Malnutrition

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

We studied health and nutritional status, feeding practices, and the reasons behind adoption of infants, in urban slums of Dhaka, the capital city of Bangladesh. Foster mothers of 46 young children (0 to 24 months old) were interviewed. Of these children (n=40, without pedal oedema), 93 % were underweight, 62% had wasting, and 70% were stunted while 13% had marasmic-kwashiorkor. Ninety-percent children were fed animal and/or formula milk and 7% received gruel with milk in their first month of life. The practice of giving gruel with milk increased with advancing age. These children often suffered from diarrhoea, cough and/or fever, skin diseases, oral thrush etc. Fifty four percent of these mothers had no biological relationship with the adopted child and 76% of them owned no child. Aunt adopted 35% of these children, and rests were by grand mother. Sixty five percent of them lost their own mother, of them 83% died during their complicated delivery while 11% mother died due to diseases of diverse cause. Thirty three percent of adopted children had own mother still alive, however, 73% of the children were given to others to be adopted because of mothers’ poverty. Maternal death, childlessness of mother, and poverty were important factors for adoption.

Studies conducted in several areas of Bangladesh have identified serious problems in practices of infant feeding. Mothers discard colostrum, delay in initiation of breastmilk and give newborns pre-lacteal feeds like honey, sugar water, cow's milk or artificial milk or even water. Exclusive breastfeeding for the first 5-6 months is practised by about 4 percent mothers. A study was conducted to identify the factors associated with colostrum feeding; pre-lacteal feeds; and failure to exclusive breastfeed for the first 5 months of life in Bangladesh. The study was carried out among a total of 582 children, of which 126 were exclusively breastfed and 456 were partially breastfed. Logistic regression analysis yielded certain factors causing mothers to exclusively breastfeed the child for 4 months or more. The analysis showed that a mother was more likely to exclusively breastfeed her child a) if she had more than 2 children; b) if she belonged to lower economic class; c) if she believed that a child should be exclusively breastfed for 5 months or more; and d) mothers who had sufficient breastmilk. It was also found that if the newborns were not separated from the mothers they were more likely to be exclusively breastfed. The logistic regression analysis also yielded some factors causing mothers to feed colostrum. Such factors were education of husband, exposure to health workers during pregnancy and types of persons attending the delivery. Feeding pre-lacteal foods was found to be almost universal. It was recommended that the primary health care programs should address the following issues: irrespective of sex of children, they should be exclusively breastfed for 5 months; the concept of exclusive breastfeeding should be promoted at the community level with special attention to the better off families, newborns should be kept in touch of mothers immediately after birth; and health workers should advocate for colostrum feeding during pregnancy of mothers.

The present study intended to evaluate the effectiveness of a dietary algorithm in hospital management of protein energy malnutrition (PEM) Study patients (n=45) had mean age 8.9±1.8 months, weight for length < 75% of median reference, oedema (in only 13 cases). All except 9 had haemoglobin < 10 g/ dL , associated pneumonia was present in 9 cases. Patients were submitted to clinical examination, anthropometric measurements and routine laboratory tests. Associated pneumonia or diarrhoea were treated according to standard guidelines. Diet started immediately after admission or after rehydration (4-6 hr). All patients were given diet I (yoghurt 100 mL, sucrose 5g, palm oil 2g) by nasogastric tube. Failure cases as expressed by development of diarrhoea with weight loss at any time or no weight gain within 7 days, were shifted to diet II (skimmed milk powder 6g, rice powder 6g, sucrose 6g, water to make 100 mL) and if failed patient was shifted to diet III (cooked chicken meat 6g, rice powder 1.5g, palm oil 2g, glucose 1.5g , water to make 100 mL ). The amount supplied was 150 mL /kg divided into 8-12 feeds daily. Vitamins and minerals were supplied in double the daily requirements. Results revealed that 38 (84.4 %) responded to diet I, 4 ( 8.9 %) to diet II and 1 (2.2% ) to diet III . Two patient died from septicaemia while on diet I. Patients who did not respond to diet I were younger and more severely malnourished. On follow-up after two months (n=31), satisfactory weight gain was observed in 20 cases (64.5%), the remaining 11 cases (35.5%) had nearly stationary weight with recurrent diarrhoeal episodes. It is concluded that this dietary algorithm is suitable to treat severe forms of PEM and even diet I can be prepared at home for ambulatory patients. However, intensive nutrition education and follow-up is required to prevent recurrence.

P26 - Vitamin A (VA) and Iron Status of Mothers and their Children in Rural Bangladesh.

Objective: Assess the VA and iron status of mothers and children and to examine the relationship among these biochemical indices. Design: A cross-sectional study. Setting: 8 randomly selected sub-districts of rural Bangladesh. Subjects: Mothers (n=1091) aged between 17 and 53 years and children (n=1289) 2-6 years old participated in the study. Results: While anaemia among mothers was common (59%), IDA constituted 23%. Six percent of the mothers had low levels of serum retinol (<0.70 m mol/L) and 7% of mothers had both IDA and low serum retinol. Nearly half of all children were anaemic (Hb <110 mg/dL) and 18% had IDA. Twenty percent of the children had low levels of serum retinol. The proportion of anaemia, iron depletion, and low serum retinol content in women remained same with a progressive increase in age except IDA. Although proportion of low serum retinol and iron depletion remained same, a significant declining trend (p=0.001) in proportion of anaemia, and IDA in children with advancing age was observed. IDA and low serum retinol constituted 13% children. When age, ferritin level, family size, green leafy vegetables consumption, practice of home-gardening, and duration of vitamin A intake were accounted for by multiple regression analysis, a significant relationship of serum retinol content with female child, Hb level, CRP concentration, household expenditure and stunting of children was observed. The study also showed that there is an interaction among serum retinol concentration, BMI, Hb level, CRP concentration, household expenditure, and practice of home-gardening while adjusting for mother’s age, family size, green leafy vegetables consumption, and ferritin concentration. Conclusions: Our observations indicate that the interactions among Hb and vitamin A and other micronutrients need to be more defined. These results may have important implications on the design of effective interventions for mothers and children with concomitant IDA and low serum retinol concentrations.

P28 - Impact of Nutrition Education in Adjunct with Food Supplementation in Rehabilitating Malnourished Children in Urban Slum Community in Dhaka, Bangladesh

Objectives: Study the impact of nutrition education in adjunct to food supplementation in rehabilitating malnourished children in urban slums of Dhaka, Bangladesh. Methods: Two groups of 68 malnourished children aged 6 to 36 months (having weight for age less than 75% of the median NCHS) were screened out from two distantly located slums in urban Dhaka to enrol for the study. The intervention group received nutrition and health education (for 2 months) in adjunct to food supplementation and the comparison group received only food supplementation. Both groups had received a diet consisting of roasted maize and pulse in powdered eaten when properly cooked which was supposed to allow approx. 200-kcal/day energy for five days a week for a period of 2 consecutive months. Anthropometry was carried out and morbidity profile was recorded on 30^th and 60^th day of intervention. Results: Significant weight gain was observed on the 30^th day of intervention among the children of intervention group (78 g/kg) than their comparison counterparts (52 g/kg), p<0.029. Weight of children from intervention group (50 g/kg) also increased significantly than that of comparison group (36 g/kg) on the 60th day of supplementation, p<0.017. On an average, children from intervention group gained 43 g/kg excess weight, in total, than that of comparison group. Increment of weight for age (W/A) of the median NCHS was also significantly higher among the children in intervention group (4.3) than the comparison one (2.9), p<0.05, after two months of intervention. Mean height increment was found significantly higher at the end of intervention than their baseline height for all the children (1.85 cm, p<0.001) but, however, the height increment didn’t differ between the two groups. Among the study children in both groups, the prevalence of diarrhoea was observed significantly decreased after intervention (25% in baseline to 18% after intervention, p<0.003) and respiratory infection (RI) though decreased but it was not statistically significant (63% at baseline to 41% after intervention). Moreover no significant difference was observed in the prevalence of diarrhoea and RI between the two groups of study children in baseline or after intervention. Conclusion: Health education in conjunction with food supplementation is more effective than only supplementation to improve the nutritional status among the undernourished children. We strongly recommended that further better designed study of this nature is to be carried out to find out the duration and the appropriate food supplementation needed for rehabilitating malnourished children.

Objectives: Assess whether iron supplementation increase the haemoglobin (Hb) level among ascaris infested anaemic children belonging to a minority group of Bihari ethnicity (originated from Pakistan) living in Dhaka urban slum, Bangladesh. Subjects and methods: A community based placebo controlled clinical trail was conducted among 2-12 years aged anaemic children (baseline Hb<11g /dL) infested with round worms (Ascaris lumbricoides). One hundred fifty seven children were divided into 2 groups: 79 subjects were dewormed (with pyrantel pamoate at a single dose of 11mg/kg body weight) and the rest 78 were not. Of the 79 dewormed children 39 children were supplemented with iron (receiving an iron syrup at a age-dependent therapeutic dose of 100 to 150 mg ferrous fumerate); and the rest 40 received placebo (receiving a non-iron syrup at similar dose), daily, for 5 consecutive months. Of the 78 non-dewormed children, 37 received iron and the rest 41 did not. Prior to final enrolment, the subjects were screened out for (i) Ascaris lumbricoides infestation (employing a parasitological examination of stool microscopy: FEC method), and, (ii) anaemia (determining haemoglobin level <11mg/dl, estimated employing cyanmethemoglobin method). Results: Statistical analysis revealed significant positive change (p<0.001) in the Hb level among the dewormed children receiving iron supplementation (2.1 g/dL) in comparison to that of receiving placebo (0.4 g/dL). Moreover, dewormed iron supplemented children had better Hb values (p<0.001) than their non-dewormed counterpart receiving placebo (0.3 g/dL); but it did not differ statistically than that of the non-dewormed children receiving iron supplementation (1.9 g/dL). Similarly, post-intervened Hb level of non-dewormed iron-supplemented children increased more in comparison to that of, both, dewormed (p<0.001), and/or, non-dewormed, placebo (p<0.001) groups. Further, in all four groups of children, post-intervened Hb level was increased significantly (p<0.001); but more higher positive changes were revealed among the children of combined iron supplemented group (2.0 g/dL) in comparison to the placebo (0.4 g/dL) ones (p<0.001). However, around 65% iron-supplemented children showed a Hb level of >11g/dl compared to that of 3% in placebo group. Thus the rate of increment of Hb among iron-supplemented children was negatively correlated with that of the baseline data (r= -0.5, p<0.001). Conclusion: Iron supplementation was effective in raising Hb level among these ascaris infested anaemic children, but no significant benefit was observed with anti-helminthic treatment among them.

P31 - Growth Evaluation and Occurrence of Malnutrition in Children Aged 0-59 Months in Cameroon.

In 1996 a household survey was carried out in Cameroon during which anthropometric measures were performed on 1078 children aged 0-59 months. Weight for age (W/A), weight for height (W/H) and height for age (H/A) indices were expressed as Z-score with cutoff < -2 STD using NCHS reference median. 19% of children were underweight, 8.1% were wasted and 30% were stunted. W/A and H/A showed a significant sex group difference. The proportions of underweight and stunted individuals were statistically higher among boys than among girls, 22.2% vs 16.6% and 33.1% vs 26.8% respectively. The protein-energy malnutrition was statistically higher in rural area than in urban area regarding the three indices: 25.4% vs 14.7% for W/A; 10.0% vs 6.4% for W/H and 40.8% vs 24.9% for H/A. Boys showed higher prevalence in stunting and wasting in rural area than in urban area and than girls as well. The prevalence of underweight was statistically higher among children from poor standard of living (PSL, 25.6%) followed by children from intermediate standard living (ISL, 17.4%), then children from high standard of living (HSL, 11.3%). The same trends prevailed in wasting and stunting (p=0.000). The distribution of the three indices showed a significant sex group difference among the three standards of living in children. The proportions were higher among boys than among girls. The findings seemed to indicate that there was a high prevalence of protein-energy malnutrition among children aged 0-59 months which might have been caused by the long lasting economic crisis. (Funded by the European Union and the World Bank)

A study was conducted in 1998 in a rural area of Bangladesh to see the impact of Zinc and Vitamin A supplementation on improvement of growth of children 6-36 months and reduction of severity of diarrhoea and ARI. It was also planned to see the comparative and additive effect of Vitamin A on growth and morbidity of children. The study was conducted on the children who were moderately malnourished and aged between 6 and 36 months. After recruitment and selection, the subjects were randomly allocated to either Zinc, Vitamin A, or both in multivitamin syrup in a double blind randomised control trial. The treatment groups received 40 mg Zinc, Vitamin A 200,000 IU above one year, 100000 IU Vitamin A to below 1 year and both Zinc and vitamin A in a similar MV masked syrup per day in two divided doses for seven days, and repeated at 6 months intervals and followed up for 1 year. Patients were followed up at 15 days interval for anthropometry and weekly for morbidity record. The study showed mixed results of Zinc supplementation in young infants. After the first dose there was significant difference in weight gain after 3 months of Zinc supplementation compared to Vitamin A. Children receiving Vitamin A always showed less growth than children receiving Zinc. After the second dose, children in Zinc group showed increased weight gain than those in Vitamin A. Children above 2 years in combined Zinc & Vitamin-A group increased in length during 1 year of follow-up significantly more than those in Vitamin-A alone. Similarly children above 18 months increased in weight in Zinc supplemented group compared to those with Vitamin A after 3 months of the first dose supplements. Likewise, more increase in length was seen in these groups after 1 year of follow-up with 2 week doses of Zinc supplementation compared to Vitamin A supplementation. In our study we observed that Zinc supplementation reduced diarrhoea and respiratory infection in malnourished children. The mean number of days with blood dysentery was significantly less in children with Zinc + Vitamin A compared to those with Zinc supplementation alone and dysentery was significantly low in combined group compared to Vitamin A. The mean number of attacks was less in Zinc + Vitamin A supplemented group compared to Zinc or Vitamin A alone. Children with Zinc supplementation had significantly low duration of diarrhoea per attack compared to combined group and also had less duration than Vitamin A, but not significantly. There was a significantly shorter period of illness in children with Zinc supplementation alone compared to the combined group. Mean duration (in days) of ARI per attack in Zinc and Vitamin A supplementation group was less than the Vitamin A group.

P34 - Determinants of Severe Stunting in Children in Rural Bangladesh: Maternal Short Stature and Environment.

Objective: To evaluate the association of maternal short stature and severe stunting in under-five children in a rural area of Bangladesh. Design: A Nutritional survey during November and December 1999. Setting: Chilmari, a rural area of Northern Bangladesh. Subjects: Eight hundred and forty-two children between 6 and 59 months of age from 744 households were randomly selected for the survey. Main outcome measure: Severe stunting. Results: The prevalence of short stature (height < 145 cm) among mothers was 14%, the prevalence of stunting (Height-for-age Z--score (HAZ): less than –2 SD of NCHS reference) among children was 51%, and prevalence of severe stunting (HAZ < -3 SD) was 20%. In the crude analysis, mothers with short stature were more likely to have severely stunted children (Odds ratio (OR) = 2.5; 95% confidence interval (CI) = 1.5 to 4.0; P-value <0.001). In a multiple regression model, the odds ratio for severe child stunting was reduced, but remained significant with OR = 2.0; 95% CI = 1.2 to 3.5; P-value = 0.01 after adjustment of child age, birth order, illness, mother’s age at birth, mother’s body mass index (BMI), mother’s education, possession of cultivable lands, source of rice for consumption, total expenditure for food, education of the household head, crowding, and vulnerability to crisis. However, there was no significant association between short maternal stature and moderate child stunting (HAZ –2 to –3) (OR = 1.1; 95% CI = 0.7 to 1.9; P = 0.574). Conclusion: Maternal stature, reflecting her potential height and early environment, appeared to be an independent risk factor for severe child stunting in rural Bangladesh. However, a part of the association between short maternal stature and severe stunting could be explained by the environmental factors.

Questions or comments to info@capgan.org or Fax: +852 26360020 or Tel: +852 26322861

Last modified: December 10, 2001