Effectiveness of home-based fortified diet in the rehabilitation of malnourished children in resource restrained country: an institution based retrospective study

doi:10.21203/rs.3.rs-60166/v2

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Effectiveness of home-based fortified diet in the rehabilitation of malnourished children in resource restrained country: an institution based retrospective study

https://doi.org/10.21203/rs.3.rs-60166/v2

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published 13 Aug, 2021

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Background: Globally, it is estimated that 50 million children under five are wasted. National nutrition survey-2018 has shown that 23.3% and 45.5% of children are wasted and stunted in Pakistan. Many studies have shown that hospital-based management of malnutrition is not practical due to high cost and iatrogenic infections, and currently, WHO recommends community-based management of malnutrition with the provision of therapeutic food. There is limited evidence of community rehabilitation of malnourished children by using the home-fortified diet in Pakistan. This study evaluated the effectiveness of using the home-fortified diet in achieving recovered from malnutrition through a retrospective chart review.

Methods: A retrospective chart review of pediatric patients (aged six months –5 years) seen in Indus Hospital between January 2017 to June 2018 was conducted. A predesigned data extraction form was used to record detailed information about demographic characteristics, feeding, anthropometric, micronutrient, and nutritional details at enrollment and on follow-up.

Results: A total of 361 patients were included in the final analysis. The median age of children was 14 months. 102 children were recovered from malnutrition with a median length of stay in the program of 28 days. The median for weight gain was 4.8 (0-10.3) g/Kg/day, 226 children defaulted and 10 died.

Conclusion: This study revealed adequate weight gain and recovered from malnutrition in children by using the home-fortified diet in real-life situations. Home-fortified diets may serve as an effective strategy in community-based rehabilitation of malnourished children, especially in resource constraint contexts.

Nutrition & Dietetics

Malnutrition

children

home fortified diet

weight gain

anemia

rickets

Malnutrition can be defined as a state of nutrition in which there may be excess or deficiency of calories, nutrients and proteins. Malnutrition can adversely affect normal growth of children (1). It was estimated that in the year 2019, 144 million children under five showed stunted growth due to malnutrition globally, and South Asia was the epicenter of the global burden (2). This high burden of malnutrition in children under five years was also reflected in the national nutrition survey of Pakistan in 2018 (3). The survey reported that in Pakistan, 45.5% of children have stunted growth due to malnutrition, with the highest rate seen in the province of Sindh.

WHO initially advocated management of malnourished children in hospitals (4). However, inpatient management did not prove to be practical due to several constraints which included high cost of treatment, iatrogenic infections and prolonged hospital stay (5). Due to these challenges, WHO revised the treatment guidelines and recommended hospital management of only complicated malnourished children (4). At the same time, WHO suggested that uncomplicated cases should be managed in community-based settings (4).

To ensure optimal diet for community management in resource-restrained countries, like Pakistan, UNICEF recommended the use of therapeutic diets, like ready to use therapeutic feed (RUTF) (6) and Corn Soya Blend (CSB) (7), or fortified local diet, like Micro Nutrient Powder (MNP) (8). In Pakistan, these commercial products are costly and depend on the import of ingredients. Therefore, their availability is erratic and selective to few rural and urban areas in (9-12). In Pakistan, government-run programs supply local or international produced RUTF to selected rural and urban areas (9-12). As a result, many malnourished children in both urban and rural regions remain deprived of these nutritional supplements. The caregivers in such areas rely on unfortified indigenous food products for feeding the children, which results in lack of dietary diversity and acceptable diet remains less than recommended values (3).

One logical, cost-effective and feasible method of improving the quality and nutritive value of complementary food in Pakistani households is to enrich the existing recipes with locally available nutri-dense products (9). Such home-fortified diet is being used at The Indus Hospital, which is a tertiary care facility in the suburbs of Karachi, in province of Sindh, Pakistan. The hospital receives an average of 1200-1300 malnourished children per year. The home-fortified diet is used as a surrogate for commercial therapeutic feeds and provide a cost-effective convenient solution for nutritional rehabilitation of malnourished children who do not have access to any form of commercially developed therapeutic food supplements. The effectiveness of home-fortified diet in the management of malnutrition, however, needs to be evaluated in the given context.

The aim of the study was, therefore, to evaluate the effectiveness of using the home-fortified diet in achieving recovered from malnutrition through a retrospective chart review. The parameters for evaluating effectiveness included children’s weight-for-height SD score, mid-upper-arm circumference (MUAC), weight gain in g/Kg/day, length of treatment and recovery from micronutrient deficiencies. The findings from this study may provide guidelines for treatment of malnutrition in similar resource constraint countries.

Study area and period

The study was conducted at the nutrition rehabilitation clinic (NRC)of The Indus Hospital, Karachi, Pakistan, from January 2017 to June 2018. Community-based rehabilitation of uncomplicated malnourished children is done in the clinic by counselling and recommendation of home-fortified diet plans with regular follow-up.

Inclusion criteria

All children with ages ranging from 6–59 months with malnutrition who had been treated at NRC, from January 2017 to June 2018 were included in the study.

Exclusion criteria

Children with incomplete records and with secondary malnutrition due to other medical conditions were excluded. Children who had edema due to non-nutritional causes were also excluded from the study.

Treatment protocol

Nutrition rehabilitation clinic (NRC) was conducted twice weekly in the outpatient department of Indus Hospital. The clinic catered to malnourished children with ages ranging from 6 month- 5 years. Malnutrition was diagnosed based on weight, height and mid-upper arm circumference cut-off values prescribed by WHO. At enrollment nutritional details of each child were recorded on pilot tested, predesigned questionnaire, which included nutritional history and details of physical examination. The examination was done for anthropometry and clinical features. The clinical features included edema, dermatosis, anemia, rickets and eye changes. If there were clinical signs of micronutrient deficiencies, then relevant labs were sent. Children with rickets and anemia were treated with oral iron and vitamin D3 supplements. The dosages of iron and vitamin D were prescribed according to WHO protocols. Blood transfusion was done in cases of severe anemia, while Vitamin B12 deficiency was treated with oral Cobalamin according to institutional protocol. All the malnourished children were given multiple micronutrient powder (MNP) and zinc supplements. Antibiotics were given when needed.

Mothers were counselled on age-appropriate feeding practices and hygiene strategies using Infant Young Child Feeding (IYCF) practices counselling-cards. Caregivers were advised on preparing recipes of various nutrient-dense home-based diets. The diet plans were made by the nutritionist at Indus hospital using ingredients which were indigenous and available in average households in the community. Demonstration for quantity and texture of food was done by showing spoons and measuring cups. Brochures containing pictorial and written instructions in Urdu were also given to the mothers. Meal frequencies ranging from 2-6 times per day were advised based on the age of the child. For non-breastfed children, milk and milk products were added. About 150-220 Kcal/kg/day of calories and 3-5 g/kg/day of proteins were advised. Calories and proteins were gradually escalated in the diet.

Children were regularly followed according to the severity of malnutrition. Moderately malnourished children were followed-up after three weeks, whereas severely malnourished children were called fortnightly. At every follow-up visit, history-taking and physical examination were done along with nutritional counselling. If a child was absent for six consecutive weeks, then he/she was considered as a defaulter. The child was considered recovered when weight for the height/length Z-score was >-1.0 SD, or mid-upper arm circumference was > 12.5 cm, whichever came first. The children after recovery were followed for two months to ensure continuous weight gain.

Operational definition

Severe acute malnutrition (SAM): SAM was labelled if any of the three criteria was present (i) weight for height/length Z- score <-3.0, or (ii) mid-upper arm circumference <11.5 cm, or (iii) pitting pedal oedema (4).

Moderate acute malnutrition (MAM): MAM was labelled when weight for the height/length Z-score was <-2.0, or (ii) mid-upper arm circumference was between 11.5- 12.5 cm (4).

Anemia: Severe when hemoglobin is less than 6 g/dl and moderate when the hemoglobin level is between 6.1-11 g/dl (4).

Vitamin B12 deficiency: Plasma vitamin B 12 level < 203 pg/mL (13).

Rickets: Serum 25(OH) D levels at < 30 nmol/L with or without clinical signs of rickets (14).

Weight gain: Weight gain was calculated in g/Kg/day. 5g/kg/day was considered adequate weight gain (15).

Oedema: Presence of pitting oedema on the dorsum of feet or shin of legs or peri-orbital oedema

Recovered: Child was considered recovered when weight for height/length SD score was >-1.0 SD, or mid-upper arm circumference was > 12.5 cm, whichever came first.

Data collection procedure

A structured data extraction form was used for data collection. Data were gathered for demographic characteristics, feeding, micronutrient, anthropometric and nutritional details at enrollment, and on follow-up. Nutritionists and doctors collected the data. The data extraction form was adopted from WHO guidelines (4) and Sphere standard for the management of severe acute malnutrition (15).

Data management and analysis

The statistical analysis was performed using Stata 16.0 software. Normality assessment of continuous variables was done based on skewness and kurtosis. Normally distributed variables were reported as mean [SD] whereas median (IQR) was calculated for skewed variables. Paired T-test was applied to compare the entry and exit variables for normally distributed variables, while the Wilcoxon sign rank test was used for non-normal data. The categorical data were presented as frequencies and percentages. McNemars test was applied to measure the difference between (2x2) variables, whereas others with more than two categories were assed via McNemars Bowker test. P-value < 0.05 was considered to be significant.

A total of 490 children from 6–59 months of age (median, 15 months) with malnutrition were treated at NRC during the study period. Out of total, 129 children were excluded due to the presence of only micronutrient deficiencies (n= 69) and chronic illness (n=60). The final analysis thus included 361 patients (Figure 1). 355 children (98.3%) were malnourished at the time of enrolment based on either MUAC or SD score or both (Table 1).

Figure 1: Flow chart of patients’ enrolment and outcome

Table 1: Baseline characteristics of children

Variable (N)	Frequency n (%)
Age in months* (359)	14 (15)
District (358)
West	7(2.0)
East	18(5.0)
Central	8(2.2)
South	9(2.5)
Malir	107(29.9)
Korangi	175(48.9)
Other	34(9.5)
Gender (361)
Male	168(46.5)
Female	193(53.5)
Type of Feed (134)
Exclusive breastfeeding	48(35.8)
Top feed	66(49.3)
Combination feeding	20(14.9)
Vitamin D Deficiency (218)
Present	116(53.2)
Absent	102(46.8)
Anemia (253)
Present	213(84.2)
Absent	40(15.8)
Vitamin A Deficiency (245)
Present	12(4.9)
Absent	233(95.1)
Dermatosis (347)
Present	9(2.6)
Absent	338(97.4)
Edema (349)
Present	21(6.0)
Absent	328(94.0)
Otitis media (344)
Present	5(1.5)
Absent	339(98.6)
Respiratory Tract Infection (RTI) (352)
Present	182(51.7)
Absent	170(48.3)
Diarrhoea (305)
Present	161(52.8)
Absent	144(47.2)
MUAC at enrollment (357)
Normal	4(1.1)
MAM	104(29.1)
SAM	249(69.8)
SD score Enrollment (160)
Normal	15(9.4)
MAM	51(31.9)
SAM	94(58.8)
*Median (IQR)

Outcomes of 350 patients were known; 11 children were still receiving treatment at time of study and their data was not included in final analysis. Number of children who got recovered were 102 (29%), 226 (64%) were defaulters and 10 (3%) children died (Table 2). There was a significant difference (p value=0.00) in the number of patients who were recovered on basis of MUAC and weight for height SD score. Recovery on basis of MUAC was seen in 77 (75%) children, while 20(20%) children recovered on basis of SD score, 5 children were recovered based on both criteria (Table 2). The median (IQR) duration of stay in the program was 28 days. The median (IQR) for weight gain was 4.8 (g/Kg/day) (Table 2).

Table 2: Outcomes after the study

Variable (N)	Frequency n (%)
*Duration of stay in the program (302)**	28(101)
*Weight gain g/Kg/day (181)**	4.8 (10.3)
No of follow-ups after initial visit (98)
1	56(57)
2	20(20)
3	22(22.4)
Infections developed during treatment (98)
No	59(60.2)
Yes	39(39.8)
Recovered based on anthropometry (102)
MUAC	77(75.5)
SD score	20(19.6)
Both	5(4.9)
Outcome status (350)
defaulter	226(64.6)
recovered	102(29.1)
expired	10(2.9)
ongoing	12(3.4)
*Median (IQR)

There was a significant difference in anemia and rickets status of the patients at the time of enrolment compared to the time of exit from nutrition program ; 24 children (6.8%) had severe anemia at the time of enrollment which had reduced to 3 children (3%) (p-value: 0.0). Rickets was observed in 101 children (53%) which remained in 5 children (17%) after rehabilitation (p-value: 0.04). Recovery from vitamin B12 and Folate deficiency was not statistically significant, 49 children (32%) had vitamin B12 deficiency, out of which 45 children got recovered (p-value: 1). Five children had Folate deficiency, and all got recovered (p-value: 1), (Table 3).

Two hundred and twenty-six children (65%) patients did not follow up in the OPDs regularly out of complete record was available for 98 children. 57 % children never came after an initial visit while 22% children came for three visits, (Table 2). There was no significant difference between males and females in the number of follow-ups. Children with the maximum number of follow-ups belonged to Korangi district; 49% (n=175), while children belonging to district West 2 % (n=7) had least number of follow-ups (Figure 2).

Table 3: Comparison of Status of anthropometry and micronutrients among children at enrollment and exit

Variable	At Entry n (%)	At Exit n (%)	P-Value
Nutritional status on MUAC			0.00^¥
Normal	4(1.1)	82(30.7)
SAM	104(29.1)	71(26.6)
MAM	249(69.8)	114(42.7)
Nutritional status on SD score			0.00^¥
Normal	15(9.4)	25(37.3)
SAM	51(31.9)	26(38.8)
MAM	94(58.8)	16(23.9)
Anemia (based on Hb)			0.00^¥
Normal	56(15.9)	23(21.5)
Mild Anemia	74(21)	26(24.3)
Moderate	198(56.3)	55(51.4)
Severe Anemia	24(6.8)	3(2.8)
Vitamin D (based on 25(0H) D level)			0.04^¶
Normal	88(46.6)	24(82.8)
Deficient	101(53.4)	5(17.2)
Folate			1.00^¶
Normal	54(91.5)	11(100)
Deficient	5(8.5)	0(0)
B 12 (based on serum levels)			1.00^¶
Normal	104(68)	34(89.5)
Deficient	49(32)	4(10.5)
Height*	69 (63-74.3)	72 (60-77)	0.00^€
Weight	6.2(1.7)	7.1(1.8)	0.00^Ʈ
*Mcnemar bowker test (¥), McNemars (¶), Wilcoxon signed rank test (€), Paired T-test (Ʈ), Median (IQR)

This study analyzed the effectiveness of using fortified, energy-dense, home-prepared diet, in the rehabilitation of uncomplicated malnourished children, aged 6 to 59 months, treated in a tertiary care hospital. Findings of this study showed that the median age of children was 14 months. Out of 361 enrolled children, 226 (65%) were defaulters, 102 (29%) were recovered and 10 (2.9%) died. The average stay in nutrition rehabilitation program was 28 days. The average weight gain of the children was 4.8 g/kg/day.

In our study, we were able to achieve weight gain more than 4 g/kg/day, which is the WHO minimum standard for community treatment of malnourished children (16). We did not achieve good weight gain (5-10 g/Kg/day), which is stated to be in the range of 5-10 g/kg/day according to SPHERE standards (15). The low weight gain in our study could be because of multiple factors, which may include lack of mothers’ compliance in preparation of recipes, infrequent feeding of children, food sharing at home and unhygienic feeding practices. An additional explanation of slow weight gain in our study could be a high rate of infections both at enrollment and follow up. We observed that 54% and 48% of children had respiratory tract infections and diarrhoea, respectively. The infections could be due to poor hygienic conditions and incomplete vaccination status of the children in our study.

Several studies have shown weight gain ranging from 1.7 g/kg/day to 8.7 g/kg/day with the use of therapeutic, fortified diet (17-21). However most of these studies (3-6) were done in a controlled environment, where therapeutic nutrition supplements were given to the children free of cost and regular monitoring through home visits were done. We conducted this study in a real-life situation without any external monetary or food support, and there were no home visits, which may have contributed to slow weight gain. We measured height and weight in every follow-up and used the height recorded in the last follow-up for calculating final WHZ score. This was done to ensure accuracy; however, this method showed slow recovery from malnutrition (22) and could also be a contributing factor for slow weight gain in our children.

We observed a significantly high default rate (65%) among the patients in this study. Despite frequent telephonic reminders, children did not show-up for their follow-up visits. Default rates of up to 11% have been reported by other researchers in the region (23). The researchers suggested non-affordability and lack of awareness as likely causes, and recommended home monitoring of children by health workers to reduce the default rate (24, 25). However, such home-monitoring facility was not available in our hospital. The unexpected high default rate in this study needs further research to explore the underlying reasons. The implications from such exploration can guide community workers in developing methods to enhance healthcare delivery in these communities.

World Health Organization (16) recognizes that there is a difference in the groups of children recognized by mid-upper-arm circumference (MUAC) and weight-for-height Z-scores (WHZ). They estimated a 40 % overlap between the two indicators in identifying malnutrition (26). Grellety and Golden (27) collected data on these two variables from 47 countries. They found that both criteria identify different sets of malnourished children, however, the two criteria were complementary to each other in identifying risks of mortality. They further noted that relying on one criterion may under-detect cases and deny treatment to children who are at risk from malnutrition-related complications. This was also reflected in our findings through e the differences observed between MUAC and WHZ scores. Seventy-seven children were considered as recovered based on MUAC, while 20 children based on WHZ. Thereby, our study supports the recommendations that both MUAC and WHZ should be used in nutrition programs to prevent the risk of mortality and under detection of cases.

This study significantly contributes to the literature on treatment of malnutrition in resource constraint communities. The results of this study showed that by using the home-fortified diet, we were able to achieve recovered from malnutrition in all the children who completed the treatment regimen, with an average weight gain of 4.8 g/Kg/day. The results have important pragmatic implications for malnourished children in low-income communities. They provide evidence for cost-effective and practical feasible alternate for expensive commercially available therapeutic feeds in the given context. The benefits of home-fortified diet may further enhance by ensuring higher patient compliance and robust community monitoring.

Strengths and limitations of the study

To the best of our knowledge, this is the first study done in Pakistan which has assessed the efficacy of home-based fortified diet in the rehabilitation of malnourished children in a real-life situation, without the provision of food or financial support. This has critical operational implications as many therapeutic nutrition centers in urban areas of Pakistan do not provide diet supplements or offer home monitoring of children. We used both MUAC and WHZ for enrolment and exit, which minimized risk of under detection of malnourished children.

The retrospective design of study has inherent limitations which are beyond the control of the research team. For example, the charts reviewed for collecting data in this study may have missing or inaccurate information. Moreover, the study could have been informed with additional socio-demographic information like parental education and household details of patients. These limitations were discussed among the research team to maximize the research outcome within the given circumstances. Future research may investigate the influences of parameters prospectively.

This study revealed adequate weight-gain and recovery in malnourished children by using the home-fortified diet in real-life situations without using commercially available therapeutic food or monetary support. These findings may have implications for planning future nutrition programs in Pakistan, especially in urban areas. We, therefore, recommend that a robust community reach out programs, using home-fortified diet and effective nutritional counselling should be implemented for the rehabilitation of malnourished children.

National nutrition survey-2018: (6), World Health Organization: WHO, severe acute malnutrition: SAM, moderate acute malnutrition: MAM, UNICEF: United Nation Children’s Fund, RUTF: Ready to use therapeutic feed, CSB: Corn Soya Blend, MNP: Micro Nutrient Powder, Infant young child feeding practices: IYCF.

Ethics approval and consent to participate: Ethical approval was taken from the Institutional Review Board (IRB) of Interactive Research & Development, registered with the U.S. Department of Health and Human Services, Office for Human Research Protections at The Indus Hospital. As the study data was a retrospective chart review, without direct interaction with patients or their caregivers; therefore, the IRB waived off the requirement of written informed consent from study participants.

Consent for publication: Not applicable

Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: No funding was received for this research.

Authors’ contributions: SS and MM conceived the idea of the study and participated in study design and write up. SN and ND carried out data collection, MM and ND assisted with statistical analysis. All authors were involved in the coordination of the study, drafting the manuscript and approving the final version.

Acknowledgements: Not applicable

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Effectiveness of home-based fortified diet in the rehabilitation of malnourished children in resource restrained country: an institution based retrospective study

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