Nutritional Assessment, Prevalence and Predictors of Malnutrition among Children Aged 0 – 5 Years

World Health Organisation (WHO) (2020) defines malnutrition as deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins and minerals). The other is overweight, obesity and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and cancer).

In the opinion of Yvette (2020), Malnutrition refers to when a person’s diet does not provide enough nutrients or the right balance of nutrients for optimal health. This according to her is as a result of inappropriate dietary choices, a low income, difficulty obtaining food, and various physical and mental health conditions.

Mother and Child Nutrition (2019) noted that child malnutrition is the single biggest contributor to under-five mortality due to greater susceptibility to infections and slow recovery from illness. Children who do not reach their optimum height or consistently experience bouts of weight loss during childhood are affected in the long term in numerous ways. They do not reach their optimum size as adults (and so may have less physical capacity for work), their brains are affected (resulting in lower IQs) and they are at greater risk of infection (which kills many children during their early years).

Child malnutrition impacts on education attainment. The degree of cognitive impairments is directly related to the severity of stunting and iron deficiency anaemia. Studies show that stunted children in the first two years of life have lower cognitive test scores, delayed enrolment, higher absenteeism and more class repetition compared with non-stunted children. Vitamin A deficiency reduces immunity and increases the incidence and gravity of infectious diseases resulting in increased school absenteeism. Child malnutrition impacts on economic productivity. The mental impairment caused by iodine deficiency is permanent and directly linked to productivity loss.

Prevalence of Malnutrition among Children Aged 0 – 5 years in Nigeria

The worldwide malnutrition estimation rates indicate that 35.8% of preschool children in developing countries are underweight, 42.7% are stunted, and 9.2% are wasted (Müller & Krawinkel, 2005). In children aged 6–59 months, an arm circumference less than 110 mm is also indicative of severe acute malnutrition. Apart from marasmus and kwashiorkor (the 2 forms of protein- energy malnutrition) micronutrient deficiencies also exist among these children. Deficiencies in iron, iodine, vitamin A and zinc are the most common in developing countries. In these communities, a high prevalence of poor diet and infectious disease regularly unites into a vicious cycle (Sachdev, 1996).

United Nations Children’s Fund (UNICEF) (2020) declares that Nigeria has the second highest burden of stunted children in the world, with a national prevalence rate of 32 percent of children under five. An estimated 2 million children in Nigeria suffer from severe acute malnutrition (SAM), but only two out of every 10 children affected is currently reached with treatment. Seven percent of women of childbearing age also suffer from acute malnutrition.  The States in northern Nigeria are the most affected by the two forms of malnutrition – stunting and wasting. High rates of malnutrition pose significant public health and development challenges for the country. Stunting, in addition to an increased risk of death, is also linked to poor cognitive development, a lowered performance in education and low productivity in adulthood – all contributing to economic losses estimated to account for as much as 11 percent of Gross Domestic Product (GDP).

The prevalence of stunting and severe stunting were 29% for children aged 0–23 months, and 36.7% children aged 0–59 months. Multivariate analysis revealed that the most consistent significant risk factors for stunting and severe stunting among children aged 0–23 months and 0–59 months are: sex of child (male), mother’s perceived birth size (small and average), household wealth index (poor and poorest households), duration of breastfeeding (more than 12 months), geopolitical zone (North East, North West, North Central) and children who were reported to having had diarrhoea in the 2 weeks prior to the survey (Akombi, Agho, Hall, et al., 2017).

Causes (Contributory Factors) of Child Malnutrition

According to Mother and Child Nutrition (2019), the main underlying preconditions that determine adequate nutrition are food, health and care: the degree of an individual’s or a household’s access to these preconditions affects how well they are nourished

Food Quantity and Quality

Food security exists when, at all times, everyone has access to and control over sufficient quantities and quality of food needed for an active and healthy life. For a household this means the ability to secure adequate food to meet the dietary requirements of all its members, either through their own production or through food purchases. Food production depends on a wide range of factors, including access to fertile land, availability of labour, appropriate seeds and tools and climatic conditions. Factors affecting food purchases include household income and assets as well as food availability and price in local markets. In emergency situations, other factors may come into play including physical security and mobility, the integrity of markets and access to land. On an immediate level, malnutrition results from an imbalance between the required amount of nutrients by the body and the actual amount of nutrients introduced or absorbed by the body. Adequacy of food intake relates to the quantity of food consumed, the quality of the overall diet with respect to various macronutrients and micronutrients, the energy density and palatability of the food consumed and how frequently the food is consumed (Mother and Child Nutrition, 2019).

Health and Sanitation Environment

Access to good quality health services including affordability, safe water supplies, adequate sanitation and good housing are preconditions for adequate nutrition. Inadequate sanitation and hygiene is a major contributing factor for anaemia due to the link with intestinal worm infection. Health and nutrition are closely linked in a “malnutrition-infection cycle” in which diseases contribute to malnutrition, and malnutrition makes an individual more susceptible to disease. Malnutrition is the result of inadequate dietary intake, disease or both. Disease contributes through loss of appetite, malabsorption of nutrients, loss of nutrients through diarrhoea or vomiting. If the body’s metabolism is altered the greater the risk of malnutrition (Mother and Child Nutrition, 2019).

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Social and Care Environment

The social and care environment within the household and local community also can directly influence malnutrition. Appropriate childcare, which includes infant and young child feeding practices, is an essential element of good nutrition and health. Cultural factors and resources such as income, time and knowledge also influence caring practices as well as attitudes to modern health services, water supplies and sanitation. While it is true that improving care for young children is vital, the emphasis on behavioural change should be accompanied by an understanding and commitment to addressing the economic constraints placed on caregivers (Mother and Child Nutrition, 2019).

Signs and Symptoms of Child Malnutrition

Khan, Khan, Zia-ul-Islam et al., (2017) described malnutrition as a deficiency caused by poor diet in term of under nutrition and over nutrition. The signs and symptoms of malnutrition were highlighted as loss of fat (adipose tissue), breathing difficulties, a higher risk of respiratory failure, higher risk of complications after surgery, higher risk of hypothermia, abnormally low body temperature, higher susceptibility to feeling cold, longer healing times for wounds, longer recover times from infections, longer recovery from illnesses, lower sex drive, problems with fertility, reduced muscle mass, reduced tissue mass, fatigue, or apathy and irritability etc. The following are some of the common signs any symptoms to watch out for among children include:

  1. Unintentional weight loss
  2. Low body weight
  3. Lack of interest in eating and drinking
  4. Feeling of fatigue
  5. Feeling weakness
  6. Improper growth of a child.

Consequences of Child Malnutrition

According to Mother and Child Nutrition (2019), child malnutrition is the single biggest contributor to under-five mortality due to greater susceptibility to infections and slow recovery from illness. Children who do not reach their optimum height or consistently experience bouts of weight loss during childhood are affected in the long term in numerous ways. They do not reach their optimum size as adults (and so may have less physical capacity for work), their brains are affected (resulting in lower IQs) and they are at greater risk of infection (which kills many children during their early years). Below are some of the most common consequences of malnutrition among children:

Child Malnutrition Impacts on Education Attainment

The degree of cognitive impairments is directly related to the severity of stunting and Iron Deficiency Anaemia. Studies show that stunted children in the first two years of life have lower cognitive test scores, delayed enrolment, higher absenteeism and more class repetition compared with non-stunted children. Vitamin A deficiency reduces immunity and increases the incidence and gravity of infectious diseases resulting in increased school absenteeism (Mother and Child Nutrition (2019).

Child Malnutrition Impacts on Economic Productivity

The mental impairment caused by iodine deficiency is permanent and directly linked to productivity loss. The loss from stunting is calculated as 1.38% reduced productivity for every 1% decrease in height while 1% reduced productivity is estimated for every 1% drop in iron status (Mother and Child Nutrition (2019).

United Nations Children’s Fund (UNICEF) (2021) noted that death is the worst outcome of malnutrition’s ugly grasp, but it’s not the only outcome. Children who survive can face a long list of devastating side effects that last a lifetime, preventing them from achieving success in school and pursuing meaningful work in adulthood. Such effects of malnutrition include increased vulnerability to diseases, developmental delays, stunted growth and even blindness. Malnutrition affects every system in the body and always results in increased vulnerability to illness, increased complications and in very extreme cases even death (Bapen Partners, 2018).

Treatment and Management of Child Malnutrition

According to WHO (2013), the following guidelines should be strictly adhered to in the treatment and management of malnutrition among children:

  1. In order to achieve early identification of children with severe acute malnutrition in the community, trained community health workers and community members should measure the mid-upper arm circumference of infants and children who are 6–59 months of age and examine them for bilateral pitting oedema. Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm, or who have any degree of bilateral oedema should be immediately referred for full assessment at a treatment centre for the management of severe acute malnutrition
  2. In primary health-care facilities and hospitals, health-care workers should assess the mid-upper arm circumference or the weight-for-height/weight-for-length status of infants and children who are 6–59 months of age and also examine them for bilateral oedema. Infants and children who are 6–59 months of age and have a mid-upper arm circumference <115 mm or a weight-for-height/length <–3 Z-scores of the WHO growth standards, or have bilateral oedema, should be immediately admitted to a programme for the management of severe acute malnutrition.
  3. Children who are identified as having severe acute malnutrition should first be assessed with a full clinical examination to confirm whether they have medical complications and whether they have an appetite. Children who have appetite (pass the appetite test) and are clinically well and alert should be treated as outpatients. Children who have medical complications, severe oedema (+++), or poor appetite (fail the appetite test) or present with one or more IMCI danger signs should be treated as inpatients.
  4. Children with severe acute malnutrition who are admitted to hospital can be transferred to outpatient care when their medical complications, including oedema, are resolving and they have good appetite, and are clinically well and alert. The decision to transfer children from inpatient to outpatient care should be determined by their clinical condition and not on the basis of specific anthropometric outcomes such as a specific mid-upper arm circumference or weight-for-height/length.
  5. Children with severe acute malnutrition should only be discharged from treatment when their weight-for-height/length is ≥–2 Z-scores and they have had no oedema for at least 2 weeks, or mid-upper-arm circumference is ≥125 mm and they have had no oedema for at least 2 weeks. The anthropometric indicator that is used to confirm severe acute malnutrition should also be used to assess whether a child has reached nutritional recovery, i.e. if mid-upper arm circumference is used to identify that a child has severe acute malnutrition, then mid-upper arm circumference should be used to assess and confirm nutritional recovery. Similarly, if weight-for-height is used to identify that a child has severe acute malnutrition, then weight-for-height should be used to assess and confirm nutritional recovery. Children admitted with only bilateral pitting oedema should be discharged from treatment based on whichever anthropometric indicator, mid-upper arm circumference or weight-for-height is routinely used in programmes. Percentage weight gain should not be used as a discharge criterion.
  6. Children with severe acute malnutrition who are discharged from treatment programmes should be periodically monitored to avoid a relapse.
  • visible severe wasting is not included as a diagnostic criterion . However, all malnourished children should be clinically examined when undressed, as part of routine management;
  • all anthropometric indicators are assumed to be derived from the WHO growth standards;
  • children with severe acute malnutrition with medical complications or failed appetite test should be admitted to hospital for inpatient care;
  • admission may also be warranted if there are significant mitigating circumstances such as disability or social issues, or there are difficulties with access to care;
  • children with severe acute malnutrition and without these signs or mitigating circumstances can be managed as outpatients by providing appropriate amounts of ready-to-use therapeutic food.
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Prevention of Child Malnutrition

According to Lankester, Grills and Lankester (2019), the following are measures to prevent child malnutrition:

Ensure Pregnant Mothers have Adequate Nutrition

The baby’s weight at birth and during the first few weeks of life depends mainly on the health and nutritional state of the mother. In order to achieve adequate nutrition for the child at the time of birth:

  1. Encourage Adequate Weight Gain in Pregnancy: Mothers should ideally gain about five to eight kilograms during pregnancy. This depends on eating sufficient, well-balanced food, with plenty of fluids throughout pregnancy and taking enough rest.
  2. Prevent and Treat Anaemia: Prevention of anaemia should start pre-conception: adolescent girls after starting menstruation, and all women of child-bearing age should eat iron-rich foods, such as green leafy vegetables, eggs, and meat where locally available and acceptable. Daily iron-folate tablets should be given in pregnancy. Prevent and treat malaria, hookworm, and schistosomiasis (bilharzia), ideally before becoming pregnant.
  3. Prevent and Treat Vitamin A Deficiency in Mothers and Infants: The mother should eat foods rich in vitamin A—green leafy vegetables; orange, red, or yellow fruits or vegetables; fish; red palm oil in small quantities. Mothers are only recommended to take vitamin A supplements if the prevalence of night blindness is higher than 5 per cent or more. It should then be given for the 12 weeks before delivery either as a capsule of 10,000 units per day or 25,000 IU per week. Mothers are not otherwise recommended to take vitamin A supplements.
  4. Prevent and Treat Iodine Deficiency: WHO and UNICEF recommend iodine supplements for pregnant and lactating women in countries where less than 20 per cent of households have access to iodized  As mentioned, this salt needs to be reliably iodized in areas where there is iodine deficiency. Communities can be taught how to test this and take action through advocacy if legalized levels are not reached. Children under six months should receive their iodine through breastmilk but will need extra iodine supplements between six and 24 months. We should follow specific national guidelines as to how this is best done at community level. Where goitre is commonly observed and in many mountainous areas, iodine supplements are especially important unless mothers are regularly using iodized salt. If salt is not reliably iodized they can take a capsule of iodized poppy-seed oil.
  5. Discourage Smoking, Alcohol, and Drug-abuse: If the mother smokes or drinks alcohol during pregnancy, the baby is often born smaller and weaker and is more likely to die in the first months of life. Mothers should not drink alcohol or smoke during pregnancy.
  6. Treat and Prevent Serious Illness: Tuberculosis, sexually transmitted infections, HIV/AIDS and other chronic illnesses can all seriously affect the baby’s health.
  7. Ensure Regular Antenatal Care: Teaching pregnant women about nutrition is much more effective if we also encourage husbands and other family members to support them in this. (Lankester, Grills and Lankester, 2019).

Promote Breastfeeding

If every child was breastfed within an hour of birth, was given only breast milk for their first six months of life, and continued to breastfeed up to the age of two years, about 800,000 child lives would be saved every year. Many mothers today are being wrongly persuaded to use the bottle instead of the breast. They may listen to the advertising of artificial milk manufacturers, or think that wealthy, fashionable women use infant formula. They may start thinking that breastfeeding is dirty or old-fashioned. What often happens is that a mother tries to combine breastfeeding and formula, then finds her supply of breast milk reduces until she becomes dependent on formula to feed her baby. Bottle-fed babies are much more likely to die than breastfed babies (Lankester, Grills and Lankester, 2019)

Introduce Complementary Feeding at six Months

In order to meet the growing nutritional needs of babies at six months of age, mashed solid foods should be introduced as a complement to continued breastfeeding. Foods for the baby can be specially prepared or modified from family meals. The WHO notes that breastfeeding should not be decreased when starting on solids; food should be given with a spoon or cup, not in a bottle; food should be clean and safe; and young children should be given ample time to learn to eat (Lankester, Grills and Lankester, 2019)

Continue to Feed Sick Children

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The belief that food should not be given to sick children is a dangerous one, and many children die as a result. Illness leads to malnutrition and malnutrition to illness. Mothers should continue breastfeeding when children are ill, as much and as often as the child can manage. A child who has started complementary feeding should be gently encouraged to eat, even if not very hungry. We should give soft foods especially if the mouth and throat are sore, and we must give extra fluids if the child has a fever or diarrhoea. Sick children will have small appetites; they should therefore eat their favourite soft foods in small quantities as often as they like. After an illness there will be catching up to do. Children will need to eat more often than usual, with extra oil or super-flour porridge, until they have regained any weight lost. Children with diarrhoea should also continue to be fed. Oral rehydration can be done with home-prepared liquid foods such as rice water instead of salt-sugar solution. We must ensure that sick children eat enough so they can fight any infection successfully (Lankester, Grills and Lankester, 2019)

Prepare, Cook and Store Food Correctly

The following measures should be adhered to in ensuring that food is prepared, cooked and store correctly:

  1. Clean or Process Food Appropriately: While many foods, such as fruits and vegetables, are best in their natural state, others are not safe unless they have been processed. For example, always buy pasteurized milk.
  2. Cook Food Thoroughly: Many raw foods, most notably poultry, meats, eggs, and unpasteurized milk, may be contaminated with disease-causing organisms. Thorough cooking will kill the germs but it must reach all parts of the food.
  3. Eat Cooked Foods Immediately: When cooked foods cool to room temperature, germs start to multiply. To be on the safe side, eat cooked foods as soon as they come off the heat, and always within two hours.
  4. Store Cooked Foods Carefully: If foods are prepared in advance or leftovers are kept, they must be stored in hot (near or above 60 °C) or cool (near or below 10 °C) conditions. This is very important if foods are to be stored for more than four or five hours.
  5. Reheat Cooked Foods Thoroughly: This is the best protection against germs that may have developed during storage. All parts of the food must be thoroughly recooked, in other words, reach at least 70 °C.
  6. Avoid Contact between Raw Foods and Cooked Foods: Safely cooked food can become contaminated through any contact with raw food. For example, this can happen when raw meat comes into contact with cooked foods, or the same surface and knife are used to cut both raw and cooked food.
  7. Wash Hands Repeatedly: Wash hands thoroughly before starting to prepare food and after every interruption—especially after cleaning the baby, going to the toilet, or touching animals. Any sores on hands should be covered before cooking. Fingernails should be kept short. Teach children to wash their hands regularly, and always before eating.
  8. Keep all Surfaces Meticulously Clean where Food Is Prepared: Cloths that come into contact with dishes and utensils should be changed and washed frequently. Use separate cloths for cleaning the floor and any surfaces where food is prepared. Avoid feeding infants with a bottle, as bottles and teats are very difficult to clean. Use a cup and spoon instead. Never use containers that have contained chemicals or pesticides for food. Bury or burn any rubbish.
  9. Protect Foods from Insects, Rodents, and Other Animals: Animals frequently carry germs which cause foodborne disease. Storing foods in closed containers is the best protection. Keep poultry and animals away from the kitchen.
  10. Use Safe Water: Safe water is just as important for food preparation as for drinking. Wash fruit and vegetables using the cleanest water available, or peel them instead. Be especially careful with any water used to prepare an infant’s meal.

(Lankester, Grills and Lankester, 2019).

Avoid Harmful and Unnecessary Foods

Harmful foods include spoiled or mouldy cereals, beans, and groundnuts, and food that has been inadequately recooked, or stored in containers that have held pesticides, fuels, or chemicals. The use of unnecessary foods is becoming common in developing countries. Overweight children are fed on ‘junk foods’ such as artificial milk, tinned baby foods, tonics, bottled drinks, excessive sweets, biscuits, or other fashionable products seen on TV. The money could have been spent to buy healthy, nutritious foods (Lankester, Grills and Lankester, 2019).

References        

Akombi, B.J., Agho, K.E., Hall, J.J. et al. (2017). Stunting and severe stunting among children under-5 years in Nigeria: A multilevel analysis. BMC Pediatr 17, 15 . https://doi.org/10.1186/s12887-016-0770-z

Bapen Partners (2018). Introduction to Malnutrition. Retrieved from https://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition?start=2 on 28th April, 2021.

Khan A, Khan S, Zia-ul-Islam S, et al. (2017). Causes, sign and symptoms of malnutrition among the children. J Nutr Hum Health. 1(1):24-27. DOI: 10.35841/nutrition-human-health.1.1.24-27

Lankester, T., Grills, N. & Lankester, T. (2019). Preventing and treating childhood malnutrition. In Setting up Community Health Programmes in Low and Middle Income Settings. Oxford, UK: Oxford University Press. Retrieved 28 Apr. 2021, from https://oxfordmedicine.com/view/10.1093/med/9780198806653.001.0001/med-9780198806653-chapter-14.

Mother and Child Nutrition (2019). Malnutrition. Retrieved fromhttps://motherchildnutrition.org/malnutrition/about-malnutrition/impact-of-malnutrition.htmlon 27th April, 2021.

Müller, O. & Krawinkel, M. (2005). Malnutrition and health in developing countries. CMAJ. 173(3):279-86.

Sachdev, H.P.S. (1996). Assessing Child Malnutrition – Some Basic Issues. Nutritional Foundation of India Archives 156. New Delhi: NFI

United Nations Children’s Fund (UNICEF) (2021). Malnutrition. Retrieved from https://www.unicef.ca/en/malnutrition#:~:text=Children%20who%20survive%20can%20face,stunted%20growth%20and%20even%20blindness on 28th April, 2021

United Nations Children’s Fund (UNICEF) (2020). Nutrition. Retrieved from https://www.unicef.org/nigeria/nutrition#:~:text=Nigeria%20has%20the%20second%20highest,percent%20of%20children%20under%20five. On 27th April, 2021

World Health Organisation (WHO)(2020).  Malnutrition. Retrieved from https://www.who.int/news-room/q-a-detail/malnutrition on 27th April, 2021

World Health Organisation (WHO) (2013). Updates on the management of severe acute malnutrition in infants and children. Retrieved from http://www.who.int/nutrition/publications/guidelines/updates_management_SAM_infantandchildren/en/ on 28th April, 2021.

Yvette, B. (2020). Malnutrition: What you need to know. Retrieved from https://www.medicalnewstoday.com/articles/179316#:~:text=Malnutrition%20refers%20to%20when%20a,physical%20and%20mental%20health%20conditions. On 27th April,2021.

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