|Year : 2015 | Volume
| Issue : 3 | Page : 148-153
Socioepidemiological determinants of severe acute malnutrition and effectiveness of nutritional rehabilitation center in its management
HS Aprameya1, Sowmini P Kamath1, Prashant K Kini1, BS Baliga1, UV Shenoy1, Animesh Jain2, Balakrishna NS Rao1
1 Department of Pediatrics, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
2 Department of Community Medicine, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
|Date of Web Publication||16-Jul-2015|
Sowmini P Kamath
Department of Paediatrics, Kasturba Medical College, Light House Hill Road, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Severe acute malnutrition (SAM) continues to be the reason for increasing hospitalization and also a major killer disease. Objectives: Identify socio-epidemiological determinants among both groups of SAM and evaluate impact of nutritional rehabilitation center (NRC) in its management. Methodology: A prospective observational study was conducted in a medical college on SAM children aged 6 months to 5 years over 1 year. Socio-epidemiological risk factors were compared in both groups. Therapeutic nutrition was provided as per World Health Organization guidelines. Serial weight monitoring and response criteria were analyzed at the time of discharge. Cases were followed up serially at 1, 2, 3, and 6 months for weight monitoring to assess long-term impact of NRC. Results: A total of 91 cases were enrolled; (Group 1: Group 2: 43: 48). Assessment of risk factors in SAM groups revealed a significant association between late initiation and lack of exclusive breastfeeding with group 1 SAM. Significant referrals (P : 0.001) from anganwadi centers included group 1 SAM. Majority responded to NRC management. Statistically significant weight gain noted at each follow-up in both types of SAM. At the end of 6 months, the recovery rate of group 1 SAM was statistically significant (P : 0.023), total defaulter rate was high (29.6%) and none had relapsed. Conclusion: Though NRC was effective in improving nutrition in SAM, results were not sustained in view of high defaulter rates at follow-ups. There is a need to improvise health education to caregivers, link NRC centers with community health centers for better follow-up and address modifiable socioepidemiological risk factors.
Keywords: Children, nutritional rehabilitation center, severe acute malnutrition, socioepidemiological determinants
|How to cite this article:|
Aprameya H S, Kamath SP, Kini PK, Baliga B S, Shenoy U V, Jain A, Rao BN. Socioepidemiological determinants of severe acute malnutrition and effectiveness of nutritional rehabilitation center in its management. Int J Health Allied Sci 2015;4:148-53
|How to cite this URL:|
Aprameya H S, Kamath SP, Kini PK, Baliga B S, Shenoy U V, Jain A, Rao BN. Socioepidemiological determinants of severe acute malnutrition and effectiveness of nutritional rehabilitation center in its management. Int J Health Allied Sci [serial online] 2015 [cited 2020 Jan 25];4:148-53. Available from: http://www.ijhas.in/text.asp?2015/4/3/148/160873
| Introduction|| |
Worldwide, the prevalence of severe acute malnutrition (SAM) is estimated to be around 1-2% in developing and in least developed countries.  Mortality in SAM children is around 9 times higher than that found in well-nourished children and continues to be pediatric killer disease. 
Although India has made advances in medical science with economic growth, SAM continues to be a significant public issue. As per National Family Health Survey-3 (NFHS-3), nearly 8.1 million children aged <5 years (6.4%) suffer from SAM and is one of the important co-morbidities leading to hospital admissions in our country.  SAM increases mortality, morbidity, impairs physical and mental capabilities of child. Thus, SAM children require immediate attention with proper nutritional rehabilitation. Nutritional rehabilitation center (NRC) is a unit in health facility where SAM children are admitted and provided medical and nutritional therapeutic care as per SAM management guidelines by World Health Organization (WHO)  and Indian academy of pediatrics. 
Previous studies regarding effectiveness of NRC have shown a definite impact in reducing case-fatality rates; however, defaulter rates in their subsequent follow-ups have been high. ,, Furthermore, to reduce occurrence and long-term consequences of malnutrition, there is an urgent need for recognizing risk factors/determinants of malnutrition and implement interventions to rectify them. The present study was undertaken to assess socio-epidemiological determinants of SAM and evaluate the effectiveness of NRC functioning.
| Methodology|| |
Regional Advanced Pediatric Care Centre, Wenlock District Hospital, Mangalore is a regional center catering pediatric/neonatal services for below poverty line children. NRC unit was initiated at this hospital in 2013, with functioning of unit as per recommended guidelines. It was a prospective study conducted at NRC unit, over 1 year (May 2013-May 2014). Study protocol was based on WHO/UNICEF recommendations. 
Study population and sampling
All children aged between 6 and 59 months were sequentially included if they met the study criteria. SAM either primarily due to dietary deficiency (referred as group 1) or as a consequence of chronic infections/systemic illness (referred as group 2) was admitted to NRC. These included referred cases by Anganwadi workers and cases that were identified at the outpatient department of the hospital.
Detailed clinical examination to detect presence/absence of medical complications based on the criteria for the integrated management of neonatal and childhood illness was done. If present, was appropriately treated. Specified therapeutic nutrition was given to babies for a minimum period of 14 days. Children with medical complications, and/or bilateral pitting edema, and/or with poor appetite were fed F-75 to provide (75 cal and 0.9 g protein/100 ml). These children were fed F-75 diet every 2 hours for 2 days while their medical complications were treated and monitored by a physician. After completion of initial 48 hours in NRC, children were fed F-100 diet, 6 times a day until the child was discharged from the unit. Kichidi/ragi porridge and one egg per day were initiated from the 3 rd day. Mothers were counseled regarding hygiene, health, and nutrition. Daily weight was monitored.
Children were discharged when they met following criteria's, (i) child had persistent weight gain (5 g/kg/day for 3 consecutive days on catch up diet) (ii) was active and alert (iii) had absence of bilateral pitting edema, fever and/or evidence of any infection. (iv) Child was tolerating home based feeds. (v) Primary caretaker was confident about taking care of the child.
At discharge that is, day 14, outcome measures were taken as responders, nonresponders, and defaulters. Children were called for follow-up for the first 3 months consecutively, at monthly intervals to monitor weight gain and also to ensure, primary caretakers are doing their duties well. Subsequently, they were called for a follow-up at 6 months to monitor weight gain. At 6 months follow-up, outcome measures were classified as (i) recovered, (ii) not recovered, (iii) defaulters/drop outs, and (iv) mortality.
Severe acute malnutrition
We have used WHO definition for severe acute malnutrition (SAM) as follows: 
- Weight/height or weight/length (Z score below –3 standard deviation [SD] of the median WHO child growth standards); or
- Presence of visible severe wasting; or
- Presence of bipedal edema of nutritional origin; or
- Mid-upper arm circumference (MUAC) < 115 mm.
Group 1 SAM: SAM purely due to inadequate/poor nutrition.
Group 2 SAM: SAM secondary to an underlying systemic illness or chronic infections.
Weight gain >5 g/kg/day for three successive days after feeding freely on catch-up diet.
Discharged before 10 days of NRC management.
At 6 months follow-up
Weight for height ≥ –1 S.D.
Lost follow-up more than 1 visit.
Ethical approval was obtained from the Institutional Ethical and Research Review Committee. SAM children were enrolled in the study, after written consent from parent/guardian. Socio-epidemiological details were collected by questionnaire method. Socioeconomic status assessed using Kuppuswami scale 2007  standards of sanitation scored as per Briscoe scale (1978).  Anthropometric measurements (weight, height/length, MUAC, weight for height, edema) at admission were taken. Weight of the children was measured using electronic weighing scales (model DS-415 Series; model number IND/09/99/158). Height was measured against a nonstretchable tape fixed to a vertical wall, with the participant standing on a firm/level surface and it was measured to the nearest 0.5 cm. Recumbent length (for children <24 months of age) was measured using an infant measuring board and MUAC measured by an MUAC tape designed by UNICEF and based on Shakir's tape for measuring MUAC.
Using SPSS version 11.0, (SPSS Inc. Illinois, Chicago, USA) Chi-square test was administered for qualitative data, Mann-Whitney U-test for continuous data, comparison of SAM determinants by Fischer's exact test and ANNOVA test was applied for serial weight gains at follow-ups. P < 0.05 was taken as statistically significant.
| Results|| |
Of 91 SAM children, there were 50 males and 41 females. Sixty (65.93%) children had weight for height/length z score (WHZ) below -3 SD, fourteen (15.38%) had an MUAC < 115 mm, 17 (18.68%) had both a WHZ below -3 SD and an MUAC < 115 mm. None had edema at presentation.
Baseline characteristics of SAM children is depicted in [Table 1]. Majority were <2 years (41.8%). Forty-three children (47.3%) were referred. Prevalence of group 1 and group 2 SAM was 47.3% and 52.7%, respectively. Most common underlying illness in group 2 SAM was cerebral palsy (60.4%). A significant number (P < 0.001) of group 1 SAM were referred by anganwadi workers (65.3%) when compared to group 2 SAM (34.9%).
The majority of SAM (65.1%) children were low birth weight. Birth order of three and more was seen in 16.5% families. Details on breastfeeding/complementary feeding practices are as in [Table 2]. Inappropriate feeding practices like late initiation of breastfeed (68.2%), lack of exclusive breastfeed (79.1%), early introduction of complementary feed (60.4%), and bottle feeding (41.8%) were documented [Table 2]. [Table 3] describes the family, social, economic, and sanitation determinants for SAM. On comparison of above determinants in [Table 2] and [Table 3] with groups of SAM, late initiation and lack of exclusive breastfeeding were significantly (P - 0.039 and 0.026, respectively) associated with group 1 SAM.
A total of 55 (60.44%) SAM children were responders to nutritional rehabilitation. Total defaulter rate was 10.99% [Table 4]. Net weight gain of all SAM children was 5.5 g/kg/day; group 1 had 6.59 g/kg/day, and group 2 had 4.85 g/kg/day. Breakup representation of both groups is in [Table 4]. Statistically significant weight gain was noted at each follow-up in both groups [Table 5].
At 6 months follow-up, total of 38 (41.76%) had recovered from SAM, total defaulter rate being 29.67% [Table 4]. Mortality was seen in four children with underlying illness (ventricular septal defect, bronchopneumonia, and two cerebral palsy). Weight gain follow ups of SAM and its split up with respect to groups of SAM is depicted in [Table 5]. Group 1 SAM recovered better than group 2 SAM and was statistically significant (P : 0.023). None had relapsed.
| Discussion|| |
0 Socioepidemiological determinants of severe acute malnutrition
The incidence of group 1 and 2 SAM was almost equal in our study. These two are interlinked and can form a vicious cycle perpetuating malnutrition. Distribution of illness in group 2 SAM was (29 [60.41%] cerebral palsy with developmental delay, 7 [14.5%] pneumonia, 4 [8.3%] surgical cases, 3 [6.25%] congenital heart diseases, 2 [4.1%] thalassemias, 2 [4.1%] tuberculosis, 1 [2.1%] leukemia on maintenance chemotherapy. Similarly,  30 (10%) children had systemic/medical illness; central nervous system was affected in 40% of children.
Male gender was a protective biological factor  and female gender was a risk factor  for the occurrence of malnutrition. In our study, females were less affected.
Mother was primary caretaker for our SAM children. Majority had their schooling till primary or was illiterate. Previous studies , have shown an association between maternal illiteracy and occurrence of SAM while Sharghi  had no causal relationship. Maternal practical knowledge about nutrition may be more important than formal maternal education for affecting nutrition status in children.  Nearly half of the mothers in this study were from a joint/extended family. Residing in a joint/extended family, adds onto her responsibilities compromising her time with children. Large family size adversely affects the nutritional status of children, has been concluded by studies. ,,
As per Rao et al.,  86.1% children of alcoholics had malnutrition when compared to 49.4% children of nonalcoholics. Majority of fathers in the present study were alcoholics.
The occurrence of subsequent malnutrition among low birth weight babies has been substantiated. , Our study had low birth weight/very low birth weight babies together to be around 68.1%. As per NFHS-3, 22% of newborns are low birth weight. 
Breastfeeding initiation within an hour of birth in our study was followed in 29 (31.9%) children. The same was initiated in 72% cases.  Significant association between time of initiation of breastfeeding with child's nutritional status was documented.  Late initiation of breastfeeding and lack of exclusive breastfeeding were found to be significantly associated in group 1 SAM. In the state, only 75% were put to breast within the 1 st day of life, including 36% who started breastfeeding within 1 st h of life and only 59% of children under 6 months were exclusively breastfed.  Lack of exclusive breastfeeding for the first 6 months was significantly associated with SAM in studies. , In our study, 24 (26.4%) children were never breastfed; this rate is similar to study by Kumar et al.  There was four-fold increased risk of SAM with the lack of breastfeeding in study by Islam et al.  Increased the risk of malnutrition either with early introduction  or with delayed initiation of complementary feeding  has been documented. Independent association of SAM with the consistency of complimentary feeds was found in a study by Mishra et al. 
Fourteen (15.4%) children were partially immunized for their age in our study. It was 52% in study by Kumar et al.  In the state, little more than half (55%) of children age 12-23 months are fully vaccinated.  Risk of SAM is independently associated with partial immunization status.  Update vaccinations were protective against malnutrition. 
In this study, the majority of SAM children were found to have poverty/low socioeconomic status, poor sanitation status, and lack of personal hygiene. Low socioeconomic statuses have an impact on malnutrition. , Unhygienic latrines, defecation within premises, and use of unprotected surface water , have an increased association with malnutrition. Recurrent respiratory and diarrheal illness had occurred in 39 (42.9%) and 14 (15%) SAM children over last year in the study. As per Kumar et al.  diarrhea and acute respiratory tract infections were seen in 54% and 27.9%, respectively. Recurrent respiratory infections; recurrent diarrhea, or other co-morbidities were present in 72.56%. 
Effectiveness of nutritional rehabilitation center
At discharge, majority (60.3%) responded to nutritional rehabilitation indicating that NRC is feasible and efficacious for inpatient management of both types of SAM. Taneja et al.  concluded statistically significant difference between mean weight at discharge and admission for the study group. However, we found a linear relationship between weight at admission and discharge as well as at each follow-up. There was a statistically significant weight gain at 6 months follow-up compared to the weight at admission.
About 10.99% had defaulted before 14 days, mainly since these mothers had some unspecified family issues which hampered them to continue staying in the hospital. There was no fatality during NRC stay.
Follow-ups had showed a significant weight gain at every visit. Overall functioning and performance of NRC could be monitored by sphere standards.  During 6 months follow-up, mortality occurred in four children (group 2) who had an underlying illness and was as per sphere standards. None of SAM children had relapsed. The recovery rate (41.76%) was not in the acceptable level. Recovery rates of 53.76% and 52.7% were reported by Taneja et al.  and Gaboulaud et al., respectively. 
Defaulter rate (29.7%) had increased by 3 times and did not match the standard rates probably because of the distant location of NRC, and 42% had no access to Anganwadi centers to ensure follow-up. Previous studies done had higher defaulter rates of 61.76%  and 45.3%. 
Reasons for low compliance of follow-ups have to be seriously studied, and effective measures need to be implemented. Mostly, distance factor from residence to NRC, travelling and food expenses, loss of daily wages deter parents to be compliant with follow-ups. Increasing community awareness of SAM, educating parents/caretakers, providing outreach workers deputed from NRC could decrease the incidence of SAM. Outreach workers could keep track of follow-up schedules of admitted children, personally do visit their residences and check parent's compliance and clarify, if any attributable risk factors associated with malnutrition have been rectified. These personal visits would help follow-ups of those children who do not have accessibility to Anganwadi centers as seen in our study. All these measures would aid frontline community workers (AWW, ASHA, ANM) who are involved in follow-ups and help in achieving the set objectives for SAM.
Applying the updated guidelines for SAM, only 12 children had achieved their weight for height/length score to be >2 SD. However, there are feasibility constraints and practical problems with newer guidelines. They stipulate children should be discharged from treatment only when their weight-for-height/length is at least ≥ –2 Z score and they have had no edema for at least 2 weeks, or mid-upper-arm circumference is ≥125 mm, and they have had no edema for at least 2 weeks.  Two weeks stay in the hospital itself is a constraint and to keep children in hospital for long enough to see that they satisfy this new criterion would be impractical. This study was started before these new guidelines were enforced. However, we have compared results with new guidelines as well, to have an idea about impact that it has made on results, though this was not the preliminary aim of this study and the methodology and treatment adopted at our NRC does not justify such a comparison.
Thus to conclude, among studied risk factors, infant feeding practices especially delayed initiation of breastfeeding and lack of exclusive breastfeeding were significantly associated with group 1 SAM. Recognition of SAM by AWW was significant with respect to group 1 SAM implying there is a need for a relook into the nutritional aspects of SAM secondary to systemic/medical illness. Though NRC was effective in SAM management, the recovery rate was significantly less in SAM secondary to underlying illness. Higher defaulter rate at follow-up should be reduced in future to come by strong support groups which would complement the services of the frontline community workers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361:2226-34.
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-6: India. Vol. I. Mumbai: IIPS; 2007.
World Health Organization (WHO). Guidelines for the Inpatient Treatment of Severely Malnourished Children. Geneva: World Health Organization (WHO); 2003.
Indian Academy of Pediatrics (IAP). IAP guidelines 2006 for hospital-based management of severely malnourished children (adapted from WHO guidelines). Indian Pediatr 2007;44:443-61.
Taneja G, Dixit S, Khatri AK, Yesikar V, Khatri D, Chourasiya S. A study to evaluate the effect of nutritional intervention measures on admitted children in selected nutrition rehabilitation centres of Indore and Ujjain divisions of the state of Madhya Pradesh (India). Indian J Community Med 2012;37:107-15.
Singh K, Badgaiyan N, Ranjan A, Dixit HO, Kaushik A, Kushwaha KP, et al.
Management of children with severe acute malnutrition: Experience of Nutrition Rehabilitation Centers in Uttar Pradesh, India. Indian Pediatr 2014;51:21-5.
Mamidi RS, Kulkarni B, Radhakrishna KV, Shatrugna V. Hospital based nutrition rehabilitation of severely undernourished children using energy dense local foods. Indian Pediatr 2010;47:687-93.
Ministry of Health and Family Welfare, Government of India. Operational guidelines on facility-based management of children with severe acute malnutrition. New Delhi, India: National Rural Health Mission, Ministry of Health and Family Welfare; 2011.
Kumar N, Shekhar C, Kumar P, Kundu AS. Kuppuswamy′s socioeconomic status scale-updating for 2007. Indian J Pediatr 2007;74:1131-2.
Elizabeth KE, editor. Standards of sanitation. In: Nutrition and Child Development. 4 th
Revised Edition. Hyderabad: Paras Publication; 2010. p. 486.
Sanghvi J, Mehta S, Kumar R. Predicators for weight gain in children treated for severe acute malnutrition: A prospective study at nutritional rehabilitation center. ISRN Pediatr 2014;2014:808756.
Sharghi A, Kamran A, Faridan M. Evaluating risk factors for protein-energy malnutrition in children under the age of six years: A case-control study from Iran. Int J Gen Med 2011;4:607-11.
Sakisaka K, Wakai S, Kuroiwa C, Cuadra Flores L, Kai I, Mercedes Aragón M, et al.
Nutritional status and associated factors in children aged 0-23 months in Granada, Nicaragua. Public Health 2006;120:400-11.
Mishra K, Kumar P, Basu S, Rai K, Aneja S. Risk factors for severe acute malnutrition in children below 5 y of age in India: A case-control study. Indian J Pediatr 2014;81:762-5.
Kumari PS. A study of predictors of SAM in children of NRC of Guntur medical college, Guntur. J Evol Med Dent Sci 2015;4:393-9.
Appoh LY, Krekling S. Maternal nutritional knowledge and child nutritional status in the Volta region of Ghana. Matern Child Nutr 2005;1:100-10.
Khokhar A, Singh S, Talwar R, Rasania SK, Badhan SR, Mehra M. A study of malnutrition among children aged 6 months to 2 years from a resettlement colony of Delhi. Indian J Med Sci 2003;57:286-9.
Rao KN, Begum S, Venkataramana V, Gangadharappa N. Nutritional neglect and physical abuse in children of alcoholics. Indian J Pediatr 2001;68:843-5.
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), India, 2005-06. Karnataka, Mumbai: IIPS; 2008.
Kumar R, Singh J, Joshi K, Singh HP, Bijesh S. Co-morbidities in hospitalized children with severe acute malnutrition. Indian Pediatr 2014;51:125-7.
Islam MA, Rahman MM, Mahalanabis D. Maternal and socioeconomic factors and the risk of severe malnutrition in a child: A case-control study. Eur J Clin Nutr 1994;48:416-24.
Bloss E, Wainaina F, Bailey RC. Prevalence and predictors of underweight, stunting, and wasting among children aged 5 and under in western Kenya. J Trop Pediatr 2004;50:260-70.
Mitra M, Tiwari A, Ghosh R, Bharati P. Dimensions and causes of child malnutrition: A study of preschool children of Raipur, Chhattisgarh, India. Anthropologist 2004;6:247-52.
The Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian Response. 3 rd
ed. Rugby, UK: The Sphere Project Publications; 2011.
Gaboulaud V, Dan-Bouzoua N, Brasher C, Fedida G, Gergonne B, Brown V. Could nutritional rehabilitation at home complement or replace centre-based therapeutic feeding programmes for severe malnutrition? J Trop Pediatr 2007;53:49-51.
World Health Organization. Updates on the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Determinants of severe acute malnutrition among under five children in rural Enebsie Sarmidr District, East Gojjam Zone, North West Ethiopia, 2016
| ||Abate Awoke,Mulatu Ayana,Tenaw Gualu |
| ||BMC Nutrition. 2018; 4(1) |
|[Pubmed] | [DOI]|
||Risk factors for malnutrition among preschool children in rural Karnataka: a case-control study
| ||Tenaw Ansuya,Baby S. Nayak,B. Unnikrishnan,Anice George,Shashidhara Y. N.,Suneel C. Mundkur,Vasudev Guddattu |
| ||BMC Public Health. 2018; 18(1) |
|[Pubmed] | [DOI]|
||Follow-up between 6 and 24 months after discharge from treatment for severe acute malnutrition in children aged 6-59 months: A systematic review
| ||Natasha Phillipa O’Sullivan,Natasha Lelijveld,Alexandra Rutishauser-Perera,Marko Kerac,Philip James,Jacobus P. van Wouwe |
| ||PLOS ONE. 2018; 13(8): e0202053 |
|[Pubmed] | [DOI]|