Evaluation of the Dietary Management of Marasmic Children (24

The National Ribat University
Faculty of Graduate Studies & Scientific Research
Evaluation of the Dietary Management of Marasmic
Children (24-59 months old) Admitted to Al-Buluk Pediatric
Hospital Omdurman Locality
By: Salha Mubarak El-Tayeb El-Bashir
Supervisor: Professor Bahiedin I. Magboul
A dissertation submitted in partial fulfillment of the requirements for the
degree of Master of Sciences in Human Nutrition and Dietetics
2016
Dedication
To my Mother the only star in my life, to my father I
never can explain your real value. To my sisters and my
brothers you are always lighting my life. To all my
aunties and my uncles thanks for your support. To my
lovely son Bakory, my sweet niece Tasneem my nephews
Omer and SAAD.
TO ALL MY FRIENDs WITH LOVE
SaLHA MUBARAK EL-TAYEB EL-BASHEER
IN MEMORIES OF D. OSAMA MOHAMMED HUSSIEN FAYED AND MY
BROTHER MAHMOUD.
I
Acknowledgement
I
wish
to
express
my
heartfelt
gratitude
to
all
individuals and groups of people too numerous to mention
for their various support rendered to me throughout my
research and the whole Master of Human Nutrition and
Dietetics.
The following deserve to be mentioned: Professor Bahiedin
Ibrahim
Magbuol
my
Thesis
supervisor,
for
his
support,
guidance and encouragement during this critical stage of
my studies. I appreciate your commitment and assistance
despite your tight schedules. I am also grateful to all
Staff
of
Nutrition
department
in
Al-Buluk
Pediatrics
hospital. I would like to thank my colleagues for their
varied support. I cannot forget to thank Mohammed Saeed
Madani and Alaaedin yuosife Abbu for helping me to fix my
computer issues. May I also take this opportunity to thank
Alrasheed for his input on statistics without your help
the whole analysis was a headache. Special thanks to
salma
al-tayeb
al-waleed
abdulmoneem
and
altohami for the nonstop motivations in my bad times.
II
abdulrahim
Abstract
This cross-sectional hospital –based study was carried out to assess the
hospital dietary management of marasmus in children aged 24-59 month old
admitted to Al-Buluk Pediatrics Hospital in Omdurman. The sample size
consisted of 44 patients. The study data were collected using a questionnaire,
patient's records and 24 hour recall.
The result showed that 86% were discharged, 6.8% escaped and 6.8% died. The results
showed that (34.4%) of children aged 24 month. males were the majority (54.5%) and
female were (45.5%). Nutritional status of marasmic children admitted to Al-Buluk
Pediatric Hospital showed that 54.5% of admitted children were suffering from severe
wasting and 45.5% were suffering from moderate wasting. The prevalence of comorbid conditions in the children studied, diarrhea was the most prevalent disease
complicating severe acute malnutrition followed closely by ARI. Diarrhea was the
higher percentage of 47.7%, diarrhea+ ARI was 34.1% and was18.2% diarrhea+
malaria. 5.2% of participants achieved weight gain 8.9-9.8 gm/kg/day, 42.1% of
participants achieved weight gain of 10.5-11.1gm/kg/day and 52.6% of participants
achieved weight gain 12.5-14.4gm/kg/day. Length of hospital stay in stabilization
phase was 3-6 days and the length of hospital stay in rehabilitation by the majority of
children was ranged between 20 to 23 days. The mean intake of energy in the
stabilization phase was 588 Kcal and the mean intake of protein was 7 gram. The mean
intake of energy in the rehabilitation phase was 994 kcal and the mean intake of protein
was 30 gram. The study recommended the hospital must apply the WHO discharge
criteria for severely malnourished children.
III
‫الخالصة‬
‫أجريت هذه الدراسة الوصفية المقطعية المستندة إلى تقييم اإلدارة الغذائية في مستشفى البلك التخصصي لالطفال‬
‫بامدرمان في األطفال الذين تتراوح أعمارهم ‪ 59-24‬شهرا من العمر ‪..‬حجم العينة يتكون من ‪ 44‬مريضا‪ .‬تم جمع‬
‫بيانات‬
‫الدراسة‬
‫باستخدام‬
‫سجالت‬
‫المريض‬
‫االستبيان‬
‫واستدعاء‬
‫‪24‬ساعة‬
‫وأظهرت النتيجة أن ‪ ٪86‬خرجوا‪ ،‬وقد نجا ‪ ٪6.8‬وكانت وفاة ‪ .٪6.8‬أظهرت النتائج أن األطفال الذين شاركوا‬
‫في الدراسة تتراوح اعمارهم ما بين‪ 34 -24‬شهرا‪ .‬الغالبية من الذكور (‪ ،)٪54.5‬وكانت اإلناث (‪.)٪45.5‬‬
‫أظهر الوضع التغذوي لألطفال المصابين بمرض الهزال أن ‪ ٪54.5‬من األطفال الذين أدخلوا المستشفى يعانون‬
‫من الهزال الشديد وكان ‪ ٪45.5‬يعانون من الهزال المعتدل‪ .‬اشارت الدراسة الى االمراض االكثر انتشارا‬
‫مصاحبة لمرض الهزال في األطفال ‪ .‬كان اإلسهال يعبر المرض األكثر انتشارا تعقيدا لسوء التغذية الحاد‪ .‬كان‬
‫لإلسهال النسبة أعلى ‪ ،٪47.7‬اإلسهال ‪+‬االلتهاب الرئوي كان ‪ ٪34.1‬و ‪ ٪18.2‬اإلسهال المالريا‪ .‬اظهرت‬
‫الدراسىة ان زيادة الوزن مابين ‪ 9.6-8.5‬جرام\ كيلو جرام\اليوم حققه ‪ %5.2‬من األطفال وزيادة الوزن مابين‬
‫‪ 11.1-10.5‬جرام\ كيلو جرام\اليوم حققه ‪ %42.1‬من األطفال وزيادة الوزن مابين ‪ 14.4-12.5‬جرام\ كيلو‬
‫جرام\اليوم حققه ‪ %52.6‬من األطفال‪ .‬كان متوسط طول اإلقامة في المستشفى في مرحلة االستقرار ما بين ‪-3‬‬
‫‪ 6‬أيام و متوسط طول البقاء في المستشفى إلعادة التأهيل من قبل غالبية األطفال بين ‪ 23-20‬يوم‪ .‬وكان متوسط‬
‫استهالك الطاقة في مرحلة االستقرار ‪ 588‬كيلو كالوري وكان متوسط كمية البروتين ‪ 7‬جرام‪ .‬وكان متوسط‬
‫استهالك الطاقة في مرحلة إعادة التأهيل ‪ 994‬كيلو كالوري وكان متوسط كمية البروتين ‪ 30‬جرام‪ .‬وأوصت‬
‫الدراسة يجب أن تطبق المستشفى معايير منظمة الصحة العالمية لعالج االمراض الت ّغذوية لألطفال المصابين‬
‫بسوء التغذية الحاد اقل من عمر خمس سنوات‪.‬‬
‫‪IV‬‬
Table of Content
Dedication
I
Acknowledgement
II
Abstract
III
Abstract in Arabic
IV
Table of Content
V
List of Figure
VIII
List of abbreviations
IX
1.1
Introduction
1
1.2
Justification:
2
1.3
Objectives
2
1.3.1
General Objective
2
1.3.2
Specific Objectives
2
1.4
STUDY LIMITATIONS
3
2.1
PROTEIN ENERGY MALNUTRITION
4
2.2
Global Acute Malnutrition
5
2.3
Severe Acute Malnutrition
5
V
2.4
Types of Sever Acute Malnutrition
6
2.4.1
Marasmus
6
2.4.2
kwashiorkor
6
2.4.3
Marasmic Kwashiorkor
6
2.5
Complication of Protein Energy Malnutrition
7
2.5.1
Hypoglycemia
7
2.5.2
Hypothermia
7
2.5.3
Dehydration
7
2.5.4
Anemia
8
2.5.5
Electrolyte imbalance
8
2.6
Anthropometric Measurements for SAM
8
2.6.1
Weight-for-height
8
2.6.2
Mid-Upper Arm Circumference
9
2.7
Therapeutic Feedings for Inpatient Treatment of
10
Severely Malnourished Children
2.7.1
F-75 Formula
10
2.7.2
F-100 Formula
10
2.8
WHO Protocol for Inpatient Management of Severe
10
Acute Malnutrition
VI
2.8.1
INITIAL PHASE
10
2.8.2
Rehabilitation Phase
11
2.8.3
DISCHARGE PHASE
11
2.9
Socioeconomic Factors Related to PEM
12
Subject and Method
3.1
Study Design
13
3.2
Study Population
13
3.3
Study Area
13
3.4
Data Collection
13
3.4.1
Primary
13
3.4.2
Secondary
14
3.5
Inclusion Criteria
14
3.6
Exclusion Criteria
14
3.7
Nutritional Status
14
3.8
Feeding the F75 and F100
15
3.9
Data Analysis
15
4.1
Results
16
4.1
Parents Education and Occupation
16
VII
4.2
Age, Gender and Infection on Admission
18
4.3
Marasmus Classifications on Admission and
Discharge
19
4.4
Total Number of Enrolled Children
20
4.5
Length of Stay in Stabilization and Rehabilitation
21
4.6
Gain in Weight in Both Periods
22
4.7
Energy and Protein Intake in Both Periods
22
4.8
Cross-tabulation of Weight Gain with Different
23
Variables
5.1
Discussion
24
6.1
Conclusion
28
6.2
Recommendations
28
List of References
30
Appendix
35
VIII
List of Figures
Figure 1
Mothers educational level.
Figure 2
Mothers Occupation.
Figure3
Fathers Education levels.
Figure 4
Fathers Occupation.
Figure 5
Ages of Participants.
Figure 6
Participants Gender.
Figure 7
Type of Infection.
Figure 8
Marasmic Classification on Admission.
Figure 9
Marasmic Classification on Discharge.
Figure 10
Total Number of Study Participants.
Figure11
Stay in Stabilization Phase.
Figure 12
Stay in Rehabilitation Phase.
Figure 13
Weight Gain in Both Periods.
Figure 14
Protein Intakes in Both Periods.
Figure 15
Energy Intakes in Both Periods.
IX
List of abbreviations
AIDS
Acquired Immune Deficiency Syndrome
CM
Centimeter
CMAM
Community Management of Acute Malnutrition
F100
Formula 100 used in rehabilitation phase
F75
Formula 75 used in stabilization phase
GAM
Global Acute Malnutrition
GM
Gram
Kcal
Kilo Calories
Kg
Kilo Gram
MAM
Moderate Acute Malnutrition
MUAC
Mid Upper Arm Circumference
NCHS
National Center for Health Statistics
PEM
Protein Energy Malnutrition
SAM
Severe Acute Malnutrition
SD
Stranded Deviation
WFP
World Food Program
WHO
World Health Organization
X
WHZ
Weight for Height Z score
XI
Chapter One
Introduction
1.1 Introduction
World Health Organization (WHO) defines Protein Energy Malnutrition (PEM) as "the
cellular imbalance between the supply of nutrients and energy and the body's demand
for them to ensure growth, maintenance, and specific functions (Shashidhar and
Grigsby, 2009).
Protein Energy Malnutrition is the condition that develops when the body does not get
the right amount of the protein, energy and other nutrients it needs to maintain healthy
tissues and organ function (Kaneshiro and Zieve, 2010).
The primary causes of morbidity and mortality among children aged less than 5 years
are pneumonia, diarrheal diseases, malaria etc. One out of every two such deaths has
malnutrition as the underlying cause. However malnutrition is rarely cited as being
among the leading causes of death even though it is prevalent in developing countries
(WHO, 2000).
United Nations Children’s Fund (UNICEF, 2004) classifies the immediate causes of
childhood malnutrition as insufficient diet as well as stress, trauma, disease (Severe or
frequent infections) and poor psychosocial care. Insufficient dietary intake may refer to
poor breastfeeding practices, early weaning, delayed introduction of complementary
foods and insufficient protein in the diet. The inadequate intake can also be linked to
neglect and abuse. Other factors that influence food intake include health status, food
taboos, growth and personal choice related to diet (Vorster and Hautvast, 2002).
Children between 12 and 36 months old are especially at risk since they are the most
vulnerable to infections such as gastroenteritis and measles (WHO, 2000). It is
1
estimated that, in developing countries, more than one-quarter of all children younger
than 5 years of age are malnourished (UNACC, 2000).
1.2 Justification:
In Sudan 12.4% of children under age five years are wasted, 35% are stunted. In
Khartoum state 16.4% are wasted and 31.1% are stunted (SHHS, 2010). From the above
it is evident that PEM is a public health problem in Sudan which should be given a high
priority. In certain areas when PEM is not accompanied by medical complications
(diarrhea, pneumonia, malaria etc) it is treated by supplementary foods supplied by
UNICEF (Plumby- nuts) or WFP (Super Cereal) under community management of
acute malnutrition (CMAM) programs. However, in Sudan, children are generally
brought to the hospital not for suffering from marasmus but because of medical
complications. In most cases it is identified and treated with therapeutic foods. This
study aims to investigate the inpatient management of such children in Al-Buluk
Pediatric Hospital, Omdurman Locality.
1.3 Objectives
1.3.1 General Objective:
Assess hospital dietary management of PEM.
1.3.2 Specific Objectives:
1.
Assessment of nutritional status at admission and discharge.
2.
Monitor weight gain during stabilization and rehabilitation phases.
3.
Estimating energy and protein intake during stabilization and rehabilitation
phases using F75 and F100 RUTF.
2
1.4 Study Limitations:
1. Due to the limited time, the study could not assess all potential impact factors
on the outcome of the treatment e.g. use of guidelines, availability and
competence of health workers etc.
2. Quantity of hospital food intake was assessed by 24 hour recall which can be
rather biased when compared to the actual measured RUTFs.
3. Another I was unable to measure MUAC on discharged of Children that was
why it was not included in the result.
3
Chapter Two
Literature Review
2.1 Protein Energy Malnutrition
Nutritional status affects every aspect of a child’s health, including normal growth and
development, physical activity, and response to serious illness. Malnutrition may
originate from the deficiency or absence of any nutrient. The establishment and severity
of malnutrition depends on the cause, intensity and duration of the nutritional
deficiency. It can be caused, primarily, by an inadequate diet or, secondarily, by
deficiency in gastrointestinal absorption and/or increase in demand, or even, by an
excessive excretion of nutrients. Protein-Energy Malnutrition (PEM), Rodríguez et al
(2011) defined PEM as being a pathological condition that results from a lower
ingestion of protein and calories, which occurs more frequently in children under five
years of age. There are many reasons behind malnutrition such as inadequate intake of
nutrients and/or from disease factors that affect digestion, absorption, transport, and
utilization of nutrients. However, there are also economic, social, political, and cultural
causes of malnutrition (Isabel et al, 2002). Several studies in different regions in the
third world reported high percentage of malnutrition in children less than five years.
The condition affects mostly children who live in poor socio-economic environment,
particularly children in displaced and refugee camps. In displaced Sudanese children,
the prevalence was 56.1% (Nuha et al, 2005). Child age is one of factors associated
with malnutrition (Kebede et al, 2013). The malnutrition is also associated with
mothers’ education, weaning of the child, income of the family and family size
(Sahibzada et al, 2011). In a study carried out in Karachi, it was found that Mother's
literacy status has a definite association with the malnutrition of the children <3 years
(Syed et al, 2005). Malnutrition can be cured by removing the causes and contributory
factors behind it. The improvement in nutrition resulted in reduction of high mortality
4
rates among children less than five years, the assurance of physical growth, social and
mental development of children as well as academic achievement (Agozie et al, 2012).
2.2 Global Acute Malnutrition:
GAM is a population-level indicator referring to overall acute malnutrition defined by
the presence of bilateral pitting edema or wasting defined by WFH < -2 z-score (WHO
standards or NCHS references). GAM is divided into moderate and severe acute
malnutrition (GAM = SAM + MAM) (WHO, 2011).
2.3 Severe Acute Malnutrition
Severe Acute Malnutrition (SAM) is common in sub-Saharan Africa, with
approximately 3% of children under five affected at any one time, it is also associated
with several hundred thousand child deaths each year (Briend and Collins, 2010).
Complicated severe acute malnutrition is a life-threatening condition requiring urgent,
specialized treatment.
WHO defines severe acute malnutrition as a mid-upper arm circumference (MUAC) <
11.5 cm, a weight-for-height z-score (WHZ) below −3, or the presence of bilateral
pitting edema in children with kwashiorkor. In the absence of anthropometric
assessment, severe acute malnutrition can also be diagnosed by assessing children for
visible severe wasting, defined as the presence of muscle wasting in the gluteal region,
loss of subcutaneous fat, or prominence of bony structures, particularly over the thorax
(WHO, 2009). Severe acute malnutrition differs from chronic malnutrition, which
manifests as stunting. Early recognition of severe acute malnutrition among sick
children is important because standard management protocols may reduce mortality
(Morgenia et al, 2011).
5
2.4 Types of Severe Acute Malnutrition
2.4.1 Marasmus:
Marasmus is characterized by a massive loss of weight and muscle tissue. Due to the
disequilibrium experienced in weight and height, children suffering from Marasmus
look almost elderly and their bodies are skeletal. At this point, their bodies’ vital
processes are compromised: their metabolism has slowed, thermal regulation is
disrupted, intestinal absorption and kidney function are diminished, the liver’s capacity
to synthesize proteins and eliminate toxins is reduced, and the immunological system
doesn’t function properly, which means less resistance to illness and disease. At this
stage, even if the child manages to survive its bout with marasmus, the damage is done
and the deficiencies sustained from the disease can never be overcome ( Action Against
Hunger, 2009).
2.4.2 Kwashiorkor:
The term “kwashiorkor” comes from a Ghanian word that means “the sickness the older
child gets when the new child is born.” Its principal characteristic is the presence of
bilateral edemas on the extremities and on the face (a full-faced child). Underneath
these edema, the muscles have been severely weakened, causing excruciating cramping
and muscle pain. As is the case with marasmus, children with kwashiorkor suffer from
significant damage to the functioning of their internal systems (Action Against Hunger,
2009).
2.4.3 Marasmic Kwashiorkor
A severely malnourished child with features of both marasmus and kwashiorkor. The
features of kwashiorkor are severe edema of feet and legs and also hands, lower arms,
abdomen and face. Also there is pale skin and hair, and the child is unhappy. There are
6
also signs of marasmus, wasting of the muscles of the upper arms, shoulders and chest
so that you can see the ribs (Trehan and Manary, 2014).
2.5 Complication of Protein Energy Malnutrition
2.5.1 Hypoglycemia
An extreme low blood sugar level, common cause of death among severely
malnourished children during the first 2 days of treatment. It is caused by a serious
infection or when a malnourished child has not been fed for 4-6 hours (WHO, 2009).
2.5.2 Hypothermia
An extreme low body temperature, occurring usually together with hypoglycemia
among severely malnourished children and forms a common cause of death (WHO,
2009).
2.5.3 Dehydration
Dehydration is defined as the condition that results from excessive loss of body water.
In severe acute malnutrition, dehydration is caused by untreated diarrheal disease which
leads to the loss of water and electrolytes. Severe acute malnutrition and diarrheal
disease run in a vicious cycle, each making the other more severe and more likely to
occur (Carmichael, 2011).
Dehydration with severe acute malnutrition can be difficult to identify, as many of the
typical signs such as skin elasticity are not reliable. Useful indicators include an
eagerness to drink, exhaustion, cool and moist extremities, weak or absent radial pulse,
and reduced or absent urine flow. In order that proper treatment can be given, it is
important to differentiate between dehydration and septic shock, which have several
symptoms in common. A history of diarrhea indicates that dehydration is present and
7
can be treated accordingly. In areas where severe acute malnutrition is a problem, multistep programmers are used. The management of mild, moderate and severe
dehydration, which is the third step in the initial treatment of severe acute malnutrition,
takes place in the hospital (Carmichael, 2011).
2.5.4 Anemia
Anemia is common between severely malnourished children and severe anemia is a
medical emergency (Thakur et al, 2013).Currently, for inpatient treatment, it is strongly
recommended not to add iron during treatment initial phase (stabilization phase).
Prescribing iron to treat anemia, in the initial phase of the treatment, increases the death
(Amorim et al, 2011).It is due to deficiency of protein, iron, folic acid, B12, B1and
Vitamin C (Trehan and Manary, 2014).
2.5.5 Electrolyte imbalance
All severely malnourished children have deficiencies of potassium and magnesium
which may take 2 weeks or more to correct. Edema is partly a result of these
deficiencies (WHO, 2000).
2.6 Anthropometric Measurements for SAM
2.6.1 Weight-for-height
Using weight-for-height: WHO and UNICEF recommend the use of a cut-off point for
weight-for height of below -3 standard deviations (SD) of the WHO standards to
identify infants and children as having SAM. The commonly used cut-off is the same
cut-off for both the new 2006 WHO child growth standards as with the earlier National
Center for Health Statistics (NCHS reference). The reasons for the choice of this cutoff are as follows:
8
1) Children below this cut-off have a highly elevated risk of death compared to those
who are above;
2) These children have a higher weight gain when receiving a therapeutic diet compared
to other diets, which results in faster recovery;
3) In a well-nourished population there are virtually no children below -3 SD (<1%).
4) There are no known risks or negative effects associated with therapeutic feeding of
these children applying recommended protocols and appropriate therapeutic foods
(WHO, 2009).
2.6.2 Mid-Upper Arm Circumference
Using MUAC: WHO standards for mid-upper arm circumference (MUAC)-for-age
show that in a well-nourished population there are very few children aged 6–60 months
with a MUAC less than 115 mm. Children with a MUAC less than 115 mm have a
highly elevated risk of death compared to those who are above. Thus it is recommended
to increase the cut-off point from 110 to 115 mm to define SAM with MUAC. When
using the WHO child growth standards to identify the severely malnourished among 6–
60 month old children, the below -3SD cut-off for weight-for-height classifies two to
four times as many children compared with the NCHS reference. The prevalence of
SAM based on weight-for height below -3 SD of the WHO standards and those based
on a MUAC cut-off of 115 mm, are very similar. The shift from NCHS to WHO child
growth standards or the adoption of the new cut-off for MUAC will therefore sharply
increase caseloads (de Onis, 2006).
2.7 Therapeutic Feedings for Inpatient Treatment of Severely
Malnourished Children:
9
2.7.1 F-75 Formula:
F-75 Formula (75 kcal/100ml) is the milk-based diet recommended by WHO for the
initial phase of treatment for children with SAM in inpatient care (WHO, 2011).
2.7.2 F-100 Formula:
F-100 Formula (100 kcal/100ml) is the milk-based diet recommended by WHO for the
nutrition rehabilitation of children with SAM after stabilization in inpatient care and
was used in this context before RUTF was available. F100 is used for the rehabilitation
of infants under 6 months of age in inpatient care. A formula diet used during the
rehabilitation phase of severely malnourished children, after the appetite has returned
(WHO, 2011).
2.8 WHO Protocol for Inpatient Management of Severe Acute
Malnutrition:
2.8.1 INITIAL PHASE:
The initial phase is a critical time that emphasizes treatment of disorders that may be
life-threatening, including hypoglycemia, hypothermia, infection, and dehydration.
Prolonged fasting that may be required for diagnostic procedures should be delayed
until the end of this phase. When the malnourished patient is in Phase 1, administer a
milk diet only: either F75 or an equivalent locally-produced milk product (WHO,
2002).The quantity of milk a child needs to receive in phase one is equivalent to
130ml/kg/day. For older children and adults, the quantity of milk per kg of body weight
is different than for children younger than five years (WHO, 2002).
The milk diet is given at regular intervals throughout the day (approximately every two
to three hours). The quantity required for each 24 hour period is determined by the
child’s weight (WHO, 2002).
10
2.8.2 Rehabilitation Phase:
Intensive feeding is given to cover most of the lost weight. Emotional and physical
stimulations are increased. The rehabilitation phase begins as the appetite improves. At
this time, the formula is gradually changed to F-100, which contains 100 kcal/100 mL.
The volume of oral intake is increased slowly to provide 150 to 220 kcal/kg per day.
This treatment is continued until the child's weight-for-height Z-score is >–1. Children
older than two years of age can be successfully rehabilitated using the same formulas
that are given to infants. The child should be fed at least five times daily during the
rehabilitation phase. Feeding frequency can be decreased to three times daily when the
child attains -1 SD of the median WHO Child Growth Standard values. The adjustment
of feeding frequency should take place under supervision before discharge. It is done
by gradually reducing and then stopping the supplementary feeds of F-100 while adding
or increasing the mixed diet until the child is eating a diet similar to what will be eaten
at home (WHO, 2009).
2.8.3 DISCHARGE PHASE:
During rehabilitation, preparations should be made to ensure that the child is fully
reintegrated into the family and community after discharge. The family must be
prepared to prevent recurrence of severe malnutrition (WHO, 1999).
A child is considered ready for discharge when his or her weight-for-height has reached
-1 SD (90 percent) of the median WHO Child Growth Standard values. To achieve this
goal, the child should eat four to six meals daily. Some children may be discharged
before the target weight-for-height has been reached. In these cases, continued
outpatient care is needed through full recovery (WHO, 1999).
Other discharge criteria include completed treatment of all nutritional deficiencies and
infections, and initiation or continuation of the standard immunization schedule. The
11
mother or caregiver should be willing to care for the child. She should be able to provide
food, and initial treatment for diarrhea and infections (WHO, 1999).
2.9 Socioeconomic Factors related to PEM:
Apart from diet deficiency and infections, there are socioeconomic factors that can
cause under nutrition. Education and household income are the major factors; under
nutrition increases with decreased mother's education and decreased family income
(SHHS, 2006). Other factors include the age of child especially the <35 months old
(SHHS, 2006), number of children in the family and family size, breast feeding
practices and artificial feeding (Nabag et al, 2013).
12
Chapter Three
Subjects and Method
Subjects and Method
3.1 Study Design:
Cross-sectional hospital based study
3.2 Study Population:
All PEM children admitted during the period between October- November 2015. Data
were collected originally from 44 subjects who were found to be fulfilling the inclusion
criteria. Most of children admitted to Al-Buluk Hospital were aged less than 24 month.
The age group in this study was specified from 24 month to 59 month; this explains the
small number investigated. In addition 3 escaped and 3 died during stabilization phase,
therefore, only 38 children were fully investigated.
3.3 Study Area:
Al-Boluk Pediatric Hospital in Omdurman Locality.
3.4 Data Collection:
3.4.1 Primary:
Obtained from hospital records (age, weight, height, MUAC, dietary intake during the
duration of stay, discharge criteria).
A- Weight:
Measured from admission to discharge, Children were weighed with a 25 kg hanging
sprint scale, graduated to 0.100 kg. The scale adjusted to zero before each weighing.
A plastic wash basin was supported by four ropes that attach (are knotted) to the
underneath the basin. The basin should be close to the ground in case the child falls out
and to make the child feel secure during weighing.
13
B- Height:
Height was measured at admission using standard procedure. For children less than 87
cm the measuring board was placed on the ground. The child was placed lying down
along the middle of the board. The assistant holds the sides of the child’s head and
positions the head until it firmly touches the fixed headboard with the hair compressed.
The measurer placesed her hands on the child’s legs, gently stretches the child and then
keeps one hand on the thighs to prevent flexion. While positioning the child’s legs, the
sliding foot-plate is pushed firmly against the bottom of the child’s feet. To read the
height measurement, the foot-plate must be perpendicular to the axis of the board and
vertical. The height was read to the nearest 0.1cm
Food intake was measured by the weighing method, hospital food was measured before
serving it to the children, and then it was measured again after they ate to determine
their actual food intake.
3.4.2 Secondary:
Collected from books journals etc.
3.5 Inclusion Criteria:
All 24-59 month marasmic children admitted to the pediatric ward.
3.6 Exclusion Criteria:
All PEM children suffering from marasmic kwashiorkor or kwashiorkor and chronic
disease.
3.7 Nutritional Status:
14
A) WFH-Z score (de Onis et al, 2006).
B) MUAC (UNICEF tape and cut-off-point)
3.8 Feeding the F75 and F100:
One packet (410g) of F75 or F100 was added to two (2) liters of water. (Water must be
boiled and cooled prior to mixing.). F75 and F100 were prepared according to the
number and weights of children treated to avoid excess amounts that will be discarded.
Smaller volumes can be mixed using the red scoop (4.1g) included with the F75and
F100 package (20 ml water per red scoop/4.1g of F75). Prepare enough milk for the
next three hours, not longer, to assure that it will not spoil.
Intake of hospital food was assessed using 24 hour recall, energy and protein intake
calculated using food composition table (Boutros, 1986).
3.9 Data Analysis:
Data were analyzed using SPSS, the result presented in form of figures and tables
(Appendix2). Chi-square analysis was used to analyze the relationship between the
variables and P<0.05 was taken as the least level of statistical significance.
15
Chapter Four
Results
4.1 Parents Education and Occupation
Figure 1 Mothers Education
40
36.4
36.4
35
30
25.0
25
20
15
10
5
2.3
0
illiterate
primary
secondary
university
Mothers had similar illiteracy and primary educational rates, 25.0% had secondary
and 2.3% university educational levels. (Figure1, Appendix 2, Table1).
Figure 2 Mother's occupation
80
70
68.2
60
50
40
30
18.2
20
11.4
10
2.3
0
housewife
employee
worker
self-employed
Mothers occupation was 68% were housewives 18.2% workers and 11.4% were selfemployed (Figure2, Appendix 2, Table1).
16
Figure 3 Father's education
45
38.6
40
35
31.8
30
22.7
25
20
15
10
6.8
5
0
illiterate
primary
secondary
university
Fathers educational level was 6.8% illiterate, 22.7% had primary education, 38.6%
had secondary and 31.8% had university educational level (Figure, Appendix 2, Table
1).
Figure 4 Father's occupation
63.6
70
60
50
31.8
40
30
20
2.3
10
2.3
0
employee
worker
without job
policeman
Fathers occupation was 34.1% were employees, 63.3% were workers, 2.3% were
police men and 2.3% were unemployed (Figure 4, Appendix 2, Table1).
17
4.2 Age, Gender and Infection on Admission
Figure 5 Particepantes Age
40
36.4
35
30
22.8
25
20.4
20
13.6
15
10
5
0
24
25-26
27-28
29-30
Majority 36.4% were 24 months old; the number of children decreased with increasing
age/ months, that is, 22.8% (25-26 months), and 20.4% (27-28months), 13.6% (2930months) and some were in 30-59 months age range (Figure 5,Appendix 2, Table2).
Figure 6 Participants Gender
45.5, 46%
54.5, 54%
male
female
Marasmic children included 54.6% male and 45.5% female (Figure 6, Appendix 2,
Table 2).
18
Figure 7 Type of infection
47.7
50
34.1
40
30
18.2
20
10
0
diarrhea
diarrhea + malari
diarrhea+ARI
47.7 % had diarrhea, 34.1% had diarrhea combined with ARI and 18.2 had diarrhea
combined with malaria (figure 7, Appendix 2, Table 2).
4.3 Marasmus Classification on Admission and Discharge
Figure 8 Marasmus Classifications on
Admission
moderate
45.5%
severe
54.5%
moderate
severe
Marasmus classifications showed that 54.5% suffered severe wasting and 45.5%
moderate wasting (Figure 8, Appendix 2, Table 3).
19
Figure 9 Zscore at discharge
38.5
40
35
29.5
30
25
18.1
20
15
10
5
0
Mild
Moderate
Severe
38.6% discharged with moderate wasting, 29.5% as mild wasting and 18.1 as severe
wasting. (Figure 9, Appendix 2, Table 3).
4.4 Total Number of Children Enrolled in the Study
Figure 10 Total number of children enrolled in
the study
86.4
100
80
60
40
20
6.8
6.8
0
escaped
died
discharged
A total number of 44 severely malnourished children aged 6 to 59 months old were
enrolled in the study. All of them were suffering from marasmus. 86.4% were
discharged, 6.8% were self-discharged and 3 died 6.8 %.( Figure 10, Appendix 2, Table
4).
20
4.5 Length of Stay in Hospital
Figure 11 Length of stay in stabilization
60
55.2
50
40
26.3
30
13.1
20
5.2
10
0
three days
four days
five days
six days
Length of hospital stay in stabilization phase was 55.2% for 3 days, 26.3% for 4 days,
13.1% for 5 days and 5.2% for 6 days. (Figure 11, Appendix 2, Table 5).
Figure 12 lenght of stay in rehabilitation phase
76.3
80
70
60
50
40
30
18.4
20
5.2
10
0
Less than 20
20-23
More than 23
Length of stay in rehabilitation phase 76.3% stayed for 20-23 days, 18.4% stayed less
than 20 days and 5.2 stayed more than 23 days. (Figure12, Appendix 2, Table 5).
21
4.6 Gain in weight in Both Phases:
100
90
80
70
60
50
40
30
20
10
0
Figure 13 weight gain in stabilization and
rehabilitation phases
86.4
52.6
42.1
5.2
8.5-9.6g
10.5-11.1g
12.5-14.4g
0g
No weight was gained during the stabilization phase. During the rehabilitation phase, 5.2%
gained 8.9-9.8 gm./kg/day, 42.1% gained 10.5-11.1gm/kg/day and 52.6% gained 12.5-
14.4g/kg/day (Figure13, Appendix 2, Table 6).
4.7 Protein and Energy intakes in the Two Phases:
Figure 14 Protein intake in two phases
35
30
30
25
20
15
10
7
5
0
Protein
Protein
Stabilization phase
Rehabilitation phase
Mean intake of protein in the stabilization phase was 7.1 g and mean intake in
rehabilitation phase was 30.7g. (Figure14, Appendix 2, Table 7).
22
Figure 15 Energy intake in two phases
1200
994
1000
800
588
600
400
200
0
0
0
energy
energy
Stabilization phase
Rehabilitation phase
Mean energy intake in the stabilization phase was 588 kcal and in the rehabilitation
were 994 kcal. (Figure15, Appendix 2, Table 7).
4.8 Cross-tabulation of Weight Gain with Different Variables:
Cross-tabulations analysis was attempted to identify the influence of socio demographic
factors, co-morbid conditions and length of hospitalization on weight gain during the
rehabilitation phase.
Weight gain was independent of children's gender (P=0.343), their co-morbid
conditions (P=0.775), mother's education (P=0.343).
However, there was a strong relationship between children's age (P=0.000) and their
hospitalization period (P=0.000).
23
Chapter five
Discussion
5.1 Discussion
Severe acute malnutrition is a preventable and treatable cause of childhood
morbidity and mortality. This study was designed to assess the hospital
dietary management of 24-59 months old marasmic children admitted to AlBuluk Pediatric Hospital in Omdurman Locality
the period between
1st of
October – November 30- 2015.
Nowadays, it has become easier to manage SAM in hospital settings, with
least possible stay in hospital due to the introduction of RUTF formulas.
Children with malnutrition fulfilling criteria for SAM such as weight for
height <-3 SD severe wasting, and mid arm circumference <10.5 cm and
acute complications are admitted.
Out of 44 children enrolled in this study 54.5% were males and 45.5% were
females respectively, only 38 were discharged, 3 escaped and 3 died.
The
majority of children were diagnosed as severe wasting 54.5% and the rest
were moderate wasting 45.5%.
The majorities of the children mothers were illiterate or had primary
educational level, some of the mothers had a secondary school education and
few of them completed their education to university level. The lower
educational level of the mothers is considered a risk factor for malnutrition
(SHHS, 2006). Findings of this study are in agreement with many authors as
Nabag et al (2013) who found that the higher the educational level of the
mothers, the better perception of malnutrition is in their children. The study
also showed that most of the mothers were housewives, some of them were
worker or self-employed and few were employees.
24
The educational background of the fathers showed that the majority had a
secondary school and university education respectively some of them had
primary school education and few were illiterate. The majority of the fathers
were working as workers, some of them were employees.
This is indicated
the low socioeconomic status which contributed to the high prevalence of
malnutrition among children under five years of age.
The results also showed the majority of children aged between 24-28 month.
The reasons for high number of marasmic cases among this age group is due
to bad weaning practice followed by poor complementary feeding practices
by their mothers. The common co-morbid conditions in this study was
diarrhea either alone or in combination with malaria or ARI. The findings
were comparable to those reported by Abdelsafi et al (2014) who reported
high prevalence of diarrhea and ARI among severely inpatient malnourished
children at Gaafar Ibn Oaf Pediatric Hospital.
According to WHO guidelines, stabilization feeding starts by using F-75
formula, which is given till child’s appetite improves, the average duration
for using F-75, was 3 days in this study, and subsequently F-100 diet was
given. Patient’s
improvement status
was
monitored
by weight,
appetite,
activity and interest in surroundings. Average weight gain in our study was
10.9 gm./kg/day, and average duration of stay in the hospital in the
rehabilitation
phase
was
20-23
days.
No
weight
gain
was
noticed
in
stabilization phase.
It is apparent that only those children who stayed a minimum of 3 weeks in
the rehabilitation phase on catch up feeding were recovered. The low
recovery rate reported in this study was contributed to the generally low
25
calorie
intake
in
the
rehabilitation
phase
and
shorter
duration
of
hospitalization.
The mean energy intake in the stabilization phase was 588 kcal and the mean
protein intake was 7 grams. The mean energy intake in the rehabilitation
phase was 994 kcal and mean protein intake was 30 grams.
Weight gain (g/kg body weight/day) was directly related to children's age
(P=0.000) and length of hospitalization (P=0.000); probably due to more
extent of SAM among the youngest and longer stay in hospital ensured better
nourishment. However, weight gain was independent of gender, co-morbid
conditions and mother's education.
Before these guidelines, patients had to stay for at least 6 weeks, but due to
financial constraints it was not possible for parents to stay at hospital along
with their children, however, it is possible now to treat and discharge SAM
patients using facility based guidelines, and after discharge continuing home
based treatment on being using RUTFs. Therefore it becomes possible to
convert severe malnutrition (wt/ht < -3 SD) to moderate malnutrition (wt/ht >
-2 SD) and complete the treatment at home or rehabilitation center. In WHO
protocol for management of severe acute malnutrition, weight for age is not
considered for management related decisions, this is so because weight for
height and height for age reflect physiological parameter (wasting or stunting
respectively), weight for age is composite calculation of both and does not
reflect any physiological parameter. In this study most of the patients who
were admitted as severe malnourished became moderately malnourished.
Most of study participants had a good appetite after starting gaining weight
and before discharge, they started hospital food intake in addition to the
26
therapeutic food. These children were discharged after three days after they
start eating the food.
Some of the factors that were likely to have contributed to low calorie, low
weight
gain
include
delayed
transition
to
catch
up
feeds,
failure
to
appropriately increase feeds and infrequent use of nasogastric tube feeding.
The factors that were likely to have contributed to low weight gain are:
shorter duration of hospitalization that included inadequacy of ward space
relative to large patient numbers, inadequate knowledge of W.H.O standard
discharge criteria for
severely malnourished children
and preference
for
outpatient nutritional rehabilitation. Deficiencies of nurses and nutritionists
are likely to have contributed to inadequate supervision and monitoring of
feeds intake. Most of children were discharged before the WHO criteria for
discharge could be met.
27
Chapter SIX
Conclusions and
Recommendations
6.1 Conclusion
1. Thirty-eight marasmic children aged 24-59 months, slightly more boys
than girls were included in this study.
2. All suffered from diarrhea either alone mostly or in combination with
ARI or malaria.
3. Children were mostly from low socioeconomic status evident by low
educational level of mothers and most fathers.
4. On admission 45.5% suffered from moderate marasmus and 54.5%
from suffered severe marasmus and on discharge 29.5% had mild
wasting 38.6% moderate wasting and 18.1 as severe wasting.
5. Hospital stay averaged 3 days in stabilization phase and 20-23 days in
rehabilitation phase.
6. Average weight gain in rehabilitation phase was 10.9 g/kg body
weight/day and mean protein intake 30 g/day and mean energy intake
994 kcal/ day.
7. WHO Guidelines for treating malnourished children were not followed
in discharge criteria.
6.2 Recommendations
1. Improvement in record keeping and documentation of all data in all the hospitals
will result in better accountability and thus case management.
2. Proper practice of the standardized case management protocol according to
WHO/National guide line for the management of severe PEM in all the health
facilities is necessary.
28
3. The management should include offering therapeutic diet frequently over day
and night (preferably by using culturally acceptable local inexpensive foods).
4. Studies to determine factors contributing to suboptimal feed intake, poor weight
gain and to describe long term outcomes are recommended.
29
List of Reference:
1. Abdelsafi A Gabbad, Alawia Adam, Mohammed A Elawad (2014)
Epidemiological Aspects of Malnutrition in Children Less than Five Years
Admitted to Gaafar Ibn Oaf Pediatric Hospital, Khartoum, Sudan.
2. Agozie, C., Ngozi, S., Chika, N., Chinyeaka, M. &Chinelo, A. N. (2012). Underfive protein energy malnutrition admitted at the University of Nigeria Teaching
Hospital, Enugu: a 10 year retrospective review. Nutrition Journal, 11:43
3. Boutros, J.Z. (1986). Sudan Food Composition Tables, 2nd edition. National
Chemical Laboratories, Ministry of Health, Khartoum, Sudan.
4. Briend A and Collins S (2010). Therapeutic Nutrition for Children with Severe
Acute Malnutrition: Summary of African Experience From the Department of
International Health, University of Tampere, Finland; and Valid International Ltd,
35, Leopold Street, Oxford, OX4 1 TW, UK.
5. Carmichael A (2011). Initial treatment of dehydration for severe acute
malnutritionhttp://www.who.int/elena/titles/bbc/dehydration_sam/en/[Accessed
17 February 2016].
6. De Araújo de Amorim, R.C., De Fátima Costa Caminha, M., Da Figueira, M.A.,
Falbo, A.R., Gallindo, T.C. and Filho,M.B. (2011) Co-Existence of Micronutrient
Deficiencies in Hospitalized Children with Severe Malnutrition Treated
According
to
the
WHO
Protocol.
Tropical
Doctor,
41,
230-232.
http://dx.doi.org/10.1258/td.2011.100140.
7. De Onis M, Onyango AW, Borghi E. (2006) Comparison of the WHO Child
Growth Standards and the NCHS/WHO international growth reference:
implications for child health programmes. Public Health Nutr 9, 942–947.
30
8. Fernandez I, John, H. H. & Mercedes, d. O. (2002). Prevalence of nutritional
wasting in populations: building explanatory models using secondary data.
Bulletin of the World Health Organization, 80 (4), 282 – 292.
9. Government National Unity and Government of South Sudan (2006). Sudan
Household Health Survey Khartoum: Sudanese Central Bureau of Statistics/
Southern Sudan Commission for Census, Statistics and Evaluation.
10. Kaneshiro NK, Zieve D. (2010). Kwashiorkor. Pub Med Health. Available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002571.
[Accessed
21
February 2016].
11. Kebede, M., Kassahun, A. and Bikes, D. (2013). Prevalence of Malnutrition and
Associated Factors Among Children Aged 6-59 Months at HidabuAbote
District, North Shewa, Oromia Regional State. Nutritional Disorders & Therapy,
22-15
12. Mogeni P, Twahir H, Bandika V, Mwalekwa L, Thitiri J, Ngari M , Toromo C,
Maitlanda K and Berkleya JA (2011). Diagnostic performance of visible severe
wasting for identifying severe acute malnutrition in children admitted to hospital
in Kenya. http://www.ncbi.nlm.nih.gov/pubmed/22271947 Bull World Health
Organ. 2011 Dec 1;89(12):900-6. doi: 10.2471/BLT.11.091280. Epub 2011 Oct
19.
13. Nabag FO, Elfaki AE and Ahmed K (2013). Socio - economic and environmental
risk factors of protein energy malnutrition among children under five years of age
in Omdurman pediatric hospital. Journal of Since and Technology, 1(1): 1-8.
14. Nuha, M., Susan, H., Mustafa, M., Hussan, M. A., Salah, T. and Ishag, A. (2005).
Prevalence, Types and Risk Factors for Malnutrition in Displaced Sudanese
Children. American Journal of Infectious Diseases, 1 (2): 84-86.
31
15. Rodriguez, L., Cervantes, E. and Ortiz, R. (2011). Malnutrition and
gastrointestinal and respiratory infections in children: A public health problem.
International Journal of Environmental Research and Public Health, 8, 1174-205.
doi:10.3390/ijerph8041174
16. Sahibzada, S. M., Saleh, M. &Zahid, K. B. (2011). Nutritional Assessment of
Children under the Age of Sixty Months in District Sialkot, Pakistan. J Pak Med
Stud, 1(1), 7 – 12.
17. Shashidhar HR, Grigsby DG. (2009). Malnutrition. E Medicine. Available at
http://emedicine.medscape.com/article/985140-overview. [Accessed 21 February
2016].
18. SHHS (2010) Sudan Household Health Survey. Summary report of National
Ministry of Health and Central Bureau of Statistic, 2nd edition Khartoum.
19. Syed, S. A., Nasim, K., Abdulghaffar, B. & Syed, S. H. (2005)11 Association of
Literacy of Mothers with Malnutrition among Children Under Three Years of Age
in Rural Area of District Malir, Karachi. J Pak Med Assoc, 55(12), 550-553.
20. Thakur, N., Chandra, J., Pemde, H. and Singh, V. (2013) Anemia in Severe Acute
Malnutrition.
Nutrition,
30,
440-
442.http://dx.doi.org/10.1016/j.nut.2013.09.011[Accessed17. February 2016]
21. Trehan I. and Manary MJ (2014). Management of severe acute malnutrition in
low-income and middle-income countries.
http://adc.bmj.com/content/early/2014/11/24/archdischild2014 306026.abstract.
[Accessed 21 February 2016].
22. UNACC (2000) Fourth report on the world nutrition situation: United Nations
Administrative Committee on Coordination/Sub-Committee on Nutrition,
Geneva.
32
23. UNICEF Action Against Hunger (2009).Acute Malnutrition A Preventable
Pandemic Report. www.actionagainsthunger.org [Accessed 17 February 2016].
24. UNICEF. (2004). Strategy for Improved Nutrition of Children and Women in
Developing Countries. A UNICEF Policy Review. New York, USA.
25. Vorster, H.H. and Hautvast, J. (2002). A Global perspective on Food and Nutrition
in, The Nutrition Society Textbook Series, Introduction to Human Nutrition.
United Kingdom: Blackwell Publishing. PP (5-6).
26. WHO (1999). Management of severe malnutrition: a manual for physicians and
other senior health workers, Geneva.
27. WHO (2000). Management of the child with a serious infection or severe
malnutrition: guidelines for care at first referral level in developing countries.
Geneva.
28. WHO (2007) Community-based management of severe acute malnutrition
[Internet]. A joint statement by the World Health Organization, the World Food
Programme, the United Nations System Standing Committee on Nutrition and the
United
Nations
Fund.
Children’s
Geneva
Available
from:
http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/inde
x.html. [Accessed 17 February 2016].
29. WHO (2009). WHO child growth standards and the identification of severe acute
malnutrition in infants and children A Joint Statement by the World Health
Organization and the United Nations Children’s Fund, Geneva.
30. WHO (2011). Guidelines for Selective Feeding: The Management of Malnutrition
in Emergency. With the collaboration of the United Nations Standing Committee
on Nutrition and the World Health Organization Geneva.
33
Appendix
Appendix (1)
The National Ribat University
Faculty of Postgraduate Studies & Scientific Research
Faculty of Medicine
Department of Biochemistry
Questionnaire about: Evaluating Hospital Dietary Management of Malnutrition in
Under Five Children:
1-Background
Mother Education Level
Illiterate
Primary
Secondary
College/university
Mother Occupation
Housewife
Employee
Worker
Self Employed
Father Education level
Illiterate
College/university
Father Occupation
Employee Worker without job
police man
2-Chiled
Age month
Gender
Male
Female
Weight …….
kg
Height……….
cm
MUAC………
3-Admission
Infection: Yes
No
If Yes: Diarrhea
ARI
Malaria
Other Specify …………………………………………………………..
Nutritional status:
Marasmus
Kwashiorkor
Marasmic kwashiorkor
Degree:
Moderate
Severe
Discharge
Wight
Z score
34
mm
Appendix (2)
Table 1. Parents’ education and occupation
Mothers
Parameters
Indicator
education
Frequency
Percent
Frequency
Percent
illiterate
16
36.4
3
6.8
primary
16
36.4
10
22.7
secondary
11
25.0
17
38.6
university
1
2.3
14
31.8
44
100.0
44
100.0
housewife
30
68.2
0
0.0
employee
1
2.3
14
31.8
worker
8
18.2
self-employed
5
11.4
28
0
63.6
0.0
Unemployed
0
0.0
1
2.3
Policeman
0
0.0
44
100.0
1
44
2.3
100.0
Total
occupation
Fathers
Total
Table 2. Age, gender and infection type on admission
Frequency
Percent
16
36.4
25-26
10
22.8
27-28
9
20.4
29-30
6
13.6
33-34
3
6.8
44
100.0
Male
24
54.5
Female
20
45.5
44
100.0
Diarrhea
21
47.7
diarrhea + malaria
8
18.2
diarrhea+ARI
15
34.1
44
100.0
Parameter
Age
Indicator
24
Total
Gender
Total
Infection type
Total
35
Table.3 Marasmus Classification on Admission and Discharge
Admission
Parameters
Indicator
classification
Mild
Discharge
Frequency
Percent
Frequency
Percent
-
-
13
29.5
Moderate
20
45.5
17
38.6
Severe
24
54.5
44
100.0
8
38
18.1
100.0
Total
Table 4. Total Number of Enrolled Children
Parameter
Number
Percent
Discharged
38
86.4
Escaped
3
6.6
Died
3
6.8
Total
44
100.0
Participants
Indicator
Table 5. Length of Stay in Stabilization and Rehabilitation
Parameter
Stabilization
days
Frequency
Percent
21
55.2
4
10
26.3
5
5
13.1
6
2
5.2
38
100.0
Less than 20
7
18.4
20-23
29
76.3
More than 23
2
5.2
38
100.0
Number of Days
3
Total
Rehabilitation
days
Total
36
Table 6. Weight Gain in Stabilization and Rehabilitation phases
Pattern of weight gian in
stabilization
Frequancy
Percent
0
38
100.0
Pattern of weight gian in
Rehabilitation
Frequency
Percent
8.5-9.6
2
5.2
10.5-11.1
14
42.1
12.5-14.4
22
52.6
Total
38
100.0
Table 7 . Protein and Energy Intake in Both Phases
Mean
N
Energy in Stablization
phase
588. 8
38
protein in stabilization
phase
7.1
38
energy in rehabilitation
phase
994.0
38
protein in rehabilitation
phase
30.7
38
37
Appendix (3)
Table (1) Association between weight gain, socio-demographic factors, co-morbid
conditions and length of Stay in Rehabilitation Phase:
Parameter
Indicator
Good
Moderate
Poor
Total
Age
24
11(28.9%)
2(5.2%)
0(0.0%)
13(34.2%)
25-26
5(13.1%)
4(10.5%)
0(0.0%)
9(23.6%)
27-28
4(10.5%)
4(10.5%)
0(0.0%)
8(21.0%)
29-30
1(2.6%)
2(5.2%)
1(2.6%)
4(10.5%)
33-34
1(2.6%)
2(5.2%)
1(2.6%)
4(10.5%)
22(57.8%)
14(36.8%)
2(5.2%)
38(100%)
P=0.000
Total
Gender
male
11(28.8%)
8(21.0%)
1(2.6%)
20(52.6%)
P=0.343
female
11(28.8%)
6(15.7%)
1(2.6%)
18(47.3%)
22(57.8%)
14(36.8%)
2(5.2%)
38(100%)
Total
Co-Morbid
diarrhea
9(23.6%)
8(21.0%)
1(2.6%)
18(47.3%)
Condition
diarrhea +
malaria
diarrhea+ARI
5(13.1%)
1(2.6%)
0(0.0%)
6(15.7%)
8(21.0%)
5(13.1%)
1(2.6%)
14(36.8%)
22(57.8%)
14(36.8%)
2(5.2%)
38(100%)
illiterate
6(15.7%)
5(13.1%)
0(0.0%)
11(28.8%)
primary
9(23.6%)
5(13.1%)
0(0.0%)
14(36.8%)
secondary
7(18.4%)
2(5.2%)
2(5.2%)
11(28.8%)
university
0(0.0%)
2(5.2%)
0(0.0%)
2(5.2%)
22(57.8%)
14(36.8%)
2(5.2%)
38(100%)
P=0.775
Total
Mother Education
P=0.343
Total
Length of Stay in
<20
5(13.1%)
0(0.0%)
2(5.2%)
7(18.4%))
Rehabilitation
20-23
17(44.7%)
12(31.5%)
0(0.0%)
29(76.3%)
Phase
>23
2(5.2%)
0(0.0%)
2(5.2%)
0(0.0%)
P=0.000
Total
22(57.8%)
38
14(36.8%)
2(5.2%)
38(100%)
Weight-for-Height WHO Charts 2006 for Children Aged from 6-60
Months
39
40
Nutritional Composition of F100 and F75 Formulas
41