Background: Malnutrition is a major cause of child morbidity and mortality. There are several interventions to prevent the condition but it is unclear how well they are taken up by both malnourished and well nourished children and their mothers and the extent to which this is influenced by socio-economic factors. We examined socio-economic factors, health outcomes and the uptake of interventions to prevent malnutrition by mothers of malnourished and well-nourished in under-fives attending Princess Marie Louise Children’s Hospital (PML). Methods: An unmatched case control study of malnourished and well-nourished children and their mothers was conducted at PML, the largest facility for managing malnutrition in Ghanaian children. Malnourished children with moderate and severe acute malnutrition were recruited and compared with a group of well-nourished children attending the hospital. Weight-for-height was used to classify nutritional status. Record forms and a semi-structured questionnaire were used for data collection, which was analysed with Stata 11.0 software. Results: In all, 182 malnourished and 189 well-nourished children and their mothers/carers participated in the study. Children aged 6-12 months old formed more than half of the malnourished children. The socio-demographic factors associated with malnutrition in the multivariate analysis were age ≤24 months and a monthly family income of ≤200 GH Cedis. Whereas among the health outcomes, low birth weight, an episode of diarrhoea and the presence of developmental delay were associated with malnutrition. Among the interventions, inadequate antenatal visits, faltering growth and not de-worming one’s child were associated with malnutrition in the multivariate analysis. Immunisation and Vitamin A supplementation were not associated with malnutrition. Missed opportunities for intervention were encountered. Conclusion: Poverty remains an important underlying cause of malnutrition in children attending Princess Marie Louise Children’s Hospital. Specific and targeted interventions are needed to address this and must include efforts to prevent low birthweight and diarrhoea, and reduce health inequalities. Regular antenatal clinic attendance, de-worming of children and growth monitoring should also be encouraged. However, further studies are needed on the timing and use of information on growth faltering to prevent severe forms of malnutrition.
An unmatched case–control study was conducted at the Princess Marie Louise Children’s Hospital in Accra. Cases were defined as children under the age of 5 years with either Moderate Acute Malnutrition (MAM- a weight for height Z score of ≥ −3SD to < − 2 SD) or Severe Acute Malnutrition (SAM-a weight for height Z score of − 2SD). The study was part of a larger study which also examined feeding practices, maternal, social, medical and biologic factors associated with malnutrition. We present here the extent of exposure of these children and their mothers to selected health interventions that prevent the malnutrition and the socio-demographic and health outcomes affecting them. Princess Marie Louise Children’s Hospital is the largest centre dedicated to treating children with malnutrition in the country. The hospital is a 74 bed children’s hospital situated in the commercial centre of the capital, Accra. It provides both primary care and specialized paediatric services for patients brought in by their parents and referrals from health facilities in other parts of Accra and from other regions. In 2012, there were 157 admissions for MAM and SAM at PML with a mortality rate of 11.7 % as reported by the Dietetic unit. The WHO protocol informs case management at the hospital. Patients with malnutrition were identified initially by measuring the Mid Upper Arm Circumference (MUAC) as this is the main measurement used for admitting and identifying patients with SAM and MAM in Ghanaian nutritional rehabilitation centres. Those with Severe Acute malnutrition (SAM), a weight for height Z score of < − 3 SD with or without bilateral pitting oedema (WHO) and Moderate Acute Malnutrition (MAM), a weight for height Z score of ≥ −3SD to − 2SD presenting with other conditions were included as controls. Children who met MUAC criteria but did not meet weight for height criteria or had missing weight or height measurements were excluded from the study. Children with chronic diseases which have an influence on nutritional status, including congenital heart disease, renal failure, sickle cell disease or liver disease and their mothers were also excluded from both study groups. Also excluded were children who had been in the nutritional rehabilitation programme for more than 7 days and their mothers. Children who were severely ill were also excluded until they were stable, if this was within the 7 days. Purposive sampling was used in this study. We recruited consecutive patients with MAM and SAM admitted to the malnutrition ward or referred to the nutritional rehabilitation unit into the study between 9th January and 10th June 2013 who met weight-for height and other inclusion criteria, and gave consent. A comparative group of children attending PML who were being seen or treated for conditions other than malnutrition were recruited from the out-patients department and from the general paediatric wards if they had a weight-for-height z score of < −2SD, met inclusion criteria and gave consent. These were classified as controls but were not matched by age or sex to the cases. We had some challenges recruiting controls especially from the general wards as many of those screened did not meet the criteria for being “well nourished”. Thus we extended the time of recruitment of the comparison group to 10th September 2013 due to difficulty obtaining suitable controls and because of an industrial action which reduced patient attendance. A Class III infant scale (Seca 334) was used to measure the children’s weight. A Seca 417 measuring board was used to measure length while height measurements were done using a Leicester height measure. These were recorded to the nearest millimetre. MUAC and head circumference were done using non-stretch tape measures. Research personnel making these measurements were trained in standardized techniques for performing these measurements. A Royal College of Paediatrics and Child Health training video clip was used as part of the training. Weight-for-height measures wasting or acute malnutrition and can be expressed as a z-score which is the number of standard deviations or Z-scores below or above the reference mean or median value [21]. The Mid-Upper Arm Circumference (MUAC) is the arm circumference taken at the midpoint between the tip of the shoulder (acromium process) and the tip of the elbow (olecranon process). Both measurements measure wasting or acute malnutrition but correlation between them is often poor. MUAC is better predictor of mortality, easier and less cumbersome to perform and therefore is recommended for use in community-based screening [22]. A semi-structured questionnaire and a data record form were used to collect the information on the child’s profile. The information collected included data on the child’s age, sex, birth weight and birth order, maturity and problems at birth, child development, HIV status, chronic illness, illness episodes and diarrhoeal episodes over the past year. Information on nutritional status, sources of nutrition advice, growth pattern, immunisation status and preventive interventions such as de-worming, vitamin A supplementation and antenatal and postnatal visits was also obtained. Information on faltering growth was obtained from the Child Health Record and in this study it was defined as a fall off the growth curve through two or more centile spaces on the growth chart. At the time, adequacy of antenatal visits was defined as 4 or more antenatal visits and postnatal visits as two or more postnatal visits. The data were entered into a Microsoft Access (Microsoft Corporation, Redmond, Washington) and analysed using Stata 11.0® (College Station, Texas 77845 USA). Classification of malnutrition using weight for length/height measurements was done using the WHO Anthro for personal computers, version 3.2.2, 2011. Frequencies and means were computed. The results were presented using tables, graphs with statistical inference. Both univariate and multivariate analysis were done to determine factors associated with malnutrition with the variables grouped under socio-economic and demographic factors, health outcomes and uptake of interventions. Variables significant at p < 0.2 in the univariate analysis were entered into the final multivariate analysis model. Statistical significance was accepted at a 5 % probability level, i.e. a p-value of less than 0.05. Ethical approval was sought and obtained from the University of Ghana Medical School’s Ethical and Protocol Review Committee [Protocol Identification Number: MS-Et/M.8-P.5.8/2011-2012]. Ethical approval was also obtained from the Ghana Health Service Ethical Review Committee [Protocol Identification Number GHS-ERC 05/07/2012]. Written consent was obtained from the mothers/guardians of the children using consent forms which were signed or thumb printed.
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