Background: Severe Acute Malnutrition (SAM) is the third leading cause of mortality among under-five children in Ethiopia and more than a quarter of the deaths occur during admission. Local based information is important to improve inpatient treatment for SAM. The study aimed to determine the incidence and predictors of death among SAM children in Amhara region.

Methods: A retrospective record review was conducted from September 2012 to November 2016 in Felege Hiwot, Debre Birhan, and University of Gondar referral hospitals and in selected health institutions from rural North Gondar Zone. A total of 1,690 patient charts were reviewed. The median time from admission to death was estimated. Shared frailty survival model with Gompertz distribution and gamma frailty was fitted. A p-value <0.05 was used in the multivariable model to declare a statistical significance. Hazard Ratio (HR) with its 95% confidence interval (CI) was computed as a measure of association.

Result: The median time to death was 8 (IQR= 3-21) days. At the end of the follow-up 196(11.6%) of the children were died giving the overall incidence density of 19.6 per 100 person-month of observation. HIV infection (AHR= 2.95, 95%CI: 1.58, 5.48), no antibiotics administration (AHR= 2.98, 95%CI: 1.58, 5.48), marasmic kwashiorkor (AHR= 2.48, 95%CI: 1.44, 4.29), no folic acid (AHR= 1.93, 95%CI: 1.11, 3.35) and no vitamin A supplementation (AHR=2.05, 95%CI: 1.25, 3.38) were the predictors of death.

Conclusion: The mortality rate among under-five children was higher than the minimum SPHERE standard (10%). HIV infection, mixed form of under nutrition (marasmic-kuashiorkor), not taking vitamin A, folic acid and antibiotics have increased the risk of mortality. Thus, treating co-morbidities and supplementing the children with essential micronutrients would be helpful to reduce their risk of mortality and improve their recovery from SAM.

Key words: SAM, Amhara region, under-five, mortality.