Nutritional Status of Children Seeking Medical Treatment in a Rural Hospital in Ilam District, Nepal

Introduction: Childhood malnutrition is a leading cause of mortality and morbidity in children under five years in Nepal. There is evidence to show that childhood malnutrition varies from region to region, within Nepal. But there is no data available about nutritional status of children in the 75 districts in Nepal. The aim of this study was to evaluate the nutritional status of children less than five years of age in Ilam district. Material and Methods: We analysed the anthropometric data for the children of Ilam district who visited Dr. Megh Bahadur Parajuli Community Hospital in Ilam district. Results: Our data showed that 15.7% of girls and 21.2% of boys under-five years suffered from moderate malnutrition. Severe malnutrition was present in 6.7% of girls and 9.6% of boys. Stunting was seen in 32.6% girls and 30.16% boys. Moderate stunting was present in 19.6% of girls and 19% of boys; while severe stunting was present in 11% of the boys and 13% of the girls. Conclusion: Our data shows that stunting among under-fives in Ilam is less as compared to that reported for Nepal, but underweight is comparable to the national data. However, a systematic study needs to be carried out in Ilam before drawing firm conclusions.


Introduction
N epal demographic health survey reported that 41% of children under fi ve years were stunted, 11% wasted and 29% underweight 1 .Several factors were noted to contribute towards malnutri on-for example, socio-economic factors, mother's literacy, acute illnesses, age of the child 2 .Social problems such as poverty, skewed land distribu on and food insecurity are some of the underlying factors which cause malnutri on 3 .Several independent studies have been carried out in Nepal, es ma ng the prevalence of acute malnutri on to be anywhere from 8-18%, as measured by MUAC 4,5,6 .World Health Organisa on (WHO) data from 2011 report the prevalence of moderate and severe malnutri on to be 29.8% and 8.5% respec vely, among boys under fi ve in Nepal.These fi gures were 28.4 and 7.7 respec vely for girls in the same age group.Moderate and severe stun ng among Nepali boys who are under fi ve were reported to be 41.3% and 16.8% respec vely, and that among girls were 39.5% and 15.8% respec vely 7 .Malnutri on is not evenly distributed throughout Nepal.It varies ecologically and regionally.Stun ng, was ng and underweight is reported to be much higher in the mountains compared to the na onal average 8 .Children from Newar community were found to be more malnourished, in a report from Kathmandu (9).Previous study from Mugu district in the mid-Western region of Nepal reports that 18% of children under fi ve years were malnourished (10).Data from Jirel in Eastern Nepal showed that 36.25% and 12.62% children under fi ve years of age had mild to moderate and severe malnutri on respec vely based on their MUAC measurements.The prevalence of stun ng among girls were higher than that in boys in Jirel 4 .
Nepal is divided into 75 administra ve districts.Ilam district is situated in the hilly Eastern part of Nepal, and has a total popula on of over 300,000.Popula on of Ilam belongs to several castes, the major ones being Rai, Limbu, Bahun and Chhtri.Dr. Megh Bahadur Parajuli Community Hospital (DMBPCH) is located in rural Ilam district and is one of the 2 hospitals in Ilam district.Most of our pa ents come from Ilam district, although a small number of pa ents also come from nearby districts of Panchthar and Taplejung.There are no published reports on the prevalence of malnutri on among children in Ilam or nearby districts to date.Hence we undertook an analysis of the anthropometric data available to us from the children who visited our facility in order to understand the prevalence of malnutri on among under-fi ves in Ilam district.

Materials and Methods
We analysed the anthropometric data which was collected from children during their visits to our paediatric clinics at the hospital and in the community over 2010-2011.Data available to us were the weight, height and gender of the children (it was not rou ne prac ce in our Paediatric clinics to measure mid upper arm circumference (MUAC)).All the observa ons were measured by the same person on the calibrated equipments used in the paediatric clinic.Data from all the children who had chronic medical condi ons and/ or severe acute medical condi ons were excluded, in order to obtain a representa ve sample of children from Ilam district.Observa ons from children with acute medical condi ons such as gastroenteri s which are likely to aff ect the anthropometry were also excluded from this dataset.
Weights for age and heights for age for a total of 193 children under the age of 5yrs (89 boys and 104 girls) who a ended the paediatric clinic in our hospital during 2010-11 were plo ed on WHO growth charts.Moderate and severe acute malnutri on and stun ng was determined as 2 and 3 standard devia ons (SD) respec vely below the mean z-scores for the weight for age and height for age respec vely, as per the WHO guidelines.

Results
Weight for age data was available for 193 children (89 boys and 104 girls), and height for age data for 109 children (46 girls and 63 boys) under fi ve years of age.We excluded the children with severe acute or chronic medical condi ons which had the poten al to aff ect their nutri onal status.In our group, 15.7% girls and 21.2% of the boys suff ered from moderate malnutri on, and 6.7% girls and 9.6% boys suff ered from severe malnutri on.A total of 19% of boys and 19.6% of girls suff ered from moderate stun ng; and 11% of boys and 13% of girls suff ered from severe stun ng.
It can be noted that below 1year of age, there was more uniform distribu on of the weights around the mean.In the >1.5 yr age groups, the weights of majority of children fell below the mean z-scores, as can be seen from the graphs.

Discussion
Malnutri on is a major problem among underfi ves in Nepal, contribu ng to signifi cant morbidity and mortality in this group.Our data from Ilam reveals that the prevalence of moderate malnutri on among under-fi ves is less than that reported in all of Nepal.As is apparent from the na onal data, malnutri on becomes worse a er 18 months of age 1 .
Overall, our data reveals that malnutri on among under-fi ves is lesser in Ilam district compared to the na onal data for under-fi ves.There was evidence of a much lower prevalence of stun ng (decreased weight for age) in Ilam when compared with the na onal fi gures 1,7 .The la er fi nding may be because of the small data set in our group, compared with the na onal data for Nepal.
Our data shows that the nutri onal status of children under fi ve in Ilam in 2010-11 was be er in comparison to the data from Jirel, from 2005 4 and Sarlahi 6 .The prevalence of malnutri on and stun ng seen in Ilam was more than that reported from Mugu district, and much higher compared to the prevalence of malnutri on in Humla district, in the study carried out by Thapa et al. 10,11 .Stun ng was more in girls than boys, a fi nding consistent with the data published from Dhankuta district 12 .There is a wide varia on in the data published from diff erent districts, although there were very few studies (see table ).
There is no previously published data from Ilam district on malnutri on among under-fi ves.This makes our study an important step towards evalua on of the nutri onal status of children in Ilam.By excluding the observa ons from all the children with chronic illnesses and severe acute illnesses, we believe that our data is representa ve of the nutri onal status of children who are under fi ve years of age in Ilam district.However, our data is based on a small cross-sec onal observa onal dataset collected from children who visited our clinical Paediatric facility at DMBPCH or our village health clinics in Ilam.A larger study involving healthy children from all over Ilam district is required to fully understand the current nutri onal status of under-fi ves in Ilam.
Acknowledgements: This work was carried out in Dr Megh Bahadur Parajuli Community Hospital (DMBPCH), Ilam, which is run by Himalayan Health Care (HHC).We are grateful to HHC and all the staff at DMBPCH for their support during our clinical work.We are grateful for the help from all the suppor ng staff , and in par cular Mr Mukesh Siva for his assistance in collec ng all the anthropometric data.We also thank Dr Anita Chan for her technical help in preparing the graphs which are included in this paper.This work would not have been possible without the coopera on of the children, their parents and the community in Ilam, to whom we express our sincere gra tude.Funding: Nil Confl ict of Interest: Nil Permission from IRB: Yes

Table 1 :
Malnutri on in boys under 5 years in Ilam district (n=104)

Malnutri on in boys Propor on of boys
Boys with moderate malnutri on 21.2% Boys with severe malnutri on 9.62% Malnutri on in boys under 5 years (moderate & severe) 30.77%

Table 2 :
Malnutri on among girls under 5 years in Ilam (n= 89) Fig 4: Height for age among girl in Ilam district (n= 46)

Table 3 :
Stun ng among the boys in Ilam district (n= 63)

Table 5 :
Malnutri on and stun ng in under-fi ves in Ilam: Comparison with the published data from diff erent districts in Nepal.Na onal data from NHDS 2011 and WHO (2011) is also included.Unless men oned otherwise, WHO criteria was used by authors.MUAC-Mid upper arm circumference; NA-data not available).