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Outcome of Facility Based Management on Severely Malnourished Children in District Ghotki and Larkana, Sindh.

Byline: Sikander Ali Mahar, Mariyam Sarfraz, Mudasir Mushtaque, Parvez Ahmed Shaikh and Abdul Aziz Humbi

Abstract

Background: A relatively effective method for the management of acute malnutrition in severely malnourished less than 5 year children is their management according to WHO guidelines in stabilization centers where they are admitted with medical complications.

Objectives: To improve the nutritional status of complicated malnourished children before their discharge from stabilization centers.

Study design, settings and duration: Hospital based, exploratory study conducting in stabilization centers at Ghotki and Larkana, Sindh from September to November 2015.

Subjects and Methods: By using universal sampling technique, all children who were enrolled and completed their treatment in October 2015 in the stabilization centers at Ghotki and Larkana, Sindh were included in the study. The parameters recorded included weight, length/height, mid upper arm circumference, heamoglobin level (both at the time of admission and discharge) while for nutritional rehabilitation, therapeutic milk F75 and F100 were given.

Results: Total 78 children were enrolled for treatment in stabilization centers. Their average length of stay in stabilization center was 7.1 days. The average weight gain was found to be 9.028 ( 3.956)gm/kg/day which was statistically significant.

The mean gain in the mid upper arm circumference, weight for height, body mass index and hemoglobin level at the time of discharge were also statistically significant (p less than 0.000). Height did not show any significant change.

Conclusion: The findings of this study indicate that management of severally malnourished children in accordance with the international standards resulted in significant improvement of nutritional status of children.

Key words: Severe malnutrition, children under five, nutritional status, stabilization center.

Introduction

Nutritional Status is considered a good indicator for the health of children throughout the world. Safe and sufficient nutrition plays an important role in the national development of countries and well being of individuals.1 Nutritional status can be assessed by anthropometric measurements, biochemical, clinical and dietary methods but we are mainly focusing on anthropometric measurement which include weight for height, weight for age, length for age, mid upper arm circumference (MUAC) and edema.2 A relatively effective method for management of acute malnutrition in children is their management in stabilization centers where severely malnourished children aged less than five year, with medical complications are admitted and treated according to world health organization guidelines.3,4

Worldwide, the prevalence of underweight, wasting and stunting in children under-five year are 16%, 8%, and 26% respectively with severe malnutrition leading to the death of one million child every year.5 A joint report release by world health organization, United Nations Children's Fund and World Bank revealed that globally 6.9 million children died in 2013, of whom 3.1 million died due to malnutrition and half of these deaths could be prevented using simple interventions.6 Every year, around 24 million children aged five year suffer from wasting in south Asia and most of these children live in 6 countries including Pakistan, Afghanistan, India, Nepal, Sri Lanka and Bangladesh.7 A systemic review conducted in low and middle income countries revealed that the cure rate, case fatality rate and average weight gain was 71%, 14%, and 5.3 g/kg /day respectively using interventions.8

A study conducted in Ethiopia showed that average length of stay of children admitted at therapeutic feeding center (TFC) was 21 days and average weight gain was 13.4 g/kg/d 9 while these figures were 3.0 (9.0) gm /kg/day for weight gain and 12.7 (6.8 SD) days for mean length of stay in the nutritional rehabilitation center in an Indian study.10 Another Indian study reported average weight gain of 6.1g/kg/day and mean weight for height gain as -1.8 SD.11

In Pakistan 6.2 to 8.3 children are stunted and 2.9 million are wasted.12 Within South Asian Association for Regional Cooperation (SAARC) countries, Pakistan has second highest stunting rate (43.7%) and this has remained so for last several decades.13 One out of every three children aged below five year is malnourished.12 In Sindh, it has been estimated that 57% children are suffering from stunting, 42% children are underweight and 13% wasted.12 According to National Nutrition Survey2010-11, prevalence of wasting, underweight and stunting was 17.6%, 40.5%, and 49.8% respectively.14

Globally, death rate has reduced from 30% to 5% after applying standard protocol in inpatient care centers.15

There are limited inpatient care centers in developing countries and these often close down due to low resource and human allocation.4 It is estimated that 30% to 50% cases of acute severe malnutrition among children under five year of age die.16 The risk of dying was 9 times higher in the children having weight for height less than -3SD than those who had Z-Score above -1 SD.15

The prevalence of under-nutrition in Sindh for stunting, underweight and wasting is 57%, 42% and 14%respectively which is higher than other provinces (Punjab, KPK) of Pakistan. This is worsening instead of improving in northern Sindh. A study conducted in Karachi showed a mean weight gain of 5.25 4.57 gm/kg/day and mean hospital stay of 10 8 days in children enrolled in therapeutic feeding center17 but there is very limited data on stabilization center in the rural Sindh. The proposed study was designed to assess and analyze the impact of an acute malnutrition intervention being used in Sindh to manage acute malnutrition in children aged below five years of age. The results of this study may help in improving intervention design and management of severely malnourished children.

Patients and Methods

This was a hospital-based, exploratory study, conducted from September to November 2015 in the stabilization centers of District Ghotki and Larkana, Sindh.

Universal sampling technique was used and all children who were enrolled and had completed their treatment by October 2015 in stabilization Centers were included in the study. Data was collected through structured questionnaire using a standard monitoring check list. All subjects were subjected to measurement for weight, height using, weight machine and height scale and BMI was calculated using standard formula. The heamoglobin level was measured using Hemoglobinometer at the time of admission (base line) and discharge. The nutritional rehabilitation i.e. therapeutic milk F75 i.e. 75 Kcal energy (0.9 protein and lactulose and 1.3g lactose per 100 ml) and F100 i.e. 2.9 Kcal energy (4.2g protein and 4.2g lactose per 100 ml) were given to improve these parameters.

Data was analyzed using software Anthrometer and SPSS (version 20). Mean and standard deviation was calculated for continuous variables, while frequency and percentages were calculated for categorical variables like gender, age, family monthly income and residence. Paired t-test was applied to assess the improvement in the nutritional status of children.

Ethical approval for conducting this research study was taken from the Institutional Review Board (IRB) of Health Services Academy, Islamabad. Permission was taken from District Health Officers of Districts Ghotki and Larkana, Medical Superintendent and the in-charge of concerned health facilities to conduct this study. Written informed consent was taken from the parents of admitted children.

Results

Seventy-eight children who had completed their treatment were enrolled. Their ages ranged from 6 to 69 months with majority aged below 24 months. There were 56.4% boys. Most children (88.5%) were from rural area and the family income was less than PKR 10,000 in 55.1% children (Table-1).

Table 1: Socio-demographic of study participant. (n=78)

Characteristic###Frequency###%

Gender

Boys###44###56.4

Girls###34###43.6

Age group (months)

6-11###21###26.9

12-23###27###34.6

24-35###14###17.9

36-47###7###9.0

47-59###9###11.5

Residence

Urban###9###11.5

Rural###69###88.5

Family monthly Income (Pakistani rupees per month)

less than 10000###43###55.1

10000-20000###23###29.5

> 20000###12###15.4

Figure shows that 39% children suffered from pneumonia, 33% from diarrhea, and remaining suffered from other disease. More than 95% children were anemic. The average length of stay was 7.154 ( 2.559) days and ranged from 5 days to 20 days.

At the time of enrollment the weight for height in 67 children was > -3 to -7 SD and in 7 children it was > -2 to -3 SD; while at the time of discharge weight for height in 51 children was > -3 to -7 SD and in 17 children was > -2 to -3 SD (Table-2).

Table-3 shows that at the time of enrollment, 46 children had a body mass index (BMI) of less than 12 kg/m2and in 30 children it was between 12 to 14 kg/m2; however, at the time of discharge 49 children had a BMI between 12 to 14 and 17 in children, it was less than 12 kg/m2.

Table-4 shows that the average weight gain was 0.340 ( 0.029) kg at discharge from stabilization center which was significant (p less than 0.000). Likewise there was -0.727 ( 0.038) z-score increase in the average weight for height and 0.758 ( 0.033) kg/m2 increase in the average body mass index at discharge which was significant (p less than 0,000). However, average gain in the height did not show any change (p > 0.320).

Discussion

This study showed a significant improvement in nutritional status of malnourished children who were admitted with complications at stabilization centers of Districts Ghotki and Larkana in Sindh. This study also reported co-morbidity like anemia (95%), pneumonia (39%) and diarrhea (33%) in these children.

Table 2: Anthropometric measurement (WZH) of malnourished children at time of admission and discharge.

###WZH (Z-Score)

Sex###less than - 1 to -2 SD###> -2 to -3 SD###> -3 to -7 SD###> -7 SD

###Admission###Discharge###Admission###Discharge###Admission###Discharge###Admission###Discharge

Boys (n = 44)###1###5###4###8###38###32###1###0

Girls (n = 34)###2###5###3###9###29###20###0###0

Total###3###10###7###17###67###51###1###0

Table 3: Anthropometric measurement (BMI) of malnourished children at time of admission and discharge.

###BMI (Z-Score)

Sex###less than 12 kg/m2###12 to 14 kg/m2###> 14 to 16 kg/m2###> 16 kg/m2

###Admission###Discharge###Admission###Discharge###Admission###Discharge###Admission###Discharge

Boys (n =44)###22###10###20###25###2###7###0###2

Girls (n= 34)###24###7###10###24###0###3###0###0

Total###46###17###30###49###2###10###0###2

Table 4: Difference in nutritional status at admission and discharge in stabilization centers.

Indicator###At the time of Admission###At the Time of Discharge###Difference (gain)###p-Value

(Variables)###(Mean SD)###(Mean SD)###(Mean SD)###(95% C.I)

Weight###5.264 1.274 kg###5.604 1.303 kg###0.340 0.029 kg###0.000

MUAC###9.671 .836 cm###10.160 .814 cm###0.490 0.022 cm###0.000

WZH###-4.580 1.240 z-score###-3.851 1.202 z-score###-0.727 -0.038 z-score###0.000

BMI###11.345 1.333 kg/m2###12.103 1.300 kg/m2###0.758 0.033 kg/m2###0.000

Hb: level###6.922 1.872 gm/dl###7.474 1.648 gm/dl###0.552 0.224 gm/dl###0.000

Height###67.680 7.613 cm###67.680 7.613 cm###0.000 0.000 cm###0.320

Other studies from Pakistan have also reported diarrhea, anemia and Pneumonia in malnourished children.15 The mean length of stay in stabilization center in the present study were comparable with other studies from Pakistan and India, which ranged from 7 to 20 days.10,17 Similar study from Dhaka - Bangladesh reported an average length of stay as 14.2 days18 and same was reported from Nepal.19 However, the average length of stay in this study was below international minimum sphere standard set for management of severe acute malnutrition which is less than 15 days.3 The length of stay was less because of good quality care at stabilization center, presence of skilled persons, supportive staff, uninterrupted supply of supplements and free treatment. Personal reasons could also play a role in shorter stay as parents want to go back home and earn their livelihood.

The average weight gain of children who had completed their treatment in stabilization center was comparable to the findings of the studies conducted in South Asia and Africa. Studies from Ethopia and India reported an average weight gain of 13.4g/kg/day and 6.1g/kg/day respectively.9,11 Similar study conducted in Bangladesh showed an average weight gain of 10.6 gm/kg/day.20 A study from Karachi reported a mean weight gain of 5.25 gm/kg/day,17 which is comparable to the International minimum standard set for management of severe acute malnutrition which is >8g/kg/day.3,21

In the present study, there was no increase in the mean height of children at time of discharge; this could be due to short length at stabilization centers. Generally 6 to 12 months are needed to attain a change in growth (Height/length) of children, with younger children gaining more rapidly than older children.22

In this study, average mid upper arm circumference gain was significant. This could be due to timely provision of recommended supplements (medical and nutritional). Similar findings were reported from Belagavi-India and Madhya Pradesh-India where mean MUAC gain was 0.23 cm and 0.62 cm respectively.2,23

In the current study, average change in hemoglobin level of children improved significantly over the course of treatment, and had a positive effect on reducing chances of complications arising due to anemia among malnourished children.

A significant association between mean weight for height (WZH) of children at the time of admission and discharge was observed in the present study. Studies from South Asia have also revealed significant increase in mean weight for height (WZH) gain among malnourished children in stabilization centers.11

The present study showed that management of complicated malnourished children in stabilization centers following international standards, results in insignificant improvement in health indicators of these children. An overall improvement in the anthropometric measurements and hemoglobin levels was observed during the course of treatment. However, there is also a need to introduce community based education and management of uncomplicated malnutrition at home to reduce malnourishment in children.

Acknowledgement

We are highly indebted to the faculty of Health Services Academy Islamabad for their support and regular guidance. We cannot forget the generous support of Dr. Saifullah Jamro and Dr. Lutifullah Kalwar during the conduction of this research and provided facilitation for study. It will be unfair not to mention the support of attendants of respondent, so special thanks to all the concerned. This study was sponsored by USAID, JSI through Government of Sindh Scholarship.

Conflict of interest: None declared.

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Publication:Pakistan Journal of Medical Research
Article Type:Report
Geographic Code:9PAKI
Date:Sep 30, 2016
Words:3478
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