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.
Diagnostic methods and clinical definition of co-morbidities
Diagnosis of HIV was made using Enzyme Linked Immunosorbent Assay [ELISA] and Westerblot. In children 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.
Ethical approval
Ethical approval was obtained from the Health Research and Ethics Committee of the University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria.