Time to Recovery From Severe Acute Malnutrition and Its Predictors Among Under-5 Children Admitted to Sheik Hassan Yebere Referral Hospital, Somali Region Eastern Ethiopia: A Retrospective Study

Time to Recovery From Severe Acute Malnutrition and Its Predictors Among Under-5 Children Admitted to Sheik Hassan Yebere Referral Hospital, Somali Region Eastern Ethiopia: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Time to Recovery From Severe Acute Malnutrition and Its Predictors Among Under-5 Children Admitted to Sheik Hassan Yebere Referral Hospital, Somali Region Eastern Ethiopia: A Retrospective Study Belay Bekretsion Mehari¹, Belay Negash², Habtamu Mitiku³, Birhanu Alie Chekol, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8898334/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Background In Ethiopia, malnutrition causes 28% of underfive deaths, making it a leading health issue. The World Health Organization and the Supporting People and Communities to Help Emergency Response Project recommend that 75% of children with SAM should recover within 28 days. Despite numerous problems determining the time to recovery from severe acute malnutrition (SAM), scarce information is available in the Somali region's pastoralist community. Objective This study aimed to determine the time to recovery from severe acute malnutrition and its predictors among underfive children admitted to the stabilization center of Sheik Hassan Yebere Referral Hospital. Methods A four-year retrospective cohort study was conducted among 535 underfive children admitted to the SAM in the Therapeutic Feeding Unit of Sheik Hassan Yebere Referral Hospital due to severe acute malnutrition from January 1, 2020, to December 31, 2023. Data were extracted from patient records via a structured data abstraction checklist and collected electronically via the Open Data Kit (ODK) tool. The collected data were exported from Google Drive in Excel and then transferred to STATA version 17 for analysis. Kaplan‒Meier survival analysis was used to estimate the time to recovery from severe acute malnutrition. Cox proportional hazards regression was performed to identify predictors of recovery time. The proportional hazards assumption was assessed. Variables with an AHR at the 95% CI and a P value less than 0.05 in the multivariable Cox regression analysis were considered significant predictors of recovery time. Results Among the 535 records of children with SAM included in the study, 78.88% (95% CI: 69.9, 89.9) recovered at the conclusion of the follow-up period, with a median recovery time of 12 days. The recovery rate was 7 per 100 child days, with a total of 7,645 person-days. Pneumonia (AHR = 0.80; 95% CI: 0.75–0.85), malaria (AHR = 0.79; 95% CI: 0.65–0.90), nonimmunization (AHR = 0.71; 95% CI: 0.59–0.84), partial immunization (AHR = 0.82; 95% CI: 0.74–0.91), hypoglycemia (AHR = 0.80; 95% CI: 0.69–0.93), and congenital heart disease (AHR = 0.80; 95% CI: 0.69–0.93) were independent predictors of delayed recovery time. Conclusions The median time to recovery and cure rate for children with severe acute malnutrition were within the acceptable ranges recommended by the WHO and Sphere standards, and recovery was significantly influenced by the presence of specific comorbid conditions. Pneumonia, malaria, incomplete or lack of immunization, hypoglycaemia, and congenital heart disease were identified as independent predictors of delayed nutritional recovery. Compared with those without comorbidities, children admitted with these conditions experienced prolonged recovery periods. Therefore, strengthening the early identification and management of these conditions at admission, alongside improving routine immunization coverage and comprehensive clinical care within therapeutic feeding programs, is essential to enhance recovery outcomes and reduce malnutrition-related morbidity. Time to recovery severe acute malnutrition under five children Sheik Hassen Yebere Referral Hospital Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 BACKGROUND Malnutrition includes both undernutrition, which includes acute and chronic malnutrition as well as micronutrient deficiencies, and overnutrition, which manifests as overweight or obesity. Nonetheless, the scientific community and our society view malnutrition as under nutrition. In underdeveloped nations, undernutrition is linked to almost 50% of deaths due to underlying infectious diseases (Kliegman and Nelson, 2011; WHO, 2013). Malnutrition affects many children worldwide and is associated, either directly or indirectly, with death or disability. Twenty million children suffer from severe acute malnutrition (SAM), whereas another 60 million children suffer from moderate acute malnutrition. Approximately 7.7%, or 52 million children under the age of five, experienced severe malnutrition-related wasting in 2016. Among them, 17 million were at risk of death. The World Bank, United Nations International Children's Emergency Fund, and World Health Organization jointly estimated the amount of improvement needed to meet the 2030 Sustainable Development Goals and the 2025 World Health Assembly targets for stunting, wasting, severe wasting, and overweight in children under five years of age (UNICEF, WHO and World Bank, 2021; Ministry of Health, 2010). Regarding the method of treatment, the World Health Organization recommends community-based treatment for simple cases of SAM (WHO, 2013). However, the WHO 10-step model should be followed when managing children with complex SAM in inpatient facilities. The Sphere Association and WHO have also recommended SAM admission and discharge criteria, which state that the anthropometric indicator used to confirm admission should also be used to discharge patients from SAM treatment (WHO, 2013; Sphere, 2018). The rate of recovery after SAM varies, with studies reporting inconsistent results between 22.1% and 95.36%. It is well known that Ethiopia's recovery rate falls short of the widely recognized international minimum threshold of 75%. Mekele, Bahir Dar, and Gondar, for example, reported 22.1%, 58.4%, and 68.5%, respectively. Similarly, studies carried out in Ethiopia revealed that recovery times from SAM varied from 14–26 days. (Gebremichael, D. Y. 2015, Asres, D. T., Prasad, R. P.C.J.&Ayele, T.A.2018). A shorter healing period indicates that the care and treatment procedure is working as needed. Medical comorbidities such as anaemia, malaria, dehydration, hypoglycaemia, HIV, TB, hypothermia, and incomplete childhood immunizations all impact recovery times despite the assumption that these variables lengthen the recovery period; some researchers have reported contradictory findings. In enumerating the potential reasons for an extended recovery period, the number of children who recover from SAM depends on recovery duration as much as on the effectiveness of the treatment. Children who are admitted for SAM treatment ought to heal as quickly as possible. The Sphere Handbook for Humanitarian Charter and Minimum Standards state that children must recover from SAM within 28 days of being admitted to the hospital (WHO, 2013; Sphere, 2018). MATERIALS AND METHODS Study design and period. The study was conducted at Sheik Hassan Yebere Referral Hospital in Jigjiga, Somali region, eastern Ethiopia. The study period was from January 1, 2020, to December 31, 2023, 4 consecutive years, which represent the most recent period. The data were extracted from February 20 to March 10, 2024. Data were extracted from the hospital’s medical records of admitted children during this period. A hospital-based retrospective follow-up study design was used. Population All children aged 6–59 months who were admitted to the TFC (therapeutic feeding center) at Sheik Hassan Yebere Referral Hospital for SAM therapy were included in the study. The study population included all eligible children with SAM admitted to the stabilization center (SC) from January 1, 2020, to December 31, 2023. Inclusion and exclusion criteria All records of 6–59-month-old children with SAM admitted to Sheik Hassan Yebere Referral Hospital's stabilization center from January 1, 2020, to December 31, 2023, were included in this study. However, incomplete records that lacked sociodemographic information, comorbidities, routine prescriptions, patient treatment results (i.e., cure, death, not recovered, and defaulter), and referrals from other health facilities were discarded. Sample size. The required sample size was computed via STATA software version 17 on the basis of the formula designed for survival analysis sample size calculations. Covariates such as the sex of the child, immunization status, and type of SAM at admission were assessed, and hazard ratios for the median time to recovery were used in the calculation. Among them, the covariate sex of the children produced the greatest sample size, which was chosen for the final estimation, yielding 535 participants. The computation considered a standard deviation of 0.5, 5% type I error, 80% power, and a 10% correction for incomplete records. Dependent variable The study's dependent variable was the time to recover from severe acute malnutrition. The time between the diagnosis of SAM and recovery/discharge was estimated in days. Independent variables. These include the sociodemographic type of malnutrition, baseline anthropometric measurements, immunization status, supplements, and therapeutic feeding, and comorbid medical conditions. Measurement Survival time is the time in days from the child was diagnosed with SAM to the occurrence of the outcome (recovered/censored). Event (recovered). Is a recovery of children from SAM or when the children fulfil the Discharge criteria were determined by the ward physician. The time to recovery is defined as the length of time in days between child admission with SAM and discharge with recovery (MoH, 2019 ). Censored observations are those children who have not developed an event or those who have not recovered from SAM (defaulter, death, nonresponder, stabilized and transferred-out) (Bizuneh et al., 2022). Kwashiorkor. A severe form of undernutrition or malnutrition in children results from a diet excessively high in carbohydrates and low protein. (MoH, 2019 ). Marasmus. This severe form of acute malnutrition is characterized by an emaciated physical appearance/severe wasting. This is a problem of carbohydrate deficiency. (MoH, 2019 ). Marasmus-kwashiorkor. It is a mixture of both kwashiorkor and marasmus. This is a problem for both carbohydrate- and protein-containing food. (MoH, 2019 ). Comorbidity is defined as a medical problem present in addition to severe acute malnutrition (MoH, 2019 ). Data collection tools, procedures, and quality control A structured data abstraction form adapted from the Sphere standard, the Ethiopian SAM management protocol, medical history sheets, and relevant published studies was used to collect data. The tool captured sociodemographic characteristics, type of malnutrition, baseline anthropometric measurements, immunization status, comorbidities, treatments, supplements, therapeutic feeding, recovery time, and treatment outcomes. Four diploma nurses and two degree-holding nurses with prior experience were recruited as data collectors and supervisors. They received two days of training on data quality, ethical considerations, and supervision procedures. Data were extracted from patient charts and the SAM Registration Book via Open Data Kit (ODK) offline software on smartphones. The supervisor and primary investigator monitored the process daily to ensure completeness, accuracy, and consistency, and the data were automatically uploaded to Google Drive for quality assurance. Method of Data Processing and Analysis After completing data collection, the data were reviewed for completeness and immediately extracted from Google Drive as an Excel file. Before being exported to STATA Version 17, the data were cleaned in an Excel file to minimize errors. Then, the Excel page was exported to STATA version 17. The consistency of the exported data was examined. Summary statistics were performed via percentages for categorical data and medians for continuous variables. To estimate recovery time from SAM and determine whether the observed difference in recovery time between various groups of predictor variables was significant, Kaplan‒Meier and log rank tests were employed. Bivariate Cox regression analysis was then performed for every predictor variable along with the recovery time. The upper limit for entering variables into multivariate Cox regression was set at a P value of less than 0.25. The predictor variables were subsequently identified by employing an adjusted hazard ratio (AHR) with a 95% confidence interval. Multiple collinearity and model fitness tests were carried out via the variance inflation factor (VIF) and Cox-Snell residual goodness-of-fit tests. The variables that had a p value less than 0.05 were considered significant. RESULTS Baseline sociodemographic and anthropometric characteristics This study analysed records from 535 children under 5 years of age with severe acute malnutrition (SAM), all of whom were admitted to stabilization centers at Sheik Hassan Yebere Referral Hospital. Among these children, 375 (70.1%) were male, and 286 (53.3) came from urban areas. The children's ages ranged from 6 to 59 months, with a median age of 28 months (SD±12), and 236 children (44.1%) were between 24 and 35 months old. Most of the children, 519 (97%), were new admissions. Marasmus was the most common form of malnutrition, affecting 395 (73.8%) of the cohort, followed by kwashiorkor at 71 (13.3%) and marasmic-kwashiorkor at 69 (12.9%) ( Table 1). Table 1: Baseline sociodemographic and anthropometric characteristics of children under five years of age with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2020 (n=535). Insert Table 1 here. Major Comorbidities and Clinical Features Among the cohort of children under 5 years of age studied, 519 (97%) had at least one comorbid condition at the time of admission. The most prevalent medical comorbidities among these children with severe acute malnutrition (SAM) were anaemia, affecting 521 (97.4%), pneumonia affecting 469 (87.7%), and diarrhoea affecting 366 (68.4%) children. In terms of clinical signs, children presented with at least one notable symptom upon admission. The most frequently observed clinical features were fever in 461 (81.2%) children, dehydration in 103 (19.3%) children and shock in 103 (19.3%) children. (Table 2) Table 2: Distributions of comorbidities and medical complications with respect to survival status among children under 5 years of age admitted with SAM to the stabilization center of Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2020 (N=535). Insert Table 2 here. Management of Severe Acute Malnutrition All cases of severe acute malnutrition (SAM) in children under 5 years of age admitted to the stabilization centre at Sheik Hassan Yebere Referral Hospital between January 1, 2020, and December 31, 2023 (N=535), were treated following the guidelines set by the World Health Organization (WHO) and the Ethiopian Federal Ministry of Health (FMOH) for SAM management. In terms of nutritional therapy, 523 children (97.8%) received F-75, while 12 (2.8%) were started on diluted F-100 as their therapeutic milk formula. In terms of routine medication, intravenous antibiotics, specifically ceftriaxone, were prescribed to 469 (87.7%) children, followed by 49 (9.2%) with ampicillin and gentamycin, while oral antibiotics, such as amoxicillin, cherimoxazole, and metronidazole, were given to 27 (5%) children. Among anaemic children, 480 (89.7%) received folic acid supplements, and 470 (88%) were supplemented with vitamin A. A total of 344 (100%) children over the age of two who were eligible were dewormed with albendazole. Additionally, 366 (68.4%) children received ReSoMal, and 100 (18.7%) underwent IV fluid therapy (Table 3). Table 3: Distributions of managements of severe acute malnutrition among children under 5 years of age to the stabilization centre of Sheik Hassen Yebere Referral Hospital from January 01, 2020,2 to December 31, 2023. Inseret Table 3 here Time to Recovery from SAM and Treatment Outcomes During the study period, a total of 422 children with severe acute malnutrition (SAM) experienced a cumulative person-time of 7,645 days, resulting in a recovery rate of 0.0552 recoveries per person-time (95% CI: 0.0647--0.0752). This translates to approximately 7 recoveries every 100 person-days or 70 recoveries per 1,000 person-days. The median recovery time for this cohort was 12 days, with an interquartile range (IQR) from 10--15 days. Among the 422 children who successfully recovered, the average length of stay was 14 days, with a standard deviation (SD) of 6 days. In terms of treatment outcomes for children with severe acute malnutrition (SAM), 422 (78.88%) children (95% CI: 61.9% - 69.9%) achieved recovery. Moreover, 32 (6%) children (95% CI: 14.7% - 21.2%) were classified as defaulted, and 32 (5.98%) children (95% CI: 6.8% - 11.7%) were categorized as having defaulted on treatment. Figure 1: Treatment outcomes of SAM among children under 5 years of age admitted to the stabilization centre of Sheik Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2023 (N=535). Insert Fig. 1 here. Life Table The cumulative likelihood of recovery was 0.4% by the end of the first week and reached 99% by the conclusion of the study . (Table 4) Table 4: Actuarial life table analysis showing the survival of SAM children admitted to the stabilization centre of Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 (N=535) Insert Table 4 here. Comparison of survival status by Kaplan–Meier curves and log rank tests The overall Kaplan‒Meier curve revealed that 50% of the cohort of children with severe acute malnutrition (SAM) recovered within two weeks (12 days) of admission. (Figure 2) As illustrated in Figure 4 and Table 5, children with severe acute malnutrition (SAM) who were fully immunized experienced earlier recovery than those who were not, demonstrating a significant difference in survival time. (log rank test, χ2 = 6.29, Prob>chi2=.0430). Conversely, children with severe acute malnutrition (SAM) who had not been dewormed were more likely to recover earlier than those who had, with a significant difference in survival time. (log rank test, χ2 =6.56, Prob>chi2=.0104) (Figure 5 and Table 5) There was a notable difference in the median recovery time between children admitted with malaria (log-rank test, X2 = 4.26, Prob>chi2= .0389) and those admitted with pneumonia. (Log-rank test, X2 = 13.13, Prob>chi2= .0003) ( Table 5 ) insert Fig. 2 here Figure 2: The overall KM survival graph for time to recovery (days) of the entire cohort of SAM children admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 Table 5: Median time to recovery and log-rank test results among a cohort of SAM children admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 Insert Table 5 here. Insert Figure 3 here. Figure 3: Kaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of the presence of pneumonia. Insert Fig. 4 here Figure 4: Kaplan‒Meier survival curves comparing the recovery times of children under 5 years of age with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of immunization status. Insert Fig. 5 here Figure 5: Kaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of deworming. Test of Proportional Hazard Assumption The Schoenfeld residuals test was used to assess the proportional hazards assumption. Both the global test, individual tests for each predictor and Cox-Snell goodness-of-fit (GOF) tests were performed, focusing specifically on the Schoenfeld residuals. The proportional hazards assumption was considered satisfied if the p value was greater than 0.05. Among the 18 predictors examined, only two did not satisfy the proportional hazards assumption (p < 0.05). However, the global test for all the predictors combined yielded a p value of 0.0776, indicating that the overall model meets the Cox proportional hazards assumption. Table 6: Test of the proportional hazard assumption by Schoenfeld residuals for each predictor as well as the global test Insert Table 6 here. Predictors of time to recovery from severe acute malnutrition In the bivariable analysis, 12 variables with a P value less than 0.25 were identified and selected for further investigation via multivariable log-logistic regression. These variables included admission type, pneumonia, malaria, immunization status, deworming, severe dehydration, shock, feeding route, hypoglycemia, intravenous (IV) fluids, tuberculosis (TB), and congenital heart disease (CHD). To assess potential multicollinearity among these variables, the variance inflation factor (VIF) was calculated. The VIF values ranged from 1 to 2.17, with a mean VIF of 1.05, indicating that there were no significant multicollinearity issues between the predictors. Five of the variables (pneumonia, malaria, immunization status, hypoglycemia, and congenital heart disease) were found to be statistically significant predictors of time-to-recovery during multivariable log logistic regression analysis at the 95% confidence level. The study revealed that recovery time was shorter by a factor of 0.70 for children admitted with no pneumonia than for those admitted with pneumonia (AHR =0.697, 95% CI: 529–918) when other variables were adjusted for in the model. Similarly, the recovery time was also shorter by a factor of 0.79 for SAM children admitted with no malaria than for those admitted with malaria (AHR: 0.79, 95% CI: 0.65–0.93). In addition, the recovery time was shortened by a factor of 0.704 for SAM children who were fully immunized compared with those who were not fully immunized (AHR: 0.704, 95% CI: 0.508--977), and the recovery time was shortened by a factor of 0.697 for SAM children who were fully immunized compared with those who were partially fully immunized (AHR: 0.697, 95% CI:502--966). Additionally, the recovery time was shortened by a factor of 0.80 among SAM children with no hypoglycemia compared with SAM children admitted with hypoglycemia (AHR: 0.80, 95% CI: (.69--93) . Finally, the recovery time of the cohort of SAM children with no CHD was shortened by a factor of 0.502 compared with that of children fed NG tubes (AHR: 0.502, 95% CI: 0.263--958) while adjusting for other variables in the model constant. Table 7: Predictors of time to recovery from severe acute malnutrition among a cohort of SAM children admitted to the stabilization centres of Sheik Hassen Yebere referral hospital from Jan 01/2020 to Dec 31/2023 (N=535). Insert Table 7 here. Cox–Snell residuals are used for goodness-of-fit analysis; generally, the model fits the data reasonably well but has several limitations. Most of the Cox–Snell residuals align closely with the expected diagonal, especially in the lower range, indicating a good fit overall. However, the deviation after a certain point (approximately 4) suggests that the fit is not perfect across the entire range. Insert Fig. 6 here Figure 6: Figure 8: Cox Snell residual graph for checking the overall fitness of the final model. DISCUSSION The current study provides valuable insights into the recovery time from severe acute malnutrition and its predictors among children under five years of age admitted to the stabilization center at Sheik Hassen Yebere Referral Hospital. The median recovery time was 12 days, with an interquartile range of 10–15 days, and the overall recovery rate was 78.88% (95% CI: 61.9%–69.9%). This median recovery time aligns with the SPHERE standards, indicating that it falls within acceptable limits (i.e., less than four weeks) (SPHERE, A. 2018). Furthermore, factors such as the presence of pneumonia, malaria, lack of immunization, hypoglycemia, and congenital heart disease (CHD) at the time of admission significantly extended the nutritional recovery time from severe acute malnutrition. The median recovery time from severe acute malnutrition (SAM) reported in this study is consistent with findings from previous studies conducted in India (11.71 ± 7.59 days) (Singh et al., 2015), Zambia (12 days) (Munthali et al., 2015), Nekemte Referral Hospital (8–14 days) (Mena et al., 2018), hospitals in the Wolaita zone (11 days) (Admasu et al., 2017), and the Waghimra zone of the Amhara region (11 days) (Tadesse, Z., Teshome, D. F., Lakew, A. M., Debalkie, G., & Gonete, K. A. 2021). However, the recovery time observed in this study was longer than the findings from Sekota Hospital, where the median recovery time was reported to be 10 days (Desta, 2015), and from selected public health facilities in the Sidama region, which indicated a recovery time of 8 days (Abebe, A., Simachew, Y. & Delbiso, T. D 2023). This variation in recovery times may be attributed to differences in sociodemographic factors, healthcare infrastructure, and the timeframes of the respective studies. Conversely, the nutritional recovery time reported in this study was shorter than that reported in several other hospitals. For example, Dilchora Referral Hospital recorded a median recovery time of 80 days (Oumer, A., Mesfin, F. and Demena, M. 2016), whereas the Afar Region's Dubti Zone Referral Hospital reported 18.4 days (Tegegne, Awoke & Belay, Denekew 2021). Yirgalem Hospital had a recovery time of 18.16 days (Daba, Alemneh & Dadi, Gezahegn 2017), and a study from Gambia indicated a median of 18 days (Alice Burrell, Marko Kerac, Helen Nabwera 2017). Additionally, Hawassa University Comprehensive Specialized Hospital reported a median recovery time of 17 days (Fikrie, A., Alemayehu, A. & Gebremedhin, S. 2019). Jimma University Comprehensive Specialized Hospital had a median duration of 16 days (Jarso, H., Workicho, A. & Alemseged, F.2015), and Asosa General Hospital had a median duration of 15 days (Kebede, F., Tolossa, T., Bekonjo, N. and Wakuma, B 2022). The disparities in these median recovery times can be attributed to various factors, including the patient load at each facility, the presence of complicated cases that may delay recovery, differences in sociodemographic characteristics, and variations in the quality of care provided to patients. In examining the factors influencing recovery time from severe acute malnutrition (SAM), it was found that children admitted without pneumonia experienced a quicker recovery than those admitted with pneumonia did. (AHR = 0.697, 95% CI: 529-.918). This finding aligns with previous retrospective cohort studies conducted in various locations, including Zambia (Munthali et al., 2015) (AHR 1.3, 95% CI 1.0–1.6), Nekemte Referral Hospital (AHR = 7.82, 95% CI 2.74, 222.29) (Mena et al., 2018) and Yekatit 12 Hospital (AHR 0.764 95% CI 0.599–0.975) (Adimasu et al., 2020), which can be understood through the interrelated dynamics between pneumonia and malnutrition. Children suffering from SAM may exhibit a diminished inflammatory response, which can mask the typical clinical signs of pneumonia, making the infection less detectable. As a result, the absence of obvious symptoms can delay diagnosis and appropriate treatment by healthcare providers. This atypical presentation of pneumonia may ultimately prolong recovery times. (Chowdhury et al., 2020) The study also indicated that children with severe acute malnutrition (SAM) who were admitted without hypoglycemia experienced a shorter recovery time than did those who presented with hypoglycemia (AHR: 0.80, 95% CI: (.69-.93)). This finding aligns with research conducted at Nekemte Referral Hospital. Hypoglycemia can significantly hinder the recovery process for children with SAM. When blood sugar levels decrease, the body’s ability to utilize energy effectively is compromised, which is crucial for healing and recovery (WHO 2018). Furthermore, the study revealed that children with severe acute malnutrition (SAM) who were admitted without malaria experienced a shorter recovery time than did their counterparts who had malaria. This finding is consistent with research conducted at Pawi General Hospital (Wondim, A., Tigabu, B., & Kelkay, M. M. 2020). and Jimma University Medical Center (Hussen Kabthymer R, Gizaw G, Belachew T 2020). The prolonged recovery time associated with malaria can be attributed to several factors. Malaria disrupts gluconeogenesis and increases energy expenditure, leading to metabolic challenges. It can also cause malabsorption and weaken the immune system, making the body less responsive to standard treatment protocols. As a result, these complications hinder nutritional recovery, as highlighted by Prendergast A. J. (2015). The study findings also indicated that children with severe acute malnutrition (SAM) who were fully immunized experienced a shorter recovery time than those who were not fully immunized or who were only partially immunized. (AHR: 0.704, 95% CI:.508-.977). This observation is supported by research conducted at Felegehiwot Referral Hospital, which reported that fully vaccinated SAM children had a recovery rate that was 4.12 (AOR; 95% CI: 1.64–10.35) times greater than that of their unvaccinated counterparts. The improved recovery time among fully immunized children can be attributed to the enhanced immune protection they receive, which helps mitigate the risk of infections and illnesses that can hinder recovery from SAM. (Adams, W. G., et al. 2017). Finally, the study results indicated that the group of severely malnourished (SAM) children with congenital heart disease (CHD) experienced a shorter recovery time than did those without CHD. This finding is corroborated by research conducted in the Sidama region (Abebe, A., Simachew, Y. & Delbiso, T. D 2023). A possible explanation for this observation is that diagnosing CHD in malnourished children can be quite challenging because underlying cardiac conditions may not be immediately apparent due to the overlapping symptoms of malnutrition (WHO, 2013). Conclusion Overall, the average length of stay, median time to recovery, and cure rate among children with severe acute malnutrition met the SPHERE standards. However, concomitant diseases, particularly pneumonia, malaria, a lack of vaccination, hypoglycemia, and congenital heart disease, severely delay nutritional recovery. These findings emphasize the importance of early detection and management of comorbidities at admission, as well as establishing coordinated care within stabilization facilities, in improving recovery outcomes for children with SAM. Limitations of the Study The retrospective design of the study and reliance on secondary data led to incomplete documentation for some variables, which limited the analysis of factors associated with nutritional recovery time. Consequently, key caregiver-related characteristics, including educational level and occupational and economic status, could not be assessed. Additionally, the lack of a comparison group from other healthcare facilities restricted broader comparisons. The classification of children into different SAM categories was based on diagnoses recorded in medical charts, which may have been subject to misclassification or diagnostic inaccuracies. Abbreviations CHR Crude hazard ratio AHR Adjusted hazard ratio SAM Severe acute malnutrition TFC Therapeutic Feeding Center WFA Weight-for-Age WFH Weight-for-height WHZ Weight-for-height Z score Declarations Ethical approval Before data collection, the research proposal was reviewed and approved by Haramaya University's College of Health and Medical Sciences Institutional Health Research Ethics Review Committee/IHRERC/, which followed institutional ethics guidelines based on the Nuremberg Code, Helsinki Declaration, Belmont Report, and WHO affiliated center of international organization for medical sciences (CIONS), and official ethical clearance was obtained. Sheik Hassan Yebere Referral Hospital approved the study and provided access to medical records. The ethical committee authorized the waiver of individual informed consent because the study was a retrospective examination of medical information. To maintain secrecy, the data abstraction forms did not include personal identifiers, the electronic data were password protected, and the data collectors were trained on data privacy and confidentiality. Consent for publication. Not applicable. Availability of data and materials The dataset used in this study is available from the corresponding author, Belay Bekretsion, upon reasonable request (email: [email protected] ). Competing interests The authors state that they do not have any competing interests. Funding No special funding was obtained for this research. Authors' contributions Belay Bekretsion developed the research topic, prepared the proposal, and participated in data collection, analysis, and manuscript writing. Belay Negash, Habtamu Mitiku, Birhanu Alle and Mulugeta Gemechu also played key roles by guiding data collection, analysis, writing, and revision. All the authors have read and approved the final version of the manuscript for submission. Acknowledgements We would like to thank the data collectors and supervisors for their valuable contributions to the data collection process. We also extend our sincere appreciation to Sheik Hassan Yebere Referral Hospital for providing access to the necessary information for this study. References Abebe, A., Simachew, Y. & Delbiso, T.D. Effect of ready-to-use therapeutic foods on time to recovery among children with severe acute malnutrition in Ethiopia: a prospective cohort study. BMC Pediatr 23, 340 (2023). https://doi.org/10.1186/s12887-023-04168-x Adams, W. G., Et Al. 2017. Immunization And Nutritional Status In Children: A Population-Based Study. Pediatrics, 139(2), E20161798 Admasu, Amare. (2017). Survival Status And Its Associated Factors Among Under-Five Children Admitted With Complicated Severe Acute Malnutrition In Hospitals Of Wolaita Zone, South Ethiopia: Retrospective Cohort Study. Journal Of Nutritional Health & Food Science. 5. 1–12. 10.15226/Jnhfs.2017.001105. Adimasu, M., Sebsibie, G., Abebe, F. & Mulu, G. 2020. Recovery Time From Severe Acute Malnutrition And Associated Factors Among Under5 Children In Yekatit 12 Hospital. Asres, D. T., Prasad, R. P. C. J. & Ayele, T. A. 2018. Recovery Time And Associated Factors Of Severe Acute Malnutrition Among Children In Bahir Dar City, Northwest Ethiopia: An Institution Based Retrospective Cohort Study. Bmc Nutrition , 4, 17. Alice Burrell, Marko Kerac, Helen Nabwera, Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia, International Health, Volume 9, Issue 4, July 2017, Pages 226–233, https://doi.org/10.1093/inthealth/ihx022 Bizuneh, F. K., Tolossa, T., Bekonjo, N. E., & Wakuma, B. (2022). Time to recovery from severe acute malnutrition and its predictors among children aged 6–59 months at Asosa general hospital, Northwest Ethiopia. A retrospective follow up study. PloS one, 17(8), e0272930. https://doi.org/10.1371/journal.pone.0272930 Chowdhury, F., Shahid, A. S. M. S. B., Ghosh, P. K., Rahman, M., Hassan, M. Z., Akhtar, Z., Muneer, S. M., Shahrin, L., Ahmed, T., & Chisti, M. J. (2020). Viral etiology of pneumonia among severely malnourished underfive children in an urban hospital, Bangladesh. PloS one, 15(2), e0228329. https://doi.org/10.1371/journal.pone.0228329 Daba, Alemneh & Dadi, Gezahegn. (2017). Factors Associated with Treatment Outcomes of Underfive Children with Severe Acute Malnutrition Admitted to Therapeutic Feeding Unit of Yirgalem Hospital. Clinics in Mother and Child Health. 14. 10.4172/2090-7214.1000261. Desta, K. 2015. Survival Status And Predictors Of Mortality Among Children Aged 0–59 Months With Severe Acute Malnutrition Admitted To Stabilization Center At Sekota Hospital Waghemra Zone. Journal Of Nutritional Disorders & Therapy , 05. Desyibelew, H. D., Fekadu, A. & Woldie, H. 2017. Recovery Rate And Associated Factors Of Children Age 6 To 59 Months Admitted With Severe Acute Malnutrition At Inpatient Unit Of Bahir Dar Felege Hiwot Referral Hospital Therapeutic Feeding Unite, Northwest Ethiopia. Plos One , 12, E0171020. Fikrie, A., Alemayehu, A. & Gebremedhin, S. Treatment outcomes and factors affecting time-to-recovery from severe acute malnutrition in 6–59 months old children admitted to a stabilization center in Southern Ethiopia: A retrospective cohort study. Ital J Pediatr 45, 46 (2019). https://doi.org/10.1186/s13052-019-0642-x Gebremichael, D. Y. 2015. Predictors Of Nutritional Recovery Time And Survival Status Among Children With Severe Acute Malnutrition Who Have Been Managed In Therapeutic Feeding Centers, Southern Ethiopia: Retrospective Cohort Study. Bmc Public Health , 15, 1267. Hussen Kabthymer, R., Gizaw, G., & Belachew, T. (2020). Time to Cure and Predictors of Recovery Among Children Aged 6–59 Months with Severe Acute Malnutrition Admitted in Jimma University Medical Center, Southwest Ethiopia: A Retrospective Cohort Study. Clinical epidemiology, 12, 1149–1159. https://doi.org/10.2147/CLEP.S265107 Jarso, H., Workicho, A. & Alemseged, F. Survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from 2010 to 2012, Jimma, Ethiopia: a retrospective longitudinal study. BMC Pediatr 15, 76 (2015). https://doi.org/10.1186/s12887-015-0398-4 Kliegman, R. & Nelson, W. E. 2011. Nelson Textbook Of Pediatrics , Philadelphia, Pa, Elsevier/Saunders Philadelphia, Pa. Mena, M. B., Dedefo, M. G. & Billoro, B. B. 2018. Treatment Outcome Of Severe Acute Malnutrition And Its Determinants Among Pediatric Patients In West Ethiopia. Int J Pediatr , 2018, 8686501. Ministry Of Health, R. O. U. 2010. Integrated Management Of Acute Malnutrition Guidelines . Ministry Of Health, R. O. U. 2019. Integrated Management Of Acute Malnutrition Guidelines Munthali, T., Jacobs, C., Sitali, L., Dambe, R. & Michelo, C. 2015. Mortality And Morbidity Patterns In Under-Five Children With Severe Acute Malnutrition (Sam) In Zambia: A Five-Year Retrospective Review Of Hospital-Based Records (2009–2013). Arch Public Health , 73, 23. Oumer, A., Mesfin, F. and Demena, M. (2016) Survival status and predictors of mortality among children aged 0–59 months admitted with severe acute malnutrition in Dilchora Referral Hospital, Eastern Ethiopia. East African Journal of Health and Biomedical Sciences, 1(1), pp.13–22. Prendergast A. J. (2015). Malnutrition and vaccination in developing countries. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 370(1671), 20140141. https://doi.org/10.1098/rstb.2014.0141 Singh, P., Kumar, P., Rohatgi, S., Basu, S. & Aneja, S. 2015. Experience And Outcome Of Children With Severe Acute Malnutrition Using Locally Prepared Therapeutic Diet. Indian Journal Of Pediatrics , 83, 3–8. Sphere, A. 2018. The Sphere Handbook Humanitarian Charter And Minimum Standards In Humanitarian Response. Tadesse, Z., Teshome, D. F., Lakew, A. M., Debalkie, G., & Gonete, K. A. (2021). Time to nutritional recovery and its determinants among children aged 6 to 59 months with severe acute malnutrition admitted to stabilization centers of WagHimra Zone, Northeast Ethiopia. Ecology of food and nutrition, 60(6), 751–764. https://doi.org/10.1080/03670244.2021.1907746 Tegegne, Awoke & Belay, Denekew. (2021). Predictors for time to recovery from sever acute malnutrition among underfive children admitted to therapeutic feeding unit at Dubti referral hospital, Afar region, Ethiopia. BMC Pediatrics. 21.10.1186/s12887-021-03043-x. Unicef 2015. Management Of Severe Acute Malnutrition In Children. Unicef, Who & World, B. 2021 Levels And Trends In Child Malnutrition: Unicef/Who/The World Bank Group Joint Child Malnutrition Estimates. Who 2013. Guideline: Updates On The Management Of Severe Acute Malnutrition In Infants And Children. Geneva. Who 2018. World Health Statistics 2018: Monitoring Health For The Sdgs, Sustainable Development Goals. Wondim, A., Tigabu, B., & Kelkay, M. M. (2020). Time to Recovery from Severe Acute Malnutrition and Its Predictors among Admitted Children Aged 6–59 Months at the Therapeutic Feeding Center of Pawi General Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. International journal of pediatrics, 2020, 8406597. Tables Tables 1 to 7 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8898334","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":598827441,"identity":"b2b63cdb-7d9d-42b3-aaed-8b669d8cfe81","order_by":0,"name":"Belay Bekretsion 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06:54:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8898334/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8898334/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104169764,"identity":"65390bca-a3d4-4d09-b524-2820d4254b2e","added_by":"auto","created_at":"2026-03-08 14:40:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":87196,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment outcomes of SAM among children under 5 years of age admitted to the stabilization centre of Sheik Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2020 (N=535).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/5e82e0be33ddb703f34af45a.png"},{"id":104169670,"identity":"4fec8568-fefc-4290-81ca-99cac370b5d9","added_by":"auto","created_at":"2026-03-08 14:40:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23968,"visible":true,"origin":"","legend":"\u003cp\u003eThe overall KM survival graph for time to recovery (days) of the entire cohort of SAM children admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/c47efb65d64566d8dd83af19.png"},{"id":104169708,"identity":"175f712f-d34c-404c-90a4-89209ecef58a","added_by":"auto","created_at":"2026-03-08 14:40:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":28811,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of the presence of pneumonia.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/3d2504b7e2720a8dd2e09415.png"},{"id":104169757,"identity":"0cdf6791-b803-4a7e-9dad-a2e9bc704674","added_by":"auto","created_at":"2026-03-08 14:40:24","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":35841,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of immunization status.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/1d1f53ec9453808b6897672c.png"},{"id":104169761,"identity":"52252b92-399d-4e42-bcd4-e2207c1fa19d","added_by":"auto","created_at":"2026-03-08 14:40:24","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":29370,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of deworming.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/c1e479bdbe0128904de64510.png"},{"id":104169760,"identity":"d6c2cb2c-5602-4c91-878a-296b927c34e8","added_by":"auto","created_at":"2026-03-08 14:40:24","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":23759,"visible":true,"origin":"","legend":"\u003cp\u003eCox Snell residual graph for checking the overall fitness of the final model.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/69ab007f2f7e6fe0709222f3.png"},{"id":104169815,"identity":"92d53d3c-73ed-4dd2-a222-c6ad3bdf1715","added_by":"auto","created_at":"2026-03-08 14:40:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1041750,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/70b77357-dda4-4c92-9cb9-53df9859c214.pdf"},{"id":104169772,"identity":"21f7d835-dbe5-4c23-bcc4-cbff668a0f76","added_by":"auto","created_at":"2026-03-08 14:40:28","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39662,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-8898334/v1/843d697710a9323a84e598e6.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTime to Recovery From Severe Acute Malnutrition and Its Predictors Among Under-5 Children Admitted to Sheik Hassan Yebere Referral Hospital, Somali Region Eastern Ethiopia: A Retrospective Study\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eMalnutrition includes both undernutrition, which includes acute and chronic malnutrition as well as micronutrient deficiencies, and overnutrition, which manifests as overweight or obesity. Nonetheless, the scientific community and our society view malnutrition as under nutrition. In underdeveloped nations, undernutrition is linked to almost 50% of deaths due to underlying infectious diseases (Kliegman and Nelson, 2011; WHO, 2013).\u003c/p\u003e \u003cp\u003eMalnutrition affects many children worldwide and is associated, either directly or indirectly, with death or disability. Twenty million children suffer from severe acute malnutrition (SAM), whereas another 60\u0026nbsp;million children suffer from moderate acute malnutrition. Approximately 7.7%, or 52\u0026nbsp;million children under the age of five, experienced severe malnutrition-related wasting in 2016. Among them, 17\u0026nbsp;million were at risk of death. The World Bank, United Nations International Children's Emergency Fund, and World Health Organization jointly estimated the amount of improvement needed to meet the 2030 Sustainable Development Goals and the 2025 World Health Assembly targets for stunting, wasting, severe wasting, and overweight in children under five years of age (UNICEF, WHO and World Bank, 2021; Ministry of Health, 2010).\u003c/p\u003e \u003cp\u003eRegarding the method of treatment, the World Health Organization recommends community-based treatment for simple cases of SAM (WHO, 2013). However, the WHO 10-step model should be followed when managing children with complex SAM in inpatient facilities. The Sphere Association and WHO have also recommended SAM admission and discharge criteria, which state that the anthropometric indicator used to confirm admission should also be used to discharge patients from SAM treatment (WHO, 2013; Sphere, 2018).\u003c/p\u003e \u003cp\u003eThe rate of recovery after SAM varies, with studies reporting inconsistent results between 22.1% and 95.36%. It is well known that Ethiopia's recovery rate falls short of the widely recognized international minimum threshold of 75%. Mekele, Bahir Dar, and Gondar, for example, reported 22.1%, 58.4%, and 68.5%, respectively. Similarly, studies carried out in Ethiopia revealed that recovery times from SAM varied from 14\u0026ndash;26 days. (Gebremichael, D. Y. 2015, Asres, D. T., Prasad, R. P.C.J.\u0026amp;Ayele, T.A.2018). A shorter healing period indicates that the care and treatment procedure is working as needed. Medical comorbidities such as anaemia, malaria, dehydration, hypoglycaemia, HIV, TB, hypothermia, and incomplete childhood immunizations all impact recovery times despite the assumption that these variables lengthen the recovery period; some researchers have reported contradictory findings. In enumerating the potential reasons for an extended recovery period, the number of children who recover from SAM depends on recovery duration as much as on the effectiveness of the treatment. Children who are admitted for SAM treatment ought to heal as quickly as possible. The Sphere Handbook for Humanitarian Charter and Minimum Standards state that children must recover from SAM within 28 days of being admitted to the hospital (WHO, 2013; Sphere, 2018).\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e \u003cb\u003eStudy design and period.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study was conducted at Sheik Hassan Yebere Referral Hospital in Jigjiga, Somali region, eastern Ethiopia. The study period was from January 1, 2020, to December 31, 2023, 4 consecutive years, which represent the most recent period. The data were extracted from February 20 to March 10, 2024. Data were extracted from the hospital\u0026rsquo;s medical records of admitted children during this period.\u003c/p\u003e \u003cp\u003eA hospital-based retrospective follow-up study design was used.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation\u003c/h2\u003e \u003cp\u003eAll children aged 6\u0026ndash;59 months who were admitted to the TFC (therapeutic feeding center) at Sheik Hassan Yebere Referral Hospital for SAM therapy were included in the study. The study population included all eligible children with SAM admitted to the stabilization center (SC) from January 1, 2020, to December 31, 2023.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion and exclusion criteria\u003c/h3\u003e\n\u003cp\u003eAll records of 6\u0026ndash;59-month-old children with SAM admitted to Sheik Hassan Yebere Referral Hospital's stabilization center from January 1, 2020, to December 31, 2023, were included in this study. However, incomplete records that lacked sociodemographic information, comorbidities, routine prescriptions, patient treatment results (i.e., cure, death, not recovered, and defaulter), and referrals from other health facilities were discarded.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSample size.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe required sample size was computed via STATA software version 17 on the basis of the formula designed for survival analysis sample size calculations. Covariates such as the sex of the child, immunization status, and type of SAM at admission were assessed, and hazard ratios for the median time to recovery were used in the calculation. Among them, the covariate sex of the children produced the greatest sample size, which was chosen for the final estimation, yielding 535 participants. The computation considered a standard deviation of 0.5, 5% type I error, 80% power, and a 10% correction for incomplete records.\u003c/p\u003e\n\u003ch3\u003eDependent variable\u003c/h3\u003e\n\u003cp\u003eThe study's dependent variable was the time to recover from severe acute malnutrition. The time between the diagnosis of SAM and recovery/discharge was estimated in days.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIndependent variables.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThese include the sociodemographic type of malnutrition, baseline anthropometric measurements, immunization status, supplements, and therapeutic feeding, and comorbid medical conditions.\u003c/p\u003e\n\u003ch3\u003eMeasurement\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSurvival\u003c/b\u003e time is the time in days from the child was diagnosed with SAM to the occurrence of the outcome (recovered/censored).\u003c/p\u003e \u003cp\u003e \u003cb\u003eEvent (recovered).\u003c/b\u003e Is a recovery of children from SAM or when the children fulfil the\u003c/p\u003e \u003cp\u003eDischarge criteria were determined by the ward physician.\u003c/p\u003e \u003cp\u003e \u003cb\u003eThe time to recovery\u003c/b\u003e is defined as the length of time in days between child admission with SAM and discharge with recovery (MoH, 2019\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eCensored observations\u003c/b\u003e are those children who have not developed an event or those who have not recovered from SAM (defaulter, death, nonresponder, stabilized and transferred-out) (Bizuneh et al., 2022).\u003c/p\u003e \u003cp\u003e \u003cb\u003eKwashiorkor.\u003c/b\u003e A severe form of undernutrition or malnutrition in children results from a diet excessively high in carbohydrates and low protein. (MoH, 2019\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eMarasmus.\u003c/b\u003e This severe form of acute malnutrition is characterized by an emaciated physical appearance/severe wasting. This is a problem of carbohydrate deficiency. (MoH, 2019\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eMarasmus-kwashiorkor.\u003c/b\u003e It is a mixture of both kwashiorkor and marasmus. This is a problem for both carbohydrate- and protein-containing food. (MoH, 2019\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eComorbidity\u003c/b\u003e is defined as a medical problem present in addition to severe acute malnutrition (MoH, 2019\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eData collection tools, procedures, and quality control\u003c/h3\u003e\n\u003cp\u003eA structured data abstraction form adapted from the Sphere standard, the Ethiopian SAM management protocol, medical history sheets, and relevant published studies was used to collect data. The tool captured sociodemographic characteristics, type of malnutrition, baseline anthropometric measurements, immunization status, comorbidities, treatments, supplements, therapeutic feeding, recovery time, and treatment outcomes.\u003c/p\u003e \u003cp\u003eFour diploma nurses and two degree-holding nurses with prior experience were recruited as data collectors and supervisors. They received two days of training on data quality, ethical considerations, and supervision procedures. Data were extracted from patient charts and the SAM Registration Book via Open Data Kit (ODK) offline software on smartphones. The supervisor and primary investigator monitored the process daily to ensure completeness, accuracy, and consistency, and the data were automatically uploaded to Google Drive for quality assurance.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMethod of Data Processing and Analysis\u003c/h2\u003e \u003cp\u003eAfter completing data collection, the data were reviewed for completeness and immediately extracted from Google Drive as an Excel file. Before being exported to STATA Version 17, the data were cleaned in an Excel file to minimize errors. Then, the Excel page was exported to STATA version 17. The consistency of the exported data was examined. Summary statistics were performed via percentages for categorical data and medians for continuous variables.\u003c/p\u003e \u003cp\u003eTo estimate recovery time from SAM and determine whether the observed difference in recovery time between various groups of predictor variables was significant, Kaplan‒Meier and log rank tests were employed. Bivariate Cox regression analysis was then performed for every predictor variable along with the recovery time. The upper limit for entering variables into multivariate Cox regression was set at a P value of less than 0.25. The predictor variables were subsequently identified by employing an adjusted hazard ratio (AHR) with a 95% confidence interval. Multiple collinearity and model fitness tests were carried out via the variance inflation factor (VIF) and Cox-Snell residual goodness-of-fit tests. The variables that had a p value less than 0.05 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003ch2\u003eBaseline sociodemographic and anthropometric characteristics\u003c/h2\u003e\n\u003cp\u003eThis study analysed records from 535 children under 5 years of age with severe acute malnutrition (SAM), all of whom were admitted to stabilization centers at Sheik Hassan Yebere Referral Hospital. Among these children, 375 (70.1%) were male, and 286 (53.3) came from urban areas. The children\u0026apos;s ages ranged from 6 to 59 months, with a median age of 28 months (SD\u0026plusmn;12), and 236 children (44.1%) were between 24 and 35 months old. Most of the children, 519 (97%), were new admissions. Marasmus was the most common form of malnutrition, affecting 395 (73.8%) of the cohort, followed by kwashiorkor at 71 (13.3%) and marasmic-kwashiorkor at 69 (12.9%) (\u003cstrong\u003eTable\u0026nbsp;1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1: Baseline sociodemographic and anthropometric characteristics of children under five years of age with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2020 (n=535).\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 1 here.\u003c/p\u003e\n\u003ch2 id=\"_Toc178296758\"\u003eMajor\u0026nbsp;Comorbidities and Clinical Features\u003c/h2\u003e\n\u003cp\u003eAmong the cohort of children under 5 years of age studied, 519 (97%) had at least one comorbid condition at the time of admission. The most prevalent medical comorbidities among these children with severe acute malnutrition (SAM) were anaemia, affecting 521 (97.4%), pneumonia affecting 469 (87.7%), and diarrhoea affecting 366 (68.4%) children. In terms of clinical signs, children presented with at least one notable symptom upon admission. The most frequently observed clinical features were fever in 461 (81.2%) children, dehydration in 103 (19.3%) children and shock in 103 (19.3%) children. \u003cstrong\u003e(Table 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc178294916\"\u003eTable 2: Distributions of comorbidities and medical complications with respect to survival status among children under 5 years of age admitted with SAM to the stabilization center of Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2020 (N=535).\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 2 here.\u003c/p\u003e\n\u003ch2\u003eManagement\u0026nbsp;of\u0026nbsp;Severe\u0026nbsp;Acute\u0026nbsp;Malnutrition\u003c/h2\u003e\n\u003cp\u003eAll cases of severe acute malnutrition (SAM) in children under 5 years of age admitted to the stabilization centre at Sheik Hassan Yebere Referral Hospital between January 1, 2020, and December 31, 2023 (N=535), were treated following the guidelines set by the World Health Organization (WHO) and the Ethiopian Federal Ministry of Health (FMOH) for SAM management. In terms of nutritional therapy, 523 children (97.8%) received F-75, while 12 (2.8%) were started on diluted F-100 as their therapeutic milk formula.\u003c/p\u003e\n\u003cp\u003eIn terms of routine medication, intravenous antibiotics, specifically ceftriaxone, were prescribed to 469 (87.7%) children, followed by 49 (9.2%) with ampicillin and gentamycin, while oral antibiotics, such as amoxicillin, cherimoxazole, and metronidazole, were given to 27 (5%) children. Among anaemic children, 480 (89.7%) received folic acid supplements, and 470 (88%) were supplemented with vitamin A. A total of 344 (100%) children over the age of two who were eligible were dewormed with albendazole. Additionally, 366 (68.4%) children received ReSoMal, and 100 (18.7%) underwent IV fluid therapy (Table 3).\u003c/p\u003e\n\u003cp\u003eTable 3: Distributions of managements of severe acute malnutrition among children under 5 years of age to the stabilization centre of Sheik Hassen Yebere Referral Hospital from January 01, 2020,2 to December 31, 2023.\u003c/p\u003e\n\u003cp align=\"center\"\u003eInseret Table 3 here\u003c/p\u003e\n\u003ch2\u003eTime\u0026nbsp;to\u0026nbsp;Recovery\u0026nbsp;from\u0026nbsp;SAM\u0026nbsp;and\u0026nbsp;Treatment Outcomes\u003c/h2\u003e\n\u003cp\u003eDuring the study period, a total of 422 children with severe acute malnutrition (SAM) experienced a cumulative person-time of 7,645 days, resulting in a recovery rate of 0.0552 recoveries per person-time (95% CI: 0.0647--0.0752). This translates to approximately 7 recoveries every 100 person-days or 70 recoveries per 1,000 person-days. The median recovery time for this cohort was 12 days, with an interquartile range (IQR) from 10--15 days. Among the 422 children who successfully recovered, the average length of stay was 14 days, with a standard deviation (SD) of 6 days. In terms of treatment outcomes for children with severe acute malnutrition (SAM), 422 (78.88%) children (95% CI: 61.9% - 69.9%) achieved recovery. Moreover, 32 (6%) children (95% CI: 14.7% - 21.2%) were classified as defaulted, and 32 (5.98%) children (95% CI: 6.8% - 11.7%) were categorized as having defaulted on treatment.\u003c/p\u003e\n\u003cp\u003eFigure 1: Treatment outcomes of SAM among children under 5 years of age admitted to the stabilization centre of Sheik Hassen Yebere Referral Hospital from January 01, 2020, to December 31, 2023 (N=535).\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Fig. 1 here.\u003c/p\u003e\n\u003ch3\u003eLife Table\u003c/h3\u003e\n\u003cp\u003eThe cumulative likelihood of recovery was 0.4% by the end of the first week and reached 99% by the conclusion of the study\u003cstrong\u003e. (Table 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4: Actuarial life table analysis showing the survival of SAM children admitted to the stabilization centre of Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 (N=535)\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 4 here.\u003c/p\u003e\n\u003ch3\u003eComparison of survival status by Kaplan\u0026ndash;Meier curves and log rank tests\u003c/h3\u003e\n\u003cp\u003eThe overall Kaplan‒Meier curve revealed that 50% of the cohort of children with severe acute malnutrition (SAM) recovered within two weeks (12 days) of admission. \u003cstrong\u003e(Figure 2)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs illustrated in \u003cstrong\u003eFigure 4 and Table 5,\u003c/strong\u003e children with severe acute malnutrition (SAM) who were fully immunized experienced earlier recovery than those who were not, demonstrating a significant difference in survival time. (log rank test, \u0026chi;2\u0026thinsp;= 6.29, Prob\u0026gt;chi2=.0430). Conversely, children with severe acute malnutrition (SAM) who had not been dewormed were more likely to recover earlier than those who had, with a significant difference in survival time. (log rank test, \u0026chi;2\u0026thinsp;=6.56, Prob\u0026gt;chi2=.0104) \u003cstrong\u003e(Figure 5 and Table 5)\u0026nbsp;\u003c/strong\u003eThere was a notable difference in the median recovery time between children admitted with malaria (log-rank test, X2 = 4.26, Prob\u0026gt;chi2= .0389) and those admitted with pneumonia. (Log-rank\u0026nbsp;test, X2 =\u0026nbsp;13.13, Prob\u0026gt;chi2=\u0026nbsp;.0003)\u0026nbsp;(\u003cstrong\u003eTable 5\u003c/strong\u003e)\u003c/p\u003e\n\u003cp align=\"center\"\u003einsert Fig. 2 here\u003c/p\u003e\n\u003cp id=\"_Toc178329313\"\u003eFigure 2: The overall KM survival graph for time to recovery (days) of the entire cohort of SAM children admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023\u003c/p\u003e\n\u003cp id=\"_Toc178294919\"\u003eTable 5: Median time to recovery and log-rank test results among a cohort of SAM children admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 5 here.\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Figure 3 here.\u003c/p\u003e\n\u003cp\u003eFigure 3: Kaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of the presence of pneumonia.\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Fig. 4 here\u003c/p\u003e\n\u003cp\u003eFigure 4: Kaplan‒Meier survival curves comparing the recovery times of children under 5 years of age with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of immunization status.\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Fig. 5 here\u003c/p\u003e\n\u003cp\u003eFigure 5: Kaplan‒Meier survival curves comparing the recovery time of children under 5 years with SAM admitted to the stabilization center of Sheik Hassen Yebere Referral Hospital from Jan 01/2020 to Dec 31/2023 on the basis of deworming.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTest of Proportional Hazard Assumption\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Schoenfeld residuals test was used to assess the proportional hazards assumption. Both the global test, individual tests for each predictor and Cox-Snell goodness-of-fit (GOF) tests were performed, focusing specifically on the Schoenfeld residuals. The proportional hazards assumption was considered satisfied if the p value was greater than 0.05. Among the 18 predictors examined, only two did not satisfy the proportional hazards assumption (p \u0026lt; 0.05). However, the global test for all the predictors combined yielded a p value of 0.0776, indicating that the overall model meets the Cox proportional hazards assumption.\u003c/p\u003e\n\u003cp\u003eTable 6: Test of the proportional hazard assumption by Schoenfeld residuals for each predictor as well as the global test\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 6 here.\u003c/p\u003e\n\u003ch2\u003ePredictors\u0026nbsp;of time\u0026nbsp;to\u0026nbsp;recovery\u0026nbsp;from\u0026nbsp;severe acute malnutrition\u003c/h2\u003e\n\u003cp\u003eIn the bivariable analysis, 12 variables with a P\u0026nbsp;value less than 0.25 were identified and selected for further investigation\u0026nbsp;via\u0026nbsp;multivariable log-logistic regression. These variables included admission type, pneumonia, malaria, immunization status, deworming, severe dehydration, shock, feeding\u0026nbsp;route, hypoglycemia, intravenous (IV) fluids, tuberculosis (TB), and congenital heart disease (CHD). To assess potential multicollinearity among these variables, the variance inflation factor (VIF) was calculated. The VIF values ranged from 1 to 2.17, with a mean VIF of 1.05, indicating\u0026nbsp;that there were\u0026nbsp;no significant multicollinearity issues between the predictors.\u003c/p\u003e\n\u003cp\u003eFive of the variables (pneumonia, malaria, immunization status, hypoglycemia, and congenital heart disease) were found to be statistically significant predictors of time-to-recovery during multivariable log logistic regression analysis at\u0026nbsp;the\u0026nbsp;95% confidence level.\u003c/p\u003e\n\u003cp\u003eThe study\u0026nbsp;revealed\u0026nbsp;that recovery time was\u0026nbsp;shorter\u0026nbsp;by a factor of 0.70 for children admitted with no pneumonia\u0026nbsp;than for\u0026nbsp;those admitted with pneumonia (AHR =0.697, 95%\u0026nbsp;CI:\u0026nbsp;529\u0026ndash;918) when\u0026nbsp;other variables\u0026nbsp;were adjusted for\u0026nbsp;in the model. Similarly, the recovery time was also\u0026nbsp;shorter\u0026nbsp;by a factor of 0.79 for SAM children admitted with no malaria\u0026nbsp;than for\u0026nbsp;those admitted with malaria (AHR: 0.79, 95% CI: 0.65\u0026ndash;0.93).\u003c/p\u003e\n\u003cp\u003eIn addition, the recovery time was shortened by a factor of 0.704 for SAM children who\u0026nbsp;were\u0026nbsp;fully immunized compared\u0026nbsp;with\u0026nbsp;those who\u0026nbsp;were\u0026nbsp;not fully immunized (AHR: 0.704, 95% CI:\u0026nbsp;0.508--977),\u0026nbsp;and\u0026nbsp;the\u0026nbsp;recovery time was shortened by a factor of 0.697 for SAM children who\u0026nbsp;were\u0026nbsp;fully immunized compared\u0026nbsp;with\u0026nbsp;those who\u0026nbsp;were\u0026nbsp;partially fully immunized (AHR: 0.697, 95% CI:502--966).\u0026nbsp;Additionally, the recovery time was shortened by a factor of 0.80 among SAM children with no hypoglycemia compared\u0026nbsp;with\u0026nbsp;SAM children admitted with\u0026nbsp;hypoglycemia\u0026nbsp;(AHR: 0.80,\u0026nbsp;95% CI: (.69--93)\u0026nbsp;. Finally,\u0026nbsp;the recovery time of\u0026nbsp;the\u0026nbsp;cohort of SAM children with no CHD was shortened by a factor of 0.502 compared\u0026nbsp;with that of children fed NG tubes\u0026nbsp;(AHR: 0.502,\u0026nbsp;95% CI: 0.263--958) while adjusting\u0026nbsp;for\u0026nbsp;other variables in the model constant.\u003c/p\u003e\n\u003cp\u003eTable 7: Predictors of time to recovery from severe acute malnutrition among a cohort of SAM children admitted to the stabilization centres of Sheik Hassen Yebere referral hospital from Jan 01/2020 to Dec 31/2023 (N=535).\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Table 7 here.\u003c/p\u003e\n\u003cp\u003eCox\u0026ndash;Snell residuals are used for goodness-of-fit analysis; generally, the model fits the data reasonably well but has several limitations. Most of the Cox\u0026ndash;Snell residuals align closely with the expected diagonal, especially in the lower range, indicating a good fit overall. However, the deviation after a certain point (approximately 4) suggests that the fit is not perfect across the entire range.\u003c/p\u003e\n\u003cp align=\"center\"\u003eInsert Fig. 6 here\u003c/p\u003e\n\u003cp\u003eFigure 6: Figure 8: Cox Snell residual graph for checking the overall fitness of the final model.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe current study provides valuable insights into the recovery time from severe acute malnutrition and its predictors among children under five years of age admitted to the stabilization center at Sheik Hassen Yebere Referral Hospital. The median recovery time was 12 days, with an interquartile range of 10\u0026ndash;15 days, and the overall recovery rate was 78.88% (95% CI: 61.9%\u0026ndash;69.9%). This median recovery time aligns with the SPHERE standards, indicating that it falls within acceptable limits (i.e., less than four weeks) (SPHERE, A. 2018). Furthermore, factors such as the presence of pneumonia, malaria, lack of immunization, hypoglycemia, and congenital heart disease (CHD) at the time of admission significantly extended the nutritional recovery time from severe acute malnutrition.\u003c/p\u003e \u003cp\u003eThe median recovery time from severe acute malnutrition (SAM) reported in this study is consistent with findings from previous studies conducted in India (11.71\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59 days) (Singh et al., 2015), Zambia (12 days) (Munthali et al., 2015), Nekemte Referral Hospital (8\u0026ndash;14 days) (Mena et al., 2018), hospitals in the Wolaita zone (11 days) (Admasu et al., 2017), and the Waghimra zone of the Amhara region (11 days) (Tadesse, Z., Teshome, D. F., Lakew, A. M., Debalkie, G., \u0026amp; Gonete, K. A. 2021). However, the recovery time observed in this study was longer than the findings from Sekota Hospital, where the median recovery time was reported to be 10 days (Desta, 2015), and from selected public health facilities in the Sidama region, which indicated a recovery time of 8 days (Abebe, A., Simachew, Y. \u0026amp; Delbiso, T. D 2023). This variation in recovery times may be attributed to differences in sociodemographic factors, healthcare infrastructure, and the timeframes of the respective studies.\u003c/p\u003e \u003cp\u003eConversely, the nutritional recovery time reported in this study was shorter than that reported in several other hospitals. For example, Dilchora Referral Hospital recorded a median recovery time of 80 days (Oumer, A., Mesfin, F. and Demena, M. 2016), whereas the Afar Region's Dubti Zone Referral Hospital reported 18.4 days (Tegegne, Awoke \u0026amp; Belay, Denekew 2021). Yirgalem Hospital had a recovery time of 18.16 days (Daba, Alemneh \u0026amp; Dadi, Gezahegn 2017), and a study from Gambia indicated a median of 18 days (Alice Burrell, Marko Kerac, Helen Nabwera 2017). Additionally, Hawassa University Comprehensive Specialized Hospital reported a median recovery time of 17 days (Fikrie, A., Alemayehu, A. \u0026amp; Gebremedhin, S. 2019). Jimma University Comprehensive Specialized Hospital had a median duration of 16 days (Jarso, H., Workicho, A. \u0026amp; Alemseged, F.2015), and Asosa General Hospital had a median duration of 15 days (Kebede, F., Tolossa, T., Bekonjo, N. and Wakuma, B 2022). The disparities in these median recovery times can be attributed to various factors, including the patient load at each facility, the presence of complicated cases that may delay recovery, differences in sociodemographic characteristics, and variations in the quality of care provided to patients.\u003c/p\u003e \u003cp\u003eIn examining the factors influencing recovery time from severe acute malnutrition (SAM), it was found that children admitted without pneumonia experienced a quicker recovery than those admitted with pneumonia did. (AHR\u0026thinsp;=\u0026thinsp;0.697, 95% CI: 529-.918). This finding aligns with previous retrospective cohort studies conducted in various locations, including Zambia (Munthali et al., 2015) (AHR 1.3, 95% CI 1.0\u0026ndash;1.6), Nekemte Referral Hospital (AHR\u0026thinsp;=\u0026thinsp;7.82, 95% CI 2.74, 222.29) (Mena et al., 2018) and Yekatit 12 Hospital (AHR 0.764 95% CI 0.599\u0026ndash;0.975) (Adimasu et al., 2020), which can be understood through the interrelated dynamics between pneumonia and malnutrition. Children suffering from SAM may exhibit a diminished inflammatory response, which can mask the typical clinical signs of pneumonia, making the infection less detectable. As a result, the absence of obvious symptoms can delay diagnosis and appropriate treatment by healthcare providers. This atypical presentation of pneumonia may ultimately prolong recovery times. (Chowdhury et al., 2020)\u003c/p\u003e \u003cp\u003eThe study also indicated that children with severe acute malnutrition (SAM) who were admitted without hypoglycemia experienced a shorter recovery time than did those who presented with hypoglycemia (AHR: 0.80, 95% CI: (.69-.93)). This finding aligns with research conducted at Nekemte Referral Hospital. Hypoglycemia can significantly hinder the recovery process for children with SAM. When blood sugar levels decrease, the body\u0026rsquo;s ability to utilize energy effectively is compromised, which is crucial for healing and recovery (WHO 2018).\u003c/p\u003e \u003cp\u003eFurthermore, the study revealed that children with severe acute malnutrition (SAM) who were admitted without malaria experienced a shorter recovery time than did their counterparts who had malaria. This finding is consistent with research conducted at Pawi General Hospital (Wondim, A., Tigabu, B., \u0026amp; Kelkay, M. M. 2020). and Jimma University Medical Center (Hussen Kabthymer R, Gizaw G, Belachew T 2020). The prolonged recovery time associated with malaria can be attributed to several factors. Malaria disrupts gluconeogenesis and increases energy expenditure, leading to metabolic challenges. It can also cause malabsorption and weaken the immune system, making the body less responsive to standard treatment protocols. As a result, these complications hinder nutritional recovery, as highlighted by Prendergast A. J. (2015).\u003c/p\u003e \u003cp\u003eThe study findings also indicated that children with severe acute malnutrition (SAM) who were fully immunized experienced a shorter recovery time than those who were not fully immunized or who were only partially immunized. (AHR: 0.704, 95% CI:.508-.977). This observation is supported by research conducted at Felegehiwot Referral Hospital, which reported that fully vaccinated SAM children had a recovery rate that was 4.12 (AOR; 95% CI: 1.64\u0026ndash;10.35) times greater than that of their unvaccinated counterparts. The improved recovery time among fully immunized children can be attributed to the enhanced immune protection they receive, which helps mitigate the risk of infections and illnesses that can hinder recovery from SAM. (Adams, W. G., et al. 2017).\u003c/p\u003e \u003cp\u003eFinally, the study results indicated that the group of severely malnourished (SAM) children with congenital heart disease (CHD) experienced a shorter recovery time than did those without CHD. This finding is corroborated by research conducted in the Sidama region (Abebe, A., Simachew, Y. \u0026amp; Delbiso, T. D 2023). A possible explanation for this observation is that diagnosing CHD in malnourished children can be quite challenging because underlying cardiac conditions may not be immediately apparent due to the overlapping symptoms of malnutrition (WHO, 2013).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOverall, the average length of stay, median time to recovery, and cure rate among children with severe acute malnutrition met the SPHERE standards. However, concomitant diseases, particularly pneumonia, malaria, a lack of vaccination, hypoglycemia, and congenital heart disease, severely delay nutritional recovery. These findings emphasize the importance of early detection and management of comorbidities at admission, as well as establishing coordinated care within stabilization facilities, in improving recovery outcomes for children with SAM.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the Study\u003c/h2\u003e \u003cp\u003eThe retrospective design of the study and reliance on secondary data led to incomplete documentation for some variables, which limited the analysis of factors associated with nutritional recovery time. Consequently, key caregiver-related characteristics, including educational level and occupational and economic status, could not be assessed. Additionally, the lack of a comparison group from other healthcare facilities restricted broader comparisons. The classification of children into different SAM categories was based on diagnoses recorded in medical charts, which may have been subject to misclassification or diagnostic inaccuracies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrude hazard ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAHR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted hazard ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSevere acute malnutrition\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTFC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTherapeutic Feeding Center\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWFA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeight-for-Age\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWFH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeight-for-height\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWHZ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWeight-for-height Z score\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eapproval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore data collection, the research proposal was reviewed and approved by Haramaya University\u0026apos;s College of Health and Medical Sciences Institutional Health Research Ethics Review Committee/IHRERC/, which followed institutional ethics guidelines based on the Nuremberg Code, Helsinki Declaration, Belmont Report, and WHO affiliated center of international organization for medical sciences (CIONS), and official ethical clearance was obtained. Sheik Hassan Yebere Referral Hospital approved the study and provided access to medical records. The ethical committee authorized the waiver of individual informed consent because the study was a retrospective examination of medical information. To maintain secrecy, the data abstraction forms did not include personal identifiers, the electronic data were password protected, and the data collectors were trained on data privacy and confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used in this study is available from the corresponding author, Belay Bekretsion, upon reasonable request (email: [email protected]).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors state that they do not have any competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo special funding was obtained for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBelay Bekretsion developed the research topic, prepared the proposal, and participated in data collection, analysis, and manuscript writing. Belay Negash, Habtamu Mitiku, Birhanu Alle and Mulugeta Gemechu also played key roles by guiding data collection, analysis, writing, and revision. All the authors have read and approved the final version of the manuscript for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the data collectors and supervisors for their valuable contributions to the data collection process. We also extend our sincere appreciation to Sheik Hassan Yebere Referral Hospital for providing access to the necessary information for this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAbebe, A., Simachew, Y. \u0026amp; Delbiso, T.D. Effect of ready-to-use therapeutic foods on time to recovery among children with severe acute malnutrition in Ethiopia: a prospective cohort study. 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J. \u0026amp; Ayele, T. A. 2018. Recovery Time And Associated Factors Of Severe Acute Malnutrition Among Children In Bahir Dar City, Northwest Ethiopia: An Institution Based Retrospective Cohort Study. \u003cem\u003eBmc Nutrition\u003c/em\u003e, 4, 17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlice Burrell, Marko Kerac, Helen Nabwera, Monitoring and discharging children being treated for severe acute malnutrition using mid-upper arm circumference: secondary data analysis from rural Gambia, International Health, Volume 9, Issue 4, July 2017, Pages 226\u0026ndash;233, https://doi.org/10.1093/inthealth/ihx022\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBizuneh, F. K., Tolossa, T., Bekonjo, N. E., \u0026amp; Wakuma, B. (2022). Time to recovery from severe acute malnutrition and its predictors among children aged 6\u0026ndash;59 months at Asosa general hospital, Northwest Ethiopia. A retrospective follow up study. PloS one, 17(8), e0272930. https://doi.org/10.1371/journal.pone.0272930\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChowdhury, F., Shahid, A. S. M. S. B., Ghosh, P. K., Rahman, M., Hassan, M. Z., Akhtar, Z., Muneer, S. M., Shahrin, L., Ahmed, T., \u0026amp; Chisti, M. J. (2020). Viral etiology of pneumonia among severely malnourished underfive children in an urban hospital, Bangladesh. PloS one, 15(2), e0228329. https://doi.org/10.1371/journal.pone.0228329\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaba, Alemneh \u0026amp; Dadi, Gezahegn. (2017). Factors Associated with Treatment Outcomes of Underfive Children with Severe Acute Malnutrition Admitted to Therapeutic Feeding Unit of Yirgalem Hospital. Clinics in Mother and Child Health. 14. 10.4172/2090-7214.1000261.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesta, K. 2015. Survival Status And Predictors Of Mortality Among Children Aged 0\u0026ndash;59 Months With Severe Acute Malnutrition Admitted To Stabilization Center At Sekota Hospital Waghemra Zone. \u003cem\u003eJournal Of Nutritional Disorders \u0026amp; Therapy\u003c/em\u003e, 05.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDesyibelew, H. D., Fekadu, A. \u0026amp; Woldie, H. 2017. Recovery Rate And Associated Factors Of Children Age 6 To 59 Months Admitted With Severe Acute Malnutrition At Inpatient Unit Of Bahir Dar Felege Hiwot Referral Hospital Therapeutic Feeding Unite, Northwest Ethiopia. \u003cem\u003ePlos One\u003c/em\u003e, 12, E0171020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFikrie, A., Alemayehu, A. \u0026amp; Gebremedhin, S. Treatment outcomes and factors affecting time-to-recovery from severe acute malnutrition in 6\u0026ndash;59 months old children admitted to a stabilization center in Southern Ethiopia: A retrospective cohort study. Ital J Pediatr 45, 46 (2019). https://doi.org/10.1186/s13052-019-0642-x\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGebremichael, D. Y. 2015. Predictors Of Nutritional Recovery Time And Survival Status Among Children With Severe Acute Malnutrition Who Have Been Managed In Therapeutic Feeding Centers, Southern Ethiopia: Retrospective Cohort Study. \u003cem\u003eBmc Public Health\u003c/em\u003e, 15, 1267.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHussen Kabthymer, R., Gizaw, G., \u0026amp; Belachew, T. (2020). Time to Cure and Predictors of Recovery Among Children Aged 6\u0026ndash;59 Months with Severe Acute Malnutrition Admitted in Jimma University Medical Center, Southwest Ethiopia: A Retrospective Cohort Study. Clinical epidemiology, 12, 1149\u0026ndash;1159. https://doi.org/10.2147/CLEP.S265107\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJarso, H., Workicho, A. \u0026amp; Alemseged, F. Survival status and predictors of mortality in severely malnourished children admitted to Jimma University Specialized Hospital from 2010 to 2012, Jimma, Ethiopia: a retrospective longitudinal study. BMC Pediatr 15, 76 (2015). https://doi.org/10.1186/s12887-015-0398-4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKliegman, R. \u0026amp; Nelson, W. E. 2011. \u003cem\u003eNelson Textbook Of Pediatrics\u003c/em\u003e, Philadelphia, Pa, Elsevier/Saunders Philadelphia, Pa.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMena, M. B., Dedefo, M. G. \u0026amp; Billoro, B. B. 2018. Treatment Outcome Of Severe Acute Malnutrition And Its Determinants Among Pediatric Patients In West Ethiopia. \u003cem\u003eInt J Pediatr\u003c/em\u003e, 2018, 8686501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry Of Health, R. O. U. 2010. \u003cem\u003eIntegrated Management Of Acute Malnutrition Guidelines\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinistry Of Health, R. O. U. 2019. \u003cem\u003eIntegrated Management Of Acute Malnutrition Guidelines\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMunthali, T., Jacobs, C., Sitali, L., Dambe, R. \u0026amp; Michelo, C. 2015. Mortality And Morbidity Patterns In Under-Five Children With Severe Acute Malnutrition (Sam) In Zambia: A Five-Year Retrospective Review Of Hospital-Based Records (2009\u0026ndash;2013). \u003cem\u003eArch Public Health\u003c/em\u003e, 73, 23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOumer, A., Mesfin, F. and Demena, M. (2016) Survival status and predictors of mortality among children aged 0\u0026ndash;59 months admitted with severe acute malnutrition in Dilchora Referral Hospital, Eastern Ethiopia. East African Journal of Health and Biomedical Sciences, 1(1), pp.13\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrendergast A. J. (2015). Malnutrition and vaccination in developing countries. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 370(1671), 20140141. https://doi.org/10.1098/rstb.2014.0141\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSingh, P., Kumar, P., Rohatgi, S., Basu, S. \u0026amp; Aneja, S. 2015. Experience And Outcome Of Children With Severe Acute Malnutrition Using Locally Prepared Therapeutic Diet. \u003cem\u003eIndian Journal Of Pediatrics\u003c/em\u003e, 83, 3\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSphere, A. 2018. The Sphere Handbook Humanitarian Charter And Minimum Standards In Humanitarian Response.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTadesse, Z., Teshome, D. F., Lakew, A. M., Debalkie, G., \u0026amp; Gonete, K. A. (2021). Time to nutritional recovery and its determinants among children aged 6 to 59 months with severe acute malnutrition admitted to stabilization centers of WagHimra Zone, Northeast Ethiopia. Ecology of food and nutrition, 60(6), 751\u0026ndash;764. https://doi.org/10.1080/03670244.2021.1907746\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTegegne, Awoke \u0026amp; Belay, Denekew. (2021). Predictors for time to recovery from sever acute malnutrition among underfive children admitted to therapeutic feeding unit at Dubti referral hospital, Afar region, Ethiopia. BMC Pediatrics. 21.10.1186/s12887-021-03043-x.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnicef 2015. Management Of Severe Acute Malnutrition In Children.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUnicef, Who \u0026amp; World, B. 2021 Levels And Trends In Child Malnutrition: Unicef/Who/The World Bank Group Joint Child Malnutrition Estimates.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWho 2013. Guideline: Updates On The Management Of Severe Acute Malnutrition In Infants And Children. Geneva.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWho 2018. World Health Statistics 2018: Monitoring Health For The Sdgs, Sustainable Development Goals.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWondim, A., Tigabu, B., \u0026amp; Kelkay, M. M. (2020). Time to Recovery from Severe Acute Malnutrition and Its Predictors among Admitted Children Aged 6\u0026ndash;59 Months at the Therapeutic Feeding Center of Pawi General Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. International journal of pediatrics, 2020, 8406597.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 7 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Time to recovery, severe acute malnutrition, under five children, Sheik Hassen Yebere Referral Hospital, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-8898334/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8898334/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIn Ethiopia, malnutrition causes 28% of underfive deaths, making it a leading health issue. The World Health Organization and the Supporting People and Communities to Help Emergency Response Project recommend that 75% of children with SAM should recover within 28 days. Despite numerous problems determining the time to recovery from severe acute malnutrition (SAM), scarce information is available in the Somali region's pastoralist community.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study aimed to determine the time to recovery from severe acute malnutrition and its predictors among underfive children admitted to the stabilization center of Sheik Hassan Yebere Referral Hospital.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA four-year retrospective cohort study was conducted among 535 underfive children admitted to the SAM in the Therapeutic Feeding Unit of Sheik Hassan Yebere Referral Hospital due to severe acute malnutrition from January 1, 2020, to December 31, 2023. Data were extracted from patient records via a structured data abstraction checklist and collected electronically via the Open Data Kit (ODK) tool. The collected data were exported from Google Drive in Excel and then transferred to STATA version 17 for analysis. Kaplan‒Meier survival analysis was used to estimate the time to recovery from severe acute malnutrition. Cox proportional hazards regression was performed to identify predictors of recovery time. The proportional hazards assumption was assessed. Variables with an AHR at the 95% CI and a P value less than 0.05 in the multivariable Cox regression analysis were considered significant predictors of recovery time.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong the 535 records of children with SAM included in the study, 78.88% (95% CI: 69.9, 89.9) recovered at the conclusion of the follow-up period, with a median recovery time of 12 days. The recovery rate was 7 per 100 child days, with a total of 7,645 person-days. Pneumonia (AHR\u0026thinsp;=\u0026thinsp;0.80; 95% CI: 0.75\u0026ndash;0.85), malaria (AHR\u0026thinsp;=\u0026thinsp;0.79; 95% CI: 0.65\u0026ndash;0.90), nonimmunization (AHR\u0026thinsp;=\u0026thinsp;0.71; 95% CI: 0.59\u0026ndash;0.84), partial immunization (AHR\u0026thinsp;=\u0026thinsp;0.82; 95% CI: 0.74\u0026ndash;0.91), hypoglycemia (AHR\u0026thinsp;=\u0026thinsp;0.80; 95% CI: 0.69\u0026ndash;0.93), and congenital heart disease (AHR\u0026thinsp;=\u0026thinsp;0.80; 95% CI: 0.69\u0026ndash;0.93) were independent predictors of delayed recovery time.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe median time to recovery and cure rate for children with severe acute malnutrition were within the acceptable ranges recommended by the WHO and Sphere standards, and recovery was significantly influenced by the presence of specific comorbid conditions. Pneumonia, malaria, incomplete or lack of immunization, hypoglycaemia, and congenital heart disease were identified as independent predictors of delayed nutritional recovery. Compared with those without comorbidities, children admitted with these conditions experienced prolonged recovery periods. Therefore, strengthening the early identification and management of these conditions at admission, alongside improving routine immunization coverage and comprehensive clinical care within therapeutic feeding programs, is essential to enhance recovery outcomes and reduce malnutrition-related morbidity.\u003c/p\u003e","manuscriptTitle":"Time to Recovery From Severe Acute Malnutrition and Its Predictors Among Under-5 Children Admitted to Sheik Hassan Yebere Referral Hospital, Somali Region Eastern Ethiopia: A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-08 14:38:50","doi":"10.21203/rs.3.rs-8898334/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-21T06:09:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T08:47:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8583200048432266560963768276591412752","date":"2026-03-30T06:29:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"184273446116685651549569317121274571995","date":"2026-03-28T10:30:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T14:20:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142961648464342255238845485772460545892","date":"2026-03-05T06:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-26T04:08:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-18T03:50:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T22:27:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-17T22:25:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2026-02-17T06:49:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6ab88b84-17e4-4a74-84c6-d67a2a41d851","owner":[],"postedDate":"March 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T06:24:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-08 14:38:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8898334","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8898334","identity":"rs-8898334","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}