Nutritional Status of Under-Five Children in Western Nepal

Introduction: Undernutrition is a major health problem in developing countries which may have adverse effects on growth and development of an individual. The objectives of this study were to assess the prevalence and grades of malnutrition in children below 60 months of age, attending outpatient department at Gandaki Medical College teaching hospital. Materials and Methods: A prospective study was conducted among 556 children below 60 months of age from August to December 2013. Weight and length/height were measured using standard technique and were plotted on WHO centiles curves and severity determined based on WHO classification. The prevalence of underweight, stunting and wasting were determined by anthropometry. Results: Based on WHO classification, out of 556 children, 20.2% were underweight, 34% were stunted and 15.1% were wasted respectively. Of them, severe underweight were 4.7%, severe stunted were 14.1% and severe wasted were 7.2% respectively. Conclusion: A high prevalence of undernutrition exists in underfive children attending a tertiary hospital in a western region of Nepal.


Introduction
U nder nutri on is a major global public problem in the developing countries.It directly or indirectly aff ects many aspects of the child's health which may have adverse eff ects on growth and development and also the child's ability to learn and process informa on and grow into adults.World Health Organiza on (WHO) es mated globally of around 6.6 million under fi ve children died in the year 2012.Under nutri on is the underlying cause of death in an es mated 45% of all deaths among children under fi ve years of age 1 .
Nepal Demographic and Health Survey 2011 (NDHS) shows 41% of children below fi ve years of age are stunted, 29% of the children are underweight and 11% of the children below fi ve years are wasted 2 .Under nutri on is not evenly distributed throughout Nepal; it varies both ecologically and regionally.Exact data of under nutri on a ending a ter ary hospital of western region of Nepal is not known.
Therefore the objec ve of this study was to know the prevalence of three indicators of undernutri on that is, stun ng, underweight and was ng among the under fi ve children a ending the ter ary hospital of western region.It also aims to iden fy the grades of under nutri on and its rela on to diff erent age groups, sex and ethnicity.

Materials and Methods
This was a prospec ve study conducted among the 556 children below 60 months of age a ending out-pa ent department at Gandaki Medical College Teaching Hospital, Pokhara from August 2013 to December 2013.Consent was taken from all the parents before the assessment.All children aged one month to sixty months of age a ending the paediatric outpa ent department were included in the study.The children whose dura on of illness exceeded seven days, diarrhoea with moderate to severe dehydra on and gross congenital malforma on were excluded from this study so as to exclude the child with under nutri on due to chronic illnesses.Ethical approval was taken from the Ins tu onal Review Board (IRB) of Gandaki Medical College.
Each of the individual who were more than 24 months of age were weighed barefoot with minimal clothing using a standard electronic weighing machine which was kept on the hard and plane surface on the ground to avoid the error on recording.Weight was recorded nearest to 0.1 kg.Body length was taken in children less than 24 months of age and was measured nearest to 0.5 cm by standard technique using infantometer in recumbent posi on.Height in older children was taken nearest to 0.5 cm on the stadiometer.
Weight and height of the boys and girls were compared to those of same aged boys and girls of NCHS/WHO standard.Based on the WHO classifi ca on, the z-scores < -2.0 was considered to classify stunted, wasted and underweight children based on their HAZ (height for age z score), WHZ (weight for height z score) and WAZ (weight for age z score) values respec vely.Similarly severe was ng and stun ng were defi ned when weight for height and height for age z-scores < -3.Mean and standard devia on were calculated.All the data were calculated using SPSS version 16.The
The overall prevalence of underweight, stun ng and was ng in this study in reference to WHO growth chart based on WHO classifi ca on were 20.2% (n= 112), 34.5% (n = 193) and 15.1% (n= 84) respec vely (Table 2).Of them, 4.7% were severely underweight, 14.1% were severely stunted and 7.2% were severely wasted (Table 2).Underweight and stun ng among the boys were signifi cantly more compared to girls [(p=0.003for underweight and p=0.002 for stun ng) (Table 3

and 4)].
There was signifi cant associa on of underweight and stun ng among the diff erent ethnics groups [(p=0.01 for underweight and p= 0.006 for stun ng) (Table 3 and  4)].But the associa on of was ng with sex, ethnicity and age groups were not found to be sta s cally signifi cant (Table 5).

Discussion
Anthropometric indices are the major tool for assessing the nutri onal status among the children by comparing them to a reference growth chart.Any devia on in anthropometric indices from the median value of the standard popula on is regarded as evidence of malnutri on.There are three indicators of malnutri on; underweight, stun ng and was ng 3 .
Underweight is used as a composite indicator to refl ect both acute and chronic under nutri on, although it cannot dis nguish between them 3 .The overall prevalence of underweight in this study was 20.2% (n= 112).According to NDHS 2011 preliminary report, 29% children below fi ve years are underweight 2 , which is more as compared to the present study.A study conducted by Thapa M et al found 28.2% children of Humla and 31.9% of Mugu were underweight 4 .Similarly a study in Western Kenya found 30% of children were underweight 5 .But the prevalence of underweight from western region 2 is only 23%, which is comparable to the present study.High prevalence of underweight in various studies 2,4,5 as compared to the present study might be because of the fact that the most of the study popula on in the present study were from the urban region whereas their study popula on were from rural areas.
This study showed that underweight was signifi cantly more in boys compared to girls (p=0.003).Sta s cally, there was a signifi cant associa on between underweight and gender of the study popula on (23.1% boys Vs 15.3% girls).Two studies conducted in Nigerian children in two diff erent se ngs also had a similar result with a higher prevalence of underweight in boys than in girls 6,7 .Similarly, higher prevalence of underweight in boys than girls was also noted in NDHS 2011 and a study conducted by Rijal P et al 2,8 .This study further adds a small propor on (16.2%) of children aged 7 to 12 months to be underweight but it dras cally increased in the age group 37 to 48 months which has the highest prevalence of underweight (n= 16; 25%) followed by the age groups 25 to 36 months (n= 24; 24.7%).A study by Shah N 9 conducted in Dhanusha district also reported a small propor on of children aged 7 to 12 months were underweight which is as comparable to the present study.
The overall prevalence of stun ng in the current study was 34.71% (n=193).Of them, boys were signifi cantly stunted compared to girls (39.9% Vs 26.2%; p=0.002) and has an inverse linear associa on with the age of the child, being highest in the age groups of 37 to 48 months and lowest in children below six months of age.Studies conducted by NDHS 2011 in Nepal 2 and Kandala NB in Democra c Republic of Congo 10 showed similar results; boys were more stunted than girls.Most children at this age group (37-48 months) have a habit of ea ng junk food, which could be the reason contribu ng to chronic under nutri on in the form of stun ng.In contrast, study conducted in Western Kenya found children in their second year of life were more likely to be underweight and stunted 5 .In addi on, propor on of stunted children is noted least below six months of age in the current study which is comparable to the study conducted in Dhanusha district 9 .Furthermore this study adds that the risk of stun ng increases with age, and is comparable with other studies 3,5 .Children in the youngest age group below six months had a signifi cantly lower risk of stun ng than children in the older age group.It is likely that adequate maternal care during early life is protec ve and that stun ng becomes more likely as the child grows and becomes dependent on extra food intake for growth 9,11,12 .
This study showed 84 (15.1%) children are wasted, out of which half the children were severely wasted (n= 40).It was slightly higher than the NDHS report 2011.Similar studies conducted in Mugu, Humla and Dhankuta district found 9.4%, 8.8% and 11% of the children were wasted respec vely 4,12 .These studies showed low prevalence of was ng compared to the present study.It is likely that the study popula ons enrolled were children a ending OPD of the hospital and can have acute food defi cit during the acute illness too.But the prevalence of was ng in this study is comparable to the similar study conducted by Rijal P who found 14.2 % of the children were wasted 8 .Similar study conducted in Oromia found that 16.3 % of the under fi ve children were stunted which was similar to the present study 13 .

Conclusion
This study shows that malnutri on in the form of underweight, stun ng and was ng s ll cons tute a major health problem among the under fi ve children from Western Region of Nepal.Of the three indicators of malnutri on, stun ng is the commonest, indica ng that chronic under nutri on existed as the commonest problem which is increasing as the child age increases.

Limitation
It was an ins tu on based study to iden fy the prevalence of under nutri on in children.But it fails to predict the various factors which contributed under nutri on.A further study needs to be conducted to know the factors contribu ng to under nutri on among under-fi ve children.

Table 2 :
Nutri onal status of the par cipants using the Height-for-age Z-scores (HAZ) and Weight-for-Age Z-scores (WAZ) and weight -for-height Z scores (WHZ) test was used for assessing the signifi cance of nutri onal indices and independent variables of interest.A probability level of ≤ 0.05 was considered to be sta s cally signifi cant.

Table 4 :
Distribu on of height for age z score( HAZ)