia
2
Associate professor of pediatrics, consultant pediatric nephrologist, Department of pediatrics and Child Health, Addis
Ababa University, Addis Ababa, Ethiopia.
20
Ethiopian Journal of Pediatrics and Child Health. Vol. 11, No. 1
INTRODUCTION
Hematuria is defined as a positive dip strip on
urinary specimen with microscopic confirmation
of the presence of >5 RBCs/HPF (centrifuged) or
>6 RBCs/0.9 mm3 (uncentrifuged) (1, 2, 3,).
Hematuria may originate from the glomeruli, renal
tubules and interstitium, or urinary tract (including
collecting systems, ureters, bladder, and urethra).
In children, the source of bleeding is more often
from glomeruli than from the urinary tract (4).
Likely the most commonly used laboratory
test for examining renal function or injury to the
kidney or urinary tract, the urinalysis is easy to
perform and is used as a screening test, a
diagnostic test and, at times, a follow up
examination (5). The commonest indicator of an
abnormality of the urine is a ―positive‖ or
abnormal urine strip test for blood (4). When
tested on urine samples in which a predetermined
amount of blood has been placed, dipsticks have a
sensitivity of 100 and a specificity of 99 in
detecting one to five RBCs/hpf (2).However if the
dipstick test is positive, the presence of red cells
should be confirmed by microscopic examination
(6, 7).
Hematuria is a common finding in the
unselected population of children and most of the
data relative to prevalence of hematuria have
come from population-based studies of school
children (4). Microscopic hematuria may be
transient, intermittent, or persistent. Since the
persistent type seems to be uncommon, the results
of an epidemiologic study depend on the number
of specimens examined from each individual (2).
The prevalence of asymptomatic hematuria has
been markedly variable. Generally microscopic
hematuria in two or more urine samples is found
in 1 to 2% of children 6 to 15 years of age (4) and
reaches up to 4 % in a single urine sample (1,2,)
where as Gross hematuria is an uncommon finding
in an unselected Population of children with a
prevalence of 0.13%(8). Variation in the detection
rate of urinary abnormalities on screening in these
studies may be due to varying ethnic backgrounds
and the prevalence of renal diseases in these
populations (9). There are also considerable
differences in the pattern of renal disease around
the world which arise from racial variation in the
susceptibility to renal disease compounded with
November 2015
socioeconomic status further contributing to the
variation (10).
Worldwide, screening for chronic kidney
disease (CKD) is controversial, primarily because
of the uncertainty whether early detection of renal
disorders in childhood will lead to effective
interventions and reduction in the number of
individuals who develop end-stage renal disease
(ESRD). There appears to be a clear consensus
among Japanese, Taiwanese, and Korean
investigators that the screening programs currently
in place in these countries have led to early
detection and effective intervention. This opinion
is not shared by investigators from North America
and Europe and differences in the effectiveness of
mass urine screening between populations may be
due to different incidence rates of renal diseases or
to different approaches to an abnormal urine
screening test (5, 7, 10-15).
However the case may be different for
developing countries where renal replacement
therapy (RRT) that is dialysis and transplantation
is not readily available and the cost of prevention
is by far lower than treatment. Some authors
argued that, with some effort, prevention of the
progression of renal disease with the combination
of pharmacologic and non-pharmacologic
approaches can be exported to less-developed
countries. In line with this argument screening
programs can be implemented with simple, cheap,
and reliable tests, such as measurement of body
weight, blood pressure, blood glucose, and
dipstick urinalysis as has been seen In India and
Bolivia (16-18).
The International Pediatric Nephrology
association (IPNA) practical primary care
approach to hematuria in children categorize
hematuria in to 4 clinical category for the sake of
ease approach; Gross hematuria, Microscopic
hematuria with clinical symptoms, asymptomatic
microscopic
(isolated)
hematuria
and
asymptomatic microscopic hematuria with
proteinuria(1). Another goal of the design is to
discourage the random and often unnecessary use
of laboratory investigations in each child with
hematuria (19).
Many studies have shown that most children
with isolated microscopic hematuria do not have a
treatable or serious cause for hematuria and do not
require an extensive evaluation. Because the most
common diagnoses in children with persistent
Magnitude of Assymptomatic …
microscopic hematuria without proteinuria are
benign persistent or familial hematuria(thin
basement
membrane
disease),
idiopathic
hypercalciuria, IgA nephropathy, and Alport’s
syndrome, a more extensive evaluation is
indicated only when proteinuria or other indicators
are Present(1,2,20-23). Unlike microscopic
hematuria macroscopic hematuria requires prompt
evaluation to exclude potentially life-threatening
causes. Painful gross hematuria usually is caused
by infections, calculi, or urologic conditions.
Children with macroscopic hematuria require
urine culture and renal imaging by ultrasound (1,
8, 23, and 24).
In a study of 342 children with microscopic
hematuria, no cause was uncovered in 274 patients
and the authors Conclude that diagnostic
evaluation for potential causes of asymptomatic
microscopic hematuria in children may not be
necessary (23). A recent study from china also
showed similar results to the above studies with
adverse renal events (proteinuria, hypertension, or
impaired renal function) of 6.0% patients with
asymptomatic isolated microscopic hematuria
(AIMH) and 22.8% patients with asymptomatic
microscopic hematuria with proteinuria (AMHP)
(17).
African studies on the prevalence and long term
follow up outcome are scarce with only few
studies coming from Egypt and Nigeria (16, 2528).
A short survey of the pediatric nephrology
clinic log book in Tikur Anbessa Hospital,
Department of Pediatrics and Child Health Addis
Ababa, Ethiopia (the only pediatric renal follow
up clinic in Ethiopia) showed only eight children
followed for asymptomatic hematuria over a
period of 10 years (from 2004-2014). This could
be because of failure of detection/referral of such
patients who may benefit from follow up by a
pediatric nephrologist or because of the rarity of
the condition. The objective of this study is to
determine
prevalence
of
asymptomatic
microscopic hematuria in school age children in
Addis Ababa and assess the coexisting urinary
abnormalities in those children with persistent
hematuria.
MATERIALS AND METHODS
This is a cross sectional survey done in apparently
healthy school children (7-12 years of age) from
Abate Y. et al
21
the beginning of April 2014 to the end of May
2014 over a period of 8 weeks. Assuming that the
prevalence of asymptomatic hematuria in school
age children is 7.8 % (25), using the formula n=z2
p (1-p)/d2 taking 95% CI and precision of 2.5%, p
as 7.8% and a 10 % non respondent rate,
calculated sample size (n) was 488.
The study was conducted in apparently
healthy school children from Medhanialem
Primary School in Addis Ababa city which is the
capital city of Ethiopia. Medhanialem Primary
School is one of the government primary schools
under Gullele sub city Education Office and
currently having 3238 students. The school was
selected based on its number of students and its
geographic location for ease of the study.
Informed written consent was obtained from
parents and the school administration. A consent
form with the research information written in
Amharic was sent to the parents /guardians before
the study. This study was approved by the
Department of Pediatrics and Child Health
research and publication committee.
All six grade students (grades 1-6) and both
sexes were equally represented. Two sections
from each class were randomly selected by lottery
method each having an average of 50 students
with a total number of 600, but only 490 students
fulfilled the inclusion criteria and included in the
study population. From the 490 students only 382
gave consent to participate in the study.
Students with previous history of known
renal disease, female students seeing menses
during the study and those students whose parents
did not give consent were excluded from the
study.
A day before the screening urinalysis, a
labeled urine collection cup was given for each
student with written instruction to the parents to
take midstream early morning fresh urine to the
level of the mark and send the cup to the child
after proper sealing. The urine samples were
received by the data collector and dipstick
urinalysis was done within 1 hour of collection. A
dipstick test (Multistix, Bayer Diagnostics, Miles
Inc., USA) was performed on the unspun urine
specimen by trained laboratory technician, with
reagent strip designed to react progressively
producing color changes at given intervals. The
results were decided by visual comparison of the
test strip with a color chart provided on the bottle.
22
Ethiopian Journal of Pediatrics and Child Health. Vol. 11, No. 1
November 2015
In this screening program, the dipstick adopted
consists of 10 reagents: pH, specific gravity,
protein, blood, glucose, leucocytes, nitrites,
urobilinogen, bilirubin and ketone label.
All positive hematuria results were screened for
the second time after 2 weeks to check for
persistence of hematuria. This time the positive
dipstick results were confirmed by microscopy
after centrifugation of 10ml of fresh urine and 5 or
more RBC/HPF confirms hematuria.
Those children with persistent hematuria for the
second time underwent focused history and
physical examination including blood pressure
measurement, hearing assessment, throat exam,
and evaluation for edema.
After the examination these children were
referred to a pediatric nephrologist for follow up
and further work up according to the guideline on
the evaluation of children with hematuria.
During the supervision, quality and completeness
of gathered information by the data collector was
checked periodically by the principal investigator.
The collected data was cleaned manually.
The statistical analysis was performed using
statistical package of social science SPSS version
16.0. Chi-squared and Fisher's exact test were
applied to compare proportions and mean
differences, respectively. A P value of less than
0.05 was considered significant.
RESULTS
but only 382 completed forms were returned
(response rate of 78%). Out of a total of 382
children, 173 were males (45.3%) and 209 were
females (54.7%). In the first urinalysis 32 children
(8.4%) were found to be positive for hematuria
and 75 (19.6%) had proteinuria. Among the 32
The study was performed from the beginning of
April 2014 to the end of May 2014 for a period of
8 weeks. Consent forms were given to 490
asymptomatic school children aged 7–12 years,
Magnitude of Assymptomatic …
Abate Y. et al
children with hematuria 7 (1.8%) were males and
25 (6.5%) were females in the first screening and
the difference between males and females is
statistically significant (p = 0.009). The female to
male ratio was > 3:1 in children with hematuria.
The frequency of positive children for hematuria
and proteinuria in the first screenings is presented
in table 1.
The school children were divided into three age
groups: group A (7–8 years), group B (9-10 years)
23
and group C (11–12 years). There were 42
children in the 7–8 year age group, 146 in 9-10
and 194 children in the 11–12 year age group. The
age distribution of hematuria is seen in table 2.
In the first screening the prevalence of hematuria
was higher in group A and B than group C (19, 8.9
and 5.7 % respectively). But the difference was
statistically significant in only between groups A
and C with a p value of 0.013.
Table 1. Relative frequency of abnormal urinary findings in the first urinalysis of asymptomatic school
children age 7-12 years in Addis Ababa, Ethiopia.
Variable
Gender
P value
Male
Female
Total
Isolated Hematuria
7(1.8%)
25(6.5%)
32(8.4%)
0.009
Proteinuria
32 (8.4%)
43 (11.3%)
75 (19.6%)
NS*
Leukocyte esterase
0
32 (8.4%)
32 (8.4%)
0.000
Nitrituria
1(0.3%)
0
1(0.3%)
NS
Glycosuria
* NS-not significant
0
1 (0.3%)
1(0.3%)
NS
Presence of proteinuria increases with increasing
age with prevalence of 14.3, 17.9 and 22.2% in
groups A, B and C respectively (table 3). However
the difference is not statistically significant.
Unlike hematuria proteinuria was not found to be
gender dependent being seen in 19.5% males and
20.6 % females (p=0.218). 63 students (16.5) had
trace proteinuria whereas significant proteinuria
(+1 and above) was found only in 12 students
(3.1%).
Table 2. Age distribution of asymptomatic microscopic hematuria cases in the first urinalysis in the 7-12
year old school children in Addis Ababa, Ethiopia.
Age(yrs)
Hematuria
No hematuria
Total
Prevalence (%)
7-8
8
34
42
19
9-10
13
133
146
8.9
11-12
11
183
194
5.7
Total
32
350
382
8.4
In the first screening out of 382 students only 1
child (0.3%) was found to have glycosuria, one
child tested positive for nitrite (0.3%) where as
leukocyte esterase was positive in 32 children
(8.4%), all of which were females.
Out of 32 children who had hematuria in the first
screening the second urinalysis done after 2 weeks
24
Ethiopian Journal of Pediatrics and Child Health. Vol. 11, No. 1
showed 16 children tested positive for hematuria.
Out of these 14 students (3.7%) had isolated
hematuria and 2 students (0.5%) had mixed
hematuria and proteinuria. The overall prevalence
of hematuria was 4.2% and proteinuria was 0.5%
in the studied population (table 4).
Repeat urinalysis showed leukocyte esterase
positive in 4 children (1%), urine microscopy done
in 16 children with hematuria in the second
screening showed casts in 12 children (75%). The
casts were RBC in 6 (37.5%), suggesting
November 2015
glomerulonephritis as the possible cause for
hematuria. The type of glomerular lesion was not
possible to ascertain as these study subjects were
referred to a nephrologist for further workup and it
is beyond the scope of the study objective.
Granular casts were seen in 3 (18.8%), and WBC
in 1 (6.25%) and a combination of two of the
above in 2 (12.5%). No ketone or bilirubin was
detected in the urine of study subjects and all
children had normal urine PH and specific gravity.
Table 3. Age distribution of proteinuria cases in the first urinalysis in the 7-12 years old school children in
Addis Ababa, Ethiopia.
Age (yrs)
Proteinuria
No proteinuria
Total
Prevalence (%)
7-8
9-10
11-12
Total
6
26
43
75
36
120
131
287
42
146
194
382
14.3
17.9
22.2
19.6
Table 4. Category and relative frequency of urinary findings in the two steps of the study in asymptomatic
school children age 7-12 years in Addis Ababa, Ethiopia.
Finding
First sample
Second sample
Isolated asymptomatic
hematuria
25 (6.5%)
14 (3.7%)
Isolated proteinuria
68 (17.8%)
0
Mixed asymptomatic
hematuria with proteinuria
7 (1.8%)
2 (0.5%)
Leukocyte esterase
32 (8.4%)
4 (1%)
Nitrituria
1 (0.3%)
0
Glycosuria
1 (0.3%)
0
No finding
282 (73.8%)
366 (95.8%)
Total
382 (100%)
382 (100%)
DISCUSSION
In our study 32 children (8.4%) had hematuria,75
students (19.6%) were positive for protein,7
students (1.8%) were positive for both blood and
protein, 1 student (0.3%) was positive for
glucose,1 students (0.3%) was positive for nitrite
and 32 students (8.4%) were positive for
leukocyte- esterase in the first sample.
In the Galveston County epidemiology study (20),
approximately 4.0% of school-age children had
microscopic hematuria in one of the three samples
Magnitude of Assymptomatic …
tested. When the criteria for ―persistent‖
hematuria was defined as the presence of blood in
the second and third of the three consecutive
samples,
the
prevalence
decreased
to
approximately 1% and <0.5% respectively.
Our study shows a prevalence of 8.4% for
hematuria in a single sample and decreased to
4.2% on repeat urinalysis which is higher than the
above study. However, the prevalence could
further decrease if a third sample is taken. The
result of our study is comparable to a recent
Egyptian study where 7.8% of their study subjects
showing positive results for blood in the second
sample. 5 students (0.7%) were positive for both
blood and protein but in our second sample it was
0.5% which is comparable. 1 student (0.1%) was
positive for glucose, 11 students (1.6%) were
positive for nitrite, 32 students (4.5%) were
positive for leukocyte- esterase (25). These
findings are similar to our findings except a
slightly higher rate of nitrite and leukocyte
esterase in their sample.
Our result is also comparable with a recent Indian
study in 100 subjects with proteinuria and
hematuria occurring in 16 % and 5% respectively
in the first sample (18).
In the Finnish study, 16% of their study subjects
had hematuria and proteinuria in at least one
sample with an overall prevalence of 0.7% [2]. In
our study 62 students (16.2%) had trace
proteinuria where as significant proteinuria (+1
and above) was found only in 13 students (3.4%)
in the first sample. The overall prevalence of
isolated hematuria, and combined hematuria and
proteinuria were 4.2%, and 0.5%, respectively,
among our study population. The difference in the
prevalence of proteinuria among different studies
might be due to ethnic, socio-economic and
geographic variation in the prevalence of kidney
disease or in the sensitivity of the dipstick test.
The similarity in most studies is in the prevalence
of persistent hematuria associated with proteinuria
which is 0.5 % in our study, still slightly higher
than an Egyptian study which is 0.28% (Maha
etal, 25).It is the most important indicator of renal
disease as compared to isolated hematuria which
usually follows a benign course (28).
Unlike the above studies our finding is
significantly higher than a Nigerian study (which
reveals 0.6% for hematuria as compared to ours
which is 3.7%. 1 % prevalence of proteinuria is
Abate Y. et al
25
slightly higher than ours which is 0.5%.) (26). In
the Korean study isolated proteinuria was about
0.2%, occult blood was about 0.8%, and
glycosuria was about 0.07% from January 1998 to
December 2004)(30).
In one Nepalese study 5.5% children tested
positive in the first screening for isolated
hematuria and proteinuria and for combined
hematuria and proteinuria. Of these children only
0.71% cases tested positive in a second screening.
Glomerulonephritis was the most commonly
detected disorder (50%) in this study (9).In line
with this observation in our study of the 16
children who tested positive in the second
screening, 6/16 (37.5%) showed RBC casts
suggestive of glomerulonephritis as the possible
cause of hematuria. This was also the case in
another Egyptian study (27). This conclusion
however is impossible to draw in our case as no
further workup was done to ascertain the causes.
Our finding is also similar to Turkish study. In
1848 healthy school-age children aged 7 to 14
years isolated hematuria, isolated proteinuria, and
combined hematuria-proteinuria were found in 92
(4.9%), 16 (0.8%) and 10 (0.5%) patients,
respectively. In addition, 11.9% (11/92) of cases
of isolated hematuria and 40% (4/10) of cases of
combined hematuria- proteinuria were observed to
have persisted. Persistent hematuria and persistent
hematuria-proteinuria were found in 11 (0.5%)
and 4 (0.2%) patients, respectively.
There is no ideal method for screening of
hematuria and most of the differences are likely
due to variations in methods and definitions (2).
Whether the prevalence of asymptomatic
hematuria depends on age and gender is not
obvious from the previous studies. Silverberg et al
showed in general higher percentages for older
girls, but there is no consistent trend in their
figures, and the total number of boys is too small
to draw any conclusions. Dodge et al found the
prevalence to increase with age in girls up to 11
years, but at 12 years their oldest group, there was
a marked drop. For boys their results do not show
any constant pattern. The Finnish study, with a
fairly large number of subjects in each age and sex
group, showed no significant variation with age.
Silverberg et al found almost a tenfold higher
prevalence in girls than in boys; a much smaller
difference was reported by Dodge et al, (20). The
Finnish study showed no significant difference.
26
Ethiopian Journal of Pediatrics and Child Health. Vol. 11, No. 1
There was no readymade explanation for the
disagreement (2, 20, 32, and 33). No difference in
the prevalence in male and female was found from
India (18).
However hematuria is found to be age dependent
in our study with significant prevalence in the age
group 7-8 yrs (prevalence=19%) despite the small
number of samples in this age group. Females are
also 3 times more affected (OR 3.2 and p value
0.009) in our study even if results are inconsistent
in previous studies.
There is no significant difference by age and sex
in children with proteinuria in this study. However
Indian study showed female preponderance in the
age group b/n 10-13 yrs (18).
Despite the absence of detailed workup as to the
cause of the hematuria in our case nearly half of
the children with persistent hematuria, 6
/16(37.5%) do have RBC casts suggesting a
glomerular origin for the hematuria possibly
glomerulonephritis. In line with this observation a
recent Nepalese study found that 50 % of the
hematuria was from glomerulonephritis (9).
Egyptian
researchers
also
found
glomerulonephritis as the cause of asymptomatic
hematuria in two-third of the cases (27).
One child (6.3%) from those having persistent
hematuria was found to have associated pyuria,
leukocytes and WBC casts which is suggestive of
urinary tract infection but urine culture was not
done.
After the repeat urinalysis; 16 students (4.2%) are
found to have persistent hematuria. The parents of
these children were communicated for referral to
the pediatric renal unit of Tikur Anbessa Hospital,
However; only 6 (37.5%) showed up for referral
and the other 10 (62.5%) didn’t come for a referral
despite repeated communication. We didn’t know
the reason for it but the fact that the children are
asymptomatic and low health seeking behavior of
our society may have contributed for their
absence.
November 2015
Limitation of the study
This study was done in a single governmental
school with poor representation of the different
socio-demography despite the fact that previous
studies didn’t show differences in the prevalence.
Age distribution was also the limitation as most
children (89%) were 9 years and above with only
11% being 7-8 yrs. This could be because these
young children might have failed to deliver the
consent forms to their parents/guardians as most
respondents were from the older age groups.
Conclusion and Recommendation
As this study shows high prevalence of hematuria
in Ethiopian children
a larger sample size
including different ethnic, geographic and socioeconomic groups
should be done to see the
reproducibility of the result, determine the
common causes of hematuria and if routine
screening helps to prevent end-stage renal disease
decreasing the cost of unavailable costly
therapeutic interventions.
The issue of health awareness and preventive
medicine and the community’s knowledge about
asymptomatic renal disease and its prevention may
need to be assessed altogether before
recommending a routine urinalysis for all school
children.
Magnitude of Assymptomatic …
Abate Y. et al
27
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Treatment Outcome and Predectors …
Wegen S. et al
29
ORIGINAL ARTICLE
Treatment Outcome and Predictors of Severe Acute Malnutrition
using the WHO Guideline at a Referral Hospital in Southern
Ethiopia
Wegen Shiferaw(MD)1, Birkneh Tilahun(MD)2*, Kolsteren Patrick(PhD) , Tefera Belachew (MD)
ABSTRACT
Background: Management of severe acute malnutrition (SAM) is a challenge in the developing world
because it is a common problem which consumes the majority of the scarce resources. Despite the marked
progress in improving mortality of SAM through implementation of the WHO protocol in well resourced
settings, the reported mortality from institution based management ofSAM in the developing world
remained high. This article reports on the outcome predictors of management of SAM at a developing
country setting; Methods, From September 2006 to August 2009, a total of 151 cases who fulfilled the
inclusion criteria were included for final analysis at the paediatric ward of Hawassa University Referral
Hospital (HURH). Data were abstracted from the clinical records on structured data retrieval forms. The
data were analyzed using SPSS for windows version 16.0. Bivariate and multivariable logistic regression
wasused to identify predictor variables; Results: Of the reviewed 151cases, 84(55.6%) had oedematous
malnutrition. In response to the treatment provided, 105(70%), 23(15.2%) and 23(15.2%) of the cases had
improved/ been discharged, defaulted and died respectively. The non-oedematous cases of SAM were more
likely to default from the course of treatment (COR: 2.8[95%CI: 1.0-7.68], P <0.05). Most deaths of
children with SAM occurred in the early course of treatment:8(35%) of the deaths occurred in the first
48hours while 11(48%) occurred within the first week of admission (P<0.05).On multivariable logistic
regression, fluid or blood transfusion (AOR: 8.73 [95%CI: 2, 06-37, 02]) and age of the child (AOR: 1.05
[95%CI: 1, 00-1.09]) were the independent predictors of death while on treatment. Presence of HIV
infection and severe anaemia doubled the mortality rate; Conclusion, The treatment success of SAM against
the WHO protocol at HURH is below the standard. Various predictors of death of children while of
treatment based on the WHO protocol have been identified. Addressing these risk factors for death is vital
to decreasing the child mortality due to malnutrition.
Key Words: Severe acute malnutrition, Mortality, Ethiopia
INTRODUCTION
Severe acute malnutrition is defined as weight for
height (WFH) below -3 Z score (Zs) of the median
WHO growth standards, visible severe wasting, or
the presence of bilateral pitting oedema. In
children aged 6–59 months, an arm circumference
less than 110 millimetres is also indicative of
severe acute malnutrition [1, 2].
Although various efforts were made in the last few
decades to decrease under 5 mortality rate in the
1
developing countries, little progress was seen to
improve the situation and achieve the millennium
development goal-4 (MDG4) [3]. Malnutrition
still contributes to half of the deaths of under 5
children worldwide and is one of the major
socioeconomic, political, and environmental and
health problems [4-8]. Any child with malnutrition
is at an increased risk of developing complications
which may lead to severe illness and death [1].
Department of Pediatrics and Child Health, Hawassa Unievrsity
correspondence: Birkneh Tilahun [email protected]
30 Ethiopian Journal of Pediatrics and Child Health.
Among all malnutrition related deaths, 42%
occurred in the WHO African region [9]. The risk
of death is up to 20 times higher than a healthy
child for children with severe acute malnutrition,
making severe acute malnutrition a major killer of
children less than five years of age [10-12].
In Southern Nation Nationality Peoples
Region (SNNPR) of Ethiopia, community and
family survey data estimates indicate that 45% of
children are stunted, 42% are underweight, and
12% are wasted [13]. The appropriate treatment of
SAM significantly contributes to the success of
both clinical medicine and public health in
reducing many child deaths [14]. In a country with
limited resourcesand multi-factorial causes of
malnutrition,
considering
treatment
of
malnutrition as the only solution for the problem is
not reasonable.In a situation with high prevalence
of SAM, an integrated approach salvages the life
of hundred thousands of children [15]. This study
reports on the predictors of outcome of severely
malnourished under five children managed as inpatients with the WHO protocol for the treatment
of severe acute malnutrition.
METHODS AND SUBJECTS
Setting: This study was done at Paediatrics
department of HURH. The hospital gives service
to patients from the Hawassa city administration,
cases coming from different zones of Southern
region of Ethiopia and adjacent zones of Oromiya
region. It has a total of 250 beds; out of which 50
are in the paediatric ward. The paediatric ward has
a corner for treatment of SAM patients with the
phased approach of the WHO protocol.
Study Subjects and Management of SAM:
Included were all under five children who were
admitted to HURHPaediatric ward during the
study period with a diagnosis of SAM. The
admission was decided at the Paediatrics
outpatient department (OPD) by assigned
physicians
after
standardization
of
the
anthropometric parameters using WHO curves.
Screening of all children for malnutrition was the
routine procedure at the OPD and those who fulfil
the criteria for admission were admitted to the
general paediatric ward.Children who were
nottreated according to the WHO protocol were
excluded from the study. The diagnostic criteria
for SAM at the outpatient department included:
Vol. 11, No. 1
November 2015
weight-for-height (WFH) less than 70% the
standard on the WHO curve, mid upper arm
circumference (MUAC) less than 110 mm for
children of length/height at least 65 cm or, and
the presence of bilateral pitting leg oedema [16].
After admission to the paediatric ward, the
national guideline for the management of SAM
(an adaptation of the WHO guideline) for hospital
treatment of severe malnutrition was used. The
management of SAM is organized in 3 phases:
phase I, transition phase and phase II [16].
Formula75/ Formula 100, Vitamin A, Folic Acid
and Antibiotics were routinely administered
according to the protocol for all children.
Data collection process
All data from the records of the patients were
abstracted using a structured data retrieval format.
Acomprehensive follow up chart (also called the
UNICEF/WHO multi-chart) which is prepared and
distributed by UNICEF for the follow up of
admitted cases was the main source of the
abstracted data. Other hospital records including
patient charts and follow-up sheets were used for
patients whose multi-chart is incomplete. The
multi-chart includes a wide range of patient
characteristics. On the first part, it states: the
patient’s name, sex, age in months, spaces for the
daily weight, height and weekly head
circumference. It also records if there are any
additional diagnosis, the amount of milk taken,
presence or absence of vomiting, diarrhoea, fever,
cough, transfusion and others. It is usually filled
by attending doctors and nurses.
Statistical Analysis
The data were entered, cleaned and analyzed using
SPSS for windows version 16 software (SPSS Inc.
version 16.1., Chicago, Illinois). Descriptive
statisticswere presented as mean (standard
deviation), median (range) and numbers
(percentage). On bivariate analysis, factors
associated with treatment outcome of SAM were
identified at P-values of <0.05. 95% confidence
intervals were also calculated. Multivariable
logistic model was used to identify the
independent factors associated with mortality of
children on treatment for SAM. Chi square and
Fisher’s exact tests were also used to compare
certain variables. Fisher’s exact test was especially
used when the number of children under
comparison was small.
Treatment Outcome and Predectors …
Ethical considerations
The study was approved by the institutional
review board (IRB) of the college of medicine and
health sciences of Hawassa University. The data
retrieval forms were made anonymous.
RESULTS
A total of 151 children who fulfilled the inclusion
criteria were studied. There were more males than
females with a male to female ratio of 1.25:1. The
mean age of the group was 26.5 (± 16.8SD)
months.Children below the age of 24 months
constituted 58.3% of all cases and infants
constituted nearly one third of the cases.
Oedematous SAM was the commonest form
of malnutritionaccounting for 55.6 %( n=84) of all
cases.Infants were 2.3 times at increased risk of
developing wasting than oedematous malnutrition
(P =0.019). The proportion of oedematous cases
increased from the second year of life to reach the
peak during the 4th year of life (COR: 2.93
[95%CI: 1.00-9.74]), P=0.04.
Nearly 93% of the cases had co-morbidities at
admission. The common co-morbidities identified
were diarrhoeal disease, 53 %( n=80);
tuberculosis, 35.8% (n=54); pneumonia, 31.8%
(n=48); paediatrics AIDS, 9.9% (n=15/82);
anaemia 54% (n=78/143), malaria; 13(8%) and
pyuria, 40% (25/61).
Among the 84 cases of oedematousSAM,
14(16.7%), 8(9.5%) and 62(73.8%) of cases died,
defaulted and improvedrespectively. Whereas,
among the 67 cases with marasmus, 13.4%, 22.4%
and 64.2% died, defaulted and improved,
respectively. Cases with marasmus were more
likely to default from the course of treatment
(COR: 2.8[95% CI: 1.0-7.68]), P =0.029.No
significant difference (P>0.05) was observed inthe
case fatality rate of oedematous versus nonoedematous cases of malnutrition.
Wegen S. et al
31
Co-morbidities affected the outcome of
patients with SAM; children with severe anaemia
(HCT<21%) were more likely to die (COR:
4.85[95% CI: 1.14-20.0], P-value <0.05) children
who received intravenous fluid/blood transfusion
had a significantly higher risk of death (COR:
9.31[95% CI: 3.0-29.0], P-value<0.0001).
Forty three percent (n=65) of the cases with SAM
had very severe anthropometric deficit with the
WHO Zs standard at admission (WFH <4Zs.More than half, 54.5% (n=36/67) of non
oedematous cases of SAM and 34% (n=29/84) of
oedematous cases ofSAM had very severe
anthropometric deficit at admission (WFH < 4Zs). The marasmic (non-oedematous) cases were
more likely to have very severe anthropometric
deficit (COR: 2.8[95%CI: 1.12-4.65], Pvalue=0.014).
Case fatality rate did not significantly differ
by thelevel of severity of malnutrition at
admission; though, severe anthropometric deficit
doubled the risk of dying from marasmus (COR:
2[95%CI: 0.33-11.8], P-value>0.05) (Table 1).
Further analysis of predictors of mortality
using multivariable logistic regression revealed
that the risk of dying from SAM was
independently associated with fluid and/or blood
transfusion (AOR: 8.7[95%CI: 1.31-19.5]). Even
though age category had showed no significant
association in the bivariate analysis, it was
identified as a predictor withan increment in
mortality as age in months increases (AOR:
1.05[95%CI: 1.01-1.09]). An increased odds of
mortality was observed for cases with severe
anaemia (AOR: 4.14[95%CI: 0.56-30.5]) and HIV
sero-positivity (AOR: 3.69[95% CI: 0.7-19.5]) but
no significant association was found (P> 0.05)
(Table 2).
32 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
Figure 1: Outcome of SAM treatment in Hawassa University Referral Hospital versus the Sphere project
from September 2006 to August 2009
Treatment Outcome and Predectors …
Wegen S. et al
33
Table 1: Common co-morbidities and other factors as predictors of outcome of SAM
September 2006 to August 2009
Contributing factors
Pneumonia
Died
Improved
COR
P-value
0.93
Yes
7
31/128
1.04[0.35-3.1]
No
16
74
1
Yes
14
54/128
1.47[0.54-4.1]
No
9
51
1
Yes
12
11/128
9.31[3.0-29.0 ]
No
11
94
1
Yes
9
39/128
1.09[0.39-3 ]
No
14
66
1
Reactive
5
10/74
2.45[0.57-10 ]
Non-Reactive
10
49
1
Hct < 21%
5
7/121
4.85[1.14-20 ]
0.01
Hct 21-30
7
49
0.68[0.2-1.9 ]
0.36
Hct > 30%
7
46
1
Yes
3
19/54
0.85[0.14-4.8 ]
No
5
27
1
Yes
16
97/118
1
No
2
3
4[0.43-33 ]
Exclusive Breast feeding
6month
8
42/101
1
7
8
44
0.84[0.24-2.8 ]
Immunization of measles
Not for 6 month
Yes
51/100
1
No
10
31
2.06[0.66-6.5 ]
> - 4Zs
< - 4Zs
12
10
63/127
1
42
1,25[0.45-3.5]
Diarrhoea
Fluid /blood transfusion*
Tuberculosis
HIV sero-status
Anaemia*
Pyuria (≥10WBC/HPF)
Breast feeding history
WFH-WHO Zs Deficit
*: Significant values (p<0.05), †: Fisher exact test
±: Defaulter cases were excluded from the analysis
0.28
<0.0001
0.85
0.15
1†
0.16†
0.74
0.17
0,63
34 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
Table 2: Parameter estimates from multivariable logistic regression models predicting the
probability of death in HURH September 2006 to August 2009
Predictors of
mortality
Age
Sex
Male
Female
Place of Residence
Urban
Rural
Oedema at admission
No
Yes
Anemia
Hct,†† <21%
Hct 21-30%
Hct >31%
Fluid blood Transfusion
No
Yes
WFH Zs
>-3ZS
-3Zs to-4Zs
<-4Zs
HFA Zs
>-2Zs
-2to-3Zs
<-3Zs
HIV sero status
No
Yes
Unknown
B
P-Value
Adjusted OR†
95,0% CI
0.05
0.033
1.05
[1.00-1.09] **
-0.53
0.452
1.00*
0.59
[0.15-2.35]
-0.1
0.88
1.00*
1.12
[0.30-4.02]
0.03
0.971
0,308
1.00*
1.03
[0.26-4.01]
1.42
-0.23
0,163
0.729
4.14
0.79
1.00*
2.17
0.003
0.174
1.00*
8.73
[2.06-37.02] **
-1.43
-0.19
0.127
0.807
0.245
1.00*
0.24
0.83
[0.04-1.50]
[0.18-3.81]
1.31
0.3
0.124
0.721
0.047
1.00*
3,69
1,35
[0,70-19,49]
[0,26-6,86]
1.52
-0.923
0.090
0.204
1.00*
4,57
0,4
[0,78-26,55]
[0,96-1,65]
*: Referent categories, †: Odds Ratio, , ††: Hematocrit
**:Significant at P<0.05
[0.56-30.51]
[0.21-2.98]
Treatment Outcome and Predectors …
DISCUSSION
After the introduction of WHO protocol for the
management of SAM remarkable improvement
was observed on the outcome of cases managed in
institution based (17- 19) community based(CTC)
and emergency settings (13, 20-22).
In the current study, the overall case fatality
rate was 15.2% with a recovery rate of 69.6%;
these figures are not acceptable when compared
with national and international standards (10,
16,23). The minimum standards set by the Sphere
project are recovery rate of >75%, death rate of
<10% and defaulter rate of <15 % (16, 23).
Young age at admission is an independent
predictor of mortality in the current study. Many
cases suffer from malnutrition related deaths
during the early year life. The first two years of
age is a critical period which is usually a negative
reward of sub optimal breast feeding,
inappropriate complementary feeding practices
with a low-protein diet and severe or frequent
infections (5, 7). Similar findings were reported
from a study done in the northern part of the
country (24).
In the current study, fluid and/or blood transfusion
increased mortality.This is possibly because these
children are seriously ill and need progressive
stabilization. Fluid and/or blood transfusion
areusually required in the presence of severe
illnesseslike dehydration and anaemia. Golden and
Bachou Halso showed adjustment for severity of
disease did not change case fatality in those who
had fluids and/or blood transfusion (25, 26).
Ciliberto et al identified that both severity and
poor case management are more important in low
resource setting countries and severity is the main
determinant of high case-fatality rates in central
hospitals (27).
Oedematous malnutrition was the most common
type of SAM in the current study. Similar findings
were reported by several studies (17, 28). This
increased could be because of the public
recognition of oedematous malnutrition as a more
serious problem than the marasmic malnutrition
(29). This affects the health seeking behaviour of
parents. The finding of anthropometric deficit
increasing the odds of mortality was similarly
reported by other researchers (17,24).
In the current study, most of the cases were having
one or more co-morbidities atadmission. Similar
Wegen S. et al
35
findings were reported by other Ethiopian studies
(24, 30). Carlos et al also showed diarrhoea was
the most common complication (31).
In this study, significant number of deaths
occurred in the first few days of hospitalisation.
Similarly, in Kenyan study, one third of deaths
were occur within 48 hourof hospitalisation and
the WHO danger signs were in a close relationship
with mortality (12). This finding was similarly
reported by an Ethiopian study (17).
The current study can be taken as an important
indicator or of the quality of service delivery for
patients with severe acute malnutrition in the
study area and other places with similar settings.
The main limitations of the study emanate from its
retrospective nature posing problems of
incompleteness and limited quality assurance
methods.
In conclusion, the treatment success of SAM
against the WHO protocol at HURH is below the
standard. Fluid transfusion and young age were
independent predictors of death of children while
of treatment based on the WHO protocol.
Addressing these predictors for death is vital to
decreasing the child mortality due to malnutrition.
Generally, the findings underscore the need for
better adherence to protocol.
36 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
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8. Müller Olaf, KrawinkelMichael. Malnutrition and health in developing countries. CMAJ.2005; 173:
279-86.
9. MSF, WHO, what are the consequences of malnutrition? 2008. Accessed from:
http://china.org.cn/international/malnutrition/2008-12/03/content_16891515.htm (Date accessed: July
20, 2009)
10. Ashworth A, Sultana K, Alan J, Claire S. Guidelines for the inpatient treatment of severely
malnourished children. New Delhi: World Health Organization Regional Office for South-East Asia.
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(Date accessed: December. 20, 2009)
11. Dubik M. Mortality of Children Worldwide, AAP Grand Rounds 2005; 14:22-23.
12. Maitland K, Berkley JA, Shebbe M, Peshu N, English M, Newton CR. Children with Severe
Malnutrition: Can Those at Highest Risk of Death Be Identified with the WHO Protocol? PLoS Med
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13. Yimer G. Malnutrition among children in Southern Ethiopia: levels and risk factors. Ethiop. J. Health
Dev. 2007; 14(3):283-292.
14. Collins S, Dent N, Binns P, Bahwere P, Sadler K, Hallam A.Management of severe acute malnutrition
in children. Lancet 2006; 368: 1992–2000.
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malnutrition. Food Nutr Bull 2006; 27:S49-82.
Treatment Outcome and Predectors …
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19. Morrice JS, Molyneux EM. Reduced mortality from severe protein-energy malnutrition following
introduction of WHO protocol in children in Malawi. Arch Dis Child. 2003; 88 suppl 1: A28.
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severe malnutrition: A case study from Ethiopia.Food Nutr Bull 2006; 27:95-104.
21. Belachew T, Nekatibeb H. Assessment of outpatient therapeutic programme for severe acute
malnutrition in three regions of Ethiopia. East Afr Med J 2007; 84:577-88.
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rural South African hospitals: effect on case fatality and the influence of operational factors. Lancet
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Minimum Standards in Food Security, Nutrition and Food Aid. The SPHERE Project. Geneva
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analysis of admissions. Ethiop Med J 2006; 44:151-7.
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26. Golden MHN. The development of concepts of malnutrition. J Nutr 2002; 132: 2117S-2122S.
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Gastroenterology Nutr. 2008; 46:322-8.
38 Ethiopian Journal of Pediatrics and Child Health
Vol. 20, No. 3
November 2010
ORIGINAL ARTICLE
Quality of Pediatric Prescription Writing at Department of Pediatrics
and Child Health, Tikur Anbessa Specialized Teaching Hospital,
Addis Ababa, Ethiopia
Fitsum W/Gebriel (MD)1, Damte Shimelis (MD)2
ABSTRACT
Background: Drugs are important weapons in the fight against disease and play crucial role in saving life.
Incorrect prescription of drugs is equally dangerous and could cause life threatening complications.
Erroneous prescribing habits are not uncommon in clinical practice. Hence the objective of this study is to
assess the nature of prescription deficiencies (omission and error) and documented corrective measures
taken by the dispensing pharmacist.
Objective: to assess the quality of pediatric prescriptions written by doctors in Tikur Anbessa Specialized
teaching Hospital, Department of Pediatrics and Child Health, Out-patient Department (OPD), follow up
clinics and Emergency Unit.
Materials and Methods: This is a cross- sectional hospital based study done on all prescriptions written to
non admitted patients below 14 yrs of age visiting pediatric OPD, emergency unit and follow up clinics of
Tikur Anbessa Specialized Hospital. The study was conducted from January 2014 to October 2014 based on
the national standard prescription format adopted by Food, Medicine and Health Care Administration and
Authority (FMHACA).
Results: Total number of prescriptions studied was 246. With regard to patient identification, 78% of
prescriptions lack patient age, 80.5% sex and 86.2% patient weight. 50.8% of the prescriptions do not bear
drug formulation and 19.9% lack drug generic name. 30% of the prescriptions were issued with erroneous
dose. Prescribers name was not documented in 45.5% of the prescriptions and date of prescriptions issued
was not written in 65% of the prescriptions. Documented corrective measure was not seen in any of the
prescriptions issued.
Conclusion and recommendation: From this study, prescription quality is unsatisfactory. To improve
prescription writing skills the Department of Pediatrics and Child health has to give great emphasis on
correct prescription writing. Frequent feedback should be given to incorrect prescribers to avoid or
decrease prescription errors.
INTRODUCTION
Once a patient with a clinical problem has been
evaluated and a diagnosis has been reached, the
practitioner often selects among others drug
therapy which requires the writing of a
prescription.
A written prescription is the prescriber's order to
prepare or dispense a specific treatment-usually
medication—for a specific patient. When a patient
comes for an office visit, the physician or other
authorized
health
professional
prescribes
1
medications 67% of the time and an average of
one per office visit are written because more than
one prescription may be written at a single visit
(1).
The ideal prescription format contains patient
information which includes name, age, sex,
weight, height and a diagnosis. Also it is
composed of drug information which is generic
name, formulation, concentration, dose, frequency
Hawass University Teaching Hospital, Department of Pediatrics and Child Health
Addis Ababa University, College of Health Sciences, Department of Pediatrics and Child Health
correspondence: [email protected]
2
Quality of Pediatric Prescription …
duration of treatment and treatment instructions.
The prescription should be legible and must
include the prescriber’s name, signature and date.
Prescriptions have legal implications, as they may
indicate the prescriber’s responsibility for the
clinical care of the patient and in particular for
monitoring efficacy and safety [2].
For several reasons, current methods of medical
prescription suffer deficiencies. There is lack of
knowledge in clinical pharmacology among
doctors and students [3].
Several types of prescribing errors are particularly
common. These include errors involving omission
of needed information; poor writing perhaps
leading to errors of drug dose or timing; and
prescribing drugs that are inappropriate for the
specific situation [1].
Children face the risk of medication error because
of factors such as weight –based dosing, need for
stock medicine dilution, decreased communication
abilities, inability to self-administer the
medication and the high vulnerability of young
critically ill children to have injury from
medications [4-6].
Drugs are important components of health care
and play crucial role in saving life. The limited
information available on drug use throughout the
world indicated that drugs are not optimally used
(7). Despite the importance of good quality
prescriptions erroneous prescribing habits are not
uncommon worldwide [8].
Medication errors (MEs) are major issues in health
care and are probably one of the most common
types of medical errors. Inappropriate prescription
is associated with health risks to the patient, and
children in particular are three times at risk than
adults (9-19). Studies have shown monitoring
errors in prescription writing (20), incorrect
‘corrections’ by pharmacists themselves (21) and
inadequate knowledge of prescription writing by
physicians themselves (22).
However, data regarding MEs in Africa, especially
in Ethiopia is scarce. The objective of this study
was to assess the quality of pediatric prescription
written by doctors in hospital out-patient
department and ER in a tertiary teaching hospital
in Addis Ababa, Ethiopia.
Fitsum W. et al
39
MATERIALS AND METHODS
This is a cross- sectional hospital based study.The
study was conducted at Addis Ababa University,
Department of Pediatrics and Child Health, Tikur
Anbessa Specialized Teaching Hospital, at
outpatient, emergency, follow up clinics and
special pharmacy. From January 2014 to October
2014 all prescriptions written to non admitted
patients below 14 years of age were investigated.
This
study
investigates
deficiencies
of
prescriptions written for patients when compared
with the standard prescription format adopted by
FMHACA.
A checklist is used to asses for completeness of
the following components: a) patients’
information: full name, age, sex, weight and
diagnosis b) drug information: the generic name,
dosage, concentrations, frequency, formulation
and duration of treatment c) prescriber’s
identification: clarity of hand writing, prescriber’s
name and signature and date the prescription was
written.
Prescriptions were collected at both pharmacies
(Paediatric emergency and special pharmacy)
every day till the desired number is reached and
the prescription papers were marked at the back
with a registration unique number and name of the
specific clinic that the patient was seen. Each
prescription was checked for completeness, error
and whether correction was made by the
dispensing pharmacist by the same checklist used
in the OPD.
Prescriptions issued from 5 pm to 8am on each
working day and prescriptions from paediatric
anti-retroviral treatment and diabetic clinics were
excluded.
Probability of prescription errors in the
community vary from 0.04%-24% in the
literatures (23, 24). Since there is no study in our
situation we took a probability prevalence of
prescription errors of 20%. The sample size was
calculated based on this probability and 95% level
of confidence and margin of error of 0.05.The
calculated sample size was 246.
Data was collected by two trained clinical nurses.
Each check list was evaluated by paediatric
consultant independent of OPD for the study
period for appropriateness of the specific drug
prescribed based on the hospital protocol.
At 5pm every marked prescription was collected
from Paediatric Emergency and Special pharmacy
40 Ethiopian Journal of Pediatrics and Child Health.
by a trained pharmacist and was assessed against
FMHACA approved prescription format. Drug
dosage and preparation was checked against
Nelson Text book of paediatrics 19th edition (25).
Completeness, error and correction made by the
dispensing pharmacist were also checked by the
same check list every day.
Proper data collection was checked by principal
investigator every day and problems identified
through the process was addressed on daily bases.
Data was entered and analyzed using statistical
package for social sciences (SPSS version 20)
software.
Vol. 11, No. 1
November 2015
The study was conducted after obtaining ethical
clearance from the Department of Pediatrics and
Child health, Addis Ababa University, School of
Medicine.
RESULTS
The total number of prescriptions studied was 246.
Of the 246 prescriptions; 3.6 % of the
prescriptions were issued for infants below two
months of age, 11.4% for 2-12 months, 34.6% for
12-59 months and 50.4% for 59-168 months old.
52.8% of the prescriptions were issued for male
patients and 47.2% for female patients (Table1).
Table 1: Distribution of outpatient prescriptions by age and sex, Tikur Anbessa Specialized Teaching
Hospital, DPCH*,
Age of patient in
Sex
Total
months
Male
Female
0-2
5
4
9
(3.6%)
2-12
13
15
28
(11.4%)
12-59
52
33
85
(34.6%)
59-168
60
64
124
(50.4%)
Total
130 (52.8%)
116 (47.2%)
*DPCH: Department of Pediatrics and Child Health
From all pediatric outpatient departments; 93.1%
of the prescriptions were issued from the different
follow up subspecialty clinics and 7% from
246
(100%)
regular OPD (ROPD). Table 2 shows the
distribution of prescriptions by the place where
they were prescribed.
Table 2: Distribution of prescriptions by specialty clinic’, Tikur Anbessa Specialized Teaching Hospital,
DPCH*
Name of clinic
Number of
prescriptions issued
Cardiac
65
Hematology/oncology
54
Neurology
45
Renal
19
Emergency Unit
18
Chest
18
Regular OPD
17
Others
10
Total
246
*DPCH: Department of Pediatrics and Child Health
Completeness of patient and drug information is
shown in table 3. Drug dose was omitted in 7% of
Percent (%)
26.4
22
18.3
7.7
7.3
7.3
7
4.1
100
the prescriptions among which 64.7% of the
omissions were for bronchodilators. Error in
Quality of Pediatric Prescription …
Fitsum W. et al
dosing was noted in 30% of the prescriptions. Of
the prescriptions with error in dosing 42.5% was
for prophylactic antibiotics (table 4).
46.6% of drugs with error in dosing were issued
from oncology /hematology clinic and 54.4% of
the errors in dosing were from all other clinics.
41
Clear hand writing was noted in 85.5% of the
prescriptions, prescribers’ name was mentioned in
54.5%. No documented correction was made by
dispensing pharmacist in all of the prescriptions.
Table3: Distribution of prescriptions by completeness of patient and drug information, Tikur Anbessa
Specialized Teaching Hospital, DPCH*
Patient information
Full name
Age
Sex
Weight
Diagnosis
Registration number
Omitted
Documented
Total
Number
%
Number
4
192
198
212
162
122
(1.6)
(78)
(80.5)
(86.2)
(65.9)
(49.6)
242
54
48
34
84
124
(98.4)
(22)
(19.5)
(13.8)
(34.1)
(50.4)
246 (100%)
246 (100%)
246 (100%)
246 (100%)
246 (100%)
246 (100%)
197
121
224
220
223
(80.1)
(49.2)
(91.1)
(89.5)
(90.7)
246 (100%)
246 (100%)
246 (100%)
246 (100%)
246 (100%)
Drug information
Generic name
49
(19.8)
Formulation
125
(50.8)
concentration
22
(8.9)
Frequency
26
(10.5)
Duration of treatment
23
(9.3)
*DPCH: department of pediatrics and child health
%
Table 4: Group of Drugs Vs completeness/ correctness of Dosage, DPCH*, Tikur Anbessa Specialized
Teaching Hospital
Group of prescribed
drugs
Antibiotic(prophylactic)
Antibiotic
(Therapeutic)
Anti-inflammatory
Diuretics
Omitted
5(29.4%)
1(5.9%)
Dose
Error
31 (42.5%)
8 (11%)
Correct dosing
20 (12.8%)
11 (7.1%)
56(22.8%)
20(8.1%)
0
0
7 (9.6%)
21 (28.7%)
13 (8.3%)
24 (15.4%))
20 (8.1%)
45 (18.3%)
10(6.4%)
6 (3.8%)
48 (30.7%)
11(7.1%)
10 (4%)
17 (7%)
52 (21.2%)
11(4.5%)
13 (8.3%))
156
15 (6%)
246
0
0
ACEI
11(64.7%) 0
Bronchodilator
0
4 (5.5%)
Anticonvulsant
0
0
Chemotherapeutic
agents
0
2 (2.7%)
Others
17
73
Total
*DPCH: department of pediatrics and child health
Total
42 Ethiopian Journal of Pediatrics and Child Health.
DISCUSSION
A standard prescription should contain the
essential elements of patient, drug and prescriber
information. Incomplete prescription writing may
lead to medication errors particularly in children.
Children face the risk of medication error because
of factors such as weight – based dosing, need for
stock medicine dilution, decreased communication
abilities of children, inability to self-administer the
medication and the high vulnerability of young
critically ill children to have injury from
medication [4-6]. Hence, it is mandatory for a
paediatric prescription to be of high quality,
containing essential elements to avoid medication
errors and its consequences. Analysis of this study
concerning patient information shows that the full
patient name is omitted in 1.6% of the
prescriptions. This makes them unidentifiable and
can be wrongly issued to other patients. The
patient’s age is not mentioned in 78% of
prescriptions and this makes it difficult for the
pharmacist to check the dose on prescriptions
where weight is not documented. Though weight
based dosing is the best way for the pharmacist to
check for dose error, weight was not mentioned in
86.2% of the prescriptions. On the other hand the
diagnosis of patients was not documented in
65.9% of the prescriptions leaving the dispensing
pharmacist in dark to check for the
appropriateness of the drugs prescribed.
Comparing this study to a similar study
conducted in three of the paediatric teaching
hospitals in Khartoum, writing of full patient name
was found to be 98.4% in our study while in
Khartoum study it was reported to be 81.4% (26).
Writing the patient age in our study was 22%while
in Khartoum study it was reported to be 92.7%.
Writing a diagnosis was 34.1% in our study while
it was found to be 85.2% in Khartoum’s study.
This means that the quality of prescription writing
in our study with regard to patient identification
with exception of patient full name is worse than
that of the Khartoum’s study.
Concerning drug information, omission of drug
generic name was found in 19.9% of prescriptions.
Generic name prescription will enable the patients
to choose the cheapest effective drug while
prescribing its trade name lead to loss of this
opportunity. This is much better than one noted in
Vol. 11, No. 1
November 2015
the Khartoum’s study which is 60.6%. Drug
formulations were omitted in 50.8% of our
prescriptions as compared to 22.3% in Khartoum,
drug concentration was omitted in 8.9% of our
prescriptions as compared to 39.7% in Khartoum,
and drug dosage was omitted in 7% of our
prescriptions as compared to 1.7% in Khartoum.
Drug frequency was omitted in 10.5% of our
prescriptions as compared to 3.9% in Khartoum;
duration of treatment was omitted in 9.3 % of our
prescriptions as compared to 19.4% seen in the
Khartoum study. This shows that reporting drug
information quality is lower particularly in drug
formulation, dosage and frequency.
8.9% of our prescriptions lack drug
concentration whiles a study done in Switzerland
showed 33% [27]. As the dose is calculated
according to specific concentration, this may lead
to faulty dosage. In our study omission of
treatment duration was found to be 9.3% which is
significantly better than the Ribat study (2) which
is 25.7% while it was worse than that reported
from the London study which was only 2.8%
[21,26].
Regarding the prescribers’ information our
study showed that clear handwriting was lacking
in 14.5% of the prescriptions which is higher than
seen in the Khartoum study (7-9%). The
prescriber’s name and signature were reported in
54.5% and 82.1% of our prescriptions respectively
while the Khartoum study showed 60.7% and
29.6% of the prescriptions respectively. This is
much lower than the Arizona study where
prescribers name and signature was noted in
91.7% and 97.3% respectively [30].The date was
omitted in 63% of our prescriptions as compared
to the Khartoum study where omission of date was
reported to be 11.3%.
A study done in Jimma University Hospital
(Western Ethiopia) in patients in the intensive care
unit (ICU) showed that the rate of illegible hand
writing was 8.8%, and there was no prescribers’
signature and date in 30.6% and this is better than
our study.
Among the medication errors 42.5% was for
prophylactic antibiotics, 28.7% were for diuretics.
11% of therapeutic doses of antibiotics bearing
prescriptions were issued with wrong dose. A
study done in Jimma University Hospital in the
ICU showed that 32.5% of the prescription errors
Quality of Pediatric Prescription …
were for antibiotics and 9.6% were for analgesics
(31).
Among the medications with the wrong dosage,
46.6% of medications were issued from Oncology
clinic and 27.4% from cardiac clinic. As there was
no documented correction made by dispensing
pharmacist in any of the prescriptions this calls for
careful production of prescriptions to minimize
the morbidity and mortality of patients due to
avoidable mistakes like the ones seen in our study.
In conclusion, from this study prescription
production is unsatisfactory because of the lack of
essential elements of good prescription. Patients’
identification and drug information is poorly
documented. Though it is mandatory to identify
prescriber by his/her name, rank and signature,
most of the essential elements of prescribers’
identifications were omitted. This study showed
that our prescriptions are deficient when compared
with the standard prescription format adopted by
FMHACA. The Department of Pediatrics and
Child health has to give great emphasis on correct
prescription writing. Frequent feedback should be
given to incorrect prescribers to avoid or decrease
prescription errors.
Fitsum W. et al
43
44 Ethiopian Journal of Pediatrics and Child Health.
Vol. 11, No. 1
November 2015
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46 Ethiopian Journal of Pediatrics and Child Health
Vol. 11, No. 1
November 2015
ORIGINAL ARTICLE
Incidence of Low Birth Weight and Its Associated Factors in Jimma
University Specialized Hospital
Melkamu Berhane (MD)1, Netsanet Workneh (MD, DTM&H)1 and Bitiya Admassu( BSc, MPH)2
ABSTRACT
Background: Weight at birth is a good indicator of the newborn’s chance for survival, growth and
development, as well as long term health and psychosocial development. Low birth weight newborns are at
a significantly higher risk of morbidity and mortality contributing a lot to the higher perinatal, neonatal,
infant and childhood morbidity and mortality rates specially in the developing countries like Ethiopia. They
are also at a higher risk of adulthood illnesses once they survive the early complications. Even if many
studies have been done on low birth weight, its associated factors and the short as well as long term
outcomes of low birth weight infants in the developed world, little has been done in developing countries
like Ethiopia where the burden of the problem is huge. In Ethiopia, few studies have been done on the
incidence of low birth weight and associated factors but most of these studies didn’t consider many of the
factors thought to be associated with low birth weight.
Objectives: To determine the incidence of low birth weight and its associated factors in Jimma University
Specialized Hospital.
Methods and materials: A cross sectional study was conducted on 931 newborns who were born in Jimma
University Specialized Hospital from March 1 to May 30, 2014 GC. Data were collected by using
structured questionnaire. Maternal and neonatal anthropometric measurements were done by using
standard beam balance, tape meter and measuring board. Consecutive sampling technique was used to
include all eligible newborns and their mothers until the required sample size is obtained. p value of <0.05
was used to consider significance.
Results: The mean ( ± SD) of birth weights were 3017 ± 612gm. The incidence of low birth weight (birth
weight <2500) was 24.4%. The factors found to be associated with low birth weight in this study are female
gender, maternal urinary tract infections, preterm delivery, maternal antepartal hemorrhage, and multiple
gestations.
Conclusion and recommendations: The incidence of low birth weight is found to be high in this study. An
attempt to increase the rate of ANC attendance and identifying the medical illnesses as well as obstetric
complications and addressing them timely is recommended so that the rate and complications of low birth
weight could be minimized.
Key words: Birth weight, low birth weight, intrauterine growth restriction
INTRODUCTION
Birth weight is an important determinant of
prenatal, neonatal as well as post neonatal
outcomes as poor intrauterine growth increases the
risk of prenatal, neonatal, infant and childhood
1
morbidity and mortality as well as long term
morbidity during adulthood(1). Low birth weight
refers to a newborn with birth weight of less than
2500gm and it includes those who are born
premature as well as those who are born fully
mature but with intrauterine growth restriction.
Department of Paediatrics and Child Health, Jimma University
Department of Population and family health, Jimma University
Correspondence to [email protected]
2
Pattern of Child Sexual Abuse …
Multiple factors play a role in determining the
birth weight of a newborn which could relate to
the mother; such as mother’s own fetal growth,
her diet from birth through pregnancy, her body
composition at conception, illnesses which may be
infectious or non-infectious, her life-styles like
consumption of alcohol, cigarette smoking and
physically demanding activities. The fetal factors
include gender, genetic makeup, and the number
of fetuses. Environmental factors (like altitude,
toxin exposure, air pollutants, and war) also
contribute in determining birth weight of a
newborn(1,2).
Low birth weight is associated with multiple
acute and long term complications which
contribute a lot for neonatal, infant and childhood
morbidity and mortality as well as adulthood
chronic illnesses. Among the acute complications
of LBW which could occur in the neonatal period
are respiratory distress syndrome, intra-ventricular
hemorrhages, necrotizing enter colitis, neonatal
infections, patent dactus arteriosus and metabolic
complications
like
hypothermia
and
hypoglycemia, thus directly or indirectly
increasing
the
neonatal
morbidity
and
mortality(1,6,7).
Majority of the newborns who survive these
acute complications are again at higher risk of
additional complications during their childhood
and adulthood life. Some of these complications
are neurologic and developmental abnormalities
(like cognitive dysfunction, poor school
performance, cerebral palsy, hydrocephalous,
hearing and visual impairments), chronic
obstructive lung diseases, renal damage and
chronic kidney disease, cardiovascular disorders
(like stroke, hypertension, coronary heart disease),
metabolic abnormalities (like diabetes mellitus,
hypercholesterolemia,
and
metabolic
syndrome)(2,3,4,6).
All the above mentioned complications will
add up and increase the health cost of the LBW
infant both at an individual household level and at
the national level. For all these reasons, LBW has
been a good public health indicator and target has
been made by the WHO, UNICEF, and the global
countries to reduce the prevalence and associated
complications(1,2,8).
The incidence of LBW in Sub-Saharan subregion is estimated at around 10-20% which is
higher than most other sub regions of the world,
Teferi E. et al
47
presenting a major challenge in the sub-region
(1,7).Ethiopia, being one of the countries with
higher neonatal and infant mortality rates in the
world, has a limited data on LBW since most of
the deliveries occur at home and the birth weight
is not measured. According to a data obtained
from Ethiopian Demographic and Health
Survey_(EDHS) 2011, which didn’t use objective
measurement of birth weight, rather used maternal
estimate of birth weight as giving birth to very
small baby, over a period of the preceding five
years, the incidence of LBW is found to be among
the highest in the world (9). In an institutional
based study done in a referral hospital in North
Western Ethiopia, the incidence was found to be
17.1% which is highly significant (10). In a study
done in South West Ethiopia in 2002/03 in four
health centers and JUSH, the prevalence of LBW
was found to be 22.5% which is again higher (11).
These all indicate that LBW is highly prevalent in
the country. Thus an attempt to make an accurate
measurement of birth weight and estimating the
incidence is necessary at all health institutes as
much as possible and identifying the factors which
play a role locally is very vital. The objective of
this study was to determine the incidence of low
birth weight and associated factors in JUSH,
Jimma, Ethiopia
METHODS
Study design and setting
A cross sectional study was conducted on
newborns born in JUSH. The study was conducted
on newborns born in JUSH, Jimma Zone, Jimma
town, Oromia Region, South West Ethiopia which
is located about 350Km from Addis Ababa, the
capital of the country. The study period was from
March 1 to May 30, 2014 GC. The hospital is the
only referral hospital for over 15million people in
the Southwest Ethiopia (JUSH archive, 2000). At
the same time it is a teaching hospital with various
other public health services.
The labor ward is one of the busiest wards of
the hospital where both normal & complicated
cases are served. Laboring mothers could come
having follow up in the hospital or being referred
from the nearby health centers as well as hospitals.
There are six first stage and three second stage
beds in the labor ward of the hospital. There is
also one functional operating room adjacent to the
48 Ethiopian Journal of Pediatrics and Child Health.
labor ward where laboring mothers in need of
operative deliveries are operated. The neonatal
ward of the hospital is in close proximity to the
labor ward so newborns that need further care and
treatment will be referred to the ward. More than
3,830 mothers deliver in the ward per year.
Study population and Sampling: All newborns
who were born in JUSH over a period of three
months (i.e. from March 1 to May 30, 2014 G.C)
were enrolled in to the study. A consecutive
sampling technique - including all eligible
participants was used until the required sample
size was obtained (after checking willingness of
the mother or care takers).
The estimated number of deliveries in the
labor ward of JUSH hospital was around 320 per
month. The study was conducted over a period of
three months. So the total population for this study
was 960.
The minimum sample size needed for the
study was calculated by using the single
population proportion formula of calculating the
minimum sample size. 95% confidence interval
assumption was also used. So according to this
formula:Data sources
Data on maternal socio-demographic characters,
maternal medical conditions, and maternal
obstetric factors, were obtained by interviewing
the mother as well as revising her medical record.
The data on maternal behavioral factors were
obtained by interviewing the mother. The data on
maternal and neonatal anthropometric characters
was obtained by measuring the anthropometric
parameter ( by using standard beam balance for
maternal and neonatal weight, measuring board
for maternal height and measuring tape for
maternal MUAC, neonatal length and head
circumference).
Maternal
and
neonatal
anthropometric characters were measured only
once.
Vol. 11, No. 1
November 2015
RESULTS
There were a total of 938 mothers who gave birth
in the hospital during the study period and of these
910 of the mothers were willing to participate in
the study making a response rate of 97%. The total
number of newborns included in the study were
931 (19 of the mothers had twin deliveries and one
of the mothers had triplets).
Majority of the mothers(95.5%) were aged
between 18-35years. The predominant religion of
the mothers was Muslim accounting for about
63.2% of the cases. More than two third (76.3%)
of the mothers were Oromo and 35.6% of the
mothers didn’t have any education. Most (72.8%)
of the mothers were housewives. More than half
of the mothers(57.3%) reside in the rural area.
Among the mothers included in the study, 97.5%
were married. (Table 1).
Maternal obstetric factors
Half of the mothers were Para II to V whereas
46.04% and 3.96% of the mothers were Para I and
Para VI and above respectively. Of the
multiparous mothers, the birth interval was
>2years in majority of the cases (74.7%), 1-2
years in 24.8% and <1year in 0.5% of the cases.
Majority of the pregnancies (90%) were planned.
With regard to gestational age, in 41.8% of the
mothers the gestational age could not be obtained
whereas 7.1%, 49.8% and 1.3 % of the cases were
preterm, term and post term deliveries
respectively. APH was identified in 30 of the
mothers , of which 23 had placenta previa and 7
had placental abruption. Of all the mothers
included in the study, 77 of the mothers had
pregnancy induced hypertension, of which 13 had
ecclampsia and 64 had preeclampsia. With regard
to ANC attendance, 3.8% of the mothers had no
ANC follow up at all, whereas 42.6% had less
than 4 visits and 53.6% had 4 or more visits.
Pattern of Child Sexual Abuse …
Teferi E. et al
49
Table 1: socio-demographic characteristics of the mothers involved in the study.
Variable (n=910)
<18
Age(Years)
18-35
>35
Protestant
Religion
Orthodox
Muslim
Oromo
Amhara
Kefa
Ethnicity
Gurage
Others*
Single
Divorced
Marital status Widowed
Married
Education
Occupation
Residence
No education
Primary
Secondary
College & above
Student
Daily labor
Employed
House wife
Rural
Urban
Frequency
8
869
33
120
212
578
694
136
28
26
26
6
8
10
886
Percent (%)
0.9
95.5
3.6
13.2
23.6
63.2
76.3
14.9
3.0
2.9
2.9
0.6
0.8
1.1
97.5
324
308
158
120
25
90
133
662
521
389
35.6
33.8
17.4
13.2
2.7
9.9
14.6
72.8
57.3
42.7
*=Tigre, Dawuro, Yem, Wolaita, Siltie
Maternal medical disorders
With regard to maternal medical conditions,
anemia is the most common identified medical
illness whereas hypertension and renal diseases
were the second and third frequent illnesses
identified(see table 3). Only less than half of all
the mothers (45.4%) were screened for syphilis
and none of them had a positive test result. Almost
one third of the mothers (32.1%) were not tested
for HIV.
Table 2: Maternal medical disorders identified during the study
Medical disorder
Asthma
Cardiac diseases
Diabetes Mellitus
UTIs
HIV/AIDS
Malaria
Hypertension
Renal diseases
Anemia
Frequency
5
7
8
13
14
36
52
55
249
Percent(%)
0.5
0.8
0.9
1.4
1.5
3.9
5.7
6.0
27.4
P value ( for association with LBW)
1.00
.06
.21
.02
.76
.14
.000
.36
.01
50 Ethiopian Journal of Pediatrics and Child Health.
Incidence of LBW
The incidence of LBW in this study was 24.4%.
Majority (58.3%) of the newborns were males and
41.7% were females. Out of the 931 newborns
included in this study, 24.4% had LBW, whereas
70.6% and 5% of the newborns had normal birth
weight and macrosomia respectively. From the
24.4% LBW newborns, 0.8% were VLBW,
whereas 23.6% were just LBW; there is no
newborn found to be ELBW. From the newborns
with LBW, 17.5% had symmetric IUGR and 78%
had asymmetric IUGR. The rest 9 newborns didn’t
have IUGR.
Of all the 931 newborns included in the study,
99% were live births and 1% were still births.
Majority (77.8%) of the still births had LBW
whereas the rest 22.2% had NBW. The mean ± SD
of birth weights were 3017 ± 612gm.
Factors associated with low birth weight
On the binary logistic regression, factors found to
have statistically significant association with low
birth
weight
are
rural
residence
(COR=1.56,95%CI
1.14,2.13),
maternal
hypertension (COR=2.88 95%CI 1.65,5.03),
Vol. 11, No. 1
November 2015
UTIs(COR=3.70
95%CI 1.23, 11.13),
hemoglobin of less than 11gm/dl(COR=1.56
95%CI 1.12, 2.17), MUAC of less than
23cm(COR=2.09,95%CI
1.46,3.00),
prematurity(COR=22.96 95%CI 11.74, 44.92),
maternal APH (COR=3.74 95%CI 1.79, 7.78),
maternal
pregnancy
induced
hypertension(COR=3.09 95%CI 1.94, 4.92), lack
of ANC followup or infrequent (<4) visits
(COR=1.74 95%CI 1.29, 2.36), female
sex(COR=1.62 95%CI .46, .83) and multiple
gestation(COR=4.78, 95%CI 2.52, 9.07).
On the multiple logistic regression analysis, all the
variables having p value <.25 on binary logistic
regression analysis were considered for analysis.
The variables found to have statistically
significant associations with LBW include
maternal
UTIs(AOR=9.13
95%CI
1.26,
66.46),prematurity (AOR=16.03 95%CI 7.60,
33.83), maternal APH (AOR=4.74, 95%CI 1.49,
15.07), female sex (AOR=2.02 95%CI 1.22,3.36),
and multiple gestation (AOR=8.6 95%CI 1.88,
34.16). All the other factors have no statistically
significant associations.
Table 3: Comparison of the mean birth weights of the different categories of the newborns.
Variable
Gender
Mean
M
3.073
F
2.939
No. of fetus
singleton 3.038
Multiple
2.566
Parity
Multipara 3.090
Primipara 2.933
Gestational age >37weeks 3.099
<37weeks 2.223
Residence
Urban
3.084
Rural
2.968
SD
.5947
.6382
.6121
.4078
.6438
.5620
.5499
.5465
.5807
.6033
95%CI of the difference
P
lower
upper
.001 .0542
.2146
.000 .3378
.6067
.000 .0795
.2346
.000 .7332
1.0189
.004 .0373
.1941
To the contrary, statistically significant difference
was not seen in the mean birth weight of newborns
with regard to maternal age, religions, ethnicities,
marital status, educational status and occupation
when analyzed by one way Annova.
DISCUSSION
The incidence of LBW in this study is 24.4%
which is one of the highest figures in the world,
and is consistent with different studies done in
different parts of the world. In India, K.S Negi did
a longitudinal study, which showed incidence of
23.8%(12). In a cross sectional descriptive study
done in Jimma zone ( in one hospital & four health
centers),22.5% of the births were LBW(11). It is
also comparable with the EDHS-2011 report of
LBW rate of 21% which was based on maternal
report of giving birth to a small or very small
baby.
But the 24.4% incidence of LBW found in
this study is lower than some community based
Pattern of Child Sexual Abuse …
studies. For example, in a community based study
done in India by J.S. Deshmukh, 30.3% of the
deliveries were found to have LBW(13). In Kersa ,
Eastern part of Ethiopia, a community based
observational cohort study was done, and the
incidence of LBW was 28.3% (21). This
difference may be explained by the fact that these
two studies were done in the community which
might be the real reflection of the problem
whereas our study was a hospital based study.
When compared with other studies , the incidence
of LBW found in this study is much higher than
the previous ones. Some of these studies are
prospective cross sectional study done in Turkey,
Istanbul which showed incidence of 9.1%(16), a
cross sectional study done in Yazd, Iran, where
the incidence of LBW was 8.8%(17), a study
conducted in Zahdan Hospital in Iran, where the
incidence was 11.8%(18), a study done in
Tanzania, which showed 13.6 of the births to be
LBW(7), a cross sectional study done on 305
newborns in Gondar University Hospital, North
West Ethiopia, with the overall incidence of LBW
of 17.1%(10). The difference in the sociodemographic background of the participant
mothers and also the time at which these studies
were conducted may explain this difference in the
incidence of LBW between these studies and our
study.
Maternal residence in a rural area was found
to have statistically significant association with
low birth weight which is similar with study done
in Peshawar, Pakistan in public hospitals, which
has demonstrated area of residence (i.e. rural) to
have a negative association with birth weight(15).
It is also consistent with the EDHS-2011 report
which showed place of residence as one of the
factors associated with LBW(9). But in a study
done in Gondar University, maternal residence in
rural area was not found to be associated with
LBW(10), the reason behind may be the difference
in the distribution of the mothers in the two
studies ( 75% of the mothers in the Gondar
University study were urban dwellers whereas
only 42.7% of the mothers were urban dwellers in
our study).
Maternal MUAC of less than 23 was found to
be associated with LBW, a finding similar to a
study done in Eastern Ethiopia(11).
Female sex, multiple gestations, prematurity,
maternal UTIs and APH are the factors found to
Teferi E. et al
51
have statistically significant association with LBW
on the multiple logistic regression analysis during
this study. This is also consistent with some of the
studies done so far like a study done in Istanbul,
Turkey which has demonstrated multiple gestation
and prematurity to be associated with LBW(16), in
Iranian study which also showed prematurity &
multiple gestations to be associated with
LBW(17), the study done in Gondar (female sex),
and the Jimma study which has also shown
preterm and multiple gestations to be associated
with LBW(10,11). Some other studies didn’t find
significant association between sex of the newborn
and LBW(16,17) which might be explained by the
difference in sex distribution seen during those
studies.
Maternal demographic factors like age,
religion, ethnicity, marital status, and educational
status were not found to have statistically
significant associations with LBW which was also
demonstrated on other similar studies done in the
other parts of the country as well as the study done
in Jimma zone in 2002-2003(10,11,21). The
reason for this might be because of similar nature
of the mothers in the study, majority being in a
similar age group, not educated, married , and
belonging to one religion or ethnic group.
Many of the maternal medical illnesses were
not found to have a significant association with
LBW like other studies done in the past (10,21)
and in contrary to other studies done elsewhere
(7,17,18). The possible explanation for this might
be the fact that the number of mothers identified
to have these medical disorders in the current
study was minimal (which was actually the case in
the previous studies done in Ethiopia as well). The
other reason may be the fact that significant
number of the mothers were not tested for some of
the medical illnesses (54.6%, 32.1% and 9.1% of
the mothers were not screened for Syphilis, HIV,
and anemia respectively) during the current study.
Inconclusion, the incidence of LBW found in this
study is higher than many of the hospital based
studies done so far and also the national estimate
of LBW. It is even higher than the regional
average estimate for the Sub-Saharan African subregion. The factors found to be associated with
LBW in this study are rural residence, female
gender, UTIs, hypertension, anemia, maternal
MUAC of less than 23cm, preterm delivery, lack
52 Ethiopian Journal of Pediatrics and Child Health.
of or infrequent ANC follow up, pregnancy
induced hypertension and APH.
An attempt to increase the rate of ANC
attendance as part of the zonal and regional
program should be strengthened. In those having
ANC follow up health workers providing these
services should try to identify the medical
illnesses as well as obstetric complications and
address them timely so that the rate and
complications of LBW could be minimized.
Additionally, routine screening of some of the
medical illnesses such as HIV and Syphilis at
ANC visits should be strengthened.
Further study should also be carried out to
address the other factors associated with LBW and
also to determine the outcomes of these LBW
infants using follow up study.
Vol. 11, No. 1
November 2015
ACKNOWLEDGEMENTS
First and foremost, we would like to thank Jimma
University, College of Public Health and Medical
Sciences, and the department of Pediatrics and
child health for all the necessary financial support
for the study. We would also like to thank all
mothers and care takers who showed their
willingness to be involved in the study as well as
those who helped us in the data collection and
analysis process.
Pattern of Child Sexual Abuse …
Teferi E. et al
53
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page numbers (list all authors if six or less; when seven or more list only first three and add et
al) for Scientific Articles and Contributing Authors are required to meet the specified Style all
across. Reference to a book should contain author’s (s’) name (s) and initials, title of chapter,
name of editors, title or book, city and name of publisher, year, first and last page numbers.
For example:
i.
ii.
Zorc J, Kiddoo D, Shaw K. Diagnosis and management of pediatric urinary tract
infection. Clin Microbiology Rev 2005, 18: 417-22.
T. Martin Barrat, Patrick Niaude. Clinical evaluation. In Pediatric Nephrology 5th
edition. (Ellis D. Avner, William E. Harmon, Patrick Niaudet Ed). Lippincott Williams
and Wilkins, Philadelphia 2004, 387-98.
Unless specifically advised, Manuscript contributions should comprise duly structured Abstract
(not more than 250 words), concise enough Introduction, Subject and Methods, Results,
Discussion, Discussion, Acknowledgements, References, Tables and/or Figures, and other
pertinent parts. Abstracts whilst required to get structured accordingly by the main heading
parts (Introduction, Subjects and Methods, Results, and Conclusion) will have to get submitted
on separate sheet. The title page should contain (i) the title of the article, (ii) Author(s) full
names, signature(s), degrees, designations, name of institution of affiliation of the piece of
work, most current mailing address, telephone and e-mail contacts of each, and (iii) name and
address of the Author to whom all correspondences should get directly addressed to.
6. Metric System and Scientific terms: Where applicable the corresponding metric system of
nomenclature should be used. All scientific terms should get stated as exactly appearing in the
corresponding dictionary of reference for such. Both generic and trademark names may appear
in the very first instance of describing a term but only the generic along the subsequent
citations.
7. Abbreviations, acronyms and symbols: All of the applicable abbreviations, acronyms and
symbols are required to get spelled out in full at first appearance and the corresponding
abbreviation, acronym and symbol indicated alongside in parenthesis.
8. Tables and Figures: Like with all the other components of the Manuscript, Tables, Pictures,
Figures and Charts are required to get submitted in triplicates; each should get typed and
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submitted in separate sheet; clarity and legibility of them are critical. Scientific paper format
and style of Tables and Figures must get observed.
9. References: Consistent to the specification of the Vancouver’s style, references should be
numbered and listed consecutively; typed double-spaced and keyed (cited) to the
corresponding text; Author(s) should ensure accuracy of every details of the reference quoted.
10. Galley Proof: Galley Proof reading is a standard requirement in order to be able to correct
possible editing and type errors in particular. Galley Proof review and revision is set at 98
hours or one week long of return at maximum. The Corresponding Author will take direct
responsibility for fulfilling this requirement.
11. Copyright privileges: Papers already accepted for publication in the Ethiopian Journal of
Pediatrics will automatically become the copy right of the Journal and hence Contributing
Authors are required to clear through completing and signing the Copyright Form in
accordance prior to actual publication.
12. Reprints: Upon publication of the corresponding contribution, at a limit of 25 reprints of the
specific issue will get supplied to the Corresponding Author.
13. Retention policy: The Editorial Board reserves the right to retain rejected manuscripts.
14. Updates: Prospective Contributing Author(s) are advised to regularly check both on the latest
hard copy and web site versions of the Journal for possible progressive up-dates of the
Guidance and Requirements.
F