Despite all efforts and advances, malnutrition continues to be a significant public health concern around the world with about one-third of the world’s children malnourished. The WHO estimates that ∼150 to 200 million preschool children (<5 years) in developing countries are underweight and stunted 1.
Malnutrition is responsible, directly or indirectly, for 60% of the 10.9 million deaths occurring annually among children under the age of 5 years. Over two-thirds of these deaths, which are often associated with inappropriate feeding practices, occur during the first year of life 2.
The 2005 Egyptian Demographic and Health Survey (EDHS) showed that the nutritional status of young children in Egypt remained relatively stable during the period between the 2000 and 2005 surveys. The prevalence of stunting in young children was 23% in both 2000 and 2005. In 2008, however, the prevalence of stunting increased to 29%. The proportion of children who were found to be wasted (7%) and underweight (6%) in 2008 was also higher than in either of the two earlier EDHS surveys according to the new growth standards of the WHO 3.
Epidemiological studies conducted in developing countries have identified several factors associated with undernutrition, including low parental education, poverty, low maternal literacy, food insecurity, maternal depression, rural residential area, and suboptimal infant-feeding practices 4,5.
Although inadequate food intake as a result of household food insecurity is one of the important contributors to child malnutrition, the conceptual framework of the United Nations Children’s Fund (UNICEF) also recognizes disease and poor caring practices as equally important causes of malnutrition 6.
Poverty and lack of knowledge play important roles in malnutrition, especially in the developing world. Poor feeding practices in the developing world have been identified to arise from lack of knowledge about adequate breastfeeding and appropriate weaning practices. All these are closely related to the socioeconomic status and sizes of families 7.
Malnourished children have lower resistance to infection; therefore, they are more likely to die from common childhood ailments such as diarrheal diseases and respiratory infections. In addition, malnourished children that survive are likely to suffer from frequent illness, which adversely affects their nutritional status and locks them into a vicious cycle of recurring sickness, faltering growth, and diminished learning ability 8. Growth faltering among children aged 6–12 months is a global phenomenon, and this period is the window of opportunity to reverse malnutrition in children 9.
The nutritional status of children has an impact on their health and development. Therefore, the physical, mental, social, and nutritional status of children, as well as other characteristics related to malnutrition, should be evaluated periodically to monitor malnutrition, thereby enabling appropriate preventive measures 10.
The objective of this work was to determine the risk factors for malnutrition in children between 6 months and 2 years of age attending the pediatric hospital, Cairo University. This helps in defining high-risk groups and designing tailored targeted preventive intervention programs.
Participants and methods
A case–control design was chosen for this study.
A convenient sampling design was followed to include 200 children, aged 6–24 months, suffering from malnutrition who attended the Center for Social and Preventive Medicine (CSPM) Outpatient Clinic, Pediatric Hospital, Faculty of Medicine, Cairo University, from January 2010 to December 2010. Two hundred age-matched and sex-matched controls of normal nutritional status were recruited concurrently from children visiting the vaccination or routine checkup clinics at the center. Children clinically diagnosed with undernourishment comprised those of either sex whose weight-for-age Z score (WAZ) was less than or equal to 2.0 (underweight) with respect to the new growth standards of the WHO 1 and who did not have any underlying disease that might have been responsible for their underweight were. Controls were children from the same communities who attended different clinics in the center (well-baby clinic for vaccination and mother’s antenatal care clinic) during the same period of the study and whose WAZ was greater than or equal to 2.0.
Tools of the study
A structured interview questionnaire sheet and an anthropometric assessment tool were used. The structured interview questionnaire was developed specifically to collect data related to this study from mothers of both the study and control groups, including: (a) sociodemographic data related to mothers such as mother’s educational level, working status, residence, family size, and parity; (b) identification data related to the child such as age, sex, vaccination details, and vitamin A supplementation; (c) mother’s knowledge and practices related to exclusive breastfeeding, artificial feeding, and initiation of complementary semisolid foods; and (d) health-related services and patient satisfaction.
After obtaining informed consent from parents, the child’s weight for age was calculated. Children were weighed while wearing light-weight clothing; they were laid horizontally and weighed using a children’s scale that had a precision of 0.05 kg.
Data were collected and analyzed using the statistical package for social sciences (SPSS version 16; SPSS Inc., Chicago, Illinois, USA). For continuous variables, means were compared using unpaired t-tests. The differences in the proportion of patients and controls were compared using the χ2-test. A probability value of less than 0.05 was considered statistically significant. The strength of association of selected risk factors for severe underweight was determined by estimating odds ratios (ORs) and their 95% confidence intervals (CIs). All independent variables were analyzed initially in bivariate models and those that were significantly associated with severe underweight (dependent variable) were included in multiple logistic regression models.
Approval was obtained from the review board of the Faculty of Medicine, Cairo University. Verbal consent was obtained from the participants included in the study after explaining the study objectives.
The mean ages of the patients and controls were 11.3 (±5.6) and 11.5 (±5.3) months, respectively (P=0.778). There were 99 (49.5%) boys among the patients and 83 (41.5%) among the controls (OR=1.38, 95% CI 0.93–2.05); the P value was 0.108. As dictated by the study design, the patients had a significantly lower mean (−2.91±0.7 SD) WAZ compared with control children (0.17±0.7 SD), with a P value less than 0.001 (Table 1).
Table 2 illustrates the sociodemographic factors (parental and other family factors) associated with undernutrition. Illiteracy rate was higher among the mothers of patients (75, 37.5%) than among those of controls (49, 24.5%) (OR=1.85, 95% CI 1.2–2.85) and among the fathers of patients (29, 14.5%) than among those of controls (15, 7.5%) (OR=2.09, 95% CI 1.08–4.04). Most of the mothers of the patients (n=190, 95.0%) were not working when compared with controls (154, 77.0%). The main paternal occupation was manual work among both patients (85, 42.5%) and controls (93, 46.5%). A larger family size with the number of children greater than three was noticed more frequently in the household of patients (143, 71.5%) when compared with controls (80, 40.0%) (OR=3.76, 95% CI 2.48–5.71). Parity greater than three was higher among mothers of patients (146, 73.0%) when compared with controls (81, 40.5%) (OR=3.97, 95% CI 2.61–6.05).
Nutritional knowledge and feeding practice
The vast majority of mothers in both groups (92.0% of patients and 95.0% of controls) agreed that breastfeeding should be continued at least up to 2 years of age. However, mothers of only 88 (44%) patients knew that breastfeeding should be initiated within the first hour of birth when compared with 150 (75.0%) controls (OR=3.82, 95% CI 2.49–5.83). The majority of both groups (54% of patients and 60% of controls) emphasized that breastfeeding is important during illness (OR=1.28, 95% CI 0.86–1.90).
Lack of exclusive breastfeeding for the first 6 months of age was more common among patients (77%) than among controls (39%) (OR=5.24, 95% CI 3.39–8.09); these children were given infant formula feeds, yoghurt, and cheese. However, a semisolid complementary diet (at 6 months of age or more) was initiated later in patients (94, 47.0%) than in controls (18.5%) (OR=3.91, 95% CI 2.49–6.14). Bottle feeding was more frequently used in patients (43.0%) than in controls (60, 30%) (OR=1.76, 95% CI 1.17–2.66; Table 3).
Health services and nutritional education
In the present study, it was noticed that parents of 39.0% of patients were reluctant to seek medical advice during their child’s illness compared with parents of only 10.0% of controls (OR=5.75, 95% CI 3.35–9.89). Significantly, parents of 40.5% of patients and 15% of controls mentioned that, during consultation, the doctor did not recommend any special diet for their child during illness (OR=3.86, 95% CI 2.39–6.23). However, only a small percentage of both groups complained that, usually, there was inadequate time to ask questions and not all of their questions were answered. Parents of only 27 patients (13.5%) and 20 controls (10.0%) were uninformed about the time of the following visit (OR=1.41, 95% CI 0.76–2.59). The majority of both groups of patients (81%) and controls (90.5%) received vitamin A supplementation by the age of 9–18 months. A significantly higher percentage of parents of controls (50%) attended health or nutrition education sessions compared with parents of patients (35.5%) (OR=1.82, 95% CI 1.22–2.71; Table 4).
Further analysis with logistic regression revealed that the risk for undernutrition was independently associated with lack of maternal occupation for cash (OR=8.61, 95% CI 3.30–22.49), lack of exclusive breastfeeding for the first 6 months of life (OR=5.77, 95% CI 3.28–10.17), maternal illiteracy (OR=5.28, 95% CI 1.92–14.5), insufficient patient satisfaction (not all mother’s questions were answered by the doctor) (OR=2.59, 95% CI 0.99–6.7), lack of seeking medical advice during illness (OR=2.36, 95% CI 1.23–4.54), late initiation of breastfeeding after birth (OR=2.33, 95% CI 1.25–4.33), and nonattendance of health or nutrition sessions (OR=2.02, 95% CI 1.17–3.51; Table 5).
Childhood malnutrition is a major issue in developing countries. Identifying the risk factors among certain groups of children is key for planning and implementing tailored intervention programs.
Sociodemographic factors and nutritional status
Educational level of the mother and mother’s occupation are factors significantly related to undernutrition. In this study, more than 50% of mothers were illiterate and not working. Our study findings correlated with previous national and international reports. The EDHS 3 illustrated that low weight-for-age was slightly more common among infants whose mothers never attended school (8%) compared with those whose mothers have had some education.
Similarly, Youssef 11 in Assiut found that higher education level of the mothers correlated to better knowledge on malnutrition. Lack of education, especially among women in rural areas, is a leading factor contributing toward malnutrition. Most of such mothers are ignorant about the importance of breastfeeding, weaning diets, proper age of weaning, concept of a balanced diet, hazards of cow-milk or formula-milk feeding, and basic concepts of hygiene and prevention of disease. Consequently, the main victims of malnutrition are the children of these families 12.
Smith and Haddad 13 identified the determinants of child malnutrition in 63 developing countries over the past 25 years from previous studies. Six factors were explored, one of which was women’s education. Father’s education emerged as an important factor that was significantly associated with malnutrition among children under 5 years of age. Analysis showed that the proportion of weight-deficient children whose fathers had a higher level of education were lower than that of children with illiterate fathers. Usually, father is the main earner and decision maker of a family and therefore his higher level of education plays an important role in ensuring the better nutritional status of children. In our study, parental illiteracy was significantly associated with the occurrence of malnutrition.
Our finding that lower paternal education is a risk factor for malnutrition is in agreement with a study from Bangladesh, which found that lack of paternal education was significantly associated with both moderate and severe childhood stunting 14. Similarly, a study in Uganda found that both economic status and education of fathers were significantly associated with the nutritional status of children 15.
The underweight children in our study were more likely to have a significantly larger family size when compared with better nourished children. A larger family size is associated with an increased risk for malnutrition. The effect of a large family size with overcrowding and inadequate spacing has been implicated as a risk factor for severe malnutrition in different studies 16,17. This supports the notion that non-nutritional factors should be essential components in the effort to reduce malnutrition in developing countries.
Nutritional factors and nutritional status
Breastfeeding is a norm in Egypt. The majority of mothers (>90%) in both groups knew that breastfeeding should be continued at least up to 2 years of age, and more than half of them emphasized the importance of breastfeeding during illness. However, there was a statistically significant difference between patients and controls with respect to maternal knowledge on the time of initiating breastfeeding. Similarly, the UNICEF 18 in 2009 estimated that just over one-half (56%) of all newborns in Egypt receive breast milk within 1 h of birth and just over one-half (53%) of infants under 6 months are exclusively breast fed 19. In the present study, introduction of cow’s milk, infant-feeding formula, and other food elements (yoghurt and cheese) before 6 months of age was significantly more common among patients (154, 77%) than among controls (78, 39%). A study conducted in China showed that the introduction of other food stuffs before the age of 6 months increased the prevalence of pneumonia and diarrheal disease, and this consequently increased the risk of child malnutrition 20.
However, other studies suggest that introduction of infant formula before 6 months of age protects against malnutrition 17. These differences in findings between studies may be due to the manner in which infant or child feeding was assessed, as well as because of other geographical factors.
Initiation of a semisolid complementary diet after 6 months of age was significantly more common in the control group (163, 81.5%) compared with the patient group (106, 53%). The reason for this could be that mothers think that after the age of 6 months breast milk is no longer adequate to meet the nutritional and caloric requirements of the child and hence essential complementary feeding must be introduced by the age of 6 months. This indicates that it is not only lack or shortage of food that predisposes young children to malnutrition but also a lack of knowledge on appropriate infant-feeding and young child-feeding practices. This is in concordance with a study conducted in Ethiopia that showed that introduction of other diets before 6 months of age is 3.2 times more common among cases than among controls and that late initiation of a complementary diet after 1 year of age was 3.4 times more common in the malnourished group, indicating that children with severe malnutrition are started on complementary diets either too early or too late 19. Inappropriate timing of introducing certain types of food supplements to a child may affect his/her nutritional status because digestive and immune systems are not yet mature. Introducing supplements before 4 months, especially under unhygienic conditions, could be an important cause of malnutrition 21.
As a global public health recommendation, infants should be exclusively breast fed for the first 6 months of life to achieve optimal growth, development, and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues at least for 2 years 22.
In the present study, bottle feeding was more commonly used in the malnourished group than in controls. Bottle feeding is discouraged at any age. It is usually associated with increased risk for illness, especially diarrheal disease, because of the difficulty in sterilizing the nipples properly. Bottle feeding also shortens the period of postpartum amenorrhea and increases the risk of pregnancy, which will consequently affect maternal health status and outcome of pregnancy 23. This is in line with the results obtained by Ahmed et al. 24 showing that artificial feeding was more prevalent among malnourished children than in the control group (52.7 and 22.7%, respectively). This might be because powdered milk, being expensive, drives mothers to dilute the formula, which affects the constitution of the milk and leads to inadequate intake of suitable food elements and caloric requirements.
Some studies revealed that a bottle-fed baby in a poor community is 14 times more likely to die from diarrheal diseases and four times more likely to die from pneumonia compared with a baby who is exclusively breast fed 25,26.
Health-related services and nutritional status
A significant association was detected between undernutrition and lack of vitamin A supplementation. Twenty-one (21%) patients did not receive the supplementation compared with 14 (9.5%) controls. This finding was in agreement with that of Caulfield et al. 8 and Mamoun et al. 27, in which vitamin A deficiency due to either lack of supplementation or an imbalanced diet was a significant risk factor for malnutrition. In our study, it was noticed that parents of 78 (39.0%) patients were reluctant to seek medical advice during their child’s illness. Interventions that provide counseling to caregivers on the initiation and continuation of appropriate and adequate complementary feeding early in life, along with improved hygiene and caring practices, may effectively tackle malnutrition. A study in Bangladesh showed that improved knowledge of preventive healthcare behaviors and infant-feeding practices by the caregivers could successfully prevent growth faltering of the children 28.
Further, the study highlighted the importance of patient–physician communication as an integral part of clinical practice. It is essential for the physician to listen to the patient’s concerns, provide comfort, satisfaction, and foster the relationship in general 29.
Conclusion and recommendations
The findings of this study confirmed the association of undernutrition with inappropriate infant-feeding and young child-feeding practices, large family size, and inadequate use of health-related services. To reduce childhood malnutrition, due emphasis should be given to improving the knowledge and practice of parents on appropriate infant-feeding and young child-feeding practices.
Children under the age of 5 years are in a stage of rapid growth and development. At this period of life, early intervention strategies must be taken to prevent growth failure.
Risk factors identified for undernutrition can be used to design targeted preventive interventions that will be necessary to ameliorate the current situation. Health education toward better child nutrition attitude and practices and family planning and birth control may serve to decrease the prevalence of malnutrition.
Conflicts of interest
There are no conflicts of interest.
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