Results
Total this study enrolled 100 under 5 children, 59(59%) males and 41(41%) females, their mean age was 33 ± 18 months and most of them 52(52%) aged from 24–36 months .
Most of the children were secondly (n = 33; 33%) and firstly (n = 28; 28%) ordered in their families
The majority of the children's families had one (n = 42;42%) and two (n = 38;38%) under 5 siblings
Concerning to children's families information, mother was the predominant caregiver in 93(93%) of families. The mean age of caregivers was found to be 32.2 ± 9 years and commonly belonged to age group from 30–39 years (n = 41;41%). Most of the caregivers were primary levels educated (n = 36;36%) and housewives in occupations (n = 83;83%). Fathers were the major persons responsible for incomes in 83(83%) of children's families. The mean of children's families' income was 11,883 ± 4,985 SDG and more than one-half of them (n = 55;55%) had income above 10,000 SDG .
In nutritional history of the children, 73(73%) of children underwent exclusive breastfeeding and the major known cause of non- exclusive breastfeeding was customs and habits in 17 out of 27 (59.3%) of children. Supplementary feeding was staring in the age 6 months in 58(58%) of children. Number of meals were mainly three meals in 45% (n = 45) of children. In addition, 71(71%) children ate fruits and vegetables and 87(87%) ate milk and dietary product in their daily nutrition.
Regarding to children's health related information; all children (i.e. 100) were immunized or undergoing immunization. The causes of health care center were; illness (n = 56;56%), follow-up (n = 25;25%) and vaccination (n = 19;19%). In illness, malaria was the major morbidity in 25(25%) of children followed by chest and tonsillitis infection in 12(12%), asthma in 7(7%), anemia in 7(7%) and diarrhea in 5(5%) children. During the last 12 months 31(31%) children were admitted to hospital and mostly due to malaria (n = 18;18%). In last 2 weeks 62(62%) children suffered from fever, cough, runny rose or chest infection. Chronic diarrhea was encountered in 29(29%) children and mainly treated at heal care center (n = 17;17%). Two children (2%) had positive history of malnutrition and all of them were treated in hospital. Ready to Use Therapeutic Food (RUTF) was received by 23(23%) children among them 20(20%) children were improved .
Source of water was principally tape water inside home in 94(94%) of children's families and public tape water outside home in 6(6%) of them .
Out of 100 children 67(67%) had medical insurance and remaining 33(33%) had not .
According to the anthropometric measurements of the children, the mean of weight was 12.6 ± 3.5 kg (4–22 kg), height 87.3 ± 12 cm (58–110 cm), head circumference 48.6 ± 2.7 cm (45–56 cm) and mid upper arm circumference (MUAC) 15.2 ± 1.2 cm (12–18 cm) .
Oedema was presented in 6(6%) children .
Based on WHO classification by BMI (mean ± SD = 16.5 ± 2.5 kg/m2), 10(10%) children were malnourished, 18(18%) were underweighted, 68(68%) were normal and 4(4%) were overweighted
The association between malnutrition and children characteristics showed that, malnutrition was significantly common among children with order above 4th (P. value = 0.000) and number of under 5 children in family above 3 children (P. value = 0.00). However, gender (P. value = 0.370) and age (P. value = 0.463) did not associated with malnutrition .
The association between malnutrition and children's families information revealed that, the highest percentages of malnutrition was significantly encountered among children from younger mother blow 20 years (60%) and from 20–29 years (18.9%) (P. value = 0.001), non-mother (relative) caregivers (60%; P. value = 0.000), illiterate mothers (33.3%; P. value = 0.046), employed mothers (66.7%; P. value = 0.000), relative as income responsible (50%; P. value = 0.009), and low income blow 6,000 SDG (88.9%; P. value = 0.000) .
Significantly malnutrition was associated with lack of exclusive breastfeeding (29.6%; P. value = 0.000), less than three meals per day (29%; P. value = 0.021), lack of vegetables and fruits in daily nutrition (24.1%; P. value = 0.006) and lack of milk and dietary products in daily nutrition (42.6%; P. value = 0.000) .
malnutrition significantly associated with illness as cause of health care center visit (17.9%; P. value = 0.018), and malnourished children were more tended to be anemic (85.7%; P. value = 0.002). Also, malnutrition significantly associated with children admission to hospital in last 2 months (22.6%; P. value = 0.005), and malnourished children were more tended to had diarrhea (28.6%) and malaria (27.8%) as cause of hospital admission (P. value = 0.011). In addition, malnourished children were significantly had rate of fever, cough, runny rose or chest infection in last 2 weeks more than those without malnutrition (16.1%; P. value = 0.032). Moreover, malnutrition significantly correlated with history of chronic diarrhea (20.7%; P. value = 0.018) and history of malnutrition (100%; P. value = 0.001).
Significantly malnutrition was associated with public pipe water outside home and lack of pipe water inside home (50% vs 7.4%; P. value = 0.003). lack of medical insurance was significantly associated with malnutrition among children (27.3% vs 1.5%; P. value = 0.047) ,odema was common among malnourished children more than those without malnutrition (83.3% vs 5.3%; P. value = 0.000) .
4.1 Discussion
Malnutrition remains as an important public health issues in both developed and developing countries affecting wide range of age in a population significantly affecting children under five. It is caused by a complex, multidimensional and interrelated condition which is largely contributed by a set of socio demographics, economic, environmental and biological factors with high prevalence rate among children under unfavourable conditions (88). In the present study we aimed to assess the recent prevalence and risk factors of malnutrition among 100 Sudanese children under five years in Helat Hassan Health Centre, Wad-Medani, Gezira State, Sudan
Based on WHO classification by BMI the present study showed that the prevalence of malnutrition among children under five years was 10% (n = 10) and underweighting was 18% (n = 18%). This rate was similar to studies in Khartoum and Gezira state where 15.4% of children were underweight, 8.8% were moderate underweight and 6.6% were malnourished (9), also our findings were comparable to rate of Gadarif State where 9.3% of the children were malnourished (38), however we reported lower rate than the figures in Sudan Millennium Development Goals Report in 2010 which indicated that one third (31.8%) of under five children suffer from moderate and severe malnutrition (19). And this indicate that the prevalence of malnutrition among children Central Sudan cities (as Wad-Medani) in decreasing.
Internationally, our frequency of malnutrition was similar to Abel G et al (16.2%) (17) and Desalegne A et al (14.3%) (81–89) in Ethiopia, Latin America and Caribbean (11.3%) (32), Sachin S et al in India (14%)(90), Jessica H et al in New Guinea (15%) (91) and Filiz E et al in Turkey (10.9%) (92). In addition we found Lower rate than Edem M et al in Ghana (49%) (93), Ngianga-Bakwin K et al in Congo (44%) (94), Bangladesh Demographic and Health Survey (BDHS-2007) (43%) (95), and Alphonse N et al in Rwanda (38%)(96), and higher than. This heterogeneity in malnutrition prevalence attributed to such factors like, differences in geographical areas, cultural habits and feeding, biological and genetic factors as well as sampling and sample sizes
The present study showed that, children order in family and number of number of under 5 children in family were found to be risk factors of malnutrition in our study group, as malnutrition was significantly common among children with order above 4th (P. value = 0.000) and number of under 5 children in family above 3 children (P. value = 0.00). These findings were in accordance several studies like Sommerfelt A et al and Jeyaseelan L et al those reported malnutrition is rare among under-five children of birth order 2–3 and that higher birth order (5+) is positively associated with child malnutrition (51, 52). Also, In a study of Rayhan M et al that carried out among 6939 children under five years in Bangladesh, the prevalence of stunting increased with birth order hence most of the children who were of birth order more than two had greater chances of stunting and wasting (53).
Age of mother/caregivers was significantly found to be risk factors of malnutrition among our study children as the highest percentages of malnutrition was significantly encountered among children from younger mother blow 20 years (60%) and from 20–29 years (18.9%) (P. value = 0.001). This could be explained by younger mothers had low experience and not ready to take care of the child including providing all the necessary attention required for the baby. Similarly, several studies have indicated that young maternal age is associated with high prevalence of malnutrition, while children of older women are less likely to suffer from malnutrition. A study carried out in Tanzania reported that children of older mothers are less likely to be malnourished than those of young mothers (42).
For no doubt, mother/caregivers literacy and education paly as corner stone in health and nutritional status of under-five children, and this study confirmed that as malnutrition was significantly high among children from illiterate mothers (33.3%; P. value = 0.046). This observation was in agreement with studies of Sufiyan et al and Ali et al those reported that, children of uneducated mothers are at risk of malnutrition (56, 57).
Another determinant of malnutrition encountered by the present study was maternal occupation or working as the highest percentages of malnutrition was significantly found among children with employed mothers (66.7%; P. value = 0.000). These results could be justified by non-working mothers have more time dedicated to the care of their children than those who are working. Also as stated by Glick and Sahn, more women participate in the labour workforce, less attention they pay to household responsibilities especially as it relates to the welfare of children, thereby placing younger children at risk of malnutrition (60). Our findings were in consistence with Abbir et al and Bose et al those mentioned that children of working mothers were more likely to be diagnosed with malnutrition than those of non-working mothers (61, 62).
Not surprisingly, poverty and low family income had crucial role in bad nutritional supplies to children and thus development of malnutrition. It is general knowledge that malnutrition is a condition that is associated with poverty since it comes with hunger and lack of food at the right quantity and quality. In the current study, low income blow 6,000 SDG found to be significant factor of malnutrition among our study participants (P. value = 0.000). These findings were confirmed by numerous of studies like Etim et al (68), Olanrewaja et al (69), Ying et al (71), and Khan et al (72)
Remarkably this study showed that, other family related risk factors of malnutrition were non-mother (relative) caregivers (P. value = 0.000) and non-father (relative) as income responsible person (P. value = 0.009).
Benefits of exclusive breastfeeding have been wildly acknowledged. They are known to promote sensory and cognitive development, and protect the infant against infectious and chronic diseases. Exclusive breastfeeding reduces infant mortality due to common childhood illnesses such as diarrhoea or pneumonia, and provide immunoglobulins which helps in a quicker recovery during illness. In the present study only 73% were exclusively breast fed for three months, and significantly malnutrition was associated with lack of exclusive breastfeeding (P. value = 0.000). Correspondingly, Shaza O et al in Sudan reported lack of exclusive breastfeeding was associated with malnutrition and only 10.8% of malnourished children were exclusively breast fed (16). Also in Ethiopia, Abel G et al reported lack of exclusive breastfeeding was associated with malnutrition and only 29% of malnourished children were exclusively breast fed (17).
Numbers of meals and quality of daily nutrition were found to be independent risk factors of malnutrition in our study as malnutrition was associated with less than three meals per day (P. value = 0.021), lack of vegetables and fruits in daily nutrition (P. value = 0.006) and lack of milk and dietary products in daily nutrition (P. value = 0.000). these results were comparable to the study of Namusoke M et al in Uganda who reported most of malnourished children (48%) fed twice per day and only 20% received milk and dietary products in their meals daily (97)
This study showed that, malnutrition significantly associated with illness as cause of health care center visit (17.9%; P. value = 0.018), and malnourished children were more tended to be anemic (85.7%; P. value = 0.002). Consistently, Ubesie AC et al in Nigeria reported similar results as malnourished children were mostly presented with anemia (98)
Also, malnutrition significantly associated with children admission to hospital in last 2 months (22.6%; P. value = 0.005). Similar finding reported by Meshram I et al and Saxton J et al those found that children have been hospitalised during the prior 12 months were more likely to be malnourished as compared to children without any history of recent illness (47, 48).
Moreover, malnourished children were more tended to had diarrhea (28.6%) and malaria (27.8%) as cause of hospital admission (P. value = 0.011). As reported by Shaza O et al, the commonest co-morbidities associated with malnourished children were gastroenteritis, malaria, anemia, and diarrhea (16).
This study demonstrated that, malnourished children were significantly had rate of fever, cough, runny rose or chest infection in last 2 weeks more than those without malnutrition (16.1%; P. value = 0.032). Consistently, Monsurul H et al in Bangladesh reported that illness in the last 2 weeks (OR 3.08, 95% CI 1.13, 8.42) was associated with malnutrition among children under five (99). Also, Abel G et al reported presence of fever and diarrhea in the past two weeks prior to the study (AOR = 4.57, 95% CI: 2.56–8.16) were the independent predictors for child wasting (17).
Furthermore, malnutrition significantly correlated with history of chronic diarrhea (20.7%; P. value = 0.018) which is similar to the study of Edem M et al who reported diarrhea was common among malnourished children to comparing to well-nourished ones (67% vs 40%; P < 0.001) (93)
The present study revealed that, odema was common among malnourished children more than those without malnutrition (83.3% vs 5.3%; P. value = 0.000)
Water sanitation and availability considered as backbone of children health and nutritional status and access to water should be from improved and secured source, in the present study, malnutrition was associated with public pipe water outside home and lack of pipe water inside home (50% vs 7.4%; P. value = 0.003). These observations were align with several pervious studies such as Jessica H (91), Alphonse N et al (96), Gashu W et al (100). Additionally, A recent survey carried out in Afghanistan revealed that water-related hardship was a major determinant of health and nutritional status of children under five years of age (67)
Those stated source of drinking water was a significant factor of malnutrition in that compared to children who have an improved water source inside home, children from a families without an improved source of water were more likely to have a worse malnutrition.
Interestingly, lack of medical insurance for children was found to be determinant of malnutrition in our study children. This finding should encourage the health authorities to totally coverage of all children under 5 years in health insurance umbrella and thus improving health care provided to those children
4.2 Conclusion
The present study concluded the following:
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The frequency of underweighting and malnutrition among under 5 years children in Helat Hassan Health Centre were 18% and 10%, respectively
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Children order above 4th and number of under 5 children in family above 3 children was significant children's related risk factors associated with malnutrition
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Younger mother, non-mother (relative) caregivers, illiterate mothers, employed mothers, relative as income responsible, lack of medical insurance, lack of in-home source of water and low income blow 6,000 SDG were the significant children's families related risk factors associated with malnutrition
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Lack of exclusive breastfeeding, less than three meals per day, lack of vegetables, fruits milk and dietary products in daily nutrition were the significant children's nutritional related risk factors associated with malnutrition
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illness as cause of health care center visit, anemia, admission to hospital in last 2 months, fever, cough, runny rose or chest infection in last 2 weeks, history of chronic diarrhea and history of malnutrition were the significant children's health related risk factors associated with malnutrition
4.3 Recommendations
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To diminish the load of malnutrition in the children, a collective attempt by the government, non-governmental organizations and the community is crucial.
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Effective, efficient and equitable program and intervention should be designed to reduce child malnutrition.
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preventing conditions such as malaria and diarrhea and providing adequate follow up is highly recommended
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Increase the awareness of mother/caregivers (specially illiterates) regarding children nutrition by community or health care center personnel is required
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Water sanitation and availability considered as backbone of children health and nutritional status and access to water should be from improved and secured source
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Efforts to reduce poverty and increase families incomes are recommended
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Interventions to increase coverage of children medical insurance is needed
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Further research to explore more malnutrition risk factors are required