|Year : 2018 | Volume
| Issue : 1 | Page : 55
Undernutrition and morbidity profile of exclusively breastfeeding children: A cross-sectional study
Sumon Chandra Debnath1, Md. Ekramul Haque2, Dewan Md. Mehedi Hasan3, Sharraf Samin4, Md. Abdur Rouf5, Md. Fazlay Rabby6
1 Bangladesh Breastfeeding Foundation, Mohakhali, Dhaka, Bangladesh
2 Communicable Disease Control (CDC), DGHS, Mohakhali, Dhaka, Bangladesh
3 Hospital Service Management, DGHS, Mohakhali, Dhaka, Bangladesh
4 TB/HIV Control Program, BRAC, BRAC Centre, Mohakhali, Dhaka, Bangladesh
5 Aichi Medical College and Hospital, Dhaka, Bangladesh
6 Associates for Community and Population Research, Dhaka, Bangladesh
|Date of Submission||03-May-2017|
|Date of Acceptance||02-Sep-2017|
|Date of Web Publication||26-Jun-2018|
Sumon Chandra Debnath
Bangladesh Breastfeeding Foundation, Mohakhali, Dhaka-1212
Source of Support: None, Conflict of Interest: None
Background: Undernutrition is common and has been recognized as a public health problem in Bangladesh. It has devastating effects on any population as it increases morbidity children and reduces the quality of life of all affected. The study was done with the objective to assess the undernutrition and morbidity profile in children who have completed exclusive breastfeeding. Methods: This was a descriptive cross-sectional study, which was carried out among children aged 6–12 completed months attending a tertiary level hospital in Bangladesh. A total of 251 children were selected through convenient sampling from January to December 2015. Nutritional assessment was done in terms of underweight, stunting, and wasting. Results: One hundred and forty-three (57.0%) were boys while 108 (43.0%) were girls. The prevalence of undernutrition (Z-score ≤−2) was observed in 11.2%, 16.3%, and 12.0% based on stunting, underweight, and wasting. Among 251 children, 16.7% were not suffering any diseases, whereas majorities (69.7%) were suffering from single disease and 13.5% were suffering from multiple diseases. Cough and fever (55.0%), pneumonia (18.3%), measles (9.9%), and diarrhea (8.3%) were the most common cause of infectious morbidity observed in children. Conclusions: The prevalence of undernutrition was high in the study population, and it continues to be a public health burden because of its major effect on morbidity and impairment of intellectual and physical development in long-term. Increasing the practice of exclusive breastfeeding, the introduction of timely complementary feeding, and standard case management of morbidities would be beneficial to combat the problem of undernutrition.
Keywords: Breastfeeding, malnutrition, morbidity, underweight
|How to cite this article:|
Debnath SC, Haque ME, Mehedi Hasan DM, Samin S, Rouf MA, Rabby MF. Undernutrition and morbidity profile of exclusively breastfeeding children: A cross-sectional study. Int J Prev Med 2018;9:55
|How to cite this URL:|
Debnath SC, Haque ME, Mehedi Hasan DM, Samin S, Rouf MA, Rabby MF. Undernutrition and morbidity profile of exclusively breastfeeding children: A cross-sectional study. Int J Prev Med [serial online] 2018 [cited 2019 Jan 23];9:55. Available from: http://www.ijpvmjournal.net/text.asp?2018/9/1/55/235336
| Introduction|| |
Undernutrition has long been major public health problems in Bangladesh leading to high morbidity and mortality among under-five children. Undernutrition in children is multidimensional; governed by biological, behavioral, and environmental factors. It reduces children's resistance to infection and increases the burden of disease in the communities. Studies have reported that despite the economic development, childhood malnutrition still remains a significant public health problem in developing countries.,, Undernutrition has been reported to be associated with diarrhea, respiratory infections, measles, tuberculosis, etc.,,, Multiple attacks of these morbidities further aggravate the malnutrition. The nutritional status may be assessed using anthropometric measurements which are needed to know the presence of stunting, wasting, and underweight. Globally, the prevalence of stunting, underweight, and wasting in children under 5 years are 26, 16, and 8%, respectively. These figures in Asia are 26.8, 19.3, and 10.1%, respectively. However, Bangladesh Health and Demographic Survey 2014 revealed that the prevalence of stunting, underweight, and wasting were 36.0, 33.0, and 14.0% in 2014, respectively.
Therefore, realizing the importance of undernutrition among children, this study was undertaken with an aim to estimate the prevalence of undernutrition and morbidity profile among exclusively breastfeeding children.
| Methods|| |
Study design and study place
The present cross-sectional study was carried out in the Breastfeeding Department of the Rangpur Medical College Hospital (RMCH), which is located at the center of Rangpur town, Bangladesh. RMCH is a government tertiary level referral hospital. The outpatient department of this hospital provides curative and referral services to about 150–200 patients from different parts of the urban and rural areas and of different sociodemographic characteristics, per week. Patients from different parts of the urban and rural area of different sociodemographic characteristics attended this hospital. The study was conducted between January and December 2016.
The study individuals consisted of children aged between 6 and 12 months who have completed exclusive breastfeeding. Mothers of eligible participants (or another responsible caregiver) were interviewed and information was collected regarding age and gender of the child, socioeconomic status (SES) of the family, household demographics, and child-feeding practices including exclusive breastfeeding
Sampling and sample size
The sample was selected through convenient sampling. A sample size of 354 was calculated using the prevalence of stunting 36%, absolute precision of 5% with 95% confidence interval. A total sample of 251 children was recruited for this study whose anthropometric measurements were provided.
Data were collected by face-to-face interview and two types of instruments were used: a structured questionnaire and anthropometric measurements including weight and length. The questionnaire used in the present study was pretested and then modified based on difficulties in understanding or interpretation that were encountered. The questionnaire, which was written in English, was translated to local language (Bangla) and again translated back to English to ensure its accuracy. Mothers of eligible participants (or another responsible caregiver) were informed about the study goals, and verbal consent was obtained to take their child's anthropometric measurements. The interview was taken at the hospital of the participants ensuring the privacy and confidentiality as far as possible.
Anthropometric measurements taken were weight, length, as per following technique.
Portable (Seca Model 881) scales were used for measuring the weight of children dressed in light clothing. The scales were checked for accuracy and calibrated every morning using standard known weights. Weights were recorded to the nearest 0.1 kg. Children who could not stand on the scale were weighed with the respondent, then the respondent has weighed alone, and the difference was used for obtaining a weight of the child.
United Nations Children's Funds provided length/height portable wooden constructed scale calibrated for length measurement. The length was measured by making child lay on the flat surface, head positioned firmly against the fixed hardboard, with the eyes looking vertically. The knees extended, by applying firm pressure and feet are flexed at right angles to the lower legs on the board. Readings of length were taken to the nearest 0.1 cm.
Anthropometric indices weight for age (underweight), height for age (stunting), and weight for height (wasting) of the children were calculated using reference medians recommended by the World Health Organization (WHO) and classified according to standard deviation (SD) units (z-scores), based on the WHO criteria.,
To assess the morbidity, we analyzed corresponding data (prescription diagnosis) collected during each interview. A medical (on duty) doctor clinically examined of all the children to detect any disease or morbid condition present at the time of the data collection.
The protocol and consent forms were reviewed and approved by the Institutional Review Board of National Institute of Preventive and Social Medicine, Dhaka, Bangladesh. Written consent and approval was given by the hospital authorities where this study was carried out while verbal consent was obtained from the mothers of the children.
The Anthro software of WHO was used for analyzing the nutritional status of children and all other analyses were done using the Statistical Package for Social Sciences version 20 (Chicago, IL, USA). The numerical data were presented as mean ± SD and categorical variables were presented as percentage. Chi-square test was used to test for significant association of the proportion. P < 0.05 was considered statistically significant.
| Results|| |
Sociodemographic status of children
A total of 251 children under 1 year of age participated in the study, of them, 143 boys and 108 girls were used in the final analyses. Children age was in a range of 6–12 months with a mean of 8.6 months [Table 1]. About 84.1% of the mothers received education below secondary and only 15.9% received education higher secondary and above [Table 1]. Monthly incomes for 31.5% households were taka ≤9999 and 27.1% households were taka 15,001–20,000 whereas 25.5% households earned above taka 10,000–15,000 and 15.9% households earned taka ≥20001 per month. The mean income was taka 144402.4 [Table 1].
Anthropometric measurements and indices
Overall mean (±SD) weight and length were 7.7 ± 1.4 kg and 70.2 ± 4.7 cm. For male children, these values were 7.7 ± 1.4 kg and 69.5 ± 5.5 cm, respectively, and for female children 8.5 ± 0.9 kg, 91.81(±8.33) cm and 71.1 ± 3.2 cm, respectively. Mean weight and height increased with the increase in age and tended to be greater for girls than for boys [Table 2].
|Table 2: Mean±standard deviation anthropometric measurements of study subjects (n=251)|
Click here to view
Height for age
For 88.8% of children's height for age Z-score was ≥−2 of the WHO median indicating that they were normal [Table 3]. The prevalence of moderate stunting (≥−3 and <−2 z-scores) 11.2%. No severe stunting was found in this category [Table 3].
Weight for age
The study revealed that 83.7% of the children were normal and 16.3% moderately underweight (≥−3 and <−2 z-scores) [Table 3].
Weight for height
Moderate acute malnutrition (MAM) was defined as a weight for height of ≥−3 and <−2 z-score and severe acute malnutrition was defined as weight for height z-score of <−3. Among all the children, 88.0% were normal and 3.92% moderately wasted/MAM. No severe wasting was found in this category [Table 3].
The prevalence of malnutrition
Among all the children, higher proportion of children 11.2% was found in malnourished (stunting) using H/A as the indicator and the prevalence of underweight and wasting was 16.3% and 12.0%, respectively [Table 4]. The age group of ≥ 6–7 months showed the highest prevalence of underweight (7.9%) and age of ≥ 10 months showed the highest prevalence of stunting (4.8%) and wasting (5.2%), accordingly [Table 4].
Morbidity status of children
Among 251 children, 16.7% were not suffering any diseases, whereas majorities (69.7%) were suffering single disease and 13.5% was suffering from multiple diseases [Table 5].
|Table 5: Morbidity characteristics of children stratified by gender (n=251)|
Click here to view
Morbidity patterns of children
The most prevalent (55.0%) disease was a cough with fever and the percentage was higher in girls compared with boys (56.4% vs. 53.9%) [Table 5]. Second prevalent (18.3%) disease was pneumonia and the percentage was greater in boys compared with girls (21.0% vs. 14.8%) [Table 5]. The third prevalent disease was the measles (9.9%) and there were more boys sufferers than girls (16.2% vs. 1.8%). Other morbidities were diarrhea (8.3%) and other problems (5.2%) [Table 5].
| Discussion|| |
The WHO working group's report on measuring the nutritional status of children recommends the use of Z-scores system as they have significant advantages over other approaches., The present study assessed the prevalence and also underlying morbidity among children under 1 year of age, with special reference to their SES. The prevalence of stunting, wasting, and underweight were 11.2%, 16.3%, and 12.0%, respectively of which all children were moderately stunted, wasted, and underweight.
The current study findings of stunting (11.2%) were lower than the national figure. Earlier studies conducted in Bangladesh have reported the prevalence of stunting among children was 44.0% and 48.0%; these findings are inconsistent with the present study., However, another study had reported that Infants aged 6–12 months had a significantly lower risk of being stunted than children in older age groups. Our findings are similar to those from a study in India.
The present study revealed the prevalence of underweight as 16.3% which is lower than the national figure (33.0%) of Bangladesh. This might be due to small sample size and convenient sampling. A multi-stage cross-sectional study  done in Vietnam also revealed that the prevalence of underweight was found to be 31.8%. The difference might be due to variation in characteristics and level of progress. A study conducted by Rahman and Biswas in Bangladesh reported that 47.0% children were underweight, which is inconsistent with the present study findings.
In our study, the overall prevalence of wasting was 12.0%, which is nearly comparable to the national figure (14.0%) of Bangladesh. This might be due to the similar sociocultural and demographic characteristics of the children. A cross-sectional study conducted in Bangladesh  and result found that the prevalence of wasting was 10.0% which was almost equal to the present study findings. Another cross-sectional study conducted by Avachat et al. had revealed that 15.7% children were wasted, which is inconsistent with the present study findings. A cross-sectional community-based survey conducted among 15408 children, under 5 years of age, in Iran had revealed the prevalence of wasting was as 8.19%, which is lower than the present study findings.
A study conducted in India revealed that the prevalence of stunting, underweight, and wasting was 70.1%, 71.5%, and 62.7%, respectively, which is higher than the present study findings. These may be due to regional variation and socioeconomical influences.
De Souza et al. reported the prevalence of stunting and wasting 9.9% and 4.1%, respectively and Zhang et al. reported the prevalence of wasting and underweight 3.1% and 7.2%, respectively., These are nearly consistent with the present study findings. In general, the prevalence of under-nutrition in various parts of the world ranged from 5% to 40% with the different risk factors categorized as child or family characteristics, socioeconomic status, healthcare, and prevalent infectious disease.,
Undernutrition and childhood morbidity have a synergistic relationship, i.e., the illness can suppress appetite precipitating undernutrition of a child, while on the other hand, nutritional deficiencies increase the susceptibility of the child to infectious diseases.
The current study revealed that the most (83.3%) of children were suffering from a single or multiple diseases in which 69.7% were suffering from single disease, and 13.6% were suffering from multiple diseases. It was noted in the present study that 55.0% of children suffered from one or multiple episodes of fever with a cough followed by pneumonia (18.3%), measles (9.9%), and diarrhea (8.3%). It was noted in the present study that the majority (45.0%) of the children suffered from one or multiple episodes of diarrhea followed by a respiratory tract infection were (32.0%), pneumonia (18.0%). This is similar to the findings of Bhavsar et al. A study conducted by Gupta in Punjab had found that 46.0% of under-five children with diarrhea suffered from malnutrition. Bisai et al. reported that children with prevalent morbidities such as diarrhea, ARI, or measles were more likely to be undernourished. Gastroenteritis was reported in 14%and fever in 19%children.
The study was not primarily designed to measure sex differentials in morbidity; the present study demonstrates that pneumonia was slightly higher in boys as compared to girls. Nagaraj et al. observed that the prevalence of pneumonia was 9.0%. Rao  carried community-based cross-sectional study and found that the prevalence of ARI was 12.4%. Giri et al. revealed that 5.8% children were suffering from acute diarrheal diseases. Above findings of morbidity was lower than the present study results.
| Conclusions|| |
Despite the decreased trend of undernutrition in the last years, the prevalence of undernutrition was high in the study population thus highlighting yet again that undernutrition continues to be a public health burden because of its major effect on morbidity and impairment of intellectual and physical development in long-term. Increasing the practice of exclusive breast feeding, the introduction of timely complementary feeding, and standard case management of morbidities would be beneficial to combat the problem of undernutrition.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chaudhuri A. Impact of Sibling Rivalry on the Nutritional Status of Children: Evidence from Matlab, Bangladesh; 2008. Available from: http://www.ssrn.com/abstract=1158815.9
. [Last accessed on 2017 Feb 09].
Wong HJ, Moy FM, Nair S. Risk factors of malnutrition among preschool children in Terengganu, Malaysia: A case control study. BMC Public Health 2014;14:785.
World Health Organization. Water Sanitation Health-Water Related Diseases-Malnutrition. Geneva: WHO; 2015.
Demissie S, Worku A. Magnitude and factors associated with malnutrition in children 6-59 months of age in pastoral community of Dollo Ado District, Somali Region, Ethiopia. Sci J Public Health 2013;1:175-83.
Masibo PK, Makoka D. Trends and determinants of undernutrition among young Kenyan children: Kenya demographic and health survey; 1993, 1998, 2003 and 2008-2009. Public Health Nutr 2012;15:1715-27.
Pasricha SR, Biggs BA. Undernutrition among children in South and South-East Asia. J Paediatr Child Health 2010;46:497-503.
Park K. Park's Textbook of Preventive and Social Medicine. 18th
ed. Jabalpur: Banarasidas Bhanot Publishers; 2005. p. 405.
Janevic T, Petrovic O, Bjelic I, Kubera A. Risk factors for childhood malnutrition in Roma settlements in Serbia. BMC Public Health 2010;10:509.
United Nations Children's Fund, World Health Organization, The World Bank. UNICEF WHO-World Bank Joint Child Malnutrition Estimates. New York, Geneva, Washington DC: UNICEF, WHO, The World Bank; 2012.
National Institute of Population Research and Training, Mitra and Associates, and ICF International. Bangladesh Demographic and Health Survey, 2014. Dhaka: National Institute of Population Research and Training; 2015. p. 346.
World Health Organization. The Use and Interpretation of Anthropometry – Report of WHO Expert Committee. WHO Tech Rep Series 854. Geneva: WHO; 1995.
World Health Organization. Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. Geneva: World Health Organization; 2006. p. 306-7.
Rahman A, Biswas SC. Nutritional status of under-5 children in Bangladesh. S Asian J Popul Health 2009;2:1-11.
Akhter N, Torlesse H, Pee SD, Ibrahim QI, Stallkamp G, Panagides D, et al
. Nutritional status of young children and their mothers in Chittagong Hill Tracts, Bangladesh. J Biosoc Sci 2003;57:172.
Olack B, Burke H, Cosmas L, Bamrah S, Dooling K, Feikin DR, et al.
Nutritional status of under-five children living in an informal urban settlement in Nairobi, Kenya. J Health Popul Nutr 2011;29:357-63.
Mittal A, Singh J, Ahluwalia SK. Effect of maternal factors on nutritional status of 1-5-year-old children in urban slum population. Indian J Community Med 2007;32:264-7. [Full text]
Hien NN, Kam S. Nutritional status and the characteristics related to malnutrition in children under five years of age in Nghean, Vietnam. J Prev Med Public Health 2008;41:232-40.
Avachat SS, Phalke VD, Phalke DB. Epidemiological study of malnutrition (under-nutrition) among under five children in a section of rural area. Pravara Med Rev 2009;1:20-2.
Myatt M, Khara T, Collins S. A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Food Nutr Bull 2006;27:S7-23.
Rasania SK, Sachdev TR. Nutritional status and feeding practices of children attending MCH Centre. Indian J Community Med 2001;26:145-50.
de Souza OF, Benício MH, de Castro TG, Muniz PT, Cardoso MA. Malnutrition among children under 60 months of age in two cities of the state of acre, Brazil: Prevalence and associated factors. Rev Bras Epidemiol 2012;15:211-21.
Zhang J, Shi J, Himes JH, Du Y, Yang S, Shi S, et al.
Undernutrition status of children under 5 years in Chinese rural areas – Data from the National Rural Children Growth Standard Survey, 2006. Asia Pac J Clin Nutr 2011;20:584-92.
Jesmin A, Yamamoto SS, Malik AA, Haque MA. Prevalence and determinants of chronic malnutrition among preschool children: A cross-sectional study in Dhaka city, Bangladesh. J Health Popul Nutr 2011;29:494-9.
Pelletier DL, Frongillo EA Jr., Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Organ 1995;73:443-8.
Bhavsar S, Hemant M, Kulkarni R. Maternal and environmental factors affecting the nutritional status of children in Mumbai urban slum. Int J Sci Res 2012;2:1-9.
Gupta A. Study of the prevalence of diarrhoea in children under the age of 5 years: It's association with wasting 2014. Indian J Sci Res 2014;7:1315-8.
Bisai S, Mahalanabis D, Sen A, Bose K. Maternal education, reported morbidity and number of siblings are associated with malnutrition among Lodha preschool children of Paschim Medinipur, West Bengal, India. Int J Pediatr 2014;2:13-21.
Khan MS, Hussain I, Kazmi NR, Majid A, Javaid A. Morbidity and mortality in children in rural community of district Peshawer. Gomal J Med Sci 2009;7:31-4.
Nagaraj A, Nagaraj VK, Lobo J. Perception of severity of acute respiratory tract infections and diarrhoea in children under the age of five in rural India: Utilization pattern of health services. Trop Doct 2004;34:222-3.
Rao VK. Prevalence of nutrition deficiency signs in rural Hyderabad preschool children by age. Nutr News NIN Hyderabad 1984;5:4-9.
Giri VC, Dhage VR, Zodpey SP, Ughade SN, Biranjan JR. Prevalence and pattern of childhood morbidity in a tribal area of Maharastra. Indian J Public Health 2008;52:207-9.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]