Asma Fozia Qureshi ( Department of Community Health Sciences, The Aga Khan University, Karachi. )
Tufail Q. Shaikh ( Department of Community Health Sciences, The Aga Khan University, Karachi. )
Razia J. Rahimtoola ( National Institute of Child Health, Jinnah Postgraduate Medical Centre, Karachi. )
To assess the nutritional status of children under 5, a survey was conducted in the under-privileged community of Mahmoodabad. Of over 1,000 children, three-fourth had varying grades of protein calorie malnutrition. The prevalence of grade III malnutrition was higher in children in their 2nd year and among those belonging to families of more than four persons. On the average, a child was reported to suffer from two spells each of diarrhoea and respiratory illness. Both the diseases seemed to be associated with age and nutritional status of the children. An association was found between history of roundworm infestation and the nutritional status. On the basis of these findings, we emphasize on education of the mothers on various aspects of child health, regular growth monitoring, and on measures to improve general health status in the underprivileged communities (JPMA 39: 3 , 1989).
Protein calorie malnutrition in children, especially those under five years of age, is persistent and wide-spread in Pakistan. Several nutritional surveys consistently found varying degrees of malnutrition in about two-thirds of infants and preschool children (birth to 5 years)1-3. It has been estimated that twenty five percent of all children born in the country die before reaching their 5th birthday. Of those who survive, a majority show defective growth patterns. For instance, at two years of age, an average Pakistani child weighs 20 lbs and is 28.5 inches in height while a European child of the same age weighs 26 lbs and is 34 inches in height. 4 Numerous risk factors have been identified for malnutrition of children under-5 years of age, such as inadequate diet, unhygienic living environment, and high illiteracy rate of women. On analysis, these risk factors may themselves reflect other diverse conditions in the society; inadequate diet may be because of low per capita income or due to late introduction of weaning food; unhygienic environment may be the manifestation of high population density, lack of potable water and sewage disposal facilities; and illiteracy of females may be the result of traditional customs in a society. 5 These risk factors occur in clusters and interact with each other to produce synergistic effects6. Malnutrition resulting from insufficient diet may be aggravated by unhygienic living conditions through recurrent diarrhoea and respiratory infections. Similarly, malnutrition resulting from recurrent infections may become severe by non-utilization of modern medicines by an unconvinced, often uneducated mother. Therefore, it is difficult to quantify the effect of each risk factor in the causation of this illness, suggesting that a successful intervention strategy for prevention of malnutrition should attack many risk factors at a time7. The present paper is based on the findings of the “Child Nutrition Project” conducted by a team of investigators from Jinnah Postgraduate Medical Centre (JPMC) Karachi. 8 The aims of this project were to assess nutritional status of children under 5 years in a poor community, and to design interventions according to the findings. This paper reports only some of the findings of the baseline survey.
SUBJECTS AND METHODS
The survey was conducted in Mahmoodabad Colony, a squatter settlement in Karachi about three miles from JPMC. A sample of 750 households, covering a population of 5,000 people, was selected from the proximity of the project field office. The baseline survey was conducted between August 1976 and June 1977. The families were interviewed by research assistants by using a predetermined questionnaire. All physical examinations were done by experienced paediatricians. Alongwith general information such as housing characteristics, family size and monthly income of the household, history of children under 5 was obtained from the mothers. The latter data included information on the length of breastfeeding, age at which weaning diet was introduced, spells of diarrhoea and respiratory tract infections during the six months preceding the date of interview and whether the mother had observed roundworms in the child’s stool. A spell of diarrhoea was defined as three or more watery stools in 24 hours and a respiratory tract infection spell was considered when a child suffered from cough and fever lasting more than 48 hours. Weights of the children and other body measurements were recorded, using beam balance scales for weighing children below 15 kg, and weighing machines for children over 15 kg. The scales were read to the nearest 0.01 kg and 0.1 kg respectively. Clinical and laboratory examinations were conducted for assessment of nutritional status. Nutritional status of the children was established by analysis of weight for age according to the Gomez classification. Children having weight of 90% or more of the standard were considered normal. Malnutrition was categorized into three grades of increasing severity according to the percentage reduction in weight from the standard. The first degree is 75% - 90%, second degree 60% - 75% and third degree is below 60% of the standard.
Infant and pre-school years are a period of very rapid growth and development with high nutrient needs. Various forms of dietary deficiencies can occur in this age group, especially in underprivileged communities. The principal form of malnutrition seen during this period is protein calorie malnutrition (PCM). Weight-for-the age is a sensitive indicator of such malnutrition9. Forty-percent of infants in our study population had weights below normal. This problem becomes more serious from the 2nd year onwards, this being the period when the young child is transitional as regards diet and immunity to infections. Mild malnutrition as found by using Gomez classification had very high prevalence among the pre-school children studied, and most of these children are liable to change to the moderate or severe form of under nutrition, if continuously exposed to health or nutrition hazards. At these later stages, nutritional rehabilitation is difficult and mortality climbs rapidly. 10 Our data show that in poor communities large family size seems to aggravate the nutritional problems of the children. As the number of family members increases there is increased frequency of 3rd degree malnutrition among the children. The addition of every new member in the family apparently further reduces the nutritional share of even those who are already malnourished. Despite the possibility of under reporting due to long recall, diarrhoea and respiratory illness are reported to be high in our study population and the data are consistent with the view that the frequency of diseases increases during the weaning period, then diminishes, as the child develops his or her immunity. Additionally higher frequency of these diseases among the malnourished children, compared to the nutritionally normal, suggests interaction between nutrition status and episodes of these illnesses. The observed relationship, however, may be due to other intervening variables. In poor communities where intestinal parasites are highly prevalent, an important concern is the contribution of parasitic infections to growth faltering in children. Despite an association evident between history of passing round-worms and the low nutritional status in our subjects, absence of laboratory data do not allow further inferences. The findings of our study re-emphasize that the health of a child under 5 is exposed to several risk factors in an underprivileged community such as poverty, late introduction of weaning diet and recurrent infections. Because of the close interactions of many of these risk factors, it cannot be assumed that addressing one contributing factor will produce improvement in the health status. A multifaceted strategy is, therefore, required to reduce morbidity and mortality in this age group. Secondly, a health education programme is urgently needed for the mothers in these communities. This programme should constitute education on weaning practices and infant nutrition, food and personal hygiene to protect children from infectious diseases, especially diarrhoeal diseases, and awareness of vaccination against immunizable diseases. Nevertheless the role of family income supplementation, mass literacy; sanitation and better housing cannot be neglected in the improvement of both general health status and the health of the children. Finally, for early detection and treatment of malnutrition and for the evaluation of preventive measures, regular growth monitoring of the children under 5 is needed in these communities. Although weight-for-the-age is a simple method for this kind of nutritional screening, other anthropometric measurements, such as height for the age, weight for the height and mid-arm circumference may be used whenever they provide more insight of this problem and help in designing of better intervention strategies.
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