Internship Report on

Moderate and Sever Malnourished Under 5 Children

Management Based on National Nutrition Treatment

Guideline at WoreIlu Health Center, Amhara Region South

Wollo Administrative zone, WoreIlu Woreda, WoreIlu Town

Course Title: Internship (INP 2314)

C

Name of the Student: Menbere Agonafr (S/r)

Year III, Semester VII

ID No. : BDU 053312 BU

December 2015
WoreIlu
 Moderate and Sever Malnourished Under 5 Children

Management Based on National Nutrition Treatment

Guideline at WoreIlu Health Center, Amhara Region South

Wollo Administrative zone, WoreIlu Woreda, WoreIlu

Town

Submitted to: Instructor Girma Nega

Submission Date: 24/03/2007 E.C

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List of Abbreviations

BSC ................................................................................................. Bachelor Degree in Science

CASHI ................................................................Clean and Safe Health Facility Initiatives

CSA ................................................................................................... Central Statistical Agency

Dx ...................................................................................................................................... Diagnosis

eHMIS ...................................... Electronics Health Management Information System

GMP …… .................................................................................... Growth Monitoring Program

HS ………………........................................................................................... Head Circumferance

ICCM……. ....................................................................... Integrated Child Case Managment

IMCI……. ................................ Integrated Maternal, Neonatal, and Childhood Illness

MAM…... .................................................................................. Moderatly Acute Malnorished

MOH ….. ..............................................................................................................Minister f Health

MUAC ….. ............................................................................. Mid Upper Arm Cercumferance

MRN ..................................................................................................... Medical Record Number

OPD …… ...............................................................................................Out Patient Department

OTP …….. ............................................................................. Outreach Therapeutic Program

Rx ……………................................................................................................................... Treatment

SAM ………….. .................................................................................. Sever Acute Malnorished

SC ……………. ............................................................................................... Stabilization Center

WHC ……….. .......................................................................................... WoreIlu Health Center

WHO ….. ........................................................................................ World Health Organization

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 Acknowledgment

First and foremost my heartily felt thanks go to the Almighty God. I would also
like to acknowledge Bahirdar University Institute of Technology Faculty of
Chemical and Food Engineering Department of Applied Human Nutrition for the
chance it delivered me in developing this Internship Report. I would like also to
thank WoreIlu Health Center Head for his dedicated support, Ato Samuel
Alemayehu, and Under 5 OPD Staffs for their cooperation and assistance by
giving me relevant information and technical Support.

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Table of Contents
List of Abbrvation ........................................................................................................................ III

Acknowledgment ......................................................................................................................... IV

List Figure ....................................................................................................................................... VI

List of table ....................................................................................................................................VII

Executive Summary ................................................................................................................. VIII

1.Introduction ................................................................................................................................. 1

2.Objective ........................................................................................................................................ 3

2.1. General Objective .......................................................................................................... 3

2.2. Specific Objectives ........................................................................................................ 3
3.Methodology ................................................................................................................................ 4

3.1. Target Population ......................................................................................................... 4

3.2. Study population: ......................................................................................................... 4
3.3. Data Collection processing ........................................................................................ 4
3.4. Plan for data processing and analyzing .............................................................. 4
4. Main Text ...................................................................................................................................... 5

A. Situational analysis …………………………………………………………………………...5

B. Introduction ………………………………………………………………………………….….6
C. Body …………………………………………………………………………………..…………..…8
a. Major Task ……………………………………………………………………………..….. 8
b. Finding and Results ……………………………………………………..………..……..9
c. Challenges faces……………………………………………………………..……..………9
d. measures taken …………………………………………………………………..…….. 10
D.Discussion, Conclussion, and Recommendation…….. ..................................... 10

a.Discussion ……………………………………………………………………………………10
b.Conclussion ………………………………………………………………...........................11
c. Recommendation………………………………………………………….......................11
5. Reference ................................................................................................................................... 12

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Fig 1: Ethiopian Administrative Map by Region

Fig 2: WoreIlu Woreda Administrative Map

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 Total Population by
S.No. Regions and Charter City Capital City
2013/2014
1 Addis Ababa Addis Ababa 3,271,697

2 Afar Semera 1,845,413

3 Amhara Bahir Dar 19,961,270

4 Beneshangul Gumz Assossa 993,584

5 Drie Dawa Drie Dawa 414,330

6 Gambela Gambela 423,278

7 Harari Harar 225,136

8 Oromia Addis Ababa 34,276,118

9 Somalia Jigjiga 5,451,028

10 Tigray Mekele 5,392,201

Southern Nation,

11 Nationalities and People Hawassa 18,950,521

(SNNPR)

Table 1: Ethiopian Population by Region, 2013/2014

VII
Summary

Malnutrition is one of the greatest challenges facing our Country and leading causes for

Child death. This problem is the most common and occurring with people having

shortage of foods and poor feeding habit. In this case there is a great need to conduct

an extensive study important for decision making to improve feeding habit.

Objective: To assess malnutrition management among under five Children those OPD

attendants 2015 in WoreIlu Health Center, WoreIlu Woreda, South Wollo zone.

Methods: Direct observation, interview with Patient care givers and report,
registration and Medical Records review is used to collect information on the
malnutrition. Diagnosis for stunting, wasted, and underweight manifestation and
clinical complication be assessed.
Conclusion: In WoreIlu Health Center most of children that are saw have protein
deficiency. And they are actively responding for the treatment. It indicates the cause of
malnutrition in the catchment is shortage of food.
Recommendation: Most of Under 5 population in the catchment is affected by
malnourishment. So the Health Center must strength its effort for screening and
management. Strengthen Supplies Chain to overcome shortage and out of stock.
Patients Medical Records shall be full and complete. It helps the health professionals
seriously follow and evaluate the outcome of the patients.
Patients who fall after MUAC measurement shall be immediately enter in to follow up.
Health education shall be held on including child feeding mechanism.

VIII
1. Introduction

Ethiopia is the greatest nation in the horn and the second Populated country of Africa.
It covers 1,119,693 Square Kilometer with the total population of 91.2 million based
on 2013/2014 estimation. From which 83% of the population live in Rural area and
the rest 17% live in mainly uncomfortable and crowded Urban cities and 51% of the
population is female and 49% is male.
From the total land of the Country 60% can be plough and cultivated. The Country
also has many rivers and lakes with full flow of both in the winter and summer.
In Ethiopia Agriculture is the foundation of Country’s Economy. Based on 2014 46.3%
of Gross Domestic Product (GDP), 83.9% export, and 80% employment is covered by
this sector. The Sector depends upon rain and very backward irrigation practice,
because of this the country affected by drought.
Even though the Ethiopia has enough Human and natural Resources, the country still
cannot secure food need for all citizens and the poorest country in the world due to
different reason. From those reason illiteracy, poor infrastructure, and unimproved
cultivation practice.
As we all know the country is structured by federalism with 9 autonomous ethnically
based region (see table 1) and 2 Chartered cities (Addis Ababa and Drie Dawa).
Amhara region is one of the federal region with the population nearly 20 million and
the second populated region next to Oromia. Its altitude varies mostly in between
1500-3000 meter above sea level.
In the region many of the population depends on small plot land agriculture. There are
highly productive areas and in contrast there are areas in the region repeatedly
affected by drought and soil degradation caused by over grazing, repeatedly ploughing
and deforestation. Many people lives in those areas have food security problem and
affected by dietary related health problems like stunting. In the Region about 33.4% of
Under 5 children are affected by moderately malnourished, that is greater than the

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Country’s average 28.7% and severely malnourished children are about 3.1%
according to the government.
Now a days the government of the country as wel as the region committed to
rehabilitated the affected areas and improve afforestation coverage.
The region is organized by 11 zones. Thus South Wollo Administrative zone is one with
the population 3.2 million by 2013 estimation and the largest zone in the region. The
zone also organized by 21 Woredas.
From those Woredas WoreIlu Woreda is one located far away from Dessie, Capital City
of South Wollo administrative zone, which is about 91km South of Dessie with the
population of 125,109 based on 2014/2015. The Woreda has 20 rural and 4 town
kebeles. The people in this area are engaged in different activities such as farming,
weaving and trading.
The people of WoreIlu are Christians and Muslims by religion and live together and
work harmoniously.
In general, the standard of living of these people is relatively low and the
environmental sanitation is poor. Now all people in this area have equal access to land
regardless of sex and the land size is less proportional to family size.
WoreIlu has many social services such as grinding mill, market, Bank, all weather road
and transport, hydroelectricity; telephone both Mobile and Fixed line, different level of
Public and Private health sectors.
In the Woreda 1 District Hospital under construction, 5 health centers, and 20 Health
posts. The Woreda health Coverage is 100%.

From those public health institutions one is WoreIlu Health Center located in capital
city of the Woreda. Its catchment Population is 28,495. The Health Center Clustered
with 2 town and 4 rural kebeles. In 2014/15 Under 5 Children are about 3,858 and
under three about 2,228. In this year the expected number of Surviving Infants at 1
year of age about 886. The health center is giving many health services. From which
Vaccination, Growth Monitoring (GMP), Screening of malnourishment, and as
Stabilization Center (SC).
In the health center there are good opportunities to find out what is good practices and
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Negligence managing moderately and severely malnourished Under 5 Children.
Based on this, my Internship report is focused on to determine the management of
malnutrition in the health center according to the National Guideline.

Why I am focused on Under 5 Children?

Malnutrition is among the reason for seeking care and one of the most common causes
of children mortality. These are still very common in the least developing countries for
different reasons. For example, majority of children in our country have different type
nutrition problems, which are stunting, wasting, underweighting and clinical
complications secondary to malnutrition. The problem is specially severed in our
region.
Moreover, some children with malnutrition and its clinical complication may be not
managed with the correct WHO management algorism; they are not well counseled
and there is not strict follow up even Children who arrive at health institutions both in
Health Post and Health Center.
The magnitude of malnutrition problem is very high in our country, there is need of
appropriate and adequate management based on WHO standards and National
Guideline.
Thus, the main aim of my internship is to assess the malnutrition management success,
limitation and Challenges in WoreIlu Health Center.
2. Objective
2.1. General Objective
 To assess malnutrition management among under five Children those OPD
attendants 2015 in WoreIlu Health Center, WoreIlu Woreda, South Wollo
zone.

2.2. Specific Objectives

 To assess malnutrition management among under five Children those OPD
attendants 2015 in the Health Center.
 To assess the success of malnutrition management.
 To evaluate limitation of malnutrition management
 To describe Challenges of malnutrition management in the health center.
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3. Methodology

3.1. Population
3.1.1. Target Population:
 All Under 5 years of age children who were attended OPD in the health
center.
3.1.2. Study population:
 All Under 5 years of age children who was attended OPD in the health
center
3.2.

3.3. Data Collection processing

Direct observation, interview with Patient care givers and report, registration and
Medical Records review is used to collect information on the malnutrition. Diagnosis
for stunting, wasted, and underweight manifestation and clinical complication be
assessed.
3.4. Data processing and analyzing
A descriptive analysis is conducted to describe malnutrition management.

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4. The Main Text
A. Situational Analysis
WoreIlu Health Center is found in Eastern Amhara South Wollo zone, WoreIlu town,
Kebele 01, 492 km away from Addis Ababa and 91Km from Dessie. It was established
in 1962 as the first and the only health institution not only for WoreIlu but for
neighboring Woredas like Legehida and Jamma (See Fig. 2).
The Health Center has 13 blocks including newly expansion blocks. Also the Health
Center has wide premises and the staff motivated to make attractive to the patient by
implementing national Clean and safe health facilities (CASH) initiatives. The Health
Center well equipped including Hematology, Chemistry, CD4, large laundry machines,
steam sterilizer advanced microscope and emergency Ambulance.
The Health Center has pipeline water with 10,000 liter reserve tanker, 24 hours
electricity and diesel Generator and fixed line telephone.
Actually the health center served 28,495 people. In the health center Antiretroviral
therapy (ART), TB treatment, Out Patient and admission service, Antenatal, skill
delivery, postnatal, safe abortion, Provide long and short term family planning method,
Vaccination both mothers and children, GMP, Children Screening, Stabilization and
OTP services are available with better laboratory and pharmacy services.
In 4 Rural kebeles there are 4 well organized Community Health Posts they serve their
catchment population by Hygiene and sanitation, Maternal and Child health including
Providing family planning methods, Antenatal, Clean and safe Delivery and postnatal
care Service, Vaccination, OTP, GMP and first aid services.
Currently it has 49 Professionals and administrative human resources among these 20
health professionals and 6 Health extension workers the remaining are supporting
staffs.

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 No. of Professionals Coverage
Profession
Hired Standard (%) Remark
Health Officer 3 4 75
Midwifery 3 3 100
Clinical Nurse (Diploma/BSC) 10 18 56
Pharmacy Technician 2 3 67 Contract
Laboratory Technician 2 3 67
Health Extension Workers (Rural) 6 8 75
Health Extension Workers (Urban) 2 2 100
Health Information Technician
1 1 100
(HIT)
Ambulance Assistance 1 1 100
Administrative staff (All) 19 24 79
Total 49 67 73

Table: 2 WoreIlu Health Center Staff by their profession Mix

B. Introduction
Malnutrition varies from country to country depending on economic, ecological, social,
and other factors.
Ethiopia is one of the poorest third World Countries, with an annual per capita income
of US $ 110, an infant mortality rate of 48 per 1000 live births, maternal mortality 646
per 100,000 and a life expectancy of 49 and 53 years for men and women, respectively.
Even though Ethiopia is a producer of a variety of agricultural products, but one of the
countries in the world with the highest number of malnourished population. Studies
showed that the health problem of the majority of the population of Ethiopia emanate
from lack of adequate and balanced diet. Children, pregnant women, lactating mothers
and adults are most affected by the problem.
The National Demographic Health Survey conducted by Central Statistical Agency
(CSA) in Ethiopia in 2005 showed that the prevalence of wasting, under weight and
Stunting was very high; 9.7, 35.7 and 51.3%, respectively.

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According to the 2000 Central Statistical Authority study, more than 50% of
Ethiopian children have not grown to the level they are expected to grow, 47% of them
have weight below the standard weight set for their age and 11% are extremely
malnourished (marasmic). A study also shows that the number of malnourished
children under the age of 5 years is increasing. Surplus food producing areas are also
among the areas where the problem of malnutrition is predominantly seen.
The 29% malnutrition prevalence among lactating mothers, the 5-15% prevalence of
vitamin deficiency diseases (night blindness) among the pregnant women, the 30%
prevalence of iodine among the general population and the 58% child death rate due
to malnutrition. These statistics show the seriousness of the problem.
C.

The most important forms of malnutrition in Ethiopia are protein energy malnutrition
(PEM), vitamin A deficiency, Iodine deficiency disorders, and
Iron deficiency anemia. Absolute poverty, poor health and sanitary conditions, limited
knowledge of nutritional matters among certain households, and fluctuations in
incomes are some of the principal reasons for the high prevalence of malnutrition.
In addition to this, the increasing growing number of people who are attacked by
diseases that occur due protein-energy malnutrition and to lack of disease protecting
foods especially low intake of vitamin A, iron and iodine, is an indication of the
problem related to malnutrition.
Malnutrition is predominantly seen among the rural population since the food of the
population is based on crops. The knowledge of the rural population about the value
and preparation of disease preventing and body building foods such as vegetables and
fruits, and animal products is limited. The cultural practice the rural population has
towards regularly feeding the family with these foods is not yet developed. The same is
about giving supplementary food to children as an addition to breast milk. The main
contributor of the above problems of malnutrition is not only low purchasing power of
families, and inadequate supply of food but the belief and the concept of the society
about nutrition is low. Hence, social and traditional pressures have a lot of
contribution to the problem of malnutrition in Ethiopia.
In Ethiopia at present the most serious nutritional problems are mainly due to low
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intake of foods. The problem is more severe among children aged 1-3 years who suffer
from Kwashiorkor and Marasmus (4%) and underweight (60%). Any change in income
or income form influence the nutritional status at the household and individual levels.
The effect of income is measured by expenditure on food which reflects a household’s
income and resources. It has been hypothesized that one of the most serious obstacles
limiting the development in rural agricultural societies is the amount of land available
to the families. It is also known that the greater the amount of land available to the
small-scale farming families, the better the nutritional status of the young children in
the families. Associated with the nutritional status of young children and may thus be
used as an indicator of health and nutritional status of the family. Among all other
things, land is a useful means of classifying much of the rural population in terms of
food, nutrition, and poverty considerations.
D.

Improved nutrition is assumed to be directly linked to expanded food production

while increased income is a good measurement for improved Child health.
The Ethiopian Government is prepared family centered nutrition package to develop
the knowledge and skills of the society about nutrition and to build its capacity for
identifying and taking appropriate actions to eradicate malnutrition and prevent its
resurgence. The health extension workers will be the implementers of the package.
E.

Malnutrition may be associated with a number of clinical complications according to

WHO. Different manifestations, which can be stunting, wasting and underweight with
many clinical complication.
Studies showed that all the above causes are severely manifested in our region. And
also in WoreIlu Woreda all the above mentioned causes are commonly seen. Because
of this WoreIlu Health center is provide food by prescription service to control and
reduce severity of malnutrition, co-related disease and death both in adult and
children.
C. Body
a. Major tasks
 Review patient Medical records and registrations by their MRN during their
appointment.
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  Observation of the procedures performed by Nurses both trained and non-
trained and health Officers during patient diagnosis and treatment in Under
5 outpatient department.
 Observation of follow up of admitted severely malnourished with edema and
nutrition related ill Under 5 children in the health center and their treatment
progress.
 Observation of Screening for Nutrition and GMP practices of Under 5
children both in Health Posts and Health center.
 Observation of Co-infected like HIV/AIDS and TB Under 5 patients according
to the national guideline.
 Interview with patients’ Parents and care givers who attentively follow the
treatment and saw the success and failarity.
b. Findings/Results
 Even if in the Health Center all Under 5 Children both ill and well are
screened for malnutrition their medical record is not full and not indicated
the measure taken for those moderately and severely malnutrition.
 Taking only one of the procedure and leave the rest. Most of the time
children are screened by MUAC. And some children their MUAC 11cm are
not registered and not enter in to OTP in health center and TSF in Health
Posts.
 Professionals during Screening and management not use Guideline and Chart
booklets especially in Health Posts.
 Admitted SAM Children has good progress by F-75, F-100 and Antibiotics
specially the first week of admission. Nurses follow correctly and support
their care giver.
 There are Nutrition Screening Campaigns. But screening quality is poor and
not sustainably follows the children screened.
 Good follow up for those Co-infected Children.
c. Challenges Faced
 Shortage of Supplies like F-75, F-100, and Plumpy Nut.
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  Children are lost from their follow up.
 Shortage of ICCM Supplies like Antibiotics.
 Shortage of trained Professionals by turnover.
d. Measure taken
 Overcoming Shortage of Supplies of Nutrients by redistribution of supplies
from over stocked Cluster and out of Cluster Health Center and Health Posts
to Short stock Health Center and Cluster Health posts.
 Allocate budget for drugs
D. Discussion, Conclusion and Recommendation
a. Discussion
In WoreIlu Health Center and its clustered Health Post all important malnutrition
diagnosis, management and follow up are performed. From July – October 2015 1,632
Under 5 Children have been measure their MUAC in Health Center and from those
screened Children Moderately malnourished (8 < MUAC < 12 ) 572 Covers 35.05% and
Severely Malnourished (8 < MUAC) 87 Covers 5.33%. It shows slightly severely
affected the catchment Population than the region average. Children Moderately and
Severely malnourished with Edema accounts 213 cover 13.05% and 52 cover 3.19%
from screened Children respectively.
From those moderately and severely malnourished Children tested for appetite 642
(97.4%) passed and the rest 17 (2.6%) children failed. Children who were appetite
tested and passed managed by Plumpy nut for 3 to 6 months based on food by
prescription guideline. 592 (89.8%) Children are cured and graduated. 32 (4.9%)
failed because they were affected by both chronic and acute malnutrition, and 12
Children are lost from their follow up due to different reason. 6 (0.9%) children are
dead. It indicates malnutrition contributes much for child mortality.
17 children are admitted for follow up because they are co-infected due to
malnutrition, edema and can’t take any food. Health Officer and Nurses in the Health
Center are chronically follow up and administered F-75 and F-100 with antibiotics for
21 days in the Health Center. 12 (70.6% from admitted Children) children are actively

10
responding to the treatment, gaining of weight and decrease from their edema. After
21 days the Children are relief and cure. 5 children are referred for further
investigation and treatment to Dessie Referral Hospital.
3 HIV/AIDS and 1 Pulmonary TB Co-infected children are referred to Dessie Referral
Hospital due to they had many health Complications.
b. Conclusion
I concluded that Malnutrition is the presence of nutritional problem due to food
deficiencies generally and particularly deficiencies of Protein, Carbohydrate, minerals,
and Vitamins with at least with one nutritional problem. As a result it may be Stunting,
Wasting or underweight.
In WoreIlu Health Center most of children that are saw have protein deficiency. And
they are actively responding for the treatment. It indicates the cause of malnutrition in
the catchment is shortage of food.
c. Recommendation
 Most of Under 5 population in the catchment is affected by malnourishment. So the
Health Center must strength its effort for screening and management.
 Strengthen Supplies Chain to overcome shortage and out of stock.
 Patients Medical Records shall be full and complete. It helps the health
professionals seriously follow and evaluate the outcome of the patients.
 Patients who fall after MUAC measurement shall be immediately enter in to follow
up.
 Health education shall be held on including child feeding mechanism.

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5. Reference

1. Tsegahun Worku, Mahilet Minwyelet. Research Methods in Human Nutrition

Bahirdar University. May 2014.

2. National Nutrition Extension Package, Ministry of Health. July 2003. (1-2)

3. Tefera Belachew, Human Nutrition for Health Science Student. Jima University.

January 2003. (143 - 147)

4. Ethiopian Nutrition Institute 1989. News Letter Publications of the Ethiopia

Nutrition Institute Ministry of Health.

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