Niger J Paed 2014; 41 (4): 326 - 330
ORIGINAL
Ocheke IE
Factors influencing the pattern of
John C
Puoane T
malnutrition among acutely ill
children presenting in a tertiary
hospital in Nigeria
DOI:http://dx.doi.org/10.4314/njp.v41i4,6
Accepted: 3rd May 2014
Abstract Introduction: The bur-
were recruited with a mean age of
den of childhood malnutrition in
21.7±13.9 months. There was no
Ocheke IE
(
)
Nigeria has remained unchanged
difference in the mean age be-
John C
tween male and female (P=0.8).
Department of Paediatrics,
for nearly a decade between the
Jos University Teaching Hospital
two Demographic and Health
The prevalence of wasting was
Jos, Nigeria.
Surveys (NDHS) of 2003 and
(26.9%), (18%) for stunting and
Email: ieocheke@yahoo.com
2008.
(18.9%) for underweight.
The
The causes of malnutrition are
prevalence
of
severe
wasting,
Puoane T
complex and multifactorial. It
WHz scores <-3SD was (5.9%),
School of public Health, Faculty of
results from the interplay of so-
(5.4%) for stunting and (4.6%) for
Community and Health Sciences
cioeconomic, dietary inadequacy
underweight. The highest preva-
University of the western cape South
and environmental factors.
lence of wasting and stunting were
Africa.
Objective: To describe factors that
in age groups 6-11 and 12-23
influence the pattern of malnutri-
months, at 9.3% and 6.3% respec-
tion in acutely ill children in a
tively. The factors associated with
tertiary Hospital in central Nige-
malnutrition included early intro-
ria.
duction of complementary diets,
Methods: Cross sectional and
number of children in the home,
descriptive study. Children aged 6
maternal illiteracy and lower so-
to 59 months presenting with
cioeconomic status of the parents.
acute illnesses to the paediatric
Female children were commenced
emergency unit were concurrently
on complementary diets much ear-
recruited over a 7 month period,
lier than male (P=0.01).
(April-October 2012). All had
Conclusion: This study demon-
comprehensive
clinical
assess-
strates the association between
ment done including anthropom-
childhood malnutrition and factors
etric (weight, mid arm circumfer-
such as early initiation of comple-
ence,
height/length)
measure-
mentary diet, maternal illiteracy,
ments and z-scores calculated for
number of children in the home
the individual nutritional charac-
and poor parental socioeconomic
teristics.
status.
Results: A total of 379 children
Introduction
In Nigeria, the pattern and severity of childhood malnu-
trition for nearly a decade have remained essentially
Child nutrition is an important indicator for monitoring
unchanged as shown in the reports of the Nigeria Demo-
health status of the populations. Children who suffer
graphic and Health Surveys of 2003 and 2008. In some
from growth retardation due to poor diet tend to have
populations, nutritional indices such as wasting and
more frequent episodes of acute illnesses and higher
stunting have shown evidence of minimal improvement
mortality . There is strong evidence that malnutrition
1-3
while in others; they have deteriorated
in children is associated with delayed mental develop-
ment, poor school performance and reduced intellectual
It is well-known that the causes of malnutrition are com-
capacity . In children under the age of 5 years, malnu-
4-6
plex and multifactorial. However, dietary and environ-
trition even of mild to moderate severity is an important
mental factors play a major role. Dietary inadequacy and
cause of increased mortality in many developing coun-
other factors related to the mother such as her socioeco-
tries .
2,7
nomic status and poor caring practices contribute
327
significantly to the risk for childhood malnutrition.
8,9
pometry (weight, height, mid-upper arm circumference).
Most often, socioeconomic and environmental factors
Weight was measured using Seca® or bassinet scales
that impact significantly on malnutrition in developing
with the subject standing or sitting respectively, bare
countries include poverty, social in-equity, ignorance,
foot, wearing only light clothing. Scale was checked for
accuracy with standard weights after every 10 meas-
th
inappropriate food preparation, large family size and
unsanitary living conditions
7,10,11
.
urement, or whenever it was moved from one place to
another. Weight measurements of each child were re-
In South Asian countries for instance, high prevalence
corded to the nearest 0.1kg.
of childhood malnutrition is due to factors such as pov-
Height measurement was done in the recumbent position
erty, high population density, low status of women, poor
(i.e. length) for children less than two years of age using
antenatal care, high rates of low birth weight, unfavour-
a stadiometer. Standing height was measured for chil-
able child caring practices and poor access to child
dren who are older than two years using a stadiometer
health care . This picture is similar to what obtains in
12
fixed vertically to the wall. With the child bare footed,
most sub-Saharan African countries.
standing erect against the wall, and looking straight
Previous studies have revealed that most mothers and/or
ahead with the lower border of the eye sockets at the
caregivers of children with malnutrition in Nigeria had
same horizontal plane as the external auditory meat us,
faulty perception of its causes. Many perceived malnu-
the height was recorded to the nearest 0.1cm. For chil-
trition as a common childhood illness that they ulti-
dren less than two years of age, measurement was done
mately grow out of or as a condition that is caused by an
on a horizontally fixed stadiometer. The head was held
evil spirit . This wrong perception may be partly re-
13
to a fixed board while a mobile foot board was moved
sponsible for the persistence of high rate of childhood
against the soles of both feet for recording of the length,
malnutrition in many parts of Nigeria despite various
recorded to the nearest 0.1cm.
interventions. As we gradually approach 2015 when it is
The mid upper arm circumference (MUAC) was meas-
expected that a significant reduction in the under-fives
ured in all the children using an inelastic tape and meas-
malnutrition should have been achieved, based on the
urement recorded to the nearest 0.1cm.
objectives of the Millennium Development Goals
(MDGs), it is important to identify what progress has
Other data collected included findings from physical
been made and what challenges still need to be con-
examination and laboratory investigations on different
fronted. The purpose of this study was to describe the
specimens as indicated. All measurements and physical
pattern of malnutrition in children presenting with acute
examination were done by the researcher. The weight-
illnesses as well as identify factors that may influence it.
for-height, height-for-age and weight-for-age standard
deviation (SD) score (z-scores) were computed using the
World Health Organisation (WHO) anthro version 3.2.2.
The World Health Organisation’s Z-scores weight for
Methodology
height, height for age and weight for age were used to
define wasting, stunting and underweight respectively.
A descriptive, cross sectional study using quantitative
data collection methods. The study was conducted in the
The breast feeding/complementary dietary history and
department of Paediatrics, Jos University Teaching Hos-
the socio-demographic information of the parents were
pital in Nigeria. The Hospital is a tertiary health facility
obtained from interviewing the mothers in most cases or
that provides all levels of care, and Paediatric depart-
where both parents were available and done by the re-
ment sees children from birth to eighteen years of age.
searcher. These included the mother’s educational
Many of the patients seen in the hospital are un-referred
status, father’s occupation, marital status of the mother
and come mainly from Plateau state, the six neighbour-
and number of children in the home. The social eco-
ing states and the Federal Capital territory. The depart-
nomic status for the parent was categorised according to
ment of paediatric offers services that include general,
the tool developed for Nigerian population by Olusanya
et al . All the information obtained was entered into a
14
consultant paediatric and specialist care.
The study participants included children aged 6 to 59
proforma designed for the study.
months who were seen in the paediatric emergency unit
and the paediatric outpatient department, from April to
Ethical approval for the study was granted by both the
October 2012. Children whose illnesses had lasted two
Research and Ethical Committees of the Jos University
weeks or less and those whose parents/care giver gave
Teaching Hospital and University of Western Cape.
consent were included in the study. Those with any con-
Data was collected over a seven month period from
genital abnormalities, hereditary disease such as sickle
April to October 2012.
cell anaemia, underlying disease conditions such as
All the data obtained were entered into EPI Info com-
chronic renal disease, tuberculosis infection and cerebral
puter software version 3.4.3. Analysis of data was done
palsy were excluded from the study. Children who were
using EPI Info, Stata IC 10, Texas 77845 USA, 800-
relatively stable were recruited into the study at the time
STATA-PC. The student‘t’ test was used to compare
of first contact with the researcher while those very sick
means while Chi-square test was applied to compare for
and unstable, were recruited later after stabilization in
proportion and multivariate analysis were needed, ac-
the ward.
cepting level of significance as (p <0.05).
Data collected included the child’s age, gender, anthro-
328
Results
Table 2: Socio-demographic factors and prevalence of
malnutrition, (n=102)
Three hundred and seventy nine children were enrolled
WFH
WFA
HFA
for the study during the period. The age ranged from 6
<-
<-
<-
<-
<-2SD
<-
to 57 months with a mean of 21.67 ± 13.94 months.
2SD
3SD
2SD
3SD
(%)
3SD
(%)
(%)
(%)
(%)
(%)
There was no difference in the mean age between male
and female (P=0.76). The mean weight of the children in
Complementary feeding
<6 months
85.1
61.5
41.4
79.0
34.4
57.9
the study was 10.6±3.1(Kg) while, the mean length/
≥ 6 months
14.9
38.5
58.6
21.0
65.6
42.1
height was 82±12.9(cm). Mean mid upper arm circum-
Number of children in
ference was 14.9±1.5(cm).One hundred and nine
the house
≤ 3
9.3
7.5
55.2
26.3
7.1
3.9
(28.8%) children were aged less than 12 months. Major-
>3
21.9
5.2
44.8
73.7
12.5
8.3
ity of the children in the study, 237 (85%) were younger
Place of delivery
than 24 months. There were more males 224 (59.1%).
Home
21.4
7.9
13.8
42.1
6.8
11.9
Acute respiratory infection was the commonest reason
Hospital
10.4
4.8.
69.0
52.6
19.2
4.2
PHC
23.1
3.9
17.2
5.3
14.2
5.0
for emergency visit followed by malaria at 36% and
Mother’s education
27.1% respectively. The highest number of children
University
9.6
3.2
13.8
0.0
4.3
3.2
with malnutrition was seen in the first 23 months of life.
Secondary
10.4
6.3
51.7
36.8
7.7
3.2
This is shown in Table 1.
No formal education
24.5
14.5
34.5
63.2
17.8
14.5
Father’s occupation
Professional
11.3
2.1
20.7
0.0
15.6
21.0
Table 1: Age distribution and pattern of malnutrition
Middle level
10.4
6.0
27.8
42.1
43.8
31.6
WHz scores
HAz scores
WAz scores
Unskilled
17.5
13.4
51.7
57.9
40.6
47.4
Social status
<-2
<-2
<-2
Upper
10.7
1.5
20.7
0.0
18.8
21.1
Age in months
N(%)
N(%)
N(%)
Middle
10.2
7.3
31.0
26.3
34.4
10.5
6-11
109(21.3)
106(11.4)
109(12.8)
Lower
17.6
13.0
48.3
73.7
47.0
68.4
12-23
128(17.5)
129(19.7)
127(13.4)
24-35
70(17.1)
72(12.5)
73(15.3)
Table 3: Relationship between complementary feeding, socio-
demographic factors and severe forms of malnutrition
36-47
35(12.5)
34(0)
34(3.1)
48-59
37(22.9)
38(10.8)
36(13.5)
Variables
Nutritional
P value
status (%)
Nutritional status
Age at commencement of com-
plementary feeding (Months)
Wasting
The overall prevalence of malnutrition in the study was
<6
n=75 (73.4)
0.0173*
26.9% for wasting (WHz-scores <-2SD). In the case of
≥ 6
n=27 (26.6)
stunting (HAz scores <-2SD), the overall prevalence
Number of children in the home
Severe stunting
was 18% while for underweight (WAz scores <-2SD), it
≤ 3
n=11 (3.9)
0.027*
was 18.9%. The prevalence of severe forms of malnutri-
> 3
n=8 (8.3)
tion (z-scores <-3SD), for wasting was 22(5.9%), (19)
Number of children in the home
Severe wasting
5.4% for underweight and (17)4.6% for stunting. The
≤ 3
n=5 (5.2)
prevalence of severe wasting (WHz scores <-3SD) was
> 3
n=21 (7.5)
0.030*
highest in the age group 6 to 11 months at (10)9.3%
Place of delivery
Severe stunting
while severe stunting (HAz scores <-3SD) had the high-
Hospital
n=13 (4.2)
est prevalence of (9)6.3% in the age group 12 to 23
PHC
n=1 (4.0)
0.002*
months.
Home
n=5 (12.0)
Mother’s education
Severe stunting
Factors associated with nutritional status of the children
University
n=3 (3.19)
Tertiary/secondary
n=7 (3.17)
The prevalence of moderate and severe forms of malnu-
0.000*
No education
n=9 (14.5)
trition among 102 children in relation to some socio-
demographic parameters is shown in Table 2. Severe
Mother’s education
Severe wasting
malnutrition was influenced by the factors shown in
University
n=3 (3.2)
0.007*
Table 3. Wasting had a significant relationship with
Tertiary/secondary
n=14 (6.3)
early introduction of complementary feeding, (before the
No education
n=9 (14.5)
sixth month of life) as compared with later commence-
Social status
Severe wasting
ment at six months or beyond. Similarly, both stunting
Upper
n=2 (1.5)
0.017*
and wasting were significantly associated with the pres-
Middle
n=10 (7.3)
ence of more than three children in the home and where
Lower
n=14 (13.0)
mother had no formal education. Wasting was associ-
Father’s occupation
Severe wasting
ated with lower social economic status of the parents
Professional
n=2 (2.1)
0.064*
while stunting was significantly related to the child’s
Middle level
n=11 (6.04)
place of delivery.
Unskilled
n=13 (13.4)
* Pearson chi
2
329
Father’s occupation was significantly associated with
the highest rate of 9.3% was seen in age 6-11 months.
This finding however, contrasts with a previous study
16
the duration of exclusive breast feeding. Based on the
three occupational levels, exclusive breast feeding up to
from another part of Nigeria, where moderate wasting
six months or more was more prevalent in children born
was most prevalent in age 30-35 months at 14.3%.
to fathers in the middle cadre at 49.2% compared with
Their study was among a population of apparently
28.2% and 22.4% top professionals and unskilled work-
healthy children. Secondly, from the findings of NDHS
ers respectively, (Chi=27.5, df=14, p=0.016). The influ-
there are clear differences in the pattern of childhood
ence of father’s occupation did not have significant ef-
malnutrition in various regions of the country and this
fect on the child’s height and weight. Among the three
may have also accounted for the difference. The highest
occupational levels from professional to unskilled in that
prevalence of severe wasting was in age group 6 to 11
order, for height, (ANOVA df=96, F=1.12, p=0.17; for
months, the period immediately following introduction
weight df=96, F=1.16 and p=0.2) respectively. There
of complementary diet. Similar findings have been re-
ported by other workers.
17,18
was an only marginal variation in the prevalence of mal-
It is known that growth
nutrition according to gender but this was not signifi-
faltering in most infants starts from age seven months
cant. Age at commencement of complementary feeding
when breast milk is no longer adequate to meet the
however, varied between genders. The mean age at com-
child’s nutritional requirement or with the introduction
of complementary diets .
19
mencement of complimentary feeding was 5.5±0.96 for
female children and 5.9±1.62 for male; (Kruskal-Wallis
test for 2 groups, X =5.9, df=1, p=0.015).
2
Socioeconomic and demographic factors associated with
malnutrition in this study were the mother’s educational
Table 3 shows factors that significantly affected the
status, number of children in the home and parental so-
prevalence of severe malnutrition in the population stud-
cial status. Maternal education has been consistently
ied. Age at commencement of complementary feeding,
shown to be an important factor for child health, nutri-
number of children in the home, place of delivery,
tion and survival. Wasting and stunting were identified
mother’s educational status and the parental social status
in this study to be more prevalent in children with moth-
have the most significant influence.
ers who had no formal education. This is in conformity
with previous reports
16,20,21,22,23
. The factors found to be
specifically associated with severe wasting were lower
socioeconomic status of parents and early introduction
Discussion
of complementary feeds. For children who were stunted,
home delivery was the only specific factor. Lack of any
This study assessed the pattern of malnutrition in chil-
formal education in the mother and greater than three
dren who presented with acute illnesses and some fac-
children in the home were associated with both severe
tors that may influence their prevalence. The study dem-
stunting and wasting in the study. The specific ways that
onstrated that the prevalence of both acute and chronic
maternal education affects child nutrition are not clear
malnutrition is high among under-five children in Jos,
but may be related to the fact that educated mothers are
Central Nigeria. The findings in the present study differs
more likely to be aware of the importance of nutrition,
from that reported by the Nigeria Demographic and
hygiene and health care generally . It is also possible
24
Health Survey (NDHS) in 2008 and from Ajao et al
15
16
that being educated may enhance their economic power
from South west Nigeria in the general population. In
and therefore contribute to family income.
both reports, stunting was (41%) and (39.3%) while
prevalence of wasting was (14%) and (6.3%) respec-
Our study has also shown that in homes where there
tively. Wasting is an indication inadequate dietary intake
were more than three children, malnutrition was more
and is typically the result of a recent episode of illness
prevalent than in those with less number. This finding is
or lack of food. Stunting on the other hand follows
similar to reports from other countries,
19,21,25
This asso-
chronic insufficiency of nourishment and may also be
ciation may be related to the amount of time the mother
affected by recurrent or chronic illness. The lower
inevitably has with older children who have been
prevalence of stunting in this study as compared with
weaned when there is a newer baby. Older children may
the NDHS reports therefore, may be an indication of
be ignored as more attention is now focused on the new
improved food supply and childhood nutrition in the
baby resulting in insufficient stimulation and care. It is
population studied.
also possible that the total number of members in the
family may relate to the incidence of adverse circum-
Age is also known to play a critical role in the develop-
stances such as availability of food per head, which may
ment of malnutrition. This may probably have to do with
frequently be lower than that available to smaller fami-
the influence of complementary feeding with regard to
lies. This difference has been shown in the growth rate
timing of introduction and composition and subsequent
and decrease in per capita food intake with increase in
breastfeeding practice. Other condition such as increased
family size. It is however, worth noting that household
16
frequency of diarrhoeal disease which is known to initi-
food security and available income are equally important
ate the process of malnutrition is related particularly to
determinants of malnutrition as well and that large fam-
younger age. When the prevalence of overall malnutri-
ily size might not act alone.
tion was categorized according to age groups, moderate
Social status of the parents was determined by their edu-
wasting, WHz scores <-2 SD, was highest at (22.9%) in
cational status, occupation and income. The prevalence
the age group 48-59 months while for severe wasting,
330
of malnutrition was noted to be higher in children of
hood malnutrition, the critical role of girl child educa-
parents in the lower social status. However, the father’s
tion, greater promotion of exclusive breast feeding for
occupation alone interestingly did not significantly af-
up to the first six months of life, adequate education on
fect the nutritional status of the child in this study. Simi-
the timing and appropriateness of complementary feed-
lar finding has been reported previously . Using the
19
ing are paramount. Furthermore, improvement in the
father’s occupation alone, it was noted among Ethiopian
overall socio economic status of the population through
children that the prevalence of malnutrition was not dif-
skill acquisition and provision of job opportunities will
ferent among those whose parents were farmers from
go a long way to improve economic well-being, quality
other skilled professionals. This finding may emphasize
of life and thus reduction in childhood malnutrition.
the importance of maternal contribution to child nutri-
tion.
The limitation of the current study is that, it is hospital
based and focused on acutely ill children only. However,
the findings are useful in reminding clinicians managing
Conclusion
this group of patients that careful search for the presence
malnutrition through simple anthropometric assessment
In conclusion, the findings of this study again demon-
in children presenting with acute illness is a worthwhile
strate the relationship between malnutrition in acutely ill
effort. Nutritional advice and counsel should therefore
children and such factors as time of initiation of comple-
be included in the management outline for under-fives
mentary feeding, socio demographic indices such as
presenting with acute illnesses.
maternal education, number of children in the home and
parental social status. These findings suggest that for
Conflict of Interest: None
any successful preventive and control measures of child-
Funding: None
References
1.
Tomkins A, Watson F. Malnutri-
7.
Pelletier DL et al. A methodology
15. Nigerian Demographic and Health
tion and infection: ACC/SCN,
for estimating the contribution of
Survey, 2008
State-of-the-art Series, Nutrition
malnutrition to child mortality in
16. Ajao KO, Ojofeitimi EO, Fatusi
Policy Discussion Paper No. 5.
the developing countries. J Nutr
AO, Afolabi OT. Influence of fam-
Geneva: United Nations Adminis-
1994; 124: 2106-2122 .
ily size, household food security
trative Committee on Coordina-
8.
Walker AF. The contribution of
status and child care practices in
tion/ Subcommittee on Nutrition,
weaning foods to protein-energy
the nutritional status of under-five
1989.
malnutrition. Nutr Res Rev.
children in Ile-Ife, Nigeria. Afr J
2.
Man WD, Weber M, Palmer A et
1990:3:25–47
Reprod Health 2010; 14:123-132 .
al.Nutritional status of children
9.
Hayes RE, Mwale JM, Bwembya
17. Basit A, Nair S, Chakraborthy K,
admitted to hospital with different
PA, Mulunga MK, Veroer AB.
Darshan B, Kamath A. Risk factors
diseases and its relationship to
Weaning practices and foods in
for under-nutrition among children
outcome in The Gambia, West
high population-density areas of
aged one to five years in Udupi
Africa. Trop Med Int
Lusaka, Zambia. Ecol Food Nutr
taluk of Karnataka, India: A case
Health1998;3:678–86.
1994; 33:45–74.
control study. Australas Med J
3.
Victora CG, Fuchs SC, Flores JA,
10. Ebrahim GJ. Nutrition and its dis-
2012; 5:163-167.
Fonseca W, Kirkwood B. Risk
orders. In: Paediatric practice in
18. Amsalu S, Tigabu Z. Risk factors
factors for pneumonia in a Brazil-
developing countries; London,
for severe acute malnutrition in
ian metropolitan area. Pedi-
MacMillan, 1981; pp. 40-71.
children under the age of five: A
atrics1994;93:977–85.
11. AL-Dabbagh H, Ebrahim GJ. The
case control study. Ethiop J Health
4.
Mendez MA, Adair LS. Severity
preventable antecedents of child-
Dev 2008; 22:21-25.
and timing of stunting in the first
hood malnutrition. J Trop Paediatr
19. Lewis IA. Young child feeding
two years of life affect perform-
1984; 30: 50-52.
practices in Nigeria in complemen-
ance on cognitive tests in late
12. Nahar B, Ahmed T, Brown K,
tary feeding of young children in
childhood. J Nutr1999;129:1555–
Hossain M. Risk factors associated
Africa and the Middle East. Ge-
62.
with severe underweight among
neva: World Health Organiza-
5.
World Health Organization. A
young children reporting to a diar-
tion,1999:311-5.
Critical Link. Interventions for
rhoea treatment facility in Bangla-
20. Islam MA, Rahman MM, Maha-
Physical Growth and psychologi-
desh. J Health Popul Nutr 2010;
lanbis D. Maternal and socioeco-
cal development. a review . Doc
28(5): 476-483.
nomic factors and risk of severe
WHO/CHS/CAH/ 99.3 . Geneva:
13. Ighogboja IS, Okuonghae HO.
malnutrition in a child: a case con-
WHO, 1999.
Maternal concept of protein energy
trol study. Eur J Clin Nutr 1994;
6.
de Onis M. Child growth and de-
malnutrition in the middle belt of
48: 416-424.
velopment. In: Semba RD, Bloem
Nigeria. Niger Med J 1993; 24: 58
MW (eds). Nutrition and Health in
-61.
Developing Countries. Totowa,
14. Olusanya O, Okpere EE, Ezimkhai
NJ: Humana Press, 2001, pp. 71–
M. The importance of social class
91.
in voluntary fertility control in a
developing country. West Afr J
Med 1985;4:4.