Assessment of nutritional status of under five years old children in Banadir Hospital Mogadishu Somalia.
Submitted To: Dr. Nadira Mehriban Assistant Professor Department of allied health science Daffodil International University
Submitted By: Abdikadir Ahmed Omar ID: 171-41-524 Program: Master of Public Health Faculty: Allied Health Science Department of Public Health Daffodil International University Dhaka, Bangladesh December, 2017
[i]
DECLARATION I hereby humbly declare that this research work entitled ―Assessment of nutritional status
of under five year’s old children in Banadir Hospital Mogadishu Somalia. Was carried out by me and is submitted as thesis in partial fulfillment of the requirements for the degree Master of Public Health, Department of Public Health, Daffodil International University, Shukrabad, Dhaka-Bangladesh.
Signature ------------------------Abdi Kadir Ahmed Omar Student ID: 171-41-524 Department of Public Health Daffodil International University Dhaka, Bangladesh.
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ACKNOWLEDGEMENTS All praise is to ALLAH Almighty, who gave me the energy and chance to accomplish this work successfully. I would also like to thank my supervisor, my mentor and teacher. My gratitude goes to, Dr. Nadira Mehriban Who assisted me in choosing the research topic, patiently stood by me through all my struggles, her support and positive outlook, being a mentor and source of inspiration. In particular I would like to thank dear of mine legend hero Shuab Abshir Jimcale his help and suggestions, am grateful. Completing this work would have been all the more difficult were if not for the support and friendship provided by six friends, Ahmed Mohamed Abdi Rashid Nawaal Mohamed Mohamud, Najma Mohamed Abdirahman, Nafisa Abdirahman Mohamed, Ifrah Salad Hossein. I am in debated to them for their help. Finally, I would like to thank my lectures in Daffodil International University for their help and encouragement.
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CERTIFICATE This is to certify that Abdi Kadir Ahmed Omar has completed this dissertation entitled “Assessment of nutritional status for under five years old children in Banadir
Hospital Mogadishu-Somalia.‖ in partial fulfillment of the requirement for the Master Degree of Public Health, Department of Public Health, Daffodil international University, and Dhaka Bangladesh my Supervision.
-------------------------Dr. Nadira Mehriban Assistant professor Faculty of Allied Health Sciences Department of public health Daffodil International University Dhaka-Bangladesh
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Approval Page Board Examination
No.
Name
Designation
1
Dr. MD. Shahjahan
Chairman
Associated Professor & head, Dept. of Public health, Daffodil international university 2
Prof. (Dr.) M. S. A. Mansur
Member
Ahmed Professor Dept. of Public Health Daffodil international university 3
Dr. Nadira Mehriban
Member
Assistant Professor Dept. of public Health Daffodil international university 4
Prof. Md Shah Alam Bhuiyan
External
Former Professor
member
Department of public health education NIPSON Mohakhali Dhaka
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Signature
DEDICATION I dedicate this work to my dear parents my mother Halimo Sidow Adan and my uncle Ali Sidow Adan for their prayers, encouragement, and Moral support and for teaching me the value of education. To my sisters‟ Ifrah Salad Hossain, Qali Ali Hassan, and Brothers Omar Ali Hassan and Sayid Ali Sharif Abdullahi who were very helpful and understanding in my situations, their support and encouragement helped me a lot in completing this thesis successfully.
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ABSTRACT Introduction. It‟s a recent emerging problem documented in developing countries, malnutrition under five children contributes major current health problems (morbidity and mortality) in several ways. Under nutrition remains a devastating problem in many developing countries affecting over 815 million people causing more than one – half of children death. Study objective was to assess the nutritional status of under-five year‟s old children in Banadir Hospital Mogadishu Somalia. Method and material. a community based a cross-sectional study was conducted that triangulated quantitative approach was carried out from June 2017 to November 2017 among 150 participants in Banadir Hospital Mogadishu Somalia, sample Random sampling was employed to select the sampled participants, a sum-structured questionnaire was used to collect the soico-demographic characteristic, Usual Dietary intake and assess adequacy, Breastfeeding and Complementary feeding pattern of the mothers and anthropometric index of the children. Results. a descriptive analysis was carried out to identify the nutritional status of the children under 5 years old, age categorized into 0-1 years old were 52.7%, 32.0% were 1-2 years old, 8.7% were 3-4 years old and 6.7% were 4-5 years old. With mean and Std. of 17.44±13.096 age was most critical variable because it was one of the scales of the MAC measurements and target objective of the study. families uses 50 US dollar per month were 32.0%, 51-100 US dollar were 22.7%, 101-150 US dollar were 20.7%, 151-200 US dollar were 12.7%, 201-250 US dollar were 10.0%, and 251-300 US dollar were 2.0%. And Mean &Std. Deviation2.52± 1.413, Intake of (cereal, grain and products): majority of the study
population were consuming 1 time were 4% these foods, those use 2 times were 45.3%, those use 3 times were 42%, and those use 4 times and above were 8.7%.meat, fish and eggs meat, fish and eggs are very nutritive foods which human being should consume and take a enough amount in his/her day what I found in my study was 36.0% uses 1 time while those use 2 time is 32.7%, another part 3 time users 18.7%, 4 and above users was 8.7% and non-users were 4.0%, Understanding of mother for the nutritional status of her child: mothers should have understood the nutritional status to their children, this study reveal that mother who had good knowledge were 39%, while 61% had poor knowledge of the nutritional status of their children, MAC test. The children, 49.3% were severe, 16.0% of the children were mild malnourished, 34.7% of the children were well-nourished children. Chronic Malnutrition based on Height-for-age (HFA) the respondents 16.0% were severe, 14.7% of the respondents were moderate, 24.0% of the [vii]
respondents were mild and 45.3% of the respondents were normal. According Weight for Height Acute malnutrition 30.7%of the respondents were severe, 19.3% of the respondents were moderate, 10.7% of the respondents were mild and 39.3% of the respondents were normal. Conclusion. The research also concludes that most of Mothers doesn‟t well understand the necessary need of child nutrition. So that in this study I recommended that this needs extra researchers should launch researches on Nutritional Status as to check, intervene or minimize the effects may result from malnutrition in community through mobilizing and health education for community workers, and Make free from harmful.
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Table of Contents DECLARATION ............................................................................................................................................... ii ACKNOWLEDGEMENTS ................................................................................................................................ iii CERTIFICATE ................................................................................................................................................. iv DEDICATION ................................................................................................................................................. vi ABSTRACT............................................................................................................................................ vii Abbreviations ..............................................................................................................................................xiv CHAPTER ONE ............................................................................................................................................... 2 1.1.
Introduction ................................................................................................................................... 2
1.2.
Problem statement ......................................................................................................................... 4
1.3.
Justification ................................................................................................................................... 5
1.4.
Operational Definition of Terms ................................................................................................... 5
1.5.
Variables ....................................................................................................................................... 6
1.5.1.
Dependent variable ............................................................................................................... 6
1.5.2.
Independent variables ........................................................................................................... 6
1.6.
The Conceptual Frame Work ........................................................................................................ 7
1.7.
Research questions ........................................................................................................................ 8
1.8.
OBJECTIVES ............................................................................................................................... 8
1.8.1.
General Objectives ................................................................................................................ 8
1.8.2.
Specific objectives are as follows ......................................................................................... 8
CHAPTER TWO .............................................................................................................................................. 9 LITERATURE REVIEW ......................................................................................................................... 9 2.1.
Malnutrition .................................................................................................................................. 9
2.2.
Types of Malnutrition ................................................................................................................. 11
2.3.
Causes of malnutrition ................................................................................................................ 11
2.3.2. Underlying causes of malnutrition ............................................................................................ 12 2.4.
Under-nutrition ........................................................................................................................... 12
2.5.
Sign and symptoms of Malnutrition............................................................................................ 13
2.6.
Measurement of malnutrition ...................................................................................................... 13
2.7.
Treatment of malnutrition ........................................................................................................... 15
2.8.
Summary of literature review ..................................................................................................... 20
CHAPTER THREE:- ........................................................................................................................................ 21
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METHODOLOGY ................................................................................................................................. 21 3.1.
Study Area .................................................................................................................................. 21
3.2.
Study period and duration ........................................................................................................... 21
3.3.
Study Population ......................................................................................................................... 21
3.4.
Study Design ............................................................................................................................... 21
3.5.
Sample Size ................................................................................................................................. 21
3.6.
Sampling Technique ................................................................................................................... 22
3.7.
Material and Methods ................................................................................................................. 22
3.8.
Eligibility of Respondents........................................................................................................... 23
3.8.1.
Inclusion criteria ................................................................................................................. 23
3.8.2.
Exclusion criteria ................................................................................................................ 23
3.9.
Data Collection Procedure .......................................................................................................... 23
3.10.
Quality Control ....................................................................................................................... 23
3.11.
Data Analysis .......................................................................................................................... 23
3.12.
Time frame chart ..................................................................................................................... 24
3.13.
Ethical Considerations ............................................................................................................ 24
3.14.
LIMITATIONS ....................................................................................................................... 24
3.15.
Important Of Public Health ..................................................................................................... 25
CHAPTER FOUR: .......................................................................................................................................... 26 RESULTS ............................................................................................................................................... 26 4.1.
Introduction ................................................................................................................................. 26
4.2.
Socio-demographic characteristic. .............................................................................................. 26
4.3.
Dietary Intake of respondents. .................................................................................................... 29
4.4.
Breastfeeding and complementary feeding. ................................................................................ 33
4.5.
Anthropometric index of children ............................................................................................... 36
4.6.
Association between anthropometric measurement and family income ..................................... 38
4.7. Association between acute malnutrition and knowledge of mother for nutritional status on her child 39 CHAPTER FIVE ............................................................................................................................................. 40 Discussion ............................................................................................................................................... 40 Chapter Six .................................................................................................................................................. 43 Conclusion and Recommendation .......................................................................................................... 43 6.1.
Conclusion .................................................................................................................................. 43 [x]
6.2.
Recommendation ........................................................................................................................ 44
6.3.
Recommendations for further studies ......................................................................................... 45
REFERENCES ....................................................................................................................................... 46 APPENDICES ................................................................................................................................................ 50 APPENDIX I: Informed consent ........................................................................................................... 50 APPENDIX II: Questionnaire ................................................................................................................ 52 APPENDIX III: Investigator Curriculum Vitae (Annexure 1) .............................................................. 57
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List of tables Table 1: socio-demographic characteristic of the study population. ............................................ 26 Table 2: Dietary Intake of respondents. ........................................................................................ 29 Table 3: Breastfeeding and complementary feeding pattern of the mothers. ............................... 33 Table 4: Association between anthropometric measurement and family income ........................ 38 Table 5: Association between acute malnutrition and knowledge of mother for nutritional status on her child ................................................................................................................................... 39
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List of figures Figure 1Educational status of the mother ..................................................................................... 28 Figure 2family income .................................................................................................................. 28 Figure 3Daily Intake of (cereal, grain and products). ................................................................... 31 Figure 4Daily use of Legumes and legume products.................................................................... 32 Figure 5Daily consumption of milk, milk products. ..................................................................... 32 Figure 6Immunization status of the children ................................................................................ 35 Figure 7knowledge of mother in practice of nutritional status on her child ................................. 35 Figure 8malnutrition status based on Middle Upper arm Circumference (MUAC) ..................... 36 Figure 9 Chronic Malnutrition ...................................................................................................... 36 Figure 10Acute Malnutrition ........................................................................................................ 37
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Abbreviations WHO World Health Organization WFP
World Food Program
PEM Protein energy Malnutrition UNPD United Nations Population Division UNSD United Nations 3 Statistics Division BMI Body mass index IDD Iodine Deficiency Disease AIDS acquired immune deficiency syndrome MAUC mid Upper Arm Circumference PEG percutaneous endoscopic gastrostomy, UNICEF United Nations Children's Fund MCH Maternal Child Health
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1. Title of Research Proposal Assessment of nutritional status of under five years old children in Banadir Hospital Mogadishu Somalia. 2. Investigator (CV is annexed: page 57) Abdi Kadir Ahmed Omar MPH/ID#: 171-41-524 Major in Nutrition Tell: +8801632552137 Email:
[email protected] 3. Place of the study: This study was conducted in Mogadishu City, Banadir region, Somalia. 4. Type of the study: A cross sectional, descriptive study. 5. Duration of the study 5.1. Start Date: June 15, 2017 5.2. Completion Date: - November 15, 2017 6. Guide: Dr. Nadira Mehriban Assistant Professor Department of Public Health Daffodil International University Dhaka-1207, Bangladesh
7. Signature of the investigator
Date:
8. Endorsement of Guide:
Date:
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CHAPTER ONE 1.1.
Introduction
Nutritional status is the balance between the intake of nutrients and the expenditure of these in the processes of growth, reproduction, and health maintenance. Under nutrition, especially in children, can lead to substantial problems in mental and physical development. Undernourished children can also suffer several diseases from nutrient deficiencies. Although the overall pattern of growth is genetically determined, it is significantly affected by nutrition. Socioeconomic status, nutritional knowledge and feeding practices among others are some of the reasons why children maybe undernourished. Female head porters who care for their children, due to the low wages they earn may not be able to afford healthy meals and provide the necessary care for these children.1 Nutrition plays the most important part in growth 2. It influences growth before and after birth 3. Proper nutrition and control are important in promoting the normal growth and development of children. Rapidly growing infants, children and maturing adolescents have specific but not necessarily fixed requirement for macronutrients and micronutrients. It plays a central role in growth and changing body composition. 4 Children are considered as the future of a nation. The health and nutritional status of the child population is a true reflection of the overall health and economic development of a country. Child malnutrition is a widespread public health problem having national and international consequences as adequate nutrition is an essential input for the wellbeing of children. It is well documented that under-nutrition, particularly among children under the age of five years, is the most tragic form of human deprivation. Malnutrition in its several forms of under-nutrition, namely wasting, stunting and under-weight has been coined as the “silent emergency” by the United Nations children‟s fund. It has been associated with endangering the health of women and children across the world.5 Children below the age of five years constitute the most vulnerable segment of the community. Their nutritional status is a sensitive indicator of community health and nutrition, and undernutrition among them is one of the greatest public health problems in developing countries.6 According to WHO, malnutrition is associated with about half of all child deaths world-wide. Malnutrition among under-five children has serious consequences. Malnourished children have [2]
lowered resistance to infection; they are more likely to die from common childhood ailments like diarrheal diseases and respiratory infections, and for those who survive, frequent illness saps their nutritional status, locking them into a vicious cycle of recurring sickness, faltering growth and diminished learning ability7 The nutritional status of any person is his/her health as dictated by the quality of nutrients consumed, and the body‟s ability to utilize them for its metabolic needs. Thus, being nutritionally vulnerable, under-5 children‟s nutritional status is generally accepted as an indicator of the nutritional status of any particular community.8 This is due to their easy susceptibility to malnutrition and infection.9It has been estimated that approximately one out of every three Under-5 children is chronically malnourished and thereby subjected to a pattern of ill health and poor development in early life10with malnutrition being associated with more than half of all deaths of children worldwide11 Early childhood starts from in-uterus to new birth and then through postnatal life. In intrauterine life, the nutritional status of the unborn fetus depends largely on the adequacy of the dietary intake of the mother and this determines the outcome of birth of the new born. Postnatal life is a continuum in human development. Normal growth and development depend largely upon the nutritional status of the new born which is in turn, related directly to the nutrition of the mother and inherited characteristics and to the dietary intake of the infant. In early childhood, nutritional status is of paramount importance for a child‟s later physical, mental and social development. The inadequate or excessive intake of nutrients may result from disease factors that affect digestion, absorption, transport, and utilization of nutrients.12 Malabsorption of nutrients may result from genetic cum environmental conditions or illness. The most critically vulnerable groups are the developing fetus, preschool children, women before and during pregnancy, and lactating women. Malnutrition affects all levels of development physically, mentally, socially, psychologically and physiologically. It thus multiplies the effect of prevailing disease or mortality in children and infants.10 Anthropometric measurements, though difficult to apply to young children, are commonly used to determine the prevalence of Protein-Energy-Malnutrition. They provide the most valid indicator of a population‟s nutritional status and the most reliable indices for determining nutritional status, especially in rural African settlements. This technique is usually preferred [3]
because it is non-invasive, relatively simple and can be easily carried out and interpreted without requiring professional expertise. It deals with techniques highly useful on wide spread field basis, and rests on well adopted classification. It is the readily available method of assessing nutritional status. Through proper assessment, it can be employed to determine how well or how poor a particular group or individual feeds.12 Whatever knowledge gathered from such assessment will help the group or individual to step up or lower food intake for better health. In this study, a combination of anthropometry, dietary assessment and socioeconomic status were used to determine the nutritional status of Under-5 children, since they have been known to give fairly accurate results.13 The study was therefore designed to establish and provide baseline information on the health and nutritional status of the target group, by determining the impact of parental socioeconomic status on the growth, nutritional status and the future outlook of Under-5 children in the study location.
1.2.
Problem statement
The right to adequate food is recognized in several instruments under international law.14Despite this recognition, globally, half of the almost 10 million children under the age of five who die annually do so from a combination of malnutrition and easily preventable disease. The world Health Organization estimates that Approximately 150 million children younger than 5 years in developing countries are underweight and an additional 200 million children are stunted.15 In Somalia malnutrition under five children contributes major current health problems (Morbidity and mortality) in several ways. Under nutrition remains a devastating problem in many developing countries affecting over 815 million people causing more than one half of children death.10,11Although WHO, UNICEF and Somali‟s National Breastfeeding policy recommended that infants be exclusively breastfed from birth to 6 Months and continue breastfeeding to 24 months and beyond for optimal survival, growth Development unfortunately only 9.00% of infants under six months of age are exclusively Breastfed in Somalia.16The poor breastfeeding and inadequate complementary feeding explained the protein energy malnutrition level in children as they grow older.
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1.3.
Justification
In Somalia malnutrition under five children contributes major current health problems (Morbidity and mortality), 19% of under five children are having Malnutrition in Somalia. Somali‟s National Breastfeeding policy recommended that infants be exclusively breastfed from birth to 6 Months and continue breastfeeding to 24 months and beyond for optimal survival, growth Development unfortunately only 9.00% of infants under six months of age are exclusively Breastfed in Somalia.16 Nutritional problems are a major cause of mortality and morbidity in children aged less than five years of age. Several nutritional policies have been suggested to improve the nutritional status but unfortunately they are either not well adopted, not accepted or not afforded by the community. No similar study was proposed to the department before. In Somalia number of malnourished children under five years attending in hospitals were increasing so that it was crucial to assess nutritional status among children less than five years.
1.4.
Operational Definition of Terms
Nutrition: -is the intake of food, considered in relation to the body‟s dietary needs. Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity. Malnutrition; It refers to over or under nutrition, nutrient imbalances or deficiencies. This study will focus on under nutrition. Nutrition Status this is the body‟s status of nutrition that is expressed according to certain scientifically tested parameters including weight, height, age or a combination of them. This study will involve Anthropometry to measure the nutrition status. Good Nutrition is a daily regime of healthy eating which includes all the food groups in their right proportions for one‟s activity level. Chronic Food Shortage is the extreme and protracted shortage of food resulting in wide spread hunger and substantial increase in the death rate.
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Anthropometrics: Anthropometry is widely used as a tool to estimate the nutritional status of populations and to monitor the growth and health of individuals. The three most frequently used anthropometric indices are weight-for-height, height-for-age, and weight-for-age. Chronic malnutrition, or stunting, is form of growth failure, it is relationship between observed height to the expected height for the specific age and sex of the child (H/A). Slum, according to the United Nations agency UN-HABITAT (2005), is a run-down area of a city characterized by substandard housing and squalor and lacking in tenure security. Acute Malnutrition (Wasting) is inadequate nutrition over long period of time leading to failure of linear growth. This phrase refers to the relationship between body mass and body stature of the child (W/H). Good knowledge: those mothers who answer correctly the breastfeeding and complementary feeding questions and if they score the median value and above Poor knowledge: those mothers who answer correctly the breastfeeding and complementary feeding questions and if they score the below median value
1.5.
Variables
1.5.1. Dependent variable The dependent variable for the study was the nutritional status of the children under five years old.
1.5.2. Independent variables The independent variables for the study included social economic, demographic, daily dietary intake, knowledge and practice of mothers regarding children‟s nutrition
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1.6.
The Conceptual Frame Work
Anthropometry;
Child Nutrition Status
MUAC, Weight for Height, Height for Age. Weight for
Age
Dietary Diversity
Food reserves
Access to food
Socio economic attributes and Caregivers Knowledge on child nutrition, Availability of food. Daily food intake
The Nutritional status of children is dependent on several factors which include dietary intake that is in turn influenced by food variety and frequency of food intake. Food reserves and access to food and socio economic attributes determine the nutritional status. Anthropometric measurements reflect the nutritional status of children.
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1.7.
Research questions What is the level nutritional status of under five years old children in Banadir hospital in Mogadishu Somalia?
1.8.
OBJECTIVES
1.8.1. General Objectives To assess the level of nutritional status of under five years old children by using anthropometric measures in Banadir hospital, Mogadishu Somali.
1.8.2. Specific objectives are as follows
To determine the socio economic status of subjects parent in Banadir hospital in Mogadishu Somali.
To determine the usual dietary intake of the subjects and assess the adequacy.
To assess the knowledge and practice of mother regarding to infant feeding, breastfeeding and immunization.
To determine association between anthropometric measurement and family income
To find out association between acute malnutrition and knowledge of mother of nutritional status on her child.
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CHAPTER TWO LITERATURE REVIEW 2.1.
Malnutrition
The World Health Organization (WHO) says that malnutrition is the largest contributor to child mortality globally, currently present in 45 percent of all cases. Underweight births and interuterine growth restrictions are responsible for about 2.2 million child deaths annually in the world. Deficiencies in vitamin A or zinc cause 1 million deaths each year. WHO adds that malnutrition during childhood usually results in worse health and lower educational achievements during adulthood.17
2.1.1. Child malnutrition About one sixth of the populations of the world‟s developing nations are malnourished. Over 200 million of them are children.18 Under nutrition is the underlying cause of more than half of all deaths in children aged less than five years and is associated with infectious diseases.19 Underweight is the leading underlying cause of disability and illness worldwide. In the course of one year, the number of children who die from malnutrition is over 3 milslion.20 2.1.2. Nutritional status of children Nutritional status of children is a proxy indicator for assessing the entire population health status and one of the major predictors of child survival. Despite the various efforts, malnutrition among children is remaining as a major public health problem in Nepal. This study was conducted to assess the nutritional status of under-five year children and to find out the factors associated with childhood malnutrition.21
2.1.3. Macronutrients Protein, fat and carbohydrates are macronutrients that make up the bulk of a diet and supply the body‟s energy. In resource-poor populations, carbohydrates (i.e. starches and sugars) are often a large part of the diet (80%) and the main source of energy. Fats are also important in cell formation. Proteins are required to build new tissue and derived mostly from animal origin such as milk, meat and eggs, and from cereals and pulses. Animal by-products contain essential amino acids that cannot be produced by the body but must be eaten to promote growth and food health.22 [9]
2.1.4. Micronutrients There are around forty different micronutrients that are essential for good health. Formal functional point of view. Micronutrients can be divided into two classes: type I and type II. Type I micronutrients, or functional nutrients, include nutrients that are required for the hormonal, immunological, biochemical and other processes of the body. They include iodine, iron, vitamins A and C among others. Deficiencies in type I micronutrients do not affect growth directly (i.e. the individual can have the normal growth with appropriate weight and still be deficient in micronutrients) and thus a deficiency in type I micronutrients cannot be identified by anthropometric measurements. Deficiencies in type I micronutrients will cause major illness such as anemia, scurvy and impaired immunity. Type II micronutrients, or growth nutrients, include magnesium, Sulphur, nitrogen, essential amino acids, phosphorus, zinc, potassium, sodium and chloride. They are essential for growth and tissue repair. Type II micronutrients are required only in small quantities by every cell and system, but the correct balance is essential for good health. A deficiency in any of the type II micronutrients will lead to growth failure, measured by stunting and /or wasting. Replacement of all these nutrients, in the correct balance, is essential for recovery from malnutrition and restoration from acute illness. 22
2.1.5. Water Most of the body is water. Water is necessary for good nutrition as well as for maintaining hydration. Only half of the body‟s water is obtained through drinks, the rest being absorbed from foods and produced by the body. Water often needs to accompany in order to provide good dilution and absorption of nutrients.24
2.1.6. Breastfeeding Breast milk is a valuable, readily available resource with extensive short- and long-term benefits for both mother and infant. It is essential that health professionals understand the benefits and management of breastfeeding and that this topic be included in their education and training. Health professionals can thus insure the improved health and development of almost all infants, children23
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2.1.7. Breast-milk Composition Human milk is radically different from cow‟s milk and even from prepared infant formula, despite attempts to modify formulas to make them similar to breast-milk. Breast-milk is extremely low in protein (about 0.9g/100 mL) compared with raw cow‟s milk, which has nearly four times the concentration of protein. Infant formulas are diluted to provide a low protein concentration that is comparable to human milk, but the protein structure (which is more difficult for young infant to absorb) remains the same as that cow‟s milk. Breast-milk composition varies during the course of breastfeeding colostrum, the initial milk, is higher in protein and lower in fat and lactose concentrations than mature milk. Throughout the course of lactation, secretory IgA concentration gradually declines, allowing the infant‟s own immune system to develop and lose its dependency on the mother‟s sources. Because the mother and infant share the same environment, the mother develops and secretes specific antibodies to the viruses and bacteria to which the infant is exposed. This response is rapid, requiring only a few days.24
2.2.
Types of Malnutrition 1. Under nutrition: too little
Protein Energy Malnutrition (PEM)
Micronutrient deficiencies.
2. Over nutrition: too much
2.3.
Obesity
Chronic diseases (diabetes, hypertension)25
Causes of malnutrition
In generally there are two main causes of malnutrition A. Immediate causes of Malnutrition B. Underlying causes of malnutrition
2.3.1. Immediate causes of Malnutrition Malnutrition, is defined as an imbalance between the supply of nutrients and the body‟s demand for growth, maintenance, and specific functions (World Health Organization, WHO) in other words, adequate nutrition is indispensable for physical development and maintenance, resistance to disease and capacity to work. Malnutrition is the effect of an unbalanced diet and/ or disease [11]
(e.g. tuberculosis, HIV) inadequate food intake (in quality or quantity) leads to increased sensitivity for infections. Infections often cause nutrient mal-absorption and reduced food intake such appetite, nausea what can lead to malnutrition, 26
2.3.2. Underlying causes of malnutrition At the household and community level, the UNICEF Framework of Underlying causes of Malnutrition and mortality identifies three underlying factors that influence nutritional status: Household food security, health and environment, and social and care environment. These factors are interrelated and need to be assessed; interventions should address insufficient access to food, poor water/sanitation, inadequate health services and inadequate care for the vulnerable. In many developing countries long-term (chronic) malnutrition is widespread - simply because people do not have enough food to eat, 26
2.4.
Under-nutrition
Under-nutrition is a condition caused by a lack of food of good nutritional value combined with interaction from infections. Micronutrient deficiency is caused by poverty, food insecurity, lack of knowledge, and lack of distribution of adequate resources. Body mass index (BMI) for age, is used to classify the nutritional status of a child. BMI is calculated by dividing the weight, in kilograms (kg), by the height squared in meters (m) 10
2.4.1. Protein energy malnutrition Protein energy malnutrition (PEM) is now regarded as a dangerous form of malnutrition basically caused by a lack of energy and protein. Kwashiorkor is a form of malnutrition caused by inadequate protein intake, while marasmus is caused by a lack of energy and protein within the diet. Estimated globally, 854 million people are undernourished, with 820 million of these living in developing countries. Poverty is associated with malnutrition and the level of PEM is also affected by political, economic, seasonal and climatic conditions, education and sanitation levels, food production and prevalence of disease PEM is associated with poor weight gain, slow linear growth and behavioral changes such as irritability, anxiety and attention deficit 27.
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2.5.
Sign and symptoms of Malnutrition
Symptoms of malnutrition are easily distinguishable among both adults and children. They may be outlined as follows.
2.5.1. Symptoms of malnutrition in children •
Growth failure. This may be manifested as failure to grow at a normal expected rate in terms of weight, height or both.
•
Irritability, sluggishness and excessive crying along with behavioral changes like anxiety, attention deficit are common in children with malnutrition.
•
The skin becomes dry and flaky and hair may turn dry, dull and straw like in appearance. In addition, there may be hair loss as well.
•
Muscle wasting and lack of strength in the muscles. Limbs may appear stick like.
•
Swelling of the abdomen and legs. The abdomen is swollen because of lack of strength of the muscles of the abdomen. This causes the contents of the abdomen to bulge out making the abdomen swollen. Legs are swollen due to edema. This is caused due to lack of vital nutrients. These two symptoms are seen in children with severe malnutrition.
2.5.2. There are classically two types of protein energy malnutrition (PEM) in children. These are Marasmus and Kwashiorkor. •
In Marasmus there may be obvious weight loss with muscle wasting. There is little or no fat beneath the skin. The skin folds are thin and the face appears pinched like an old man or monkey. Hair is sparse or brittle.
•
In Kwashiorkor the child is between 1 and 2 with hair changing color to a listless red, grey or blonde. Face appears round with swollen abdomen and legs. Skin is dry and dark with splits or stretch marks like streaks where stretched.
•
2.6.
In nutritional dwarfism the patient appears stunted in growth.28
Measurement of malnutrition
Classification of malnutrition In emergency situations where acute forms of malnutrition are predominant, the weight – for height index is the appropriate tool to quality acute malnutrition in the population (along with the assessment of edema and MUAC). Furthermore, these do not require the determination of age what is often difficult in these situations, 29 [13]
2.6.1. Acute and chronic malnutrition Acute malnutrition (Wasting)
Chronic malnutrition (stunting in children)
Weight –for-height
Height-for age
Weight-for-age
weight-for age
Mid-upper arm circumference
Body mass index
2.6.2. Body mass index Two systems of classification are used when defining acute malnutrition in individuals or in population: •
Individuals: Moderate acute or severe acute.
•
Population: severe acute and global acute. Global acute malnutrition refers to the total cases of moderate acute and severe acute malnutrition in a population.
The main anthropometric indices are used for children and adolescents W/H, bilateral edema and MUAC and for adults bilateral edema, MUAC and BMI.
2.6.3. Weight –for-height W/H does not require any specification of age; it is therefore a useful tool in crisis situations, where age is often difficult to obtain. W/H can identify minor deterioration or improvement in nutritional status of individual children, 29
2.6.4. Height-for-age H/A is an index of chronic malnutrition, when nutrition is inadequate for a long period of time, children grow slowly. The height is reduced, compared to other children of the same age. This is called “stunting”. H/A reflects an individual‟s nutritional status over time. H/A should not be used as a criterion for the admission of children into feeding programmes. 2.6.5. Weight-for-age W/A can be used to identify both chronic malnutrition (stunting) and acute malnutrition (wasting). W/A is used to minor the individual growth of children; this is generally done using” the Road to Health Chart” in clinics. Since W/A does not differentiate between acute and chronic malnutrition, is should not be used as a criterion for the admission of children into feeding programmes aiming at actually malnourished children, 29
[14]
2.6.6. Mid Upper Arm Circumference (MUAC) MUAC is particularly sensitive to acute weight loss, as it reflects the peripheral wasting of muscle and subcutaneous adipose tissue. MUAC findings provide a rapid indication of the risk mortality. Persons with MUAC below 110mm are at risk of death (only valid for older than 1 year). MUAC remains relatively stable between the ages 1 and 60 month, so that only one cut off point can be used. Agencies use different cut off values, the most commonly used cut off points are given below.
2.6.7. MUAC cut-off points for children 1-5year Acute malnutrition MUAC Severe
