Socio-economic and demographic factors
In this study more than half of the malnourished children were in the 6 months to 12 months age group (Table 1). Since this coincides with the weaning period, it may well be that inappropriate weaning or complementary feeding practices may have been a major contributor to this finding [3, 14]. A similar pattern was found in a study of admissions of children under the age of five years with protein energy malnutrition in Enugu, Nigeria [23]. The study on malnutrition at PML in the 1990’s differs in methodology from our study as the researchers specifically targeted children between 8 and 36 months. The average age then was around 14 months for underweight and 17 months for severe malnutrition [6].
We found that an age of 24 months or less was associated with malnutrition in the multivariate analysis. It is well known that this age group is most vulnerable to malnutrition and its effects [24]. At the same time the age group provides a window of opportunity for intervening to reduce the effects of malnutrition hence the emergence of the Scaling Up Nutrition (SUN) movement which aims at mitigating nutritional problems during pregnancy, and in this age group [24, 25]. It is a country-led process which brings organizations together to support nations to implement nutrition interventions in their national plans through multidisciplinary working.
A monthly family income of ≤200 GH Cedis (≤100 USD) was associated with malnutrition in the multivariate analysis reiterating the importance of poverty in the aetiology of malnutrition in this setting [26]. This is similar to a previous study in Ghana which found that economic inequality is strongly associated with chronic under - nutrition. It is also similar to a study in Nigeria which found that maternal monthly income < $20, monthly household food expenditure of < $55 was associated with malnutrition [26]. In contrast, the educational status of mothers and their occupational status in this study were only significantly associated with malnutrition in the univariate analysis and not in the multivariate analysis. The researchers in Nigeria also found that malnutrition was significantly. associated with education below secondary level in a univariate but not in multivariate analysis of its determinants [27]. They also found that residence in a one room apartment, higher birth order and incomplete immunization of the child were significantly associated with malnutrition in that study consequently, they suggested a multidisciplinary approach for preventive strategies just as the SUN movement has done [27]. We did not find an association between immunisation status and malnutrition possibly because immunisation rates were similar in both groups and was high. It could be that making a health service such as immunisations readily accessible reduces the effects of poverty and health inequalities.
Although poverty can exert its influence on all three arms of the UNICEF conceptual frame work of underlying causes of malnutrition, it has a major effect on household food security [28]. Food security is determined by several factors including food prices, agricultural practices, climate change and market forces among others [29]. There was a gradual increase in the number of people worldwide who were underweight from 1990, peaking in 2008. This was worsened by the global recession in 2008 and 2009 which particularly affected the urban poor. It led to price hikes in food, limiting food consumption and causing a shift to less balanced diets. It also left less resources for buying goods and services to ensure hygienic practices, health and well being [29]. Suggestions have been made to counteract this by promoting agricultural growth, measures to reduce extreme market volatility, and expansion of social protection and child nutrition action particularly nutrition sensitive interventions [29–31].
In response to this call, there have been several studies exploring the use of social protection measures such as cash transfers to mitigate the effects of poverty on malnutrition in childhood and some have been particularly successful as reported in a study in Niger [32]. This study found that preventive distributions of supplementary food and cash transfer were better at preventing MAM and SAM than either of these measures alone. However, it is not clear how this can be sustained in the long term. In any case it is rewarding to note that there are plans to ensure that strong social protection measures are enshrined in the upcoming sustainable development goals.
Health outcomes
The results of the study showed that low birth weight, having an episode of diarrhoea within the last 6 months and the presence of developmental delay were all associated with malnutrition in the multivariate analysis. Similar findings have been reported by other studies [3, 6, 23]. On the other hand, although having been admitted to hospital within the past one year was associated with malnutrition in the univariate analysis, the association was not statistically significant in the multivariate analysis. There was also no relationship between sickness episodes and malnutrition unlike the study by Maleta et al. [33] in Malawi which found that malnutrition was associated with frequent illness episodes in infancy. It is possible that we may have found an association if we had focussed on infancy as they did.
Diarrhoeal diseases are generally more frequent and tend to be more severe in malnourished children because of the association between malnutrition and infection [1–3]. In this study, 40.7 % of the malnourished children had two or more episodes of diarrhoea compared to 23.3 % of the controls. This suggests that efforts to control diarrhoea are important for effective prevention of malnutrition. This must include providing effective advice on feeding during diarrhoea episodes and adequate follow up after each episode. It is also important that protocols exist for investigating and managing children who have relapsed after previous treatment for diarrhoea to exclude underlying medical conditions [23]. Developmental delay was more prevalent in malnourished children and associated with increased odds of being malnourished. Malnutrition often causes developmental delay however malnutrition can also be precipitated in feeding difficulties due to a chronic neurological problem [9]. It appears this association was more of an effect rather than a cause of malnutrition in most of the children. However eight (8) out of the 29 malnourished children with developmental delay were reported to have had problems at birth and one (1) had a chronic neurological condition, cerebral palsy which could have precipitated the delay in data not presented here. Early intervention will ensure that these children make the most of their developmental potential to reduce the effect of malnutrition [30, 34, 35].
Uptake of interventions
The study found that inadequate/lack of antenatal care was associated with malnutrition in the multivariate analysis although the association was marginal. This implies that mothers of malnourished children were less likely to have had adequate health contacts through antenatal visits. The present result is similar to a study in three Latin American countries which found only a weak association between antenatal care and reduction in the level of child malnutrition and some variations between countries [10]. They attributed these findings to differences in the quality of care and health inequalities.
Antenatal care provides opportunities for nutritional counselling which mothers of well nourished children may have benefited from and it has been shown to be effective if there is food security [11, 13, 14]. It is also worthy to note that the mothers of malnourished children reported the delivery room to be the main setting for nutritional counselling, whereas mothers of well nourished children reported the child health record books as their main source of nutritional advice. The study also shows that mothers of well nourished children were more likely to de-worm their children every 6 months. Regular de-worming of children has been reported to be a useful intervention for preventing malnutrition in some settings and this appears to be one [11, 14]. Furthermore, a majority of the mothers reported that they had nutritional counselling or advise from the health service which is one of the interventions expected in a national plan [16, 17, 24]. The delivery room is an important setting for counselling mothers on early initiation of breast feeding [36].
Since maternity care is free in all government health institutions, pregnant women should be encouraged to access antenatal care and the health serivice should engage those mothers who miss out through home visiting. However a more specific and targeted approach will be needed. Vitamin A supplementation was not associated with malnutrition even in the univariate analysis. Although Vitamin A reduces child mortality, it is not known to affect anthropometric measurements [14].
Growth faltering occurred in both groups; however it was significantly more common in children with malnutrition and was still significant after multivariate analysis. This is not an unexpected finding. We encountered some incomplete records which are most likely because most mothers come for growth monitoring only when their child’s immunisations are due. They used to stop at 9 months after the measles immunisation but more recently this has gone up to 18 months since the second dose of measles was introduced. Additional clinic visits may be necessary to pick up and monitor children who are faltering between the ages of 9 and 18 months and above. The usefulness of these visits needs to be established first since growth monitoring has been used in several intervention programmes with mixed results [11, 14].
The main limitation of this study was a challenge related to the classification of malnutrition. Weight for height criteria was used to make the results comparable to other studies. The WHO recommends the use of both MUAC and weight for height as independent criteria for classifying malnutrition whereas nutrition rehabilitation centres in Ghana including PML use only MUAC [20]. We found that about a third of patients who would have passed as being well-nourished using MUAC criteria could not be included in the control group because they were malnourished using weight-for-height criteria. This means that there may be several malnourished children who are missed each day. Missed opportunities for picking up malnourished children has been reported in several studies, including a study in a teaching hospital in Ghana [37–39]. Understandably, MUAC is an easier and more practical measurement in small peripheral health facilities. However, in larger health facilities like PML and teaching hospitals, it should be possible to do weight and height measurements routinely and hence record weight for height measurements. Further studies are needed to assess the effect of using either criteria on the prevalence and cost-benefit of management as it may well be that the burden of malnutrition in the hospital is much higher than we are treating.
Children with Kwashiorkor who could not stand to have their heights measured or were too ill were not included. There was a slight over representation of older children among the well nourished children. Also the patients were not matched so it is possible that this may have created a bias. We also recognise that children labelled as well-nourished are likely to contain some children with mild malnutrition; however, for the purposes of this study, we have classified them as controls in line with current classification of malnutrition.