http://doi.org/10.33698/NRF0271-Pabalpreet Kaur, Sushma K Saini, Arun Kumar Aggarwal, Suresh Kumar Bamania

ABSTRACT:

Introduction: Under ve children are prone to many preventable life-threatening diseases. These diseases contribute to high mortality of under ve children among which malnutrition is the major cause. Objective: 1)To identify 1-5 years children with malnutrition. 2) To asess the feeding practices of malnourished children, Dhanas, UT Chandigarh. Methodology: Descriptive design was used to conduct the study. Ethical approval was obtained from Institute Ethics Committee, PGIMER, Chandigarh and written informed consent was obtained from mothers. Total 152 children were enrolled by using purposive sampling technique. A list of malnourished children was taken from Anganwadi centers and they were enrolled in the study. Data was collected in August-November 2017. Assessment of feeding practices was done by using interview schedule and nutritional status was assessed by using weight for age chart. Mothers were interviewed in their home setting as per interview schedule. Results: Feeding practices revealed that all the children were not eating their meals in a separate plate, most of the children were consuming junk foods, most of the mothers were either giving junk food before meals or in place of food and only half of the children were started complementary feeding at 6 months, Half of them either started complementary feeding early or late. Conclusion: Children having malnutrition were consuming more junk food. Breast feeding and complementary feeding practices were not appropriate. Hence it is recommended that nurses and other community health workers should use the strategies to combat malnutrition which are applicable at local levels.

Key words: Malnourished children, Mothers of malnourished children.

Address for correspondence

Sushma Kumari Saini, Lecturer,

National Institute of Nursing Education, PGIMER, Chandigarh

Introduction:

Malnutrition is the one of the major causes contributing to the mortality and morbidity among under ve-year children. As per the National Family Health Survey (NFHS)-4 (2015-16), 35.7 per cent children below ve years are underweight, 38.4 per cent are stunted and 21 per cent are wasted in the country1. Malnutrition affects the child’s ability to grow normally. It makes child more prone to get infectious diseases by affecting the immune system. It delays the physical, intellectual, cognitive as well as psychomotor growth of child. Malnutrition is not caused by single factor. Various factors are responsible for malnutrition. These can be classied as mother’s knowledge regarding feeding, care of child, lack of food availability, poor household environment.

According to WHO breast feeding should be initiated within half an hour in vaginal delivery and within 2 hours in caesarean section2. As per IYCF guidelines complementary feeding should be initiated after completion of 6 months along with breast feeding.3 Nutritional status of children remains normal till 6 months when baby is on exclusive breastfeeding. Failure in timely initiation of complementary feeding contributed to malnutrition. Either mother initiates the complementary feeding too early or too late. In India ICDS is a country wide programme in which supplementary feeding is given up to 6 years of child. In India weight –for- age chart given by WHO is used in anganwadis in which three color zones was given (green, yellow, Red). If the weight of the child falls in green zone it is considered normal. If weight of child falls in yellow zone, child is considered as moderately malnourished and if falls in red zone than the child is severely malnourished. This chart is used for children of up to 6 years and separate chart is used for boys and girls. It is important to identify the malnourished children in community and assessing their feeding habits so that causes that contributing to malnutrition can be managed. So, the present study was undertaken with the objectives to identify the malnourished children and assessing their feeding practices.

Methodology:

A descriptive research design was used in the present study. Target population comprised of malnourished children (1-5 years) and their mothers. Sample was taken by purposive sampling technique in the present study. List of malnourished children were taken from anganwadi centers. Total 152 subjects were enrolled in the study. Interview schedule was used to collect the Socio- demographic data of Child and parents of malnourished child. A set of questions was prepared to assess the feeding practices of child. Assessment of the anthropometric measurement  weight, h e i g h t , M U A C , c h e s t a n d h e a d circumference was done with the help of weight scale and measuring tape. Nutritional status of children assessed through weight for age chart separately for boys and girls. Ethical clearance was taken from Institute Ethics Committee, PGIMER, Chandigarh. Written informed consent was taken from the mothers of malnourished children (1-5 years).

List of children having malnutrition was taken from Anganwadi centers. Home visiting was done. Socio demographic Performa of child and parents was lled by investigator and f`eeding practices of children was assessed by interviewing mothers as per interview schedule. Weight of children was measured by weighing machine and height, MUAC, Head and chest circumference was measured by measuring tape. Nutritional status of children was assessed by weight for age chart.

Results:

Table 1 depicts the socio demographic prole of parents of children having malnutrition. The age of mothers was in the range of 20-36 years with mean age 25.89+3.38. Nearly half (47.4%) of mothers were in age group of 26-30 years. The age of fathers was in the range of 24-40 years with mean age 30.21+3.97. More than half (54.0%) of father were in the age group of 25-30 years. Educational status of the 41.3% of mothers of children having malnutrition was Secondary and above. Educational status of the 49.3% of fathers of children having malnutrition was secondary and above. Majority of mothers (97.4%) were housewives.

Table 1: Socio- demographic profile of parents of children having malnutrition

N=152

 

Socio- demographic variables Mother

n(%)

Father

n(%)

Age of mother (years) *
19(12.5)
20-25 65(42.7)
26-30 72(47.4) 82(54.0)
31-35 15( 9.9)
>35 51(33.5)
Education
25(16.4) 17(11.2)
Illiterate
Upto Primary 27(17.8)
Middle 38(25.0) 29(19.1)
Secondary and above 62(41.3) 106(69.7)
Occupation
148(97.4)
Housewife/non-working
Profession/ Semi profession 24(15.8)
Clerical, shop owner 31(20.4) 4(2.6)
Skilled/ Semiskilled 97(63.8)
Religion
96(63.2) 96(63.2)
Hindu
Others(Muslim, Sikh, Christian) 56(36.8) 56(36.8)
*Socio-economic status (per capita income in
Rs.)(as per BG Prasad scale, 2017)
13(8.5) 13(8.5)
upper class(> 6346)
Upper middle class (3173-6345) 15(9.9) 15(9.9)
Middle class ( 1904-3172) 48(31.6) 48(31.6)
Lower middle class (952-1903) 55(36.2) 55(36.2)
Lower class (<951) 21(13.8) 21(13.8)

mean +SD (range):  *Age of mother 25.89+3.38(20-36)      *Age of father 30.21+3.97(24-40)

Two- third (63.8%) of fathers were skilled and semi-skilled workers. In terms of religion 63.2% parents was Hindu. Per capita income ranged between Rs. 133/- 8333/-. One third (36.2%) of families were in lower middle-class status.

Table 2 depicts the socio demographic prole of children having malnutrition.

Socio demographic variable N=152(%)
*Age of child (months)

13-24

25-36

37-48

49-60

51(33.5)

50(32.9)

36(23.7)

15(9.9)

Gender of child

Male

Female

69(45.4)

83(54.6)

No. of sibling

One Two Three

Four

39(25.7)

92(60.5)

12(7.9)

9(5.9)

Birth order 1st child 2nd child 3rd child

4th child

60(39.5)

70(46.0)

14(9.2)

8(5.3)

Birth weight(kg)

<2.5

2.5-3.5

>3.5

33(21.7)

105(69.1)

14(9.2)

Nutritional status Moderately Malnourished Severely malnourished 99(65.1)

53(34.9)

*Age of children mean + SD (range) 33.4675 + 12.32 (14.0-60.0)

The age of children was in the range of 13- 6 0 m o n t h s w i t h m e a n a g e 3 3 . 4 6 +12.32months. More than half (54.6%) children were females. Birth order of 60.5% was 2. Two third (69.1%) of children were born with birth weight of 2.5-3.5kgs. Two third (65.1%) children were moderately malnourished.

Table 2: Socio-demographic and clinical profile of children having malnutrition

N=152

 

Socio demographic variable N=152(%)
*Age of child (months)

13-24

25-36

37-48

49-60

51(33.5)

50(32.9)

36(23.7)

15(9.9)

Gender of child

Male

Female

69(45.4)

83(54.6)

No. of sibling

One Two Three

Four

39(25.7)

92(60.5)

12(7.9)

9(5.9)

Birth order 1st child 2nd child 3rd child

4th child

60(39.5)

70(46.0)

14(9.2)

8(5.3)

Birth weight(kg)

<2.5

2.5-3.5

>3.5

33(21.7)

105(69.1)

14(9.2)

Nutritional status Moderately Malnourished Severely malnourished 99(65.1)

53(34.9)

*Age of children mean + SD (range) 33.4675 + 12.32 (14.0-60.0)

Table 3 depicts feeding practices of children having malnutrition. Two third (66.55) of children were eating their meals

in separate. Most of the children (84.2%) were always consuming home prepared food. Feeding pattern during illness changed in two third (75.0%) of children. Near to half (48.0%) children eat less during illness.

Table 3: Feeding practices of children having malnutrition

N=152

 

feeding practices of child n(%)
Child eats food in separate plate. Yes

No

101(66.5)

51(33.5)

Eat home prepared food

Yes No

128(84.2)

24(15.8)

Food pattern changed during illness

Yes No

114(75.0)

38(25.0)

Type of change in feeding during illness

Eat less

Drinks milk and uid only No change

73(48.0)

41(27.0)

38(25.0)

 Table 4 depicts Assessing breast feeding and complementary feeding practices of children having malnutrition. Near to half (43.1%) of children were on breastfeeding. Two third (61.0% ) of mothers fed their children 2-6 times during day time and most of (73.4%) mothers fed their child 2-6 times during night time. The practice of emptying one breast before shift to another breast was practiced by most of the mothers (75.0%). Complementary feeding was starts at 6 months in 49.3% of children and 13.8% children were given complementary feeding before 6 months, 29% at 7-9 months and 7.9% at one year.

T a b l e 4 : B r e a s t f e e d i n g a n d Complementary feeding practices of children having malnutrition

N=152

giving more food to child.

Breastfeeding and weaning practices n (%)
Breastfeed the child

Yes

No

64(43.1)

88(57.9)

Frequency of feeding during daytime

<2         N=64

2-6

>6

 

12(18.7)

39(61.0)

13(20.3)

Frequency of feeding during nighttime

<2         N= 64

2-6

 

17(26.6)

47(73.4)

Empty one breast before shift to other one.

Yes

no                  N=64

Sometimes

 

48(75.0)

5(   7.8)

11(17.2)

Timing of starting complementary feeding

Before 6 months

At 6 months

At 7-9 months

At 1 year

 

21(13.8)

75(49.3)

44(29.0)

12(7.9)

 

Table 5: Assessing the practicing of using Anganwadi services for children having malnutrition

 

N=152

Variables related to anganwadi services n(%)
Child registered with ICDS 150(98.7)
Child going to anganwadi 57(37.5)
Consuming food distributed at anganwadi 74(48.7)
Frequency of consuming anganwadi food/week

6 days

2-3 days

1-2 days Never

 

26(17.1)

14(9.2)

35(23.0)

77(50.7)

Reason for not giving anganwadi prepared food.

Child go to school   N= 77

Food is not good

We don’t have enough time to go and bring food.

Anganwadi workers told food is over.

 

16(20.8)

33(42.8)

7(9.1)

21(27.3)

 Table 5 depicts Assessing practices of using anganwadi services for children having malnutrition. Most of the subjects (98.7%) were registered with ICDS but only 37.5% children were going to anganwadi regularly. Near to half of children (48.7%) were consuming the anganwadi food. Only 1 7 . 1 % c h i l d r e n w e r e c o n s u m i n g anganwadi food. Reason for not giving anganwadi food as reported by mothers they felt that food quality was not good (42.8%)

Table 6 depicts Management for malnutrition if malnourished. Most of the mothers were informed about the nutritional status of child by AWW i.e 75.0%. Out of these 28.3%mothers took action for malnutrition in child. Near to half (44.2%) mothers as action taken started

Table 6: Management for malnutrition if malnourished

N=152

 

Management for malnutrition n(%)
Mother informed about nutritional status of child by

AWW

Doctor

Nursing students Not informed

 

114(75.0)

16(10.6)

11(7.2)

11(7.2)

Action taken for malnutrition 43(28.3)
Action taken for management of malnourished child        N= 43

Given more food to child

Given more fruits and milk to child Given Vitamin syrup (as advised by doctor, relatives)

 

19(44.2)

8(18.6)

16(37.2)

Table 7 shows the consumption of junk food in children having malnutrition. Most of the children were consuming junk foods. Frequency and quantity of all types of junk food was more in children having malnutrition. Two-third (68.4%)of mothers were giving junk food to their children before meals. Near to half (42.8%) mothers were giving junk foods in place of food to their children.

Table 7 : Assessing the practices of consumption of junk food by children having malnutrition

Practices of consumption of junk food by child (in last week) n(%)
Frequency of taking biscuits

1-2 times

>2 times Not taking

79(52.0)

52(34.2)

21(13.8)

Quantity of taking biscuits

1-5 biscuits

½ packet 1 packet

>1 packet Not taking

31(20.4)

39(25.7)

26(17.1)

35(23.0)

21(13.8)

Frequency of taking chips

1-2 times

>2 times Not taking

65(42.8)

63(41.4)

24(15.8)

Quantity of taking chips

½ packet 1 packet

>1 packet Not taking

24(15.8)

50(32.9)

54(35.5)

24(15.8)

Frequency of taking maggie

1-2 times

>2 times Not taking

70(46.1)

35(23.0)

47(30.9)

Quantity of taking Maggie

Some spoons

½ katori 1 katori

Not taking

17(11.2)

50(32.9)

38(25.0)

47(30.9)

Frequency of taking toffee

1-3 times

>3 times Not taking

 

76(50.0)

56(36.8)

20(13.2)

Junk food taken by child before meals 104(68.4)
Junk food given at place of food 65(42.8)

 

N=152

Discussion:

Malnutrition is responsible for mortality and morbidity of millions of children each year. It includes both under nutrition and over nutrition but in middle and low middle income countries under nutrition is more prevalent. Nutrition is important for physical and cognitive development of children. It is very important to provide good nutrition to growing populations especially in the inuential years of life. It is important to identify the malnourished children in community and assessing their feeding habits so that causes that contributing to malnutrition can be managed. So, the present study was undertaken with the objectives to identify the malnourished children and assessing their feeding practices.

To prevent and mange malnutrition Government of India has launched a nationwide ICDS programme. One anganwadi covers the population of 1000. It is headed by anganwadi worker (AWW) and assisted by helper. In anganwadi children of their respective places come for informal education, health checkup, supplementary feeding, immunization and growth monitoring. Under this programme routinely children are monitored for their nutritional status by using weight for age chart. AWW records the nutritional status of all the children. AWW was already having details of malnourished children in their areas. Hence, it was easy to access them and their list was obtained from anganwadi.

It is important to assess the current practices to know the causes leading to malnutrition. In present study semi structured interview schedule was used to obtain the data related to the current feeding practices of the children because for explaining the feeding practices open ended questions should be used and it is easy to administer even in the mothers having low literacy. Inappropriate feeding is emerging as one major cause for malnutrition in under ve children. Even if the food is available children are still underweight. The current practices revealed that all the children were not eating their meals in a separate plate, most of the children were consuming junk foods, most of the mothers either given junk food before meals or in place of food and only half of the children were started complementary feeding at 6 months, half of them either started complementary feeding early or late. A study was conducted to evaluate the effect of time allocated for feeding and its effect on nutritional status of infant reported that malnourished children had less time devoted to them for breastfeeding, food preparation and feeding5. Another study reported maternal education, hygienic and feeding practices of mother were found to be signicantly associated with malnutrition4.

At one year a child should take his/ her meal in separate plate. But in most of the families’ child either eats along with parents or grand-parent. Mothers will not be able know how much the child has eaten or whether he/she eaten properly or not. Feeding a child in separate plate is important because parents can come to know about how much their child has eaten. In present study one third of children were not eating in a separate plate. A similar study was conducted in Bangladesh and they reported that after the intervention there was signicant increase in use of feeding in separate pots in group in which intensive education program (100%) was implemented as compared to comparison group(48%) in which routinely education was given6.

Homemade food is more hygienic than eating from outside. Junk food known to be high in calories sugar, fats, carbohydrates and lacks protein and important nutrients. Food prepared at home has f resh ingredients and well prepared under required temperature. Preparing food at home is cost effective. In present study the frequency of consuming junk food was high. A study was conducted in Iran on effect of outside food (junk food) on growth of children. They reported that near to half parents always preferred to give junk food and 44% sometimes preferred outside food and only 11.3% were give home prepared food. Results showed that more growth retardation was present in those children whose parents preferred to give junk food more7.

During illness child eat less. Most of the mothers do not give anything to child if they refuse to eat while they were sick. Children on breastfeeding, should be breastfeed more frequently as it helps the child to ght sickness. More food and liquids should be given. Mothers should encourage the child for small and frequent meals. Child should offer simple foods like porridge and avoid spicy food. After baby recovers, baby should encourage eating extra meal of solid food each day for next two weeks. This will help the child to gain weight that reduces during illness. In present study Children were eating less or drinks only uid while they were sick. A study was conducted regarding beliefs of mothers in feeding the child during sickness. They reported that most of the mother’s belief that child should be feed less while ill. During sickness frequency of breastfeeding and meals was reduced. Even they stopped giving any feed to child during sickness8.

ICDS program run since 1975 to improve the nutrition and reduces malnutrition. In ICDS program anganwadi is created which cater a population of 1000 and headed by anganwadi workers. Supplementary food is provided to under six children that counts 1/3rd requirement of energy and proteins per day. It is important that all the under six children should be registered with their anganwadi. It is good that in present study all the subjects were registered with ICDS. But all of them were not going to anganwadi centers regularly and those who are going regularly were not consuming anganwadi food. A study was conducted in Ludhiana, they reported that out of total registered children (826) only 93 (11.3%) were attending the anganwadi centers9.

Under ICDS programmes nutritional status of children is maintained regularly and mothers are informed about it. Similarly, in present study most of the mothers in both the groups were informed about the nutritional status of child by AWW and other health professionals. But few of them have taken corrective measures for some time only. But due to lack of motivation and non-awareness about the risk of malnutrition the corrective measures were not sustained. The current practices revealed that all the children were not eating their meals in a separate plate, most of the children were consuming junk foods, most of the mothers either give junk food before meals or in place of food and only half of the children were started complementary feeding at 6 months, half of them either started complementary feeding early or late.

On the basis of results of study, it was recommended that the children having malnutrition should be identied in the community and feeding practices should be assessed time to time for identifying the major causes contributing to malnutrition. Community health nurses and other health professional working in community should educate, motivate and reinforce the mothers of under ve children for giving exclusive breast feeding,  timely  initiation of c o m p l e m e n t a r y f e e d i n g , g i v i n g supplementary food distributed through anganwadis and nutritious diet to their child. Some s t rategies to combat malnutrition should be made at local levels and these strategies can be used by nurses and other health professionals working in community.

References:

  1. National Family Health Survey [Internet]. Pib.nic.in. 2017 [cited 22 March 2018]. Available from: http://pib.nic.in/newsite/mbErel.aspx? relid=169905
  2. Exclusive breastfeeding [Internet]. World Health Organization. 2018 [cited 22 March 2018]. Available from: http://www.who.int/nutrition/topics/e xclusive_breastfeeding/en/
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