368 Original Study Nutritional Status and Anaemia with Special Reference to Morphological Classification in Underfive Children Vinod Narkhede, Asst. Prof., Dept. of Community Medicine, Peoples College of Medical Sciences & RC, Bhopal. Smita Pitale, Associate Professor, Pushpa Durge, Prof. & Head Dept. of Community Medicine, NKP Salve Institute of Medical Sciences & RC, Nagpur. Abstract Background: Nutrition of pre-school children (0-5 years age group) is of paramount importance because the foundation for lifetime health, strength and intellectual vitality is laid during this period. Aims: To assess the nutritional status and hemaoglobin status and morphological classification of anaemia of children below five years of age. Settings and Design : Community based cross-sectional study in children below five years of age from urban slum, Nagpur. Methods and Material : A house-to-house survey was done. By systematic random sampling 434 children below five years of age were included in the study. Every child was subjected to anthropometric measurements using standard technique. Haemoglobin estimation was done by using Sahli s haemoglobinometer and peripheral smear was prepared. Statistical analysis : Data was analyzed on Epi- Info Software 3.2 version. Chi square test is used to test the significance. Result : 52.23 % were suffering from various grades of malnutrition. 32.18 % children were in grade I, 16.09 % in grade II, 3.46 % in grade III and 0.5 % in grade IV malnutrition. 78.71 children had anaemia (Hb < 11gm/dl). It was observed that 34.9 % children had microcytic and hypochromic anaemia, 19.6 % had dimorphic, 13.7% had normocytic normochromic and 7.5% had macrocytic anaemia. Out of these 2 children had sickle cell disease. A statistically significant association was observed between malnutrition and anaemia. Conclusion : Nutritional rehabilitation centers should be started in the community and linked with health centers to treat less severely affected undernourished children. Keywords malnutrition, anaemia, morphologic classification Introduction Nutrition of pre-school children (0-5 years age group) is of paramount importance because the foundation for lifetime health, strength and intellectual vitality is laid during this period. They constitute an important group of a community and are among the most vulnerable section of the population from nutritional standpoint. Malnutrition is a silent emergency 1. Malnutrition is frequently part of a vicious cycle that includes poverty and disease. These three factors are interlinked in such a way that each contributes to the presence and permanence of the others. Socioeconomic and political changes that improve health and nutrition can break the cycle; as can specific nutrition and health interventions. There is strong evidence that poor growth or smaller size is associated with impaired development, and a number of studies have also demonstrated a relationship between growth status and school performance and intellectual achievement. However, this cannot be regarded as a simple causal relationship because of the complex environmental Address for correspondence: Dr. Vinod, Narkhede, 93, Shivlok Phase 4, Khajurikalan Road, Piplani, Bhopal 462 021, Madhya Pradesh, India. E-mail : drvinod72@rediffmail.com
369 or socioeconomic factors that affect both growth and development. Childhood stunting leads to a significant reduction in adult size. One of the main consequences of small adult size resulting from childhood stunting is reduced work capacity, which in turn has an impact on economic productivity. In addition, maternal size is associated with specific reproductive outcomes. Short women, for example, are at greater risk for obstetric complications because of smaller pelvic size. There is also a strong association between maternal height and birth weight which is independent of maternal body mass. Study Area Material and Methods The present community based cross-sectional study was conducted in children below five years of age from Urban Health Centre, Jaitala, Nagpur. The total population of the area was 16042. Study Period From April 2005 to July 2006. Study Subjects Study subjects consisted of children below five years of age. Total 1827 children were registered in 0-5 years age group. A list of household was prepared having the study subjects and 434 children s were included in the study. Sample Size The optimal sample size of 434 study subjects was calculated on the basis of 48% prevalence of undernourished children found in pilot survey. n = 4pq/L 2 where p = positive character, q = 100-p L= allowable error 10% of p Methodology A house-to-house survey was done. By systematic random sampling 434 children below five years of age were included in the study. Every attempt was made to cover maximum number of children by giving 3 visits to them. Total 404 children were included in the study. Every child was subjected to anthropometric measurements which includes weight and height using standard technique. Haemoglobin estimation was done by using Sahli s haemoglobinometer and peripheral smear was prepared. Statistical Analysis Data was analyzed on Epi-Info Software 3.2 version. Chi square test is used to test the significance. Results As per Table 1 it was observed that according to Indian Academy of Pediatrics (1972) classification out of 404 children studied, 47.77 percent were normal and 52.23percent were suffering from various grades of undernutrition. 32.18 percent children were in grade I, 16.09 percent in grade II, 3.46 percent in grade III and 0.5 percent in grade IV undernutrition 5. Age group wise prevalence of undernutrition was highest in 13-24 months age group (13.86 percent), followed by 0-12 months (10.9 percent), 25-36 months (10.4 percent), 49-60 months (8.66 percent) and 37-48 months (8.41 percent). In age group of 0-12 months and 25-36 months prevalence was almost equal i.e. 10.9% and 10.4% respectively. On comparing prevalence of undernutrition in 0-6 months age group with 7-60 months age group it was observed that former group had a better nutritional status as compared to later group. The difference was statistically significant (χ2 =43.07, df=1, p<0.0001). Probably indicating faulty weaning practices and dietary habits. Sex wise prevalence of undernutrition was slightly higher in females (26.49 percent) as compared to males (25.74 percent), however, no significant difference was observed. Grade IV undernutrition was found only in female (0.5 percent) children. As per Table 2 it was observed that out of 387 children whose haemoglobin percentage could be estimated 301 (77.78 percent) children were anaemic (Hb % <11 gm/ dl) 6. 15.76 percent children were having mild anaemia (Hb% 10.00-10.99 gm/dl), 58.66 percent were having moderate anaemia (Hb% 7.00-9.99 gm/dl): and 3.36 percent were having severe anaemia (Hb% <7 gm/dl).
370 Age Group In months Table 1 Distribution of children according to various grades of nutritional status Age and Sex wise (I.A.P. Classification) (n = 404) Normal Grades of Under Nutrition I II III IV M F M F M F M F M F Total no. of Children n (%) 0-3 19 12 1 1 1-1 - - - 35 (8.7) 4-6 8 15 1 3-1 - - - - 28 (6.9) 7-9 13 11 5 3 1 2 - - - - 35 (8.7) 10-12 4 4 9 7 3 3-2 - - 32 (7.9) 13-18 8 7 9 2 4 8 2 2 - - 42 (10.4) 19-24 11 7 11 8 1 7 1 1 - - 47 (11.6) 25-30 9 9 9 7 2 2 - - - 1 39 (9.7) 31-36 6 4 5 5 6 4 - - - 1 31 (7.7) 37-42 9 6 4 5-1 - - - - 25 (6.2) 43-48 5 5 4 10 2 6 1 1 - - 34 (8.4) 49-54 5 3 6 7 2 1 2 - - - 26 (6.4) 55-60 5 8 6 2 4 4 1 - - - 30 (7.4) Total 102 91 70 60 26 39 8 6-2 404 Total M+F 193(47.77) 130(32.18) 65(16.09) 14(3.46) 02(0.5) 404 (100) Table 2 Distribution of children according to Severity of Anaemia (n = 404) Type of Anaemia Total No. of Children n (%) Mild Anaemia 61 (15.76) Moderate Anaemia 227 (58.66) Severe Anaemia 13 (03.36) Total 387 (100) Note: Hemoglobin estimation of 17 children cannot be done. Moderate anaemia was most prevalent type of anaemia. The percentage of anaemic children was highest in children of 1-12 months age group (22.36%), followed by 12-24 months (16.32%), 24-36 months (14.47) 36-48 months (12.92) and 48-60 months (11.63%). It was observed that anaemia was more common in girls (42.64 percent) than boys (45.22 percent) and the difference was not statistically significant (χ2 =0.00, df=1, p<0.1). Among anaemic children, 2 children were found to be suffering from sickle cell disease further confirmed by electrophoresis. As per Table 3 it was observed that out of 387 children 22.2 percent children were normal (Hb > 11 gm/dl) and 77.8 percent were having anaemia (Hb < 11 gm/dl). Further studies for typing of anaemia 2 was done, it was observed that out of 301 anaemic children highest 34.9 percent had hypochromic microcytic anaemia and lowest 7.5 percent had macrocytic anaemia. As per Table 4 it was observed that prevalence of anaemia was higher among children having undernutrition (99.05 percent) and prevalence of anaemia was 52.27 percent among normal children. The association of nutritional status was found significant when children with anaemia were compared to children without anaemia (χ2 = 121.49, df = 1, p< 0.0001) Discussion A community based cross sectional study was carried out in urban field practice area of Urban Health Training Centre, Jaitala, Nagpur, from April 2005 to July 2006 for the assessment of nutritional status of children below five
371 Table 3 Distribution of children according to Morphological Classification of Anaemia (n = 404) Hemaoglobin Level Type of Anaemia Total No. of Children % > 11 gm/dl No Anaemia 86 22.2 < 11gm/dl Hypochromic Microcytic 135 34.9 Normocytic Normochromic 53 13.7 Macrocytic 29 7.5 Mixed/ Dimorphic 76 19.6 Total 387 100 Note: 17 children s smear cannot be assessed. Nutritional Status Table 4 Association of Anaemia and Nutritional Status (n = 404) Type of Anaemia No Anaemia n (%) Anaemia n (%) Total n (%) Normal 84 (47.73) 92 (52.27) 176 (100) Malnourished 2 (0.95) 209 (99.05) 211 (100) (χ2 = 121.49, df = 1, p< 0.0001) Total 86 (22.22) 301 (77.78) 387 (100) years of age and haemoglobin status of these children. Out of 434 children in 0-5 years age group, 404 children could be studied and formed the study population. The study group consisted of 206 (51.0 percent) males and 198 (49.0 percent) females. In Maharashtra, as per NNMB the prevalence of grade I, II, III and IV undernutrition was 39.0, 21.2, 4.8 and 0.6 percent respectively among 6-60 months children from rural area 4. In India, as per National Family Health Survey 3 the 72.2 percent of children (age 6-35 months) were anaemic 3. In Maharashtra as per National Family Health Survey 2 the 76.8 percent of children (age 6-35 months) were anaemic, which was lower than the present study among same age group (84.95 percent) 3. The present study reveals a high prevalence of malnutrition and nutritional anaemia Based on study findings following recommendations are suggested. 1. The families from community should be encouraged for home-based activities for alternative source of income, which will help in improving their purchasing power. 2. As it was observed that prevalence of nutritional anaemia was high and is significantly associated with malnutrition, use of green leafy vegetables, cooking food in iron utensils, deworming and whenever deficiencies detected correction of deficiencies is recommended. 3. Nutritional rehabilitation centers should be started in the community and person from the community is identified and linked with health centers to treat less severely affected undernourished children. Summary Community based cross-sectional study in 434 children
372 below five years of age from Urban slum. 52.23 % were suffering from various grades of malnutrition. 32.18 % children were in grade I, 16.09 % in grade II, 3.46 % in grade III and 0.5 % in grade IV malnutrition. 78.71 children had anaemia (Hb < 11gm/dl). It was observed that 34.9 % children had microcytic and hypochromic anaemia, 19.6 % had dimorphic, 13.7% had normocytic normochromic and 7.5 % had macrocytic anaemia. Out of these 2 children had sickle cell disease. A statistically significant association was observed between malnutrition and anaemia. Acknowledgement We acknowledge and thank all the staff members of our department and urban health training centre for their support. References 1. Bansal R.D. and Mehra M. Malnutrition: a silent emergency. Indian Journal of Public Health. 43: 1-2, 1991. 2. Desai N. and Choudhary V.P. Nutritional anaemia in protein energy malnutrition. Indian Pediatrics. 30: 1471-1483, 1993. 3. National Family Health Survey India 2005-06. http:// www.nfhsindia.org. 4. NNMB. Diet and Nutritional status of rural population. NNMB Technical Report No. 21, 2002. 5. Nutrition subcommittee of the Indian Academy of Pediatrics. Indian Pediatrics. 9: 360-364, 1972. 6. World Health Organization. Report of WHO Scientific group Nutritional Anaemias. Technical Report Series No. 405, 1968.