Panacea Journal of Medical Sciences

Introduction

Nutritional status plays a vital role in deciding the health status in children. Nutritional deficiencies give rise to various morbidities, which in turn, may lead to increased mortality. Malnutrition apart from impairing growth and development of the child increases his or her susceptibility to infections like diarrhea and pneumonia. ^[1]

Children under five years constitute the most vulnerable segment of a country. Their nutritional status and mortality rate are a sensitive indicator of community health and nutrition. Globally more than half of the under- five deaths are attributable to under nutrition. At national level NFHS-4 data revealed the national under five mortality rates (U5MR) is 50 per 1000 live births, with 34 in urban and 56 in rural area. Odisha’s U5MR is estimated to be 49 per 1000 live births with 25 in urban area.^[1] The latest NFHS-5 data reveals the national U5MR to be 41.9 and that of Odisha to be 41.1.

Assessing national prevalence of under nutrition among under five, NFHS -4 data shows underweight is 35.7%, wasting is 21% and stunting 38.4% in India. The same indicator for Odisha is 34.4%, 20.4 % and 34.1% respectively. Whereas the latest NFHS-5 data reveals that underweight is 32.1%, wasting is 19.3% and stunting 35.5% in India. ^[2] The same indicator for Odisha is 29.7%, 18.1% and 31.0% respectively. ^[3]

Assessment of community nutritional status among children assumes even more significance in the current COVID-19 pandemic. Recent estimates indicate that in addition to the 690 million undernourished people in 2019, at least another 83 million people, and possibly as many as 132 million, may go hungry in 2020. ^[4] As of July 2020, an estimated 370 million children are missing school meals. ^[5] With these added shocks, children’s dietary quantity and quality are expected to deteriorate below the already poor situation that existed pre-COVID-19, when only 29 per cent of children aged 6 to 23 months were fed a minimally diverse diet and only 53 per cent received the minimum meal frequency.

In July 2020, UNICEF, with the Food and Agricultural Organization, the World Food Programme and the World Health Organization issued a call to action in The Lancet, ^[6] warning of the pandemic’s potential to worsen the pre-existing crisis of malnutrition and tip an additional 6.7 million children over the edge to become wasted during its first year. This is in addition to the 47 million children affected by wasting and 144 million affected by stunting in 2019 before the pandemic, according to the 2020 Joint Malnutrition Estimates.

Malnourished children have weakened immune systems and may face a greater risk of dying from COVID-19. At the same time, it may be more difficult for these children to access the treatment and care they need to survive and thrive. UNICEF country offices reported a 30 per cent decline in overall coverage of services to improve nutrition outcomes for women and children in the early months of the pandemic, and alarming reductions of 75 to 100 per cent under lockdown contexts. ^[6]

Rationality of the study: Malnutrition has been a long standing health care problem in the Indian Community. The fact that the most vulnerable population affected by it is children makes it even more important. According to WHO, 45% child deaths are associated with malnutrition. ^[7] This makes timely and periodic assessment of nutritional status a vital healthcare activity.

The activity assumes even more significance in the wake of the global and deadly COVID-19 pandemic. It is apparent that the pandemic has hit the underprivileged section the most and malnourishment which decreases one’s immune levels, risks the young kids to fall prey to COVID-19 infections and subsequent complications.

Further, no such activity has been undertaken during the COVID pandemic and it shall be a first of its kind in the state providing a direction for further studies and shall help us to realize the extent of the problem and formulate plans to mitigate them.

Aim of the Study

To study the risk factors and prevalence of malnutrition among children of 6 months to 5 years in an urban slum of Jobra, Cuttack.

Objectives of the Study

To assess the nutritional status of the above children by Anthropometry, Clinical assessment and Dietary assessment.

To study the socio-demographic profile of the children between 6 months to 5 years in the slum area of Jobra.

To estimate the risk factors and prevalence of malnutrition (defined as per WHO) among the subjects.

To make the parents aware about their child’s nutritional status and suggests them ways to correct the problem, if any.

Materials and Methods

This study was carried out in the registered slums under Cuttack Municipal Corporation (CMC) area of the Cuttack city under UPHC Brajarambha and UHTC, Department of Community Medicine, SCBMCH from January 2021to December 22. The study was a community based cross-sectional study with descriptive and analytical elements.

Cuttack district is one of the 30 districts located in the eastern part of the country, within the state of Odisha. The Cuttack city is located at 20Ú31’25"N and 84Ú47’17"E covering an area of 192.5 square kilometers. It is bounded by Naraj in the west, Kandarpur in East, Choudwar in North and Phulnakhara in Southern side. The city’s main river is the Mahanadi. Due to the recent expansion projects of the city, a new residential area was formed across Kathajodi River, known as Markat Nagar (CDA by local residents) and consists of 15 sectors. Being under the administration of Cuttack Municipal Corporation, it consists of 59 wards. According to the census of 2011, this city catered to a population of 6, 06,007. Being the2nd most populous city of the state and 72nd nationally, its population density is 3100 per square kilometers. Of this 1, 29, 720 people reside in slums (66, 194 males and 63, 526 females) and are distributed within 180 registered slums.1 The slum near Jobra is under PHC Brajarambha and the Department of Community Medicine has a UHTC associated with the PHC. The study was carried out there.

Results

A total of 411 households were surveyed for the study. Of them 11 did not give consent for the study, 18 were excluded due to incomplete data and 20 children were excluded as they satisfied the exclusion criteria. Thus, a total of 362 children were analyzed among the children surveyed.

183(50.6%) children were females and 179(49.4%) were males. Of the children, a maximum of 24.3% belonged to 12-23 completed months while the least 14.6% were between 36-47 completed months. The mean age of the study population was 22.6 ± 14.77 months. Around 18.5% of the study population practiced Open Air Defecation (OAD) whereas the rest had access to either community toilet or had their own toilet. The study showed that 48.6% of the population use their own toilet. Around 12.4% of children used well water for drinking whereas the rest used either tube well water or tap water for drinking purposes.64.6% children were completely immunised and 32.6% were partially immunised. Only 2.8 percent children had not received any vaccination. Socio-Economic Status classification was done using the Updated Modified Kuppuswamy Scale-2021. Most of the families i.e. 40.3% and 44.5% belonged to Upper Lower and Lower Middle class. Only 2 families belonged to the lower class. The Upper Middle class was taken was reference for subsequent comparisons. The mean income of the study population was 17136.74 and the mean SES Score was 11.10.([Table 1])

As per the 24-hour recall method, it was seen that 33.4% of the children had around normal protein intake and 5% had an intake of more than 10%. Thus it was seen that 61.6% of children had a deficient protein intake with 18.8% having more than 30% deficiency and 23.8% with 20-30% deficiency. As per the 24-hour recall method, it was seen that 39.5% of the children had around normal calorie intake and 6.6% had an intake of more than 10%. Thus it was seen that 53.9% of children had a deficient calorie intake with 11.6% having more than 30% deficiency and 21% with 20-30% deficiency.([Table 2])

Data showed that 68% children had weights in the normal range, whereas 27.3% children were in underweight and 4.7% in overweight range. 12.4% of all children were severely underweight and 14.9% were moderately underweight. It was also found that 4.7% children were overweight and 0.6% were found to be obese.

68.8% children had length/heights in the normalrange whereas 31.2% children were stunted. 14.9% were severely stunted and 16.3% children were moderately stunted. It was found that 79.6% of the children were normal weight/length and 20.4% children were found to have wasting. 7.7% children were having severe wasting (Severe Acute Malnutrition) and 12.7% children were having moderate wasting (Moderate Acute Malnutrition).

MUAC was found to be normal in 79.3% of the study population and decreased in 20.7% of children. Out of them, 9.1% were having SAM and 11.6% were having MAM. On combining the results of wasting and MUAC, an overall assessmen for the prevalence of SAM and MAM was done.([Table 3])

It was found that in our study population, 27.9% children were having MAM and 12.4% children were having SAM. After anthropometry, clinical assessment of the children was done to look for features of malnutrition.([Table 4])

The evidence of pallor was found in 40.9% children whereas 59.1% were found to have apparently normal examination. The grading of pallor was not a part of the study. 22.9% children had hair changes and 77.1% children had normal hair. 79.8% children had apparently normal examination of the oral cavity, 20.2% had one of the mentioned findings.The evidence of pedal edema was found in 9.4% of the population while the rest had no evidence of pedal edema.([Table 5])

We enquired for the sanitary habits of the children from the parents and divided them into those who practised open air defecation (OAD) and those who used toilets. Toilet usage included the use of either own or community toilet.

Effects of sanitary habits was analysed and open defecation was taken as a risk factor and compared with those who used toilets. A significant association of open defecation was found for all anthropometric parameters like underweight, severely underweight, stunting, wasting, severe wasting, MAM and SAM and clinical parameters like hair changes, oral cavity changes and pallor except for severe stunting and edema for which the association was non-significant.([Table 6])

The mean values of weight, height and MUAC was compared in both groups. A lower value in all parameters was recorded in the group practising open defecation but the decrease was statistically significant in weight and MUAC.([Table 7])

Effects of drinking water supply was analysed and use of well water for drinking was taken as a risk factor and compared with those who used tap water or tube well water. A significant association of well water use was found for all anthropometric and clinical parameters except for severe stunting and MAM for which the association was non-significant.([Table 8])

On comparing the mean values, however it was seen that only the decrease in MUAC was statistically significant.([Table 9])

Comparison was done in between children who were non-immunized and the children who were partially or completely immunized with the parameters of malnutrition taken in the study and no significant association was found in between these two groups in any of the parameters except for in children with severe stunting where non-immunized children where significantly more prone for stunting than those who were immunized or partially immunized.([Table 10])

On comparing the mean values of weight, length and MUAC between non-immunized children and others, it was found that although the non-immunized children had a lower mean weight and length, the difference was not statistically significant.([Table 11])

A significant association of lower SES was seen in case of underweight, severely underweight and wasting and was non- significant with other parameters of our study.([Table 12])

On comparisons of the mean values of weight, length and MUAC with the two groups, a significant difference was seen only with MUAC.([Table 13])

A significant association was seen with deficient protein intake and all the parameters considered for assessment in the study i.e. underweight, severely underweight, stunting, severe stunting, wasting, severe wasting, MAM and SAM and clinical parameters like hair changes, oral cavity changes, pallor and edema.([Table 14])

The significant association was also reflected when the mean values of length, weight and MUAC of the deficient group was compared with the reference group in which the group with deficient protein intake was seen to have statistically significant lower values of weight, length and MUAC.([Table 15])

A significant association was seen with deficient calorie intake and all the parameters considered for assessment in the study i.e. underweight, severely underweight, stunting, severe stunting, wasting, severe wasting, MAM and SAM and clinical parameters like hair changes, oral cavity changes, pallor and edema. ([Table 16])

The significant association was also reflected when the mean values of length, weight and MUAC of the deficient group was compared with the reference group in which the group with deficient protein intake was seen to have statistically significant lower values of weight, length and MUAC.([Table 17])

Discussion

Strengths of the Study

The study was conducted in a community on a house to house basis involving the community health workers like ASHA, ANM and AWWs with pediatricians being involved in history taking, clinical and anthropometric examination. The timing of the study in the aftermath of COVID-19 lockdowns also helps us to know the nutritional impact of the economic shutdown during the pandemic. Out of nearly 1100 children in the under 5 age group out of which 400 were approached which makes it a good representation of the community. Adequate number of girl children have been a part of the study. The study analyses the effect of both nutrition and socio- demographics together on the nutritional status. Standard definitions, clinical methods, cut-offs, instruments and charts have been used in the study..Appropriate statistical methods have been applied to decide the sample size and do the analysis.

Limitations of the Study

A better sampling method to collect the study population could have been used. Maternal literacy was not taken as a parameter for evaluation in this study. A more exhaustive nutrition history could have been taken to include fruits, frequency of snacks etc. Well water could have been further classified into covered and uncovered wells to include covered wells in the improved drinking water category as per NFHS criteria. As the socio demographic risk factors are inter-linked with each other and do co-exist, a multiple regression analysis could have been done to a get a more clear data.

Recommendations

Open Air Defecation is an avoidable unhealthy practice. People must be encouraged to use toilets at home and must train their children the same. The IEC materials explaining the risks associated with OAD and how they can be averted by using a sanitary latrine must be used to impart knowledge among the slum residents. Open well water, if used, must be covered and water should be boiled before drinking. The technique to boil water and the benefits of it and risks associated if not done must be explained to the residents. The community health care workers are already doing a good job in making a good coverage of immunization. Those left out must be reached and explained regarding the risks of diseases if the child remains un-immunized. They must be explained that the vaccines are being provided by the government free of cost and must be given to all children to achieve maximum benefit. The residents must be assured that nutritious food is not a luxury and can be obtained from a common household menu if we plan our meals and cook them properly. A sample individualized diet chart can be provided to them. The parents must be counseled to utilize the health care facility services in their nearby area in case of any illness so that correct and optimal treatment may be given to them and their children. The residents must be motivated to take their children for regular health check-ups which shall also be an opportunity to assess for the growth and development. Lastly, to make them realize that the first 5 years of their children’s life is vital in shaping his entire life ahead and they must take utmost care of their children.

Source of Funding

None.

Conflict of interest

None.