Journal of ISSN: 2373-4426JPNC

Pediatrics & Neonatal Care
Research Article
Volume 5 Issue 4 - 2016
Study of Nutritional Assessment in an Indian Pediatric Population Of 0-5 Year’s Age Group in Pediatric Ward of a Tertiary Care Hospital
Desai DA*, Fichadiya NC and Singh MP
Department of Community Medicine, Government Medical College, India
Received: December 07, 2015 | Published: November 01, 2016
*Corresponding author: Devashish Desai, Department of Community Medicine, Govt. Medical College, Bhavnagar, C-57 Pushpak Tenaments, Opp Poonam Nagar, Sama, Vadodara- 390008, Tel: 8980294454; Email:
Citation: Desai DA, Fichadiya NC, Singh MP (2016) Study of Nutritional Assessment in an Indian Pediatric Population Of 0-5 Year’s Age Group in Pediatric Ward of a Tertiary Care Hospital. J Pediatr Neonatal Care 5(4): 00193. DOI: 10.15406/jpnc.2016.05.00193

Abbreviations

IMNCI: Integrated Management of Neonatal and Childhood Illnesses; MDG: millennium development goal; NFHS-3: National Family Health Survey 3; ICDS: Integrated Child Development Services; AWCs: Anganwadi centers;

Introduction

Rapid growth of children under-five makes them the most vulnerable group for malnutrition. Several factors could lead to the development of protein, energy and other micronutrients malnutrition through; insufficient intake of protein of good biologic value, impaired absorption, abnormal loss of protein, inadequate caloric intake or utilization. The present study is designed to evaluate and assess the nutritional status on an Indian-based pediatric population, by means of a carefully structured questionnaire adopted on the basis of the Integrated Management of Neonatal and Childhood Illnesses (IMNCI).

Review of Literature

At present, 65% of Indian children fewer than five years of age are underweight, including 47% with moderate and 18 % with severe malnutrition [1]. There has been no significant reduction in the prevalence of malnutrition among young children raised in a variety of developing regions of the globe, during the last 12-13 years in spite of various programmers. Malnutrition continues to be a major public health problem in most developing countries. It has been reported in 2010 that as much as eighteen per cent of children < 5 years old in developing countries are estimated to be underweight with 9% being severely underweight. The high prevalence of underweight children in South Asia stands out in comparison to other regions of the world. Globally, more than one third of childhood deaths are attributable to malnutrition. The Global Community has designated halving the prevalence of underweight children by 2015 as a key indicator of progress towards a millennium development goal (MDG) [2]. Malnutrition is a widely prevalent problem in India and one of astonishing magnitude. Nutritional status is a sensitive indicator of community health and well-being [3], and malnutrition is a major limiting factor for India. Infant-feeding practices constitute a major component of child caring practices apart from socio-cultural, economic and demographic factors [4].

Nutritional problems continue to cause major morbidity and mortality in children in India. Despite spectacular growth in food grain production in recent years, the problem of chronic malnutrition continues to exist extensively; especially in children below 6 years of age, as they are caught in a relentless sequence of ignorance, poverty, inadequate food intake and a variety of diseases [5].

According to the 2005-06 National Family Health Survey 3 (NFHS-3), 20% of Indian children fewer than five years of age were wasted and 48% had stunted growth due to malnutrition. Importantly, with a reported 43 per cent of Indian children found to be underweight, this means that Indian youth experience twice the average burden compared with others in sub-Saharan Africa 22% [6]. As a result, the nutrition of these children between 1 to 6 years of age is of prime importance as they are most vulnerable to deficiencies and the health consequences associated with it.

Integrated Child Development Services (ICDS) was initiated to address these concerns and remains India’s most ambitious multi-dimensional welfare program to reach millions of children and mothers caught in the grip of malnutrition, disease, illiteracy, ignorance and poverty. Anganwadi centers (AWCs) have been established under this program with one of the objectives to improve the nutritional and health status of children in the age group 0-6 years. Only a few studies have been done to better access the nutritional status and needs of anganwadi children. Hence the present study was undertaken in an attempt to assess the nutritional status of children between 0-6 years of age enrolled in anganwadi centers.

There are various risk factors for development of malnutrition.

Socioeconomic factors

Poverty is usually implicated for the occurrence of malnutrition. When resources are scarce at the household level, children receive a relatively lesser share of food and attention, due to limited parental awareness and education.

Feeding practices

In-appropriate breastfeeding: Introduction of infant formula, easy cessation of breast feeding and non- exclusive breastfeeding is well known risk factors for malnutrition around the world and India. The immune bodies in breast milk protect children from infections, and the mother’s milk is hygienic, cheap and accessible at all times. India’s policy of breastfeeding advises to start breastfeeding within an hour after birth and to exclusively breastfeed for six months through the second year of life.

Introduction of water, infant formula, and herbal preparations in the first 6 months are common practices that should he discouraged among women who breastfeed. These may lead to diarrhea, and consequently to increased susceptibility to malnutrition. Mothers with limited income tend to economize by offering diluted milk formula to their infants. Unhygienic feeding practices in the preparation of milk formula result in frequent episodes of diarrhea and diminished absorption of food by the infant. Inadequate complementary feeding practices lead to malnutrition. Frequency, quantity, quality and consistency of meals are important factors in child feeding at this age, and mothers should be encouraged to feed adequately.

Infections

Both water contamination and diarrhea are associated with malnutrition. During illness, the child catabolizes his or her own tissue to produce the additional needed energy, which is lost. Also, malnutrition may adversely affect the immune system and make the malnourished child more vulnerable to infections. This sets up a vicious cycle of malnutrition and infection. Parents often wrongly attribute diarrhea to teething, and hence they don’t seek medical attention. During bouts of infection, the child’s appetite is additionally impaired. The common and wrong practices of withholding food, reducing feeding or diluting infant formula during the episodes of diarrhea could lead to malnutrition. It is important to continue feeding with increased frequency and breastfeeding during illness.

Maternal malnutrition and anemia

Short maternal stature, anemia and low pre-pregnancy weight seem to be major factors in producing low birth weight infants, who are more likely to be malnourished children. Low birth intervals and large family size may contribute to the poor nutritional status of the mother. Efforts should be made to ensure adequate weight gain and iron status during pregnancy [7].

Feeding recommendations according to the IMNCI (integrated management of neonatal and childhood illnesses).

Up To 6 Months of Age

6 Months To 12 Months

12 Months To 2 Years

2 Years and Older

Breastfeed as often as the child wants, day and night, at least 8 times in 24 hours.
Do not give any other foods or fluids

Breastfeed as often as the child wants.
• Give at least one katori serving* at a time of:
-Mashed roti/rice/bread/ biscuit mixed in sweetened undiluted milk OR
-Mashed roti/rice/ bread mixed in thick dal with added ghee/ oil or khichri with added oil/ghee. Add cooked vegetables also in the servings OR
-Sevian/dalia/ halwa/kheer prepared in milk or any cereal porridge cooked in milk OR
-Mashed boiled/ fried potatoes
-Offer banana/biscuit/ cheeko/mango

• Breastfeed as often as the child wants.
• Offer food from the family pot.
• Give at least 1.5 katori serving* at a time of:
-Mashed roti/ rice/ bread mixed in thick dal with added ghee/
oil or khichri with added oil/ ghee.
Add cooked vegetables also in the servings OR
-Mashed roti/ rice/ bread/ biscuit mixed in sweetened undiluted milk OR
-Sevian/ dalia/ halwa/ kheer prepared in milk or any cereal porridge cooked in milk OR
- Mashed boiled/fried potatoes
-Offer banana/biscuit/ cheeko/mango/ papaya

Give family foods
at 3 meals each day.
• Also, twice daily,
give nutritious food
between meals, such
as: banana/biscuit/
cheeko/mango/
papaya as snacks.

 

*3 times per day if breastfed;
5 times per day if not breastfed.

 

* 5 times per day.

 

Remember:
Continue breastfeeding if the child is sick

Remember:
• Keep the child in your lap and feed with your own hands.
• Wash your own and child’s hands with soap and water every time before feeding.

Remember:
• Sit by the side of child and help him to finish the serving.
• Wash your child’s hands with soap and water every
time before feeding.

Remember:
• Ensure that the child
finishes the serving.
• Teach your child
wash his hands with
soap and water every
time before feeding

Objectives

  1. Primary objectives
  2. To assess the nutritional status and knowledge in care takers of child in the pediatric age group (0-5 years old)

  3. Secondary objective
  4. To review the degree of awareness that the care taker has of the pediatric patient with respect to nutrition.

    To assess the problems faced by these young children, receiving the nutrition.

Methodology

  1. Study design: Cross sectional - questionnaire based study.
  2. Study duration:  2 weeks. Data collection was done in the second week of March 2014.
  3. Study Site: In-patients of Pediatric Department, Sir Takhtsinhji General Hospital, Bhavnagar (STGH) – a tertiary care hospital, attached with Government Medical College, Bhavnagar from Gujarat, India. STGH is a 708 bed hospital with an average of 1300-1700 outpatient visits per day and an average of 75 inpatient admissions per day. On average, there are approximately 10 inpatients and 100 outpatients cared for / per day in the Pediatric Department.
  4. Inclusion criteria: Children below 5 years of age, and whose caretakers gave a verbal consent for the study, to be admitted as inpatients to the pediatric ward of Sir Takhtsinhji General Hospital, Bhavnagar.
  5. Exclusion criteria: Children above 5 years of age, and whose caretakers didn’t give verbal consent, to be admitted as inpatients to the pediatric ward of Sir Takhtsinhji General Hospital, Bhavnagar.
  6. Study procedure: The child’s care taker, coming to the pediatric ward of Sir Takhtsinhji Hospital was given a carefully structured questionnaire adopted on the basis of IMNCI. The questionnaire is divided into 3 parts according to the child’s age –
  7. 0 – 6 months age group questionnaire (annexure 1)
  8. 6 months – 2 years age group questionnaire (annexure 2)
  9. 2 years – 5 years age group questionnaire (annexure 3)
    1. The families received assistance in filling out the questionnaire. It was conducted in the month of March.
  10. Sample size: A total of 100 patients were surveyed.
  11. Sample collection: All families and children who granted consent

Observations and Results

A total of 100 pediatric patients below 5 years of age were studied. The division was made on the basis of age brackets:

  1. age 0 – 6 months
  2. age 6 months – 2 years
  3. age 2 – 5 years (Tables 1-5).

Age group

No. of patients

0 - 6 months

24

6 months - 2 years

44

2 - 5 years

32

Table 1: Age 0 - 6 months.

Age group

Mean age (months)

0 - 6 months

4.71

6 months - 2 years

13.58

2 - 5 years

36.12

Table 2: Mean age in months.

Age Group

Male

Female

0 - 6 months

50%

50%

6 months - 2 years

56.81%

43.19%

2 - 5 years

65.63%

34.37%

Table 3: Gender in age groups.

Age Group

Mean Weight (kg)

Mean Height (cm)

0 - 6 months

6.45

58.5

6 months - 2 years

8.47

71.35

2 - 5 years

11.63

84.56

Table 4: Average weight and height.

Age group

PEM patients

Male

Female

0 - 6 months

20.83%

20%

80%

6 months - 2 years

34.09%

66.66%

33.34%

2 - 5 years

34.38%

63.64%

36.36%

Table 5: PEM status.

It can be seen that PEM is more prevalent in female children below 6 months; this might be due to parents neglecting the girl child. PEM status was found most in the 2-5 years of age group, and this was due to avoidance of proper feeding practices (Table 6).

Age group

In present

In past

0 - 6 months

100%

-

6 months - 2 years

41.82%

58.72%

2 - 5 years

-

100%

Table 6: Breastfeeding status.

Reasons for not breastfeeding when asked were generally related to breast pain while feeding in age group of 0 – 6 months and after 6 months it was lack of knowledge and awareness of breastfeeding practices and hence the mothers were not taught to breastfeed the child until the age of 2 years. About 2-3 mothers were not acknowledged by their family for feeding their child; these children are generally the female child.

Average age from when the supplement food was started was calculated to be near to 7.5 months of age.

No. of meals taken by the child per day in accordance to the recommended no. of meals by IMNCI.

  1. 0 – 6 months: 8 or more times breastfeeding per day
  2. 6 months – 2 years: 3 times, if breastfeeding is continued, or 5 times, if breastfeeding is discontinued, per day
  3. 2 – 5 years: 3 times meals and 2 times nutritious snacks per day (Table 7).

Age Group

According to IMNCI

Not According to IMNCI

0 - 6 months

50%

50%

6 months - 2 years

43.18%

56.82%

2 - 5 years

78.125%

21.875%

Table 7: The meals which were served to children were recommended food items by the IMNCI but the only worry was the no. of meals served per day to the child.

Approximately 78 % of mothers or caretakers assisted their child (6 months – 5 years) during the meals, generally by active feeding with about 10% just watching them eat. Hygiene status was assessed with washing of hands before and after meals by the child and the caretaker (Table 8).

Age Group

Child Washing Hands

Caretaker Washing Hands

6 months - 2 years

47.73%

79.54%

2 - 5 years

56.25%

78.13%

Table 8: About 73 % of mothers or caretakers advised their child to wash hands before meals.

Mothers or caretakers who received active nutrition counselling by any medical professional (or any person related to medicine like nurses, anganwadi workers) (Table 9).

Mothers or caretaker who seek nutritional advice generally have two sources; from families or from medical professionals (Table 10-16).

Age Group

Received Counselling

0 - 6 months

70.83%

6 months - 2 years

45.45%

2 - 5 years

18.75%

Table 9: The main source for nutritional counseling was suggested to be the mamta divas and by anganwadi workers who use to visit their houses. The other source was hospitals when their child was taken to the hospitals.

Age Group

Caretaker Seeking For Nutritional Advice

From Family

From Medical Professional

0 - 6 months

100%

50%

50%

6 months - 2 years

70.45%

61.29%

38.71%

2 - 5 years

62.5%

60%

40%

Table 10: It can be seen that caretakers seek for advices for good feeding practices more when the child is less than 6 months and then it goes decreasing and thus chances of PEM are more in age group of 2-5 years.

Age Group

Children Getting Frequently Ill

0 - 6 months

29.16%

6 months - 2 years

25%

2 - 5 years

46.875%

Table 11: Out of these children, who get frequently ill, 45.45% children were having PEM.

Age Group

Caretaker Ensuring Whether Child Has Eaten Satisfactorily

6 months - 2 years

45.45%

2 - 5 years

43.75%

Table 12: Less than 50 % of caretakers check whether the child has eaten satisfactorily and this may lead to malnutrition or other nutritional disorder, as they are not paying attention towards their children’s nutrition.

Age Group

Children Eating Sufficiently

6 months - 2 years

36.36%

2 - 5 years

43.75%

Table 13: Out of the children not eating sufficiently, 50% children got hungry frequently and other 50% had no response though ate less and were prone to PEM.

 

PEM

Total

Yes

No

Frequently ill

Yes

15

18

33

No

16

51

67

Total

 

31

69

100

Table 14: This association had a chi square value of 3.85 (at p=0.05). This shows that children who get frequently ill are at more risk, than children who are not getting frequently ill, for acquiring PEM.

 

PEM

Total

Yes

No

Washing hands

Yes

10

29

39

No

16

21

37

Total

 

26

50

76

Table 15: The association had chi square value of 1.85 (at p=0.05). This shows that there is no association between washing hands of children simulating cleanliness with risk of getting PEM.

 

PEM

Total

Yes

No

 

Feeding according to IMNCI

Yes

12

44

56

No

19

25

44

Total

 

31

69

100

Table 16: The association had chi square of 4.481(at p=0.05). This shows that children who are not getting fed according to the IMNCI recommendation are at more risk, than who are fed according to IMNCI recommendation, to acquire PEM.

Discussion

The rate of PEM (Protein Energy Malnutrition) patient in the current study was 31% with the largest prevalence among 2 – 5 year olds. Females were more prevalent for getting PEM in the age group of 0 – 6 months; this might be because of family ignorance towards a female child. Low weight children are prone to PEM, and the low weight of the child might be related to their care takers socioeconomic status and education or awareness about nutrition. Nutritional knowledge was highest among the caretakers of children 0 – 6 months of age due to the provision of the various facilities like mamta day, anganwadi workers and their helpers going house to house, reaching individuals, and giving information about nutrition. More awareness should be spread to all the age groups about nutrition, especially in the pediatric age group. Mothers and caretakers should be trained to follow the recommended nutrition management (recommendation by IMNCI) and also trained or watched for good or appropriate breastfeeding. Nutritional counseling is necessary requirement. In the villages, due to lack of knowledge and their own beliefs they do not follow the recommended charts.

Frequent illness also contributes to the risk factors for PEM. There is a reported 40 – 50% increased chance for frequently ill children to develop PEM. In the present study, 45% of children who got frequently ill were found to have PEM. The association of PEM and frequently getting ill was shown using the chi square statistical method which showed the chi square value of 3.85, which proves that there is a significant association of frequently ill children with PEM. Poor hygiene of the child (ascribed by washing of hands) was also reported in about 52% of the study population, no doubt contributing to the frequent illnesses reported, as well towards developing PEM.

Mothers or caretakers of children belonging to the age group of 0 – 6 months seek more information about how to take care of the nutritional requirements of their child. The rate of seeking knowledge by the mothers and the caretakers is gradually decreasing as the age of the child is increasing. This also may lead to malpractice in feeding process, directly affecting the nutrition of the child. The knowledge or information which the mother wants is generally asked to the family first and thus the family plays a crucial role in the child’s nutritional development. Wrong beliefs and practices generally lead to poor nutritional health of the child. The mothers are not adopting a good practice for feeding. They stop breastfeeding when the child turns 6 months, and starts the supplementary diet plus other food items. They also provide fluids generally water along with feeding in first 6 months which is not recommended.

Bad feeding practices add to development of PEM. This is also confirmed in our statistical analysis by chi square method, which showed the chi square value of 4.185, confirming that there is a significant association of bad feeding practice and PEM.

The knowledge or information given, without being requested proactively, by various bodies working for better nutritional availability to the child (mainly by the anganwadi workers, mamta day celebration, etc.) offer more to the caretaker or mother of children in the youngest age group (0 – 6 months) and this also gradually declined with the increasing age of the cohort.

Conclusion

It can be concluded that malnutrition can be avoided or decreased in the pediatric population with proper awareness, knowledge and good practices in relation to the nutrition. Nutritional counseling should be done on a regular basis for all age group. Good hygiene should also be maintained.

Summary

The present cross sectional - questionnaire based study evaluated 100 pediatric patients’ caretakers and/or mothers to assess the nutritional status of the pediatric population. Underweight or cases of PEM wasting are more common in the south Asian countries, and is severely affecting the health of the child, causing many avoidable deaths. The main learning objective of our study, to stop or control low weight or wasting cases is proper nutritional awareness and more frequent nutritional assessments and counseling. The current study was designed to do the nutritional assessment and to better understand the current practices used regarding nutrition, whether appreciable or not.

Awareness about good nutritional practice (in range of 40 - 60% in different age groups) is a major obstacle, which contributes largely to the care takers avoidance in approaching health care facilities. Unawareness further leads to social stigma and/or wrong beliefs regarding nutritional practices (Appendix).

References

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  4. Kumar D, Goel NK, Mitaal PC, Misra P (2006) Influence of infant feeding practices on nutritional status of under-five children. Indian J Pediatr 73(5): 417-421.
  5. Harishankar, Shraddha Dwivedi, Dabral SB, Walia DK (2004) Nutritional status of children below 6 years of age. Indian J. Prev. Soc. Med 35(3): 4.
  6. National Family Survey 2005.
  7. Phengxay M, Ali M, Yagyu F, Soulivanh P, Kuroiwa C, Ushijima H (2007) Risk factors for protein-energy malnutrition in children under 5 years: study from Luangprabang province, Laos. Pediatr Int 49(2): 260-265.
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