Nigerian Journal of Paediatrics

Serum total protein and albumin levels among malnourished children aged 6 59 months in Zaria

Niger J Paediatr 2018; 45 (1):15 - 18

ORIGINAL

Abdullahi SM

CC – BY Serum total protein and albumin

Yakubu AM

Bugaje MA

levels among malnourished chil-

Akuyam SM

dren aged 6- 59 months in Zaria

DOI:http://dx.doi.org/10.4314/njp.v45i1.4

Accepted: 31st January 2018

Abstract : Background: Children

albumin levels were analysed on

with PEM have greater deficiency

the Boerhringer Mannheim Auto-

Abdullahi SM (

)

of total protein and albumin and

mated Hitachi system 704 using

Yakubu AM, Bugaje MA

in severe cases the total protein

the Biuret and colour change meth-

Department of Paediatrics,

may be reduced to about 50 per-

ods respectively.

cent.

Results: The prevalence of low

Akuyam SM

Objective: To determine the se-

serum protein levels (<60g/l) in

Department of Chemical Pathology

rum protein and albumin levels

this study among the cases was

Ahmadu Bello University Teaching

among children with Protein En-

46.9% with highest prevalence of

Hospital, Shika Zaria,

ergy Malnutrition and the controls

33.3% seen in severe wasting.

Kaduna State

at Institute of Child Health,

While the prevalence of low serum

Email:

Ahmadu Bello University Teach-

proteins for the control was 1.5%.

sakinaabdullahi2013@mail.com

ing Hospital (ABUTH) Zaria.

The prevalence of low serum albu-

Method: This study was a case

min levels (< 25 g/l ) among the

control health- based descriptive

cases was found to be 24.2% with

study to estimate the prevalence

severe stunting accounting for

of serum protein and serum albu-

15.2%, while for the controls, a

min in undernourished children in

low serum albumin levels of 3.0%

Zaria.

occurred in this study.

Using

systematic

sampling

Conclusion: This study has been

method, a total of 132 children

able to establish low serum levels

(cases and controls) between 6

of protein and albumin among

and 59 months of age were se-

under-nourished children in Zaria.

lected for assessment of their se-

rum protein and serum albumin.

Keywords: Serum protein; Albu-

Both the total serum protein and

min; under-nutrition; children.

Introduction

wasting and twenty-eight per cent of all severely wasted

children are living in Africa. In Nigeria, 24% of chil-

Malnutrition (Under-nutrition) is defined as an imbal-

dren under five years of age are underweight (9% se-

ance between nutrient requirements and intake resulting

verely), 36% are stunted (19% severely) and 10% are

wasted (3% severely). Malnutrition rates in the North

in cumulative deficits of energy, protein or micronutri-

ents that may negatively affect growth, development and

Western and North Eastern regions of Nigeria are higher

other relevant outcomes. Stunting , underweight and

than in the Southern parts of the country. The National

wasting are indices of malnutrition, These are defined

Demographic Health Survey (NDHS) reports of 2003,

respectively as anthropometric measurements that fall

2008 and 2013 show declining prevalence of stunting in

below minus two standard deviation (<-2SD) of normal

children under-five years of age at 42%, 41% and 37%

height/length-for-age, weight-for-age, weight-for-height/

respectively. Prevalence of wasting however was rising

length of the median World Health Organization (WHO)

at 11%, 14% and 18% respectively. Underweight was

child growth standards.

2,3

Severe acute malnutrition

24%, 23% and 29% in those respective years. The trend

(SAM) is defined by a weight-for-height/length below -

shown in the statistics on malnutrition depict significant

3z-scores of the median WHO growth standard, (<-3SD)

malnutrition in the regions mentioned. The figures are

by visible severe wasting or by the presence of nutri-

compelling and create a need for further research on

tional oedema. Severe acute malnutrition remains a

factors and associations that may be playing a part. Chil-

major cause of mortality in children under five years of

dren with PEM have greater deficiency of total protein

age. It has been estimated that more than 20 million

and albumin and in severe cases the total protein may be

reduced to around 50 per-cent. The reduction of total

children of the world mostly developing nations suffer

from severe malnutrition and 150 million children are

serum protein and albumin were marked in kwashiorkor

than in marasmus. Physical findings generally help in

underweight.

3,4.5

Globally, in 2012, 51 million children

under five years were wasted, 17 million had severe

the diagnosis of advanced malnutrition but is not fre-

quently positive in children in mild and moderate degree

status, dietary history with particular emphasis on fre-

of malnutrition. Early diagnosis of these cases is very

quency of ingestion of protein – rich foods were col-

useful as they are amenable to early rehabilitation and

lected from all children enrolled for the study. The socio

have better prognosis. The assay of total protein and

-economic scores as well as social class (1-5) were given

albumin will prove very useful in the diagnosis of PEM

to each child based on the scores awarded to the occupa-

before clinical manifestations are established and thus

tion and educational qualification of each parent of a

help in reducing problems created by PEM.

child as described by Ogunlesi et al.

Malnutrition (under-nutrition) is a public health problem

in the tropical and subtropical regions of the World. It

History of preceding illnesses within two weeks such as

has been estimated that more than 20million children of

measles, diarrhoeal diseases and acute respiratory infec-

the World )mostly developing nations) suffer from se-

tions were recorded. Physical examination looking for

vere malnutrition and 150 million children are under-

skin changes, hair changes and oedema was carried out

and also the anthropometric measurements.

8,9,10

weight. Under-nutrition has lasting effects on immune

functions, growth and development of children, learning

Approval for the study was obtained from ethical com-

ability, social adjustment, work efficiency and produc-

mittee of Ahmadu Bello University Teaching hospital

tivity of labour.

9,10

Under-nutrition is associated with

Zaria.

low serum protein an albumin. The degree of severity of

serum protein and albumin have not been widely deter-

Four millilitres of venous blood were collected into a

mined. It is hoped that this study will help provide some

plain bottle from the patients and the sera were separated

insight into this so as to guide therapeutic intervention.

by centrifugation. The specimens were then frozen at –

20 C until analysis. The pooled samples were analysed

The objective of this study was to determine the serum

total protein and albumin in malnourished children aged

for total serum protein and albumin by Boehringer

Mannheim Automated Hitachi System

6-59 months at Institute of Child Health Zaria.

in chemical

pathology laboratory ABUTH, Zaria.

Obtained data was compiled and analysed using statisti-

cal package for social sciences (SPSS) version 15.4.

Materials and methods

Comparison of mean values was done using Student t-

test and level of significance was set at p<0.05.

This was a case-control hospital-based descriptive study

conducted over a period of 10 months between June,

2010 and March, 2011.

The study was carried out at the Institute of Child Health

Results

(ICH) Banzazzau, Zaria. The Institute of Child Health

serves the community/ children mainly from Zaria and

A total of 66 each for the cases and age-matched con-

its environs and is the Primary Health Care outlet of

trols were sampled for the study. The socio-

Ahmadu Bello University Teaching Hospital (ABUTH),

demographic variables for both groups are as shown in

Zaria. The ICH offers out-patient service and receives an

table 1. Twenty six (39.4%) were males and 40 (60.6%)

average of 100 patients in a day. ICH is located in Ban-

were females with a male: female ratio of 1:1.5 among

zazzau area within the walled city of Zaria. Systematic

cases while for the controls, 30 (45.5%) were males and

sampling method was adopted to select 132 children

36 (54.5%) were females.

between 6 and 59 months of age in Zaria. The study

population consisted of consecutive malnourished chil-

Among the cases, all were wasted, out of which 13

dren between the age of 6-59 months who presented to

(19.7%), 9 (13.6%) and 44(66.7%) had mild, moderate

ICH. WHO Z-score classification was used in the classi-

and severe wasting. Similarly, all the cases were stunted

fication of malnutrition in this study into mild, moderate

with the severity ranging from mild, 11 (16.7%) moder-

and severe malnutrition using weight, height/length,

ate, 19 (28.8%) and severe, 36 (54.5%). All the controls

MUAC and presence or absence of oedema, serum total

had normal anthropometry.

protein <60g/l and serum albumin <25g/l were consid-

ered low. Age matched non malnourished children who

Table 2 shows the nutritional status of the cases and

presented to the ICH with clinical features of malaria,

controls. Among the cases, all were wasted, out of

ARIs, acute diarrhoeal diseases among others were en-

which 13 (19.7%), 9 (13.6%) and 44(66.7%) had mild,

rolled as controls. Informed consent was duly obtained

moderate and severe wasting. Similarly, all the cases

from each child’s parents or care givers before recruit-

were stunted with the severity ranging from mild, 11

ment in the study. The sample size was determined us-

(16.7%), moderate, 19 (28.8%) and severe, 36 (54.5%).

ing the following formular:

All the controls were nutritionally normal.

Table 3 shows serum protein levels among cases and

controls. Thirty-one (47.0%) of cases with wasting had

low serum protein as compared to 1 (1.5%) of the con-

trols. Similarly 31 (47.0%) of stunted cases had low

Relevant data using a proforma which included patient’s

serum protein as compared to 1 (1.5%) of the controls.

name, age, sex, parental occupation and educational

There were statistical difference (P=0.0001) in serum

Table 1: Socio- demographics of the population, age, social

Table 4: Serum albumin levels among cases and controls

class and educational levels distribution

Serum albumin (g/l)

Cases

Control

Normal

Low

Total

p value

Variables

n (%)

P value

Nutritional

n (%)

(Fishers

Gender

status

exact test)

Males

26 (39.4)

30 (45.5)

0.49

0.48

Wasting

16 (24.2)

50 (75.8)

66 (100.0)

0.0006

Females

40 (60.6)

36 (54.5)

Stunting

16 (24.2)

50 (75.8)

66 (100.0)

0.0006

Tribe

Controls

2 (3.0)

64 (97.0)

66 (100.0)

0.82*

Low serum albumin = <25 g/l Normal serum albumin= 25 –

Hausa

50 (75.7)

52 (78.8)

Fulani

12 (18.3)

10 (15.2)

30g/l

Yoruba

2 (3.0)

3 (4.5)

Others

2 (3.0)

1(1.5)

Age

6-12

18 (27.5)

1.000*

Discussion

13-24

38 (57.5)

25-36

6 (9.0)

In the present study, the serum protein and albumin val-

37-48

2 (3)

ues in all grades of PEM are significantly reduced than

49-59

2 (3)

control. Lowering of these serum total protein and albu-

Social class

min values in PEM could be explained on the basis of

1 (1.5)

3 (4.5)

0.09*

generalized protein deficiency leading to impaired syn-

8 (12.2)

19 (28.7)

thesis. These results are in agreement to that of other

workers.

10,14-16

III

19 (28.8)

12 (18.4)

In the final stage of wasting, low plasma

28 (42.4)

22 (33.3)

albumin concentration can appear because of diet defi-

10 (15.1)

ciency in protein. In the development of marasmus,

Educational levels

there occur deficiencies of energy in the diet reselling in

None

1 (1.5)

0 (0.0)

the change of normal pattern.

Islamic

28 (42.4)

7 (10.6)

18.47

0.0009

Primary

10 (15.2)

13 (19.7)

It is also observed that reduction in serum albumin and

Secondary

25(37.9)

34 (51.5)

total protein in PEM was due to reduced synthesis of

Tertiary

2 (3.0)

12 (18.2)

protein because of inadequate intake of dietary protein.

The prevalence of low serum protein levels obtained

from malnourished patients were significantly lower

Table 2: Nutritional status of cases and controls

than those obtained from non- malnourished patients,

Nutritional status

Cases, n= 66

Controls, n=66

while there was statistically significant difference in

Normal

0 (0.0)

66 (100.0)

serum

protein

between

malnourished

and

non-

Wasting

66 (100.0)

malnourished children. Similarly, the concentrations of

Mild

13 (19.7)

0 (0.0)

serum protein obtained from malnourished and non-

Moderate

9 (13.6)

0 (0.0)

malnourished children were statistically different. These

Severe

44 (66.7)

0 (0.0)

results therefore demonstrate that serum protein was

Stunting

66 (100.0)

decreased in malnourished children.

Mild

11 (16.7)

0 (0.0)

Moderate

19 (28.8)

0 (0.0)

Severe

36 (54.5)

0 (0.0)

The under-nutrition was confirmed with lowered levels

of serum total protein and albumin levels in malnour-

ished were significantly(p<0.05) lowered than that of

Table 3: Serum protein levels among cases and controls

well nourished children. This is in agreement with the

Serum protein levels (g/l)

finding with Chowdbury et al 2008 in Bangladesh.

Normal

Low

Total

p value

could be due to reduced intake of protein rich diet result-

Nutritional

n (%)

(fishers

ing in reduced synthesis of protein.

status

exact

test)

Lowered serum total protein and albumin values in un-

dernourished children could be explained on the basis of

Wasting

31 (47.0)

35 (53.0)

66 (100.0)

0.0001

inadequate intake of dietary protein particularly first

Stunting

31 (47.0)

35 (53.0)

66 (100.0)

0.0001

Controls

1 (1.5)

65 (98.5)

66 (100.0)

class protein, leading to impaired synthesis: at weaning,

Only plain pap or fura which is mainly carbohydrate

Low serum protein = < 60g/l Normal serum protein= 60 -

based was given to children 1-3times daily and only

82g/

sugar, if only was added to the pap and the food intro-

duced next was tuwo (family food). Most of the animal

products obtained especially eggs were sold out in the

market for cash.

Conclusion

Authors contribution

Abdullahi SM: Planning, literature search, data collec

In conclusion, the serum total protein and albumin val-

tion, analysis and writing of manuscript

ues in all grades of PEM are significantly reduced than

Yakubu AM: Revised the manuscript and supervised

control. The under-nutrition was confirmed with low-

the conduct of the study

ered levels of serum total protein and albumin levels in

Akuyam SM: Review of drafts of manuscript and super

malnourished were significantly(<0.05) lowered than

vision.

that of well-nourished children.

Bugaje MA: Review drafts of manuscript and supervi

It is therefore recommended that a follow up study

sion.

should be conducted in the area to re-analyse the serum

Conflict of interest: None

protein level in children and compare the result with the

Funding: None

rural children or children from another ethnic group in

Nigeria in order to have a better estimate of normal pro-

tein threshold in the serum among Nigerian children.

Acknowledgements

Limitation of the study was the inability to estimate pre-

albumin level which could have provided valuable infor-

I acknowledge with thanks, the staff of paediatrics and

mation on nutritional status.

chemical pathology departments and institute of child

health ABUTH Zaria.

References

1. Mehta NM, Corkins MR,

8. National Population Com-

13. Afonja O A: Basic Clinical

Lyman B. Defining paediatric

mision. National Demographic

Biochemistry Practice.

malnutrition: a paradigm shift

Health Survey.2013. Available

2004:85-6.Sommer A.

toward aetiology related defini-

from:http:www.population.gov.

14. Bangladesh Bureaus of statis-

tions. JPEN 2013;37: 460-81.

ng. Accessed on 12 April

tics report of the child nutri-

2. De Onis M, Blossner M. The

2014.

tion status survey, 1995-96.

World Health Organization

9. National Population Commis-

Dhaka Bangladesh Bureau of

global database on child

sion. National demographic

statistics;1996:23-39.

growth and malnutrition: meth-

health survey. 2008. Available

14. Coward WA, Lunn PG. Bio-

odology and applications. IJE

from:http:www:population.gov.

chemistry and Physiology of

2003;32:518-26.

ng. Accessed on 12 April

Kwashiorkor and Marasmus.

3. Indepth network. Indepth re-

2014.

Br Med Bulletin:1981;37(1),

source kit for demographic

10. ChowdburyMST, Akhter N,

19-24.

systems: Anthropometric indi-

Haque M. Serum total protein

15. Kwena AM, Warkhisi J,

cators. Available from: http//

and Albumin levels in different

Mambo IA. Possible Bio-

www.indepth network.org/

grades of PEM.J Bangladesh

chemical Markers in Protein

Resource Kit/INDEPYH DSS

soc. Physiol. 2008 Dec(3);58-

Energy Malnutrition and Ma-

Resource Kit/Anthropometric-

60.

laria in Children in Western

status-indicators.htm. Accessed

11. Lemeshow S, Hosmer DW,

Kenya. East and Central Afri-

on 27 October 2015.

Klar J. Sample size for case

can J of Pharmaceutical Sci-

4. WHO. Management of severe

control studies: In Adequacy of

ences. Vol 15(2012):18-23.

malnutrition: A manual for

sample size in health studies ,

16. Adeglousi HS, Sule MS. An-

physicians and other senior

New York. John Wiley and

thropometric and Biochemi-

health workers. 1999;1-68.

Sons (on behalf of WHO)

cal Assessment among under-

WHO. Child growth standards

1990;16-20. Jelliffe DB.

five Children in Kusada Local

and the identification of severe

12. Ogunlesi TA, Dedeke IOF,

Government area, Katsina

acute malnutrition in infants

Kuponiyi OT. Socio-economic

State of Nigeria. Bayero J

and children: WHO Library.

classification of children at-

pure and applied Sciences

2009.1-12.

tending specialist paediatric

2011; 4(2):137-140.

6. UNICEF. The state of the

centres in Ogun state, Nigeria.

World s Children 2013: Chil-

Nig Med Pract 2008;54(1):21-

dren with disabilities .2013.

National Bureau of Statistics.

Multiple indicators Cluster

Survey. 2011.