Severe acute malnutrition and its associated factors among under-five children in two districts of Nepal

Background: Despite consistent efforts to enhance nutritional child nutrition, poor nutritional status of children continues to be a major public health problem in Nepal. This study identified the predictors of severe acute malnutrition (SAM) among children aged 6-59 months in the two districts of Nepal. Methods: We used data from a cross-sectional study conducted among mothers of 6 to 59 months children admitted to the Outpatient Therapeutic Centres (OTCs). The nutritional status of 398 children was assessed using mid-upper arm circumference (MUAC) measurement. To evaluate associated factors with SAM, adjusted odds ratio was computed using multivariate logistic regression and p-value <0.05 was considered as statistically significant. Results: Among 398 children, 5.8 percent were found to be severely malnourished including under-two years and female children. Family size (five or more members) (Adjusted Odds Ratio [AOR]: 3.96; 95% Confidence Interval [CI]: 1.23 - 12.71) was positively associated with SAM. Children from severely food insecure households (AOR: 4.04; 95% CI: 1.88-10.53) were four times more likely to be severely malnourished. Younger age-group (AOR: 12.10; 95% CI: 2.06 - 71.09) children (0 - 12 vs. 24 59 months) were significantly associated with childhood undernutrition. Conclusions: The findings of this study indicated that household size, household food access, and child’s age were the major predictors of severe acute malnutrition. Hence, nutrition health programs should be targeted to improve the nutritional status of children by ensuring household food access by focusing poor families engaging them in kitchen gardening to promote nutritious diet to the children.


Background
Children have the right to adequate nutrition and access to safe and nutritious food, and both are essential for fulfilling their right to the highest attainable standard of health [1]. Age 6-59 months is the critical period for rapid physical growth and development for children. Children may suffer from undernutrition if the nutritional requirement of children is compromised [2]. Globally, 7.5 million under five-children are wasted and 16.4 million are severely wasted [3].{UNICEF, 2015 #69} Severe acute malnutrition (SAM) refers to the condition that is identified by Mid-Upper Arm Circumference (MUAC) measurement of less than 115 mm or weight for height (wasting) less than minus 3SD z-score below the median among children aged between 6 to 59 months [4]. MUAC is a widely used rapid nutritional assessment measure based on the assumption that it closely related to muscle mass to identify SAM in children [5]. Children in the SAM category (MUAC < 115 mm) have a higher risk of dying compared to those who are above [4]. SAM contributes to over one million under-five deaths per annum. Survivors of acute malnourished children are at increased risk of developing stunting and various diseases, disorders, poor educational performance and low productive life [6].
The prevalence of stunting wasting and underweight according to the 2016 Nepal Demographic and Health Survey (NDHS) was 36, 10 and 27 percent, respectively. The rate of stunting and underweight among under five-years children showed a gradual downward trend since 1996, however, the decline in wasting was minimal. The rate of wasting among under 5 years children was higher in rural areas and in province 1 and 2 [7] [8].
Overall health indicators in province 2 are relatively low especially among poorer households [9].
During the monsoon season, districts in Eastern Terai (low land) are hard hit by flooding, disrupting infrastructure and social phenomena. Heavy rainfall in August 2017 triggered flash flood and landslide in 32 Terai districts in Nepal including Bara and Jhapa districts. Food supply, emergency, and basic medical services were heavily disrupted due to widespread flooding [10]. In addition, nutritious food consumption by the children and mothers during this period was well below minimum standards due to low availability of the ration and other food and non-food items [11]. There is limited evidence on the prevalence of SAM and its multifaceted determinants among children aged 6-59 months in the flood-affected districts. Therefore, this study addressed the gap and provides substantial evidence that could be providential in planning health programs in emergency situation in the flood-prone districts in Nepal.

Study area
This study was conducted among children in two randomly selected districts from province 1 (Jhapa) and province 2 (Bara). These are Terai (lower land) districts bordering to India. Jhapa district is better off than Bara district in terms of human development index [12].

Study settings and participants
A cross-sectional study was conducted among children 6-59 months in April to June 2018. The sample size for study was calculated using the formula, n=z 2 pq/e 2 assuming prevalence rate of acute malnutrition 14.4%, a margin of error 5%, and 95% confidence level [7,13]. The sample size of 197 plus an addition 10% non-response rate yielded a total sample size of 217 for each district. The final sample size after data cleaning and excluding incomplete data from the two districts was 404.
Outpatient Therapeutic Centres (OTCs) in a district were considered as strata. OTCs aim to provide treatment to malnourished children with an appetite and have no medical complications and can, therefore, be treated at home with simple routine medicines and ready-to-use therapeutic food (RUTF) [13]. All OTCs, 16 from Jhapa and 19 from Bara, were included in the sampling frame and selected using a systematic sampling method. The required number of children was then divided by the number of OTCs and selected consecutively after a fixed interval.

Inclusion criteria
Eligible mothers of 6 to 59 months-children attending OTCs were selected and interviewed.

Exclusion criteria
Children with known chronic illnesses, and congenital abnormality which affects the feeding pattern of the children were excluded from the study.

Questionnaire
The structured questionnaire was developed based on the study objectives. Indicators related to household socio-economic characteristics, education level, toilet facility, and food security [14], nutritional assessment, breastfeeding status, were validated and adopted from the 2016 NDHS questionnaire [7]. All the questions were pretested during the pilot test in a non-sampled OTC.

Outcome variables
Outcome of interest for this study was SAM among children aged between 6 to 59 months [4]. For this study, MUAC of less than 115 mm was used as a cut-off criteria to identify the SAM [15].

Independent variables
Independent variables were categorized into three levels; household factors, child factors, and maternal factors. A robust literature review was done to regroup the potential factors associated with SAM. Household factors included variables such as place of residence (urban and rural municipality), family type, family size, ethnicity, household income, availability of toilet facility at the household, possession of land size, kitchen garden, and household food insecurity. Family type was classified as nuclear and joint, and the family size was categorized into two categories i) 1 to 5 members, and ii) 5 or more members. Ethnicity variable was grouped into three categories: relatively advantaged (Brahmin/Chhetri), relatively disadvantaged (Janajati/Muslims), and Madhesi and other unidentified.
Madhesi is a predominant ethnic caste in Nepal who resident in Terai region [16]. The annual income of a household was asked with the respondent to determine the economic status of household. The household income was categorized based on annual family income standard as recommended by the National Bank (Nepal Rastriya Bank) [17]. The possession of land size was grouped into two categories: households having less than 0.5 hectors of land and households having 0.5 or more hectors of land. Household Food Insecurity Access Scale (HFIAS) measurement tool was used to collect the information on food insecurity at household level developed by the Food and Nutrition Technical Assistance Project (FANTA) [14]. Child factors comprised of gender and age of child, number of children in the household variables. Birth order was categorized as first, second and third or more.
Likewise, birth interval of between child was classified into two categories; i) less than 2 years and ii) more than 2 years. Maternal level factors included mother's age, education, occupation (working and employed), breastfeeding practices such as colostrum feeding and exclusive breastfeeding practice.
Maternal age was grouped as 15 to 20 years, 21 to 29 years and 30 and above years. Mother's education status was categorized as illiterate, literate, primary, secondary and higher education. Early initiation of breastfeeding indicator included two categories i) within an hour (mother who breastfeed children within an hour of birth) and ii) delayed (mother who breastfeed children after one hour of birth).

Data collection and analysis
Face to face interview was conducted with a mother of an eligible children by the trained enumerators using a paper-based structured questionnaire. Legibility and completeness of data were ensured during the data collection period and any inconsistencies were addressed during the fieldwork.
Anthropometric tools, SECA digital weighing scale for weight and height board (Stadiometer) for height/length measurement of 6 to 59 months children were used. Shakir tape was used to measure MUAC from the child's left arm to the nearest 0.1 cm (1 mm) margin. Child's weight was measured with no or minimum layer of dress and all the measurement was taken during daytime as recommended by WHO 2006 growth standards [18]. Descriptive statistics of 398 children aged 6 to 59 months was presented as frequencies and percentages along with the calculation of Pearson's chisquare test to determine associations between predictors and outcome variables. Also, we used multivariate logistic regression analysis to report association between SAM and its determinants. All characteristics associated (p < 0.05) with each outcome in chi-squared tests were included in the multivariable model. Odds ratios (OR) and 95% confidence intervals (CI) were derived and two-sided p-values less than 0.05 were considered as level of significant. No multicollinearity between independent variables was found. All analysis was performed in Stata software version 15.0 [19].

Ethical considerations and informed consent
Ethical approval was granted by the Nepal Health Research Council, Kathmandu, Nepal. Eligible mothers of under-five years children who were willing to participate in the study were interviewed after obtaining written consent.

Results
Out of total 398 children of 6 to 59 months, more than half were female, and the average age of children in the study was 24.3 (±15.4). Almost six percent of children were severely malnourished and the mean MUAC of children in SAM category was 112.0 mm (±3. 19). A higher percentage of children were from urban municipalities (59.3%), and lived in a joint family (55.3%). The average family size was 5.7 (±2.6) and the mean number of children in a household was 2.1 (±1.3); averages of family members and number of children were higher in SAM category. Nearly three-quarters of children belonged to low-income households. One fourth of the children was Madhesi and approximately one fifth (18.8%) had no toilet facility in their household. More than half (56.5%) of the mothers reported to have kitchen garden at their household. Nearly two thirds (64.1%) of the households were food secured while 11.8 % of the households were severely food insecure (Table 1).
Approximately half (46.5%) of the children participated in our study were eldest. More than half (58.3%) of the mothers were between the age group 21-29 years followed by 30 and above (29.4%) years. Almost one fifth (18.8 %) of the mothers were illiterate while nearly one fourth (24.4 %) of mothers had higher level education. Six out of ten children were breastfed within one hour of birth and more than half (67.8%) children were exclusively breastfed. Table 1 Here** In the multivariable logistic regression analysis, households with family size of five or more members was significantly associated with SAM [adjusted OR (AOR): 3.96; 95% CI: 1.23 -12.71). Children of households experiencing severe food insecurity were four times (CI: 1.12 -14.61) more likely to be severely malnourished compared to children in the food secured households.

**Insert
Three household indicators; children from Madhesi ethnicity, family without toilet facility, and no kitchen garden were significant predictors of SAM as reported in the unadjusted logistics regression model. Relative to 24 to 59 months children, children 6 to 12 months and 12 to 23 months had 12.1 and 6.6 times higher odds of being severely malnourished, respectively. However, there was no association with SAM and ethnicity, toilet facility, having kitchen garden, birth order, mother's education level, and exclusive breastfeeding practices in the adjusted multivariate model (Table 2). Table 2 here**

Discussion
Our study used WHO standards for MUAC cut-off of below 115 mm to identify SAM among children aged 6 to 59 months. The MUAC measurement was used over weight-for height below -3 SD of the WHO standards because both of these measures give almost similar prevalence of SAM [4]. MUAC is regarded as a cost-effective and easiest method to early detect SAM in children with minimal risk and many potential benefits [20]. We found that only 5.8 percent of children admitted to the OCTs were severely malnourished. Significant predictors of SAM among children aged 6 to 59 months included family size, household access to food, child age and mother's working status. The study further indicated that the prevalence of SAM was significant (p>0.05 in chi-square test and in the unadjusted regression model) among families having three or more children, children belonging to Madhesi ethnicity, households with no toilet facilities and no kitchen garden, order of birth greater than two, illiterate mothers and children with no exclusive breastfeeding practices.
Households with five or more members and households with three or more children were statistically associated with SAM. Higher the number of family members in the household more will be the burden to household to provide optimum nutritious food to all the family members and children. Higher the number of children in household, it unlikely that every child gets proper care and time, putting them at higher risk of being malnourished. This finding is coherent with a study conducted in India [21], Ethiopia [22,23], and Uganda [24]. Our study finding indicated that SAM among children was significantly associated with ethnicity. Children belonging to the Madhesi were higher at risk of being malnourished indicating that disparities in undernutrition in terms of ethnic background exist in Nepal. A study investigated the inequality in terms of ethnicity in the utilization of health services in Nepal reported a higher prevalence of childhood malnutrition among Terai ethnicities where mainly Madhesi ethnicity resides [9]. This may be due to the fact that Madhesi ethnicity is underprivileged group and have socio-cultural practices that hinder health service utilization and the adoption of health practices. In our study toilet facility at household showed a significant association with SAM.
Availability of toilet facility is directly linked with child's hygiene and nutrition. Hygiene and sanitation behaviours, therefore, are essential factors to improve the nutritional status of children. Similar results were reported in studies done previously [25,26]. Children in the food insecure households were more likely to be malnourished. Several studies have found a similar association between household food insecurity and malnutrition among children [27,28]. This finding is plausible as the reduced or compromised quality of diet due to lack of food or limited availability of food, could not meet the dietary requirement in terms of quantity and quality of child's diet. This poses children at a greater risk of undernutrition [29]. Notably, among mothers who were illiterate, the likelihood of children being severely malnourished was higher. The unadjusted model in our study reported significant association between SAM and mother education. This finding is consistent with the studies from Bangladesh [30] Ethiopia [31], and Pakistan [32] which showed that the maternal education is the key factor by which mother have better understanding of child nutrition and acts as a protective factor against undernutrition. Exclusive breastfeeding practice in this study was significantly associated with SAM. This finding was comparable with the studies from Nepal and Pakistan [32-34].
The finding highlights the importance of exclusive breastfeeding from which children receive nutrition that have several benefits including reduction in gastrointestinal infection [35]. However, the association was not found between SAM and early initiation of breastfeeding. The possible explanation for this would be the exclusive breastfeeding rather than early breastfeeding provides protective nutrition to the children for an extended period of time. This finding is in agreement with findings from Nepal and India [33, 34, 36].
Apart from these findings, this study has several limitations. The cross-sectional design of the study limits to capture the actual prevalence of acute malnutrition among children and the observational study design restrained us to eliminate associations are due to residual confounding. Since the study was conducted in two districts of province 1 and province 2 in Nepal, hence the findings are not a true representation of SAM of entire country.

Conclusions
In this study, notably higher percentages of SAM children were from the households with five or more family members. We found that household food access and child's age were independently associated with acute childhood malnutrition. Hence, education and awareness to the mothers could play a vital role in improving child nutrition status. Our findings emphasized the need to strengthen the nutrition status of children in food-insecure households by promoting access to food and various source of nutrition. Nutrition programs should be prepared to serve the poorest and disadvantaged mothers and children during and after a natural calamity.

Ethics approval and consent to participate
Ethical approval for this study was granted by the Nepal Health Research Council. A written consent was taken with the participants before starting the interview.

Availability of supporting data
The datasets analysed in this study are not publicly available due to ethical concerns.

Competing interests
The author(s) declared no competing interest with regard to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the publication of this article.   Figure 1 Adjusted prediction of SAM according to the age of child