Alemseged et al. BMC Pediatrics(2024) 24:548
https://doi.org/10.1186/s12887-024-05018-0

BMC Pediatrics

RESEARCH

Open Access

Prevalence and associated factorsof lipodystrophy in type 1 diabetic children
and adolescents at Ayder Comprehensive
Specialized Hospital, Tigray, Ethiopia
Tsehaye Alemseged1, Abdikarin Ahmed Mohamed1, Abraha Gebreegziabher Hailu1, Fikaden Berhe Hadgu1 andMohammed Mustefa Mohammedamin1*
Abstract
Introduction Lipodystrophy can cause poor glycemic control in addition to cosmetic problems in children andadolescents with type 1 diabetes mellitus. However, data on its prevalence and associated factors is scarce amongchildren and adolescents who live in developing countries like Ethiopia.
Objective To determine the prevalence and identify associated factors of lipodystrophy in children and adolescentswith type 1 diabetes mellitus who visited the endocrinology clinic of Ayder Comprehensive Specialized Hospital
between May 1 and July 31, 2020.
Method This was an institution-based cross-sectional study conducted on 57 children and 65 adolescents with
type 1 diabetes mellitus who had been taking insulin injections for a year or more. The dependent variable waslipodystrophy. A pretested, structured questionnaire was used to collect data related to lipodystrophy and othercharacteristics. The principal investigator oversaw the data collection, which was done by pediatric and child healthspecialty residents with training. Data was subjected to descriptive statistics, and predictors of lipodystrophy wereidentified by fitting a multivariable logistic regression model. Statistical significance was declared at p < 0.05.
Results More than half (53.3%) of patients were in the age range of 13 to 17. The male-to-female ratio was almost
1:1. Educational status for 63.1% of patients was primary school. Four-fifths of patients were residing in urban areas.
Of the 122 participants, 60 (49.2%) had lipodystrophy (48.3% lipohypertrophy and 0.8% lipoatrophy), with grade II
lipohypertrophy being the most common type at 81.7%. The thigh was the most common site of lipodystrophy. In
multivariable regression analysis, the long duration of insulin injection (AOR = 3.6, 95% CI, 1.5 to 9.0, p = 0.005) andinappropriate rotation of the injection site (AOR = 9.0, 95% CI, 2.2 to 37.0, p = 0.002) were significantly associated withlipodystrophy. HbA1c testing was conducted for 70 patients, and poor glycemic control (HbA1c ≥ 7%) was found in 43(61.4%) of them. Patients with lipodystrophy were more likely to have poor glycemic control (75%) than those without
lipodystrophy (47.1%) (p = 0.016).

*Correspondence:
Mohammed Mustefa Mohammedamin
mmustefa6@gmail.com
Full list of author information is available at the end of the article© The Author(s) 2024, corrected publication 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format,
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Alemseged et al. BMC Pediatrics(2024) 24:548

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Conclusion The prevalence of lipodystrophy was comparable with other studies. Long duration of insulin injection
and improper rotation of the injection site are associated with an increased risk of lipodystrophy. Patients withlipodystrophy were more likely to have poor glycemic control, defined by higher HgA1c, than those without
lipodystrophy. Proper education of patients and their parents must include correct injection techniques, rotating
injection sites, and changing injection sites intermittently to lessen the risk of developing lipodystrophy.
Keywords Children, Diabetes mellitus, Lipodystrophy

Introduction
Type 1 diabetes mellitus is a chronic condition that
affects millions of children and adolescents worldwide.
Patients with type 1 diabetes mellitus rely on exogenous
insulin, either by continuous infusion or multiple daily
injections, to control their blood glucose levels [1, 2].
However, one of the long-term complications of insulin
therapy is the development of lipodystrophy, a condition
characterized by abnormal distribution of body fat. Thiscan be a thickening of the subcutaneous fat (lipohypertrophy) or a loss of fat (lipoatrophy) at the insulin injection site.
The lipodystrophy area loses its sensitivity. Despite
being aware that it is necessary to rotate sites, patients
often stick to their injection site once they experience
pain while injecting anywhere other than the lipodystrophy area [3]. Insulin injected into a lipodystrophy
area may cause irregular insulin absorption, which could
result in unpredictable hypoglycemia and poor glycemic
control [4].
Even though the prevalence of lipodystrophy is high [3],there is a dearth of study and information about lipodystrophy in low- and middle-income countries, especiallyin Ethiopia. This study aims to explore the prevalence
and associated factors of lipodystrophy in Type 1 diabetic
children and adolescents at Ayder Comprehensive Specialized Hospital in Tigray, Ethiopia. The relevance of thisresearch lies in the fact that lipodystrophy is a relatively
understudied complication of Type 1 diabetes mellitus
in children and adolescents, particularly in low-resource
settings such as Ethiopia. Therefore, the reason for conducting this study was to determine the prevalence andidentify associated risk factors for the development of
lipodystrophy in children and adolescents. Understanding these factors can help improve diabetes management
and quality of life for these patients.
Methodology
Study area

This study was conducted at Ayder Comprehensive Specialized Hospital, located in Tigray region, Mekelle town,
which is 778 km from the capital city, Addis Ababa. It
started as a referral and specialized medical center in2008. It delivers clinical services to more than 8 million
populations in the catchment areas of Tigray, Afar, andthe south-eastern parts of the Amara regional state. It

provides a broad range of medical services to both inpatients and outpatients of all age groups. It also serves
as a teaching hospital for medical and other health science disciplines in both undergraduate and postgraduate
programs. The pediatrics and child health department
provide services at outpatient clinics, in the emergency
department, under-five and above-five wards, pediatricintensive care units, and neonatal intensive care units.
One of our outpatient clinics is the diabetic clinic, which
provides service to approximately 200 pediatric diabetic
patients monthly. There are 2 pediatricians, 2 pediatricresidents, and 4 nurses assigned to the diabetic clinic
monthly.
Study design and study period

A facility-based cross-sectional study design was conducted at the pediatric endocrinology follow-up clinic
at Ayder Comprehensive Specialized Hospital in Tigray,
Ethiopia. The study period was from May 1 to July 31,
2020.
Eligibility criteria

All children with type 1 diabetes mellitus aged ˂ 18 years
old who were taking insulin for at least 1 year during thestudy period were included in the study.
Sampling size determination and sampling procedure

We included all children with diabetes mellitus aged ˂ 18
years who had been taking insulin for at least one year
during the study period. Out of 233 registered children,
122 met the eligibility criteria (i.e., were aged ˂ 18 years
and had been taking insulin for at least one year during
the study period) and were included in the study.
Study variables

The dependent variable was lipodystrophy, which wascategorized as absent or present. Independent variables
were age, sex, educational status, BMI, RBS, FBS, hypoglycemia, insulin type, needle size, injection site, needle
reuse, injection site rotation, DKA, and injection to thelipohypertrophy area.
Data collection tool and procedure

After reviewing related research, a questionnaire wasdeveloped, and an arrangement was made that fits our
setup. This was information on the objective of theAlemseged et al. BMC Pediatrics(2024) 24:548

study, translated into Tigrigna and pretested for a week
before actual data collection. Following the pretest, we
rephrased some of the questions and corrected somelanguage errors. It was altered to better suit the context
of the native language. Both the English and Tigrigna
versions of the questionnaire were evaluated by experts(pediatrics and child health specialists).
Six pediatric and child health specialty residents were
designated as data collectors. They underwent a comprehensive one-day training program that encompassed thefollowing aspects:• 	 Interview Techniques: Ensuring proper interview
conduct and participant comfort.
• 	 Lipodystrophy Assessment: Detailed training on
evaluating injection sites for lipodystrophy.
• 	 Consistency in Data Collection: Strategies to achieve
uniformity and minimize inter-observer variability.
• 	 Ethical principles.
Weekly oversight by the principal investigator was madeto maintain data quality. Lipodystrophy was diagnosed aspresent or absent by visual inspection and palpation by
pediatric resident physicians. The presence of a noticeable or palpable lump at the injection site indicated that
lipodystrophy was present. Accordingly, lipodystrophy
was defined as having different grades based on morphology and pathogenesis.

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Operational definitions• 	 Lipodystrophy was assessed as “present” or“absent.” The presence of a noticeable swelling or
palpable lump at the injection site indicated that
lipodystrophy is present, and if there is no noticeable
or palpable lump at the injection site, it indicatedthat lipodystrophy is absent.
• 	 Lipodystrophy was graded as:– 	 Grade 0 = no change.
– 	 Grade 1 = visible hypertrophy of fat tissue but
normal consistency on palpation;– 	 Grade 2 = intensive fat tissue thickening but withfirm consistency; and.
– 	 Grade 3 = lipoatrophy [5].
• 	 Glycemic control was defined as optimal and poor
glycemic control.
– 	 Optimal glycemic control was when the recent
HbA1c levels were less than or equal to 7.5%,
whereas.
– 	 Poor glycemic control was > 7.5% in children lessthan 19 years old, according to the American
Diabetic Association and the International Societyof Pediatric and Adolescent Diabetes [6].

Data analysis

Data were entered, processed, cleaned, coded, classified,and computer-entered and analyzed using the Windows
Statistical Package for Social Scientists (SPSS) version
25.0 software. A descriptive analysis was used to describe
the prevalence of lipodystrophy and other characteristics. Results were presented using tables, graphs, andtext based on the data type. A Chi-squares test of association was used to show the relationship between categorical variables and lipodystrophy. Variables with thecrude odds ratio’s p-value less than 0.25 during pairwise
binary logistic regression were candidate variables for
multivariable logistic regression. The adjusted odds ratio(AOR), with its 95% confidence interval and significance,is reported to show an association of predictors withthe dependent variable (i.e., lipodystrophy). Those variables with a p-value less than 0.05 during multivariable
analysis were considered significant predictors of lipodystrophy. Model fitness was tested using the HosmerLemeshow test. A model was considered good-fit if the
Hosmer-Lemeshow test result was insignificant (i.e., pvalue greater than or equal to 0.05). The final multivariable model was a good fit for the data (Hosmer-Lemeshow test: p = 0.286).

• 	 Children: patients who are diabetic aged 12 years andbelow.
• 	 Adolescents: patients aged between 13 and 18 years.
• 	 Hypoglycemia: blood glucose level of ≤ 60 mg/dL(3.3 mmol/L) and/or occurrence of one or more
symptoms of hypoglycemia (such as palpitation,
tiredness, sweating, strong hunger, dizziness, andtremor) [7].
• 	 Optimal insulin injection rotation principles.
1. Choose an area.
2. Divide that area into four Sect.
3. Select an injection site in a section to start
injecting. Use one section per week.
4. Inject one finger width away from your last
injection.
5. Always use a new injection site.
6. Avoid using a single injection site more than once
every four weeks (22).
Ethical considerations

Ethical approval was obtained from the Institutional
Review Board (IRB) of the College of Health Sciences at

Alemseged et al. BMC Pediatrics(2024) 24:548

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Mekelle University with IRB number ERC 1720/2020. A
letter of approval was also obtained from the ACSH Chief
Clinical Director’s office before the commencement of thestudy. Caregivers provided informed consent after receiving a detailed explanation of the study’s objectives andpurpose. They were also informed of their right to withdraw participation at any time. To protect participant privacy, personal identifiers were replaced with codes during
the de-identification process. Collected data remained
confidential and securely stored on password-protectedcomputers, with no unauthorized third-party access.
Table 1 Sociodemographic & clinical characteristics of T1DM
children & adolescent in ACSH endocrinology clinic Mekelle,
2020
Variables
Age ofparticipant< 5 years
5 to 12 years
13 years and above
Sex ofMaleparticipant
FemaleEducational
Not started
status ofKindergarten
patient
Primary school
Secondary school
Educational
Not started
status ofPrimary School
caregiver
Secondary school
Diploma and above
Residence
Urban
Rural
Duration
1–5 yearsof insulin
6–10 years
injection
Above 10 years
Most comAbdomen
mon site ofArm
injection
Thigh
Equally all
Distance
1 finger
between in- 2 fingers
jection sites
3 fingers
I do not measure
Size of needle 8 mm
used
12 mm
Other
Technique of 45 degrees
injection
90 degrees
Body mass
Underweight
Index
NormalOverweight
Fasting blood ≤ 60 mg/dl
sugar
61 to 126 mg/dl> 126 mg/dl
Random≤ 60 mg/dl
blood sugar 61 to 200 mg/dl> 200 mg/dl

Number
13
44
65
63
59
15
8
77
22
27
34
40
21
97
25
83
38
1
8
48
48
18
10
48
2
62
117
3
2
34
88
42
78
2
6
59
57
1
54
67

Percentage
10.7%
36.0%
53.3%
51.6%
48.4%
12.3%
6.6%
63.1%
18.0%
22.1%
27.9%
32.8%
17.2%
79.5%
20.5%
68.0%
31.1%
0.8%
6.6%
39.3%
39.3%
14.8%
8.2%
39.3%
1.6%
50.8%
95.9%
2.5%
1.6%
27.9%
72.1%
34.4%
63.9%
1.6%
4.9%
48.4%
46.7%
0.8%
44.3%
54.9%

Results
Sociodemographic and clinical characteristics

Of a total of 233 patients who attended the ACSH Clinic
for Pediatric Endocrinology during the three-monthstudy period, 122 participants met the eligibility criteria. Male patients made up 63 (51.6%) of the study participants, corresponding to an M: F ratio of 1.07:1. The
median age of patients enrolled in the study was 13 years,
with the age distribution led by adolescents at 65 (53.3%)
and children at 57 (46.7%). The most common educational status of patients was primary school, accounting
for 77 (63.1%) of them. About 80% of patients reside inurban areas. The mean duration of insulin injection was
4.06 (± 2.56 SD) years. All participants were injectedwith Neutral Protamine Hagedorn (NPH) insulin andregular insulin. Sixty-five (53.3%) of the participants were
responsible for the injection, while 57 (46.7%) received
the injection from others. The thigh and arm were equally
the most commonly preferred injection sites (48, 39.3%
each). Eighty-eight (71.9%) patients inject at 90°, while
34 (27.1%) inject at 45°. Fifty-six (45.9%) patients rotate
injection sites every injection (Table 1).
Regarding the educational status of the caregivers,
more than half (63, 52.5%) of the injection providers
attended primary school, and about a third attended secondary school (Fig. 2).
All participants reused their needles, with 51 (41.8%)
reusing the needle 6–10 times, 40 (32.8%) 3–5 times, 21(17.2%) > 10 times, and 10 (8.2%) 2 times. Almost all participants (117, 95.9%) used an 8-mm needle, the syringe
available in the clinic (Fig. 3).
Prevalence of lipodystrophy

In this study, lipodystrophy was observed in 60 participants (49.2%, 95% CI: 40.4–58.1%). The thigh was themost common site of lipohypertrophy (20, 33.3%), followed by the arm (18, 30%) and multiple sites (13, 21.7%),
while the abdomen was the least common site (9, 15%).
The ratio between male and female participants withlipodystrophy was equal (1:1). Of the subjects with lipohypertrophy, 32 (53.3%) were teenagers, and 28 (46.7%)
were young children. Grade II lipohypertrophy was seenin 81.7% of cases with lipodystrophy. Grade I affected16.7%, while only 1 participant had lipoatrophy (1.6%)(Fig. 4).
Predictors of lipodystrophy

In multivariable binary logistic regression analysis, insulin injection duration (AOR = 3.7, 95% CI, 1.5 to 9.0,
and p = 0.005) and frequency of injection site rotation(AOR = 9.0, 95% CI, 2.2 to 37.0, p = 0.002) persisted significantly associated with lipodystrophy, while insulin
dose and frequency of needle reuse became less important. The odds of lipodystrophy were 3.7 times higher

Alemseged et al. BMC Pediatrics(2024) 24:548

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Fig. 1 Sampling procedure in children and adolescents with T1DM, at ACSH

Fig. 2 Educational status of insulin injection providers in T1DM children and adolescents at ACSH

in patients with a duration of insulin injection of 6 years
or more compared to patients with a duration of insulin
injection of 5 years or less. Compared to those who rotate
the injection site for every injection, the likelihood of
lipodystrophy was nine-fold higher in those who changed
the injection site after a week (Table 2).
HbA1c testing was conducted for 70 patients, and poor
glycemic control (HbA1c ≥ 7%) was found in 43 (61.4%)of them. Patients with lipodystrophy were more likely
to have poor glycemic control (75%) than those without
lipodystrophy (47.1%) (p = 0.016).

Discussion
Currently, there is a paucity of data available on the prevalence and associated factors of lipodystrophy amongchildren and adolescents who live in developing countries like Ethiopia. Our study reports on 122 consecutive
pediatric Type 1 diabetic patients on follow-up in thelargest teaching hospital in the Tigray region, Ethiopia.
Nearly half of the type 1 diabetic patients had lipodystrophy. Long duration of insulin injection and improper
rotation of the injection site are associated with anincreased risk of lipohypertrophy. In addition, patients

Alemseged et al. BMC Pediatrics(2024) 24:548

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Fig. 3 Frequency of site rotation and needle reuse in T1DM children and adolescents at ACSH

Fig. 4 lipodystrophy grade and sites in children and adolescents with T1DM at ACSH

with lipodystrophy were more likely to have poor glycemic control than those without lipodystrophy.
The prevalence of lipodystrophy in this study was
49.2% (95% CI: 40.4–58.1%) and comparable to the studies in Saudi Arabia (47.7%), Ireland (51%), and South
Africa (52%) [8–10]. This can be explained by the factthat most of the participants in these studies were in thepediatric age group and used physical examination to
detect lipodystrophy.
Lower prevalence rates were reported in a systematic review and meta-analysis of 26 studies performed
by Deng N and colleagues, who reported a prevalenceof 38% [11]. The lower rate was also reported in anotherstudy from Jordan (37.3%) and Riyadh (39.7%) [12, 13].

Alemseged et al. BMC Pediatrics(2024) 24:548

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Table 2 Binary logistic regression analysis of factors associated with lipodystrophy in children and adolescents with T1DM at
endocrinology follow-up clinic of ACSH, Mekelle, 2020
Characteristics
Injection provider
MyselfCare giver
Duration of insulin injection
1–5 years≥ 6 years
Dose of insulin (Unit/kg/day)
< 0.7
≤ 0.7
Frequency of site rotation
Every injection
Every 1 to 7 days
≥ 8 days
At irregular time
Distance between injection sites
1 to 3 fingers
Did not measure
Frequency of needle reuse
2 to 5 times≥ 6 times
Technique of injection
45 º
90 º

Lipodystrophy, n (%)
AbsentPresent

COR [95% CI]

p-value

33 (27.0)
29 (23.8)

32 (26.2)
28 (23.0)

1.0 [0.5, 2.0]
1

0.991

50 (41.0)
12 (9.8)

33 (27.0)
27 (22.1)

1
3.4 [1.5, 7.7]

36 (29.5)
26 (21.3)

22 (18.0)
38 (31.1)

33 (27.0)
21 (17.2)
3 (2.5)5 (4.1)

AOR [95% CI]

p-value

0.003

1
3.7 [1.5, 9.0]

0.005

1
2.4 [1.2, 5.0]

0.019

1
2.1 [0.9, 4.7]

0.087

23 (18.9)
16 (13.1)
18 (14.8)
3 (2.5)1
1.1 [0.5, 2.5]
8.6 [2.3, 32.7]
0.9 [0.2, 4.0]

0.835
0.002
0.848

1
1.2 [0.5, 3.0]
9.0 [2.2, 37.0]
0.6 [0.1, 3.2]

0.723
0.002
0.588

33 (27)29 (23.8)

27 (22.1)
33 (27.0)

1
1.4 [0.7, 2.8]

0.364

31 (25.4)
31 (25.4)

19(15.61)
41 (33.6)

1
2.2 [1.0, 4.5]

0.041

1
2.3 [1.0, 5.5]

0.057

15 (12.3)
47 (38.5)

19 (15.6)
41 (33.6)

1.5 [0.7, 3.2]
1

These studies were conducted in more developed countries, and adults were more involved. The counseling process in these setups may be better than ours, which may
impact the development of lipodystrophy.
Grade II lipohypertrophy was the most common form,
at 81.7% in this study, consistent with studies in Ethiopia
and Spain [14, 15]. Other studies have shown that lipohypertrophy Grade I is the most common site [8, 12]. Thisdifference may be due to the difference in diagnosis byvisual inspection of grade I, which can be difficult, especially in children. Lipoatrophy remained rare in this study(only 1 patient), as in other studies [15].
The duration of insulin injection was significantly associated with the development of lipodystrophy, consistent
with studies conducted in Dublin (p-value = < 0.001) andAlexandria (AOR = 1.16; 95% CI, 1.05–1.32; P = 0.004)[9, 14]. However, there was no significant association instudies in Addis Ababa (AOR = 0.71, CI, 0.34–1.49), andChandigarh, India (p-value = 0.381) [7, 8, 12, 16].
Injection site rotation was also significantly associatedwith lipodystrophy in this study, which is similar to thatof Addis Ababa (AOR = 0.41, CI, 0.21–0.81), Alexandria(p = 0.001) and India (p < 0.0005) [12, 16, 17]. In contrast
to other studies [8–10, 12, 14, 18, 19], the importance of
BMI for the development of lipodystrophy could not bedemonstrated in this study, which could be due to the

0.358

different body habitus of the participants. There were noobese patients in this study.
Most of the participants with lipodystrophy continue
to inject the LH site (63.3%). Most of them indicated that
this happened as part of their site rotation (68.4%), andsome were unaware of the impact of the injection there(18.4%). The possible reason could be a poor counselingprocess.
Most participants in this study used 8-mm needles, andall participants reused their needles. Those who reused
their needles more than 5 times were 1.5 times more
likely to develop lipodystrophy than those who reused
them less than or equal to 5 times.
In this study, all of the participants rotated injection
sites, but the frequency of rotation was more than a weekin 21 patients, 18 of whom had lipodystrophy and werenine times more likely to develop lipodystrophy thanthose to rotate each injection. A similar association wasobserved in Ethiopia, Saudi Arabia, and Spain [12, 18,
20].
The other remarkable finding of this study is that poor
glycemic control was significantly higher in patients withlipodystrophy. Lipodystrophy impairs insulin absorption
due to the formation of fatty lumps following repeatedinsulin injection at the same site. The overall prevalenceof poor glycemic control among the patients who had
HbA1c tests was 61.4% [95% CI, 49.8–72.2%], and thisAlemseged et al. BMC Pediatrics(2024) 24:548

finding is comparable to the study conducted in Gondar(66%), and lower than Addis Ababa (83%) [18, 21].
Limitations of the study

There was a relatively small sample size, and the study
was done in a single center. It would have been better tobe multicenter with a larger sample size to generalize theresult. HgA1c was not determined in all patients, whichmakes for a smaller sample to determine the poor glycemic control effect of lipohypertrophy. The diagnosis of
LH was done by physical examination, which is less sensitive than ultrasound.

Conclusion
The prevalence of lipodystrophy was comparable toother studies. Factors such as the long duration of insulin
injection and failure to rotate the injection site properly
are associated with an increased risk of lipodystrophy.
Patients with lipodystrophy were more likely to have poor
glycemic control defined by higher HgA1c than those
without lipodystrophy. Proper education of patients andtheir parents must include correct injection techniques,rotating injection sites, and changing injection sites
intermittently to lessen the risk of developing lipodystrophy. Health professionals should provide health education to patients and their guardians regarding proper
injection techniques and the importance of site rotation. In addition, health professionals should give clear
instructions on avoiding prolonged use of specific sites,
monitor patients’ injection habits, and screen for signs of
lipodystrophy during each visit. Health bureaus should
promote lipodystrophy awareness through communitybased health education campaigns, prepare leaflets, anddevelop guidelines for healthcare providers.
Abbreviations
ACSH	Ayder Comprehensive Specialized Hospital
BMI	body mass index
DKA	diabetic ketoacidosisDM	diabetes mellitus
HbA1c	glycated hemoglobin
LH	lipodystrophy
NPH insulin	Neutral Protamine Hagedorn insulin
SC	Subcutaneous
SPSS	Statistical Package for Social Scientists
T1DM	Type 1 diabetes
T2DM	Type 2 diabetes

Supplementary Information

The online version contains supplementary material available at https://doi.
org/10.1186/s12887-024-05018-0.
Supplementary Material 1
Acknowledgements
NA.

Page 8 of 9

Author contributions
Conception or design of the work: Data collection: Tsehaye AlemsegedData
analysis and interpretation: Tsehaye Alemseged, Abraha Gebreegziabher
Hailu, Fikaden Berhe HadguDrafting the article: Tsehaye Alemseged,
Abdikarin Ahmed Mohamed, Mohammed Mustefa MohammedaminCriticalrevision of the article: Tsehaye Alemseged, Abdikarin Ahmed Mohamed,
Abraha Gebreegziabher Hailu, Fikaden Berhe Hadgu, Mohammed Mustefa
MohammedaminFinal approval of the version to be published: Tsehaye
Alemseged, Abdikarin Ahmed Mohamed, Abraha Gebreegziabher Hailu,
Fikaden Berhe Hadgu, Mohammed Mustefa Mohammedamin.
Funding
No funding.
Data availability
The original contributions presented in the study are comprised in the article;
further inquiries can be contacted by the corresponding author.

Declarations
Consent for publication
NA.
Competing interests
The authors declare no competing interests.
Ethics statement
Ethical clearance was obtained from the Institutional Review Board (IRB) of
the College of Health Sciences of Mekelle University with IRB number ERC
1720/2020. Permission from Ayder Comprehensive Specialized Hospital
clinical director offices and a support letter from the chief clinical director
were obtained before the commencement of the study. All procedures
performed in this study were conducted in accordance with the ethicalstandards of the institutional research committee and with the 1964 Helsinki
Declaration and its later amendments.
Informed consent
Consent was obtained from all caregivers of children involved in the study
after they were informed about the objective and purpose of the study. They
were also informed about their right to refuse to participate in the study at
any time.
Author details
1
Department of Pediatrics and Child Health, College of Health Science,
Mekelle University, Tigray, Ethiopia
Received: 19 July 2023 / Accepted: 16 August 2024

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