Ubesie et al.

Nutrition Journal 2012, 11:43

http://www.nutritionj.com/content/11/1/43

RESEARCH

Open Access

Under-five protein energy malnutrition admitted

at the University of Nigeria Teaching Hospital,
Enugu: a 10 year retrospective review
Agozie C Ubesie1,2*, Ngozi S Ibeziako1,2, Chika I Ndiokwelu3, Chinyeaka M Uzoka3 and Chinelo A Nwafor3

Abstract
Objective: To determine the prevalence, risk factors, co-morbidities and case fatality rates of Protein Energy
Malnutrition (PEM) admissions at the paediatric ward of the University of Nigeria Teaching Hospital Enugu,
South-east Nigeria over a 10 year period.
Design: A retrospective study using case Notes, admission and mortality registers retrieved from the Hospitals
Medical Records Department.
Subjects: All children aged 0 to 59 months admitted into the hospital on account of PEM between 1996 and 2005.
Results: A total of 212 children with PEM were admitted during the period under review comprising of 127 (59.9%)
males and 85(40.1%) females. The most common age groups with PEM were 6 to 12 months (55.7%) and 13 to
24 months (36.8%). Marasmus (34.9%) was the most common form of PEM noted in this review. Diarrhea and
malaria were the most common associated co-morbidities. Majority (64.9%) of the patients were from the lower
socio-economic class. The overall case fatality rate was 40.1% which was slightly higher among males (50.9%).
Mortality in those with marasmic-kwashiokor and in the unclassified group was 53.3% and 54.5% respectively.
Conclusion: Most of the admissions and case fatality were noted in those aged 6 to 24 months which coincides
with the weaning period. Marasmic-kwashiokor is associated with higher case fatality rate than other forms of PEM.
We suggest strengthening of the infant feeding practices by promoting exclusive breastfeeding for the first six
months of life, followed by appropriate weaning with continued breast feeding. Under-five children should be
screened for PEM at the community level for early diagnosis and prompt management as a way of reducing the
high mortality associated with admitted severe cases.
Keywords: PEM, Under-five children, Case fatality, Co-morbidities, Admission, Enugu

Background
Globally, PEM continues to be a major health burden in
developing countries and the most important risk factor
for illnesses and death especially among young children
[1]. The World Health Organization estimates that about
60% of all deaths, occurring among children aged less
than five years in developing countries, could be attributed to malnutrition [2]. The improvement of nutrition
therefore, is the main prerequisite for the reduction of
* Correspondence: [email protected]
1
Department of Paediatrics, Faculty of Medical Sciences, College of Medicine,
University of Nigeria, Enugu, Nigeria
2
Department of Paediatrics, University of Nigeria Teaching Hospital, Ituku/
Ozalla, Enugu, Nigeria
Full list of author information is available at the end of the article

high infant and under five mortality rates, the assurance

of physical growth, social and mental development
of children as well as academic achievement [3].
Sub-saharan Africa bears the brunt of PEM in the world.
On the average, the PEM associated mortality in subSaharan Africa is between 25 and 35% [4,5]. In Nigeria,
22 to 40% of under-five mortality has been attributed to
PEM [6]. PEM is also associated with a number of comorbidities such as lower respiratory tract infections
including tuberculosis, diarrhea diseases, malaria and
anaemia [7,8]. These co-morbidities may prolong the
duration of hospital stay and death among affected
children.

2012 Ubesie et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Ubesie et al. Nutrition Journal 2012, 11:43

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There is a knowledge gap on the incidence and outcome of PEM seen in the Nigerian tertiary health facilities. In this study, the type of PEM among admitted
under-five children, the associated morbidities, and duration of hospitalization and outcome at the University
of Nigeria Teaching Hospital Enugu over a 10 year period
is reviewed.

Methods
Setting

This study was conducted at the University of Nigeria

Teaching Hospital, Enugu. Enugu is the capital of Enugu
State, and is located in south-east Nigeria. It has an
estimated population of about 3.3 million inhabitants
according to the 2006 national census figures [9]. The
main social and economic activities include small and
medium scale trading, artisan works while a significant
number of people are also employed in the various government institutions. The inhabitants are mainly Igbos
and cut across all social-economic class. The main healthrelated problems seen among children in Enugu are
diarrhea diseases, malaria and respiratory tract infections. The old site of the Teaching Hospital (where the
hospital was cited during the period under review) had
700 bed capacity and provided specialty care in paediatrics, internal medicine, surgery and obstetrics & gynaecology as well as subspecialty care in over 50 other areas.
The paediatric wards have 80 bed capacities. On the average 640 children (aged 018 years) were admitted into
the paediatric wards annually and malnutrition accounted
for nearly 3% of those admissions.
Study design

This was a 10 year (19962005) retrospective quantitative study. The source documents for retrieving information were the admission and mortality registers of the
hospital during the period under review. Available case
notes/folders were also retrieved. A proforma was used to
obtain relevant information. These information included
date of admission and discharge, bio-data, clinical features,
history of breast feeding, socio-economic status of the
Caregiver, classification of malnutrition using Modified
Wellcome Classifications, co-morbidities noted and, eventual outcome. Outcome was discharged from hospital,
died while still in the hospital or discharged against medical advice. The advantage of using retrospective quantitative study was that reasonable sample size could be
achieved in a relatively short time.

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included in this review. Their case files and/or documentations on hospital registers were retrieved from the
Medical Records Unit of the hospital. Children with
diagnosis of PEM but had in addition, other chronic
conditions such as congenital heart diseases and cerebral
palsy were excluded.
The outcome variables were recovery and discharged;
death and discharge against medical advice. Recovery
was defined as children, whose appetite has returned,
gaining weight with resolution of clinical features. Death
was defined based on hospital records and exclude those
that may have died at home. Discharged against medical
advice were those that did not meet the discharge criteria but whose Caregivers insisted on going home.

Materials
The proforma for the study contained information on the
age of the participants in months, sex, year of admission,
diagnosis, co-morbidities, mode of breast feeding and duration, socio-economic status and outcome (recovered and
discharged, discharged against medical advice or died).
Socio-economic status of each child was determined using
Oyedeji [10] classification that considers the highest educational attainment and occupation of the parents. The
scoring is from I to V; social classes I and II were regarded
as upper class, III as middle while IV and V constituted
lower social class.
Procedures

Relevant information was extracted from each retrieved

case file and/or hospital registers and transferred into
the proforma. Diagnosis of PEM was based on the Modified Wellcome Classification because it was the method
used for clinical diagnosis by the clinicians. This classified PEM into kwashiorkor, underweight kwashiorkor,
underweight, marasmus, marasmic kwashiorkor and there
was also provision for unclassified PEM. Marasmus and
the various forms of kwashiorkor are part of the recently
defined Severe Acute Malnutrition (SAM) by the World
Health Organization (WHO). The WHO defined SAM by
a very low weight for height (below -3z scores of the
median WHO growth standards), visible severe wasting
or the presence of nutritional oedema [11,12]. Modified
Wellcome classification uses weight for age and the presence or absence of oedema to classify PEM. The weights
were measured using infant weighing scales (Waymaster)
and stadiometers (Health Scale) depending on the age of
the child. A total of 212 proforma were completed covering the entire period of the study.

Participants

A total of 7703 children were admitted during the period

under review. All children aged six to 59 months admitted into the paediatric wards of UNTH Enugu between
1996 and 2005 with diagnosis of any form of PEM were

Diagnostic methods and clinical definition of comorbidities

Diagnosis of HIV was made using Enzyme Linked Immunosorbent Assay [ELISA] and Westerblot. In children

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Table 1 PEM admissions according to the age groups (months)

PEM type

0-12 m (%)

13-24 m (%)

25-36 m (%)

37-48 m (%)

Kwashiokor

16 (13.6)

19 (24.4)

3 (33.3)

1 (33.3)

Underweight

11 (9.3)

6 (7.7)

0 (0)

0 (0)

0 (0)

6 (5.1)

8 (10.3)

0 (0)

1 (33.3)

0 (0)

Marasmus

48 (40.7)

24 (30.8)

2 (22.2)

0 (0)

0 (0)

Unclassified

37 (31.4)

21 (26.9)

4 (44.4)

1 (33.3)

3 (75)

118 (100)

78 (100)

9 (100)

3(100)

4 (100)

Marasmic-kwash

Total

49-60 m (%)
1 (25)

= 19.38, df =16, P = 0. 249.

aged less than 18 months, positive antibody test was

combined with clinical features to make presumptive
diagnosis of HIV infection. Diagnosis of malaria was
confirmed using blood film and bronchopneumonia
using chest X-ray. Diarrhea was defined as passage of
watery or loose stools or an increase in frequency above
normal for a child. Severe anaemia was defined using
a packed cell volume of less than 15%. Sepsis was
defined as clinical features of systemic inflammatory
response (fever, tachycardia, tachypnea, leukocytosis
or leukopenia) associated with infection. Diagnosis of
tuberculosis was made in the presence of chronic cough
that have lasted for more three weeks supported by varied
combination of the following: positive family history of
tuberculosis, positive mantoux, suggestive chest X-ray
and elevated erythrocyte sedimentation rate. Diagnosis of
scabies was clinical based on the typical itching papular
rash located at the intertrigous areas. Chronic suppurative
otitis media and rickets were suspected clinically and
confirmed by culture of ear swab and X-ray of the
limbs respectively.
Data analysis

The data were analyzed using SPSS version 19. Chi-square

was used to test significant association of categorical variables: sex, age group, mortality rate and number of complications while One-way Analyis of Variables (ANOVA)
was used to test for significant association of the continuous variable (mean hospitalization duration and mean
number of complications). A p-value of less than 0.05
was regarded as significant and 95% confidence interval
reported where indicated.

the total paediatric admissions. One hundred and twenty

seven (59.9%) were males while 85 (40.1) were females
giving a male: female ratio of 1: 0.7. The age group studied was 6 to 59 months (under-5). The mean age of the
participants was 15.4 9.3 months.
PEM and demography

PEM was most common among the age groups 6 to 12

and 13 to 24 months, and these accounted for 55.7%
and 36.8% of the study population respectively. There
was however, no statistically significant difference between the age groups and various forms of PEM as
shown in Table 1( = 19.38, df =16, p = 0. 249). The
most common form of PEM noted in this review was
marasmus (34.9%). Except for marasmic-kwashiokor,
more males than females had more of all the various
types although this was not statistically significant
( = 8.382, df =4, p = 0. 079) as shown in Table 2.
Admissions for PEM were recorded more in 1996,
1999 and 2004 (15.1, 13.7 and 12.3% respectively), but
there were no consistent pattern in the yearly admissions
of children with PEM during the period under review
(Figure 1).
Confounding variables for PEM

Record for associated co-morbidities was available in

only 66 subjects. Diarrhea and malaria were the most
common associated conditions in 72.7% and 43.9% of
the children respectively. Other notable associated
conditions were sepsis (37.9%), severe anaemia (24.2%),
bronchopneumonia (16.7%) and tuberculosis (12.1%) as
shown in Table 3. Information on the educational level

Ethical approval

Table 2 Sex Distribution of the Clients

Ethical approval was obtained from the Health Research

and Ethics Committee of the University of Nigeria
Teaching Hospital, Enugu, Enugu State, Nigeria.

PEM type

Results
Subjects

A total of 7703 children were admitted into the paediatric wards and 212 of them were cases of PEM during
the period under review. This represented about 2.8% of

Male (%)

Female (%)

Kwashiokor

30 (23.6)

10 (11.8)

Underweight

12 (9.4)

5 (5.9)

Marasmic-kwash
Marasmus
Unclassified
Total
= 8.382, df =4, P = 0. 07.

6 (4.7)

9 (10.6)

44 (34.6)

30 (35.3)

35 (27.6)

31 (36.5)

127 (100)

85 (100)

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Figure 1 Number of children admitted with PEM by year. This figures describes the number of children admitted with PEM per year for the
years reviewed.

and occupation of the parents was available in only 33 of

the reviewed cases. Among them, 69.4% belonged to the
lower social class, 19.4% to middle class while 5.6% was of
the upper class. The predominant infant feeding in the
first six months was breast milk and water for 0 to
3 months (48.6%), breast milk and water for 4 to 6 months
(24. 3%), exclusive breast feeding for up to 3 months
(18.9%) and use of breast milk substitutes (8.1%) as shown
Table 3 The associated co-morbidities seen among
patients
Co-morbidity

Frequency
(%)

Diarrhea

48 (72.2)

Malaria

29 (43.9)

Sepsis

25 (37.9)

Severe anaemia

16 (24.2)

Bronchopneumonia.

11 (16.7)

in Table 4. These feeding methods were followed by weaning with pap gruel that was variably fortified for the
children.
Prognostic indicators

The duration of hospitalization was available in only 84

subjects and ranged from 0 to 62 days. The mean duration of hospitalization was 16 15 days. Kwashiokor
patients had the highest mean hospitalization days of
19.15 days while marasmic and underweight patients
had the least days of 14.52 and 14.55 days respectively.
There was no statistically significant difference in the
mean hospitalization days for the various types of PEM
(F = 0.317, df =4, P = 0. 866). A total of 85 (40.1%) children died while on admission, 124 (58.5%) recovered
Table 4 Prevalence of PEM by breastfeeding pattern
Breastfeeding pattern

Prevalence
(%)

95%
Confidence
Intervals

HIV

9 (13.6)

Tuberculosis

8 (12.1)

Exclusive breast feeding for 03 months

18.9

11.2 - 26.6

Scabies

2 (3.0)

Predominant breastfeeding 03 months

48.6

38.8 58.4

Chronic suppurative otitis media

1 (1.5)

Predominant breastfeeding 46 months

24.3

15.9 32.7

1 (1.5)

Breast milk substitutes

8.1

2.7 13.5

1 (1.5)

The table shows the prevalence of the various pattern of feeding for the
children during their early infancy. The 95% confidence interval is also
reported.

Rickets
Keratomalacia
The table shows the associated co-morbidities noted in the patients.

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and were discharged home while 3 (1.4%) were discharged against medical advice. Mortality was higher
among the males (50.9%) than females (34.1%) although
this was not statistically significant ( = 0.723, df =2,
P = 0. 697). Most of the deaths were recorded in the age
groups 012 (55.3%) and 1324 (36.5%) months although this difference was not statistically significant
( = 10.98, df =8, p = 0. 203). The marasmic-kwashiokor
and unclassified groups had higher mortality rates
(53.3% and 54.5% respectively) than the marasmus
(37.8%) or kwashiorkor groups (30%). There was a statistically significant difference in the mortality rates of the
various types of PEM as shown in Table 5 ( = 17.26,
df =4, p = 0. 002) The number of complications ranged
from none to four. Kwashiokor has the highest mean
number of complications (2.06) while unclassified had
the least number of 1.26. There was a statistically significant difference in the number of complications and the
various PEM (F = 8.92, df =4, P <0.05)

High PEM associated mortality

The overall mortality in our study was 40.1% which although lower than the WHO estimated 60% [2] is still
very high. Studies conducted in various parts of Africa
have documented unacceptable high mortality rates
among children admitted for PEM. In Oshogbo, South
West Nigeria, Ibekwe and Ashworth [6] documented an
average mortality rate of 22% over a five year period
among 803 children admitted for PEM in a Nutritional
Rehabilitation Center. Similarly, in a hospital based
study in north-eastern Zambia, involving children below
the age of five years, Gernaat et al. [4] documented an
overall mortality rate of 25.8% among 288 children admitted for various types of severe/complicated malnutrition . Higher mortality rate for marasmic kwashiorkor
than marasmus or kwashiorkor was noted in this review.
Gernaat et al. [4] noted similar finding in their review
among Zambian children admitted and managed for
PEM. This reason for this is unclear. However, Ibekwe
and Ashworth [6] did note that PEM associated mortality among oedematous patients was significantly higher
compared to those with marasmus. It can be argued
therefore, that presence of oedema in a malnourished
child connotes poor prognosis. The mean duration of
hospitalization was 16 days which is similar to 13.1 and
14.3 days reported by Cartmell et al. [13] but differs
from the 35 days reported by Ibekwe and Ashworth [6].
Both this review and the study by Cartmell et al. were
hospital based while that of Ibekwe and Ashworth was
conducted in a Nutrition Rehabilitation Center. The
pressure on bed spaces in a hospital setting could have
contributed to earlier discharges in hospital settings.

Discussion
Presenting features

There was no significant difference between the two

genders from our review. This agrees with an earlier review in Maputo by Cartmell et al. [13]. The age group 6
to 24 months accounted for 92.5% of the total number
of children admitted for PEM. In previous Nigerian and
Zambian studies, an approximate 64% of admitted cases
of PEM were less than two years [4,14] while Cartmell
et al. [13] documented a mean age of 21.7 months in the
Maputo study. The reasons for the high number of cases
of PEM among the age group 6 to 24 months could be
due to a number of factors including low rate of exclusive breast feeding as documented in our review as well
as poor weaning and feeding practices. Marasmus was
the most common type of PEM noted in our review
(34.9%) beside the unclassified cases. Gernaat et al. [4]
also found more of marasmic patients among males aged
less than a year in their review. Kwashiorkor and marasmus were the most common types among admitted children in Maputo in 1983 but changed to Kwashiokor and
marasmic-kwashiokor in 2001 according to the review
by Cartmell et al. [13]. This may imply that there is no
consistent geographical pattern that predicts the type of
PEM a child will manifest but rather depends on interplay of factors.

Associated risk factors for PEM

Our review noted that PEM was more common among

children from the lower social class (69.4%) and those
predominantly breast fed for three months or less
(48.6%) compared to exclusively breast fed children
(18.9%). The reason for this may not be unconnected to
the fact that poor families have low purchasing power
for adequate nutritious foods for their families. Illiteracy
on the other hand, may influence feeding practices. The
low rate of exclusive breast feeding noted in this review
despite the Baby Friendly Initiatives is also very worrisome. Poverty and illiteracy as risk factors for PEM have
been documented in the literature. . In a case control

Table 5 Prognostic indicators of protein-energy malnutrition

Prognostic indicator

Kwash (%)

UWM (%)

MK (%)

Marasmus (%)

Unclassified (%)

P-value

Mean no of complications

2.06

2.00

1.83

1.67

1.26

P < 0.05

Mean hospitalization days

19.15

14.55

16.2

14.52

16.33

0.866

Mortality rate

12 (30)

1 (5.9)

8 (53. 3)

27 (36.5)

36 (54.5)

0.002

Kwash = Kwashiokor; UWM = Underweight malnutrition, MK = Marasmic kwashiokor. The table shows some prognostic indicators: mean number of complications,
mean hospitalization days and mortality rates of the various types of PEM.

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study conducted in Dhaka, Bangladesh which involved children aged six to 24 months, Nahar et al. [15]
compared 507 children with weight-for-age z-score
(WAZ) < 3 matched for age, sex and place of residence with 500 children whose weight-for-age z-score
(WAZ) were > 2.5 . They documented that severelyunderweight children were more likely to have: undernourished poorly educated teenage mothers, history
of shorter duration of predominant breastfeeding, and
fathers who were poorly educated and unskilled daylabourers [15].
Diarrhea, malaria, sepsis and severe anaemia were the
most prevalent associated co-morbidities from our review in that order. In Maputo, the most prevalent comorbidities associated with PEM by Cartmell et al. were
anaemia, bronchopneumonia, malaria and diarrhea. The
prevalence of human immune deficiency virus (HIV)
from our review was 13.6% and this compares to a
prevalence of 12% in the Maputo study. This finding
underscored the high rate of HIV infection among children with severe forms of PEM and the need to routinely screen such children for HIV when they present at
a health facility.

Conclusions
Younger children aged less than two years accounted for
most of the admissions in this review. Marasmickwashiokor was associated with higher case fatality rate
than other types of PEM. There is need therefore to
strengthen the infant feeding practices by promoting exclusive breastfeeding for the first 6 months of life, followed by appropriate weaning with continued breast
feeding till second year of life. PEM was associated with
high rate of mortality in this hospital setting and preventive strategies need to be emphasized instead.
Limitation and strength

This is a retrospective study and was not designed to

optimize the risk factors and outcome of PEM but relied
on data from previous documentations. At best, it may
be a fair representation of some of the factors associated
with PEM in a typical Nigerian teaching hospital. It is
however the first paper to review PEM managed at a
Nigeria tertiary health facility over a 10 year period.
Competing interest
The authors declare that they have no competing interests.
Authors contributions
ACU, CMU and CAN designed the study and collected the data including
analysis. NSI, ACU and CCN did the literature review and drafted the initial
manuscript. All the authors read and approved the final version of the
manuscript.
Authors information
ACU is a Lecturer in the Department of Paediatrics, College of Medicine,
University of Nigeria and also an Honorary Consultant in the Department of

Page 6 of 7

Paediatrics, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu. NSI is

a Senior Lecturer in the Department of Paediatrics, College of Medicine,
University of Nigeria and also an Honorary Consultant in the Department of
Paediatrics, University of Nigeria Teaching Hospital Ituku/Ozalla, Enugu. CCU
is the Head of the Department of Nutrition and Dietetics, University of
Nigeria Teaching Hospital Ituku/Ozalla, Enugu.
Acknowledgement
We are grateful to Messers OO Ojelabi and Onoh of the Medical Records
Unit of UNTH Enugu for assisting us with the necessary resource documents
for data extractions. We are also indebted to the biostatistician, Dr. Okey Nna
of Safety Molecular Pathology Laboratory, University of Nigeria, Enugu
Campus for assisting us with the statistical analysis.
Author details
1
Department of Paediatrics, Faculty of Medical Sciences, College of Medicine,
University of Nigeria, Enugu, Nigeria. 2Department of Paediatrics, University of
Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria. 3Department of
Nutrition and Dietetics, University of Nigeria Teaching Hospital, Ituku/Ozalla,
Enugu, Nigeria.
Received: 2 August 2011 Accepted: 5 June 2012
Published: 14 June 2012
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