Rural children remain more at risk of acute malnutrition following exit from community based management of acute malnutrition program in South Gondar Zone, Amhara Region, Ethiopia: a comparative cross-sectional study

Introduction

Under-nutrition is the end result of nutrient deprivation either due to lack of adequate intake or repeated infection (World Health Organization, 1999) and is categorized as either chronic or acute malnutrition based on duration of deprivation (WHO & UNICEF, 2009). Acute malnutrition is further classified as either moderate acute malnutrition (MAM) or severe acute malnutrition (SAM) based on the degree of malnutrition and the presence of edema (WHO & UNICEF, 2009). According to a 2018 report, globally over 49 million children under 5 were wasted and nearly 17 million were severely wasted (UNICEF, WHO & World-Bank, 2018) while the magnitude nationally in Ethiopia and in Amhara region was found 7.25% and 7.6% (Ethiopian Public Health Institute (EPHI), 2019) and also it was 11.8% in the study area (Motbainor & Taye, 2019). Health consequences for children suffering from wasting include weakened immunity and increased risk of death, particularly when wasting is severe (UNICEF, WHO & World-Bank, 2018). The mortality rate due to SAM is between 5 and 20 times higher compared with mortality of well-nourished children (WHO & UNICEF, 2009; WHO et al., 2007). Globally about 1 million children die every year from SAM (UNICEF et al., 2010; World Health Organization, 2013a), and in Ethiopia about 57% of all under-five deaths are related to malnutrition, of which three-quarters result from complications associated with mild to moderate malnutrition (Todd et al., 2005). In addition, about 70% of all childhood mortality in developing countries is due to five major conditions, for which malnutrition (even in mild form) increases the likelihood of mortality up to 56% (UNICEF et al., 2010). In order to address nutrition-related public health problems, ten high-impact, nutrition-specific interventions have been identified that, if taken as a package up to 90% coverage, could reduce wasting by 60%, including the management of SAM and MAM as two of the 10 interventions (Bhutta et al., 2013).

Children with uncomplicated SAM (WHZ below −3 SD cutoff and/or with mid upper arm circumference (MUAC) cutoff of 115 mm and/or with bilateral edema) and MAM children (WHZ between −2 and −3 or MUAC between 115 and 125 mm) may be treated in the community setting without requiring admission to a health facility. This process is referred to as Community based Management of Acute Malnutrition (CMAM) (Collins & Yates, 2003; Sphere Project, 2018) and consists of providing a child with special therapeutic foods, most commonly Ready-to-Use-Therapeutic Food (RUTF) or F75 and F100 milk-based diets, based on severity and a short course of basic oral medication to treat infections (WHO & UNICEF, 2009). According to the WHO recommendation, children with SAM are discharged as recovered from treatment when their weight-for-height/length is ≥–2 Z-score and they have had no edema for at least 2 weeks, or mid-upper-arm circumference is ≥125 mm and they have had no edema for at least 2 weeks. Children admitted with only bilateral pitting edema should be discharged from treatment based on whichever anthropometric indicator, mid-upper arm circumference or weight-for-height is routinely used in the local program (World Health Organization, 2013b). In the current Ethiopian CMAM program, the admission criteria for children age 6 months to 18 years are: W/H or W/L <70%, or MUAC <110 mm, or presence of bilateral pitting edema. The local national discharge criteria are: W/H ≥85% or WFH ≥−2 Z score for two consecutive weeks (14 days) and no odema for 14 days (if admitted with edema) and the second option is target weight gain for two consecutive visits and no edema for 14 days (if admitted with edema) (Ethiopian Federal Ministry of Health, 2007). CMAM programing was established to treat severely acutely malnourished (SAM) children in their communities without being admitted to a health facility (Collins & Yates, 2003; Bhutta et al., 2008) has been reported effective in terms of the three key performance indicators: recovery, default and death rate (Sphere Project, 2018).

In some research findings, the recovery rate has been reported above the Sphere Handbook (Sphere Project, 2018) minimum standards of >75% (Collins, 2007; Tekeste et al., 2012) but post-discharge relapse rates of acute malnutrition (severe and moderate) have been reported as high as 78% (69% for MAM and 9% for SAM) in Bangladesh (Banerjee, Hoq & Matin, 2016) 27% (10% SAM and 17% MAM) in Malawi (Chang et al., 2013) and 72.1% (34.6% SAM and 37.5% MAM) in Southern Ethiopia (Tadesse et al., 2018).

Children discharged after recovery needs to be followed longitudinally to assess improvement over time. The Ethiopian Federal Ministry of Health has recommended one to two months follow up (Ethiopian Federal Ministry of Health, 2007), but poor post-discharge follow up has been reported (Nyirenda & Belachew, 2010) and based on current findings from the literature (Stobaugh et al., 2019), it is plausible that acutely malnourished children who were discharged as recovered may be predisposed to develop acute malnutrition (either MAM or SAM) again after returning to the same household (HH) environment.

Despite emerging data, a gap continues to exist in the evidence base on the differences in acute malnutrition between children who have been treated using CMAM and those who have not. The objective of the current study was to compare the magnitude and factors associated with acute malnutrition between children following exit from CMAM compared with those who were never treated for acute malnutrition in South Gondar Zone of Amhara Region, Ethiopia.

Method and Materials

Result

Prevalence of acute malnutrition

Regarding child nutritional status, a significant difference was observed in the magnitude of acute malnutrition (MUAC < 12.5 cm) between the recovered (34.4%, 95% CI [30.9–38.0]) and the comparison groups (26.7%, 95% CI [23.5–30.2]) P = 0.002. From these, 12.0% of the recovered and 9.5% of the comparison group were SAM (MUAC < 11.5 cm). In addition, 66.9% (95% CI [63.3–70.4]) of children in the recovered and 58.3% (95% CI [54.5–61.9]) of children in the comparison group were stunted (HAZ < −2 SD) see (Table 3; Fig. 1).

Table 3:

Prevalence of acute malnutrition.

Indicators		Recovered		Comparison group		P value
		n (%)	95% CI	n (%)	95% CI
MUAC (cm)	Normal (≥12.5)	464 (65.6)	62.0–69.1	518 (73.3)	69.8–76.5	0.002
	Wasted (<12.5)	243 (34.4)	30.9–38.0	189 (26.7)	23.5–30.2
WHZ	Normal (≥−2SD)	484 (68.5)	64.9–71.9	542 (76.7)	73.4–79.7	<0.001
	Wasted <−2SD)	223 (31.5)	28.1–35.1	165 (23.3)	20.3–26.6
HAZ	Normal (≥−2SD)	234 (33.1)	29.6–36.7	295 (41.7)	38.1–45.5	0.001
	Stunted (<−2SD)	473 (66.9)	63.3–70.4	412 (58.3)	54.5–61.9
WAZ	Normal (≥−2SD)	345 (48.8)	45.1–52.6	430 (60.8)	57.1–64.4	<0.001
	Underweight (<−2SD)	362 (51.2)	47.4–54.9	277 (39.2)	35.6–42.9

DOI: 10.7717/peerj.8419/table-3

Note:

MUAC, mid upper arm circumference; WHZ, Weight for Height Z score; HAZ, Height for age Z score; WAZ, Weight for Age Z score.

Discussion

In the current study, the prevalence of acute malnutrition was higher in the recovered than the comparison group.

Some health and nutrition organizations have reported that recovery rates from malnutrition are above the Sphere (Sphere Project, 2018) minimum standard of >75% (Collins, 2007; Tekeste et al., 2012; Efrem et al., 2010) indicating good progress, but recovered children may still be in a state of heightened risk for acute malnutrition. One possible issue is lack of follow up intervention after discharge as recovered. The Ethiopian Federal Ministry of Health has recommended linking to a supplementary feeding program for another 4 months following exit from therapeutic programs (Ethiopian Federal Ministry of Health, 2007). But in the current study, none of the children were linked to supplementary feeding programs, so were likely at high risk of relapse. Studies have reported that children who were treated for 12 weeks after fulfilling discharge criteria had lower rates of SAM (Trehan et al., 2015), similarly children who continued supplementary feeding longer than the required time remained well-nourished over the subsequent year (Chang et al., 2013). An additional potential factor could be due to the changes in the eating habits of children. Children who were in the program receiving therapeutic food (ready to use therapeutic food (RUTF), F100, and/or F75) may not be willing to return to receiving family food as frequently as before admission to the program. In addition, these recovered children may go through repeated episodes of treatment with RUTF (WHO et al., 2007) and such increased consumption could lead them to have a modification of taste preference towards sweet or fatty foods (Rozin & Vollmecke, 1986). In addition, even though the long-term impact of consumption of RUTF on the gut microbiome of SAM children is not yet fully understood, there is some evidence that microbiota are easily manipulatable by dietary changes (Alcock, Maley & Aktipis, 2014) and this has been implicated as a causal factor of kwashiorkor (Smith et al., 2013).

Regarding the factors identified to be associated with acute malnutrition, eight variables (district of residence, sex of the child, prelacteal feeding, colostrum feeding, Vitamin A supplementation, child feces disposal practice, respondent age in years, and consumption of additional food during pregnancy/lactation) in the recovered group and seven variables (district of residence, sex of the child, colostrum feeding, HH food security status, home to health post distance, respondent hand washing practice, and birth interval) in the comparison groups were identified as predictors of acute malnutrition. Three of these predictors (district of residence, sex of the child, and colostrum feeding) were common in both groups.

In the current study, sex of the child was the factor associated with acute malnutrition. Male children both in the recovered and in the comparator group were more acutely malnourished than female children. This finding was in line with studies conducted in Malawi (Chang et al., 2013; Trehan et al., 2015), Sierra Leone (Amanda et al., 2015), Tanzania (Mgongo et al., 2017), Nigeria (Udoh & Amodu, 2016), Burkina Faso (Poda, Hsu & Chao, 2017) and Ethiopia (Demissie & Worku, 2013; Taye, Wolde & Seid, 2016). One possible factor could be the typical activities of boys in to be away from home performing tasks leading to missed meals. A recent study has also noted that boys health may be more influenced by environmental stressor and diarrhea (Kumi-Kyereme & Amo-Adjei, 2016).

District of residence was a factor associated with acute malnutrition both in the recovered and comparison groups. Other studies reporting that geographic variation was associated with acute malnutrition in Bangladesh in relation to Eastern vs. Southern district (Chowdhury et al., 2016) and in Sylhet vs. Dhaka division (Talukder, 2013) as well as in Zambia between Northern vs. Western provinces (Nzala et al., 2011). This could be linked to malaria transmission by geographic area (Gone et al., 2017), or The difference could also be related to child food preparation practice (as one third of mothers from Lay-Gaying vs. one 10th from Ebnat). A study in Afar region, Ethiopia found that children’s food wasn’t prepared separately from family food were more acutely malnourished (Seid, Seyoum & Mesfin, 2017).

Children both in the recovered and in the comparison groups who were not given colostrum were found more acutely malnourished than those who were given colostrum. This is because colostrum has all the essential nutrients and immunoglobulin that are important in disease prevention. The finding was in line with studies from India (Mishra et al., 2014) and Ethiopia (Bantamen, Belaynew & Dube, 2014). Practice of colostrum feeding may be related to maternal education/counseling on child nutrition/health as those who had good nutrition knowledge had better infant feeding practices (Guldan et al., 2000; Daba & Ersado, 2015) and to have more well-nourished children (Appoh & Krekling, 2005). The practice of EBF may also linked, as exclusively breast fed children were less acutely malnourished than their counterparts (Egata, Berhane & Worku, 2014; Awoke, Ayana & Gualu, 2016).

Children who were given prelacteal feeding were more acutely malnourished than those who were not. The finding echoes other reports from India (Mishra et al., 2014; Ambadekar & Zodpey, 2017), and Ethiopia (Demissie & Worku, 2013). Prelacteal feedings disrupts the feeding of colostrum, the practice of EBF, and increase likelihood of other foods being introduced before 6 months, as has been reported in Ethiopia and Vietnam (Tewabe et al., 2016; Qadri & Srivastav, 2017). This also results in enteric infections and environmental enteropathy due to consumption of unsafe water or liquids (Sanghvi, Mehta & Kumar, 2014).

The odds of relapse were higher among children not given high dose Vitamin A supplementation in the 6 months preceding the survey. This may indicate low receipt of, or access to nutrition services such as distribution of Vitamin A capsule and has also been noted in Hawassa, and Afar region, Ethiopia (Seid, Seyoum & Mesfin, 2017; Bisrat & Kulkarni, 2017). The protective role of Vitamin A in promoting and regulating activities in both the innate and adaptive immune system (Huang et al., 2018) enhancing immune function is the rationale for recommended supplementation every 6 months (World Health Organization, 2011).

International recommendations for pregnant and lactating women include at least one extra serving of food per day to meet extra caloric needs (WHO & UNICEF, 2003). The finding was in agreement with a study conducted in East Gojjam, Ethiopia describing more wasting among children whose mothers’ were not able to consume extra food during pregnancy (Awoke, Ayana & Gualu, 2016). Undernourished (BMI < 18.5) mothers are more likely to have undernourished children (Chowdhury et al., 2016; Ambadekar & Zodpey, 2017).

Safe child feces disposal is important in reducing diarrheal diseases and malnutrition, but in the current study, more acutely malnourished children were identified in HHs who reported practicing safe child feces disposal than in those who dispose in to open field/bush. A study in Zambia noted that children who always used latrine were more wasted than those whose feces was buried (Nzala et al., 2011). Yet a study in India reported that those children who utilize latrine were less acutely malnourished (Ambadekar & Zodpey, 2017). Authors in Indonesia reported that those who disposed of child stool safely had fewer episodes of diarrhea (Cronin et al., 2016). Availability of latrine facilities and/or assuming safe child feces disposal is therefore not a guarantee unless it is been practiced in an optimal condition.

Unsurprisingly, the odds of acute malnutrition among children in food insecure HHs were higher than in food secure HHs. The finding was in agreement with studies conducted in India (Burza et al., 2016), Nigeria (Ajao et al., 2010) and Ethiopia (Bisrat & Kulkarni, 2017) Acute malnutrition in food insecure HHs can also be linked to inadequate intake of diversified foods as studies have reported that consumption of low dietary diversity food (≤3 food groups) as being associated with acute malnutrition (Miskir et al., 2017; Dodos et al., 2018; Frozanfar et al., 2016). Other studies also pointed to the role of low socioeconomic status or monthly income in food insecurity (Appoh & Krekling, 2005; Frozanfar et al., 2016) which directly or indirectly reduces the HH purchasing power, and thus, reduces access to food.

Odds of acute malnutrition were higher among children whose mothers had practiced hand washing only after one or two of the key points compared to those who washed hands more frequently. The World Health Organization (WHO) recommends washing hands at four key time points: before eating, before preparing food, after defecation, and after disposal of child feces (WHO, UNICEF & USAID, 2015). Our finding are similar to other studies where caregivers who washed hands regularly were less likely to have acutely malnourished children (Bantamen, Belaynew & Dube, 2014; Ambadekar & Zodpey, 2017; Dodos et al., 2018). Hand washing reduces the risk of contamination by excreta and thereby transmission of pathogens (Brown, Cairncross & Ensink, 2013). One of the strength of this study is that this is the first cross-sectional study employing a comparative (control) group in Ethiopia to better understand if relapse rate differed following exit compared with non-treated cohorts. Despite standardization of anthropometric instruments, intensive training, and close supervisions, misclassification of children’s nutritional status due to measurement error is potentially a limitation. Children treated for SAM before could be considered as never treated due to caretakers recall bias and also their children immunization status. Inclusion of children attending for clinical services could overestimate the burden of wasting. In addition, HH food insecurity status may be underestimated, as the data collection time was in the harvest season (October 2017 to January 2018).

Conclusion and Recommendation

In the present study, recovered children were more at risk of acute malnutrition than the comparison group. Three variables, (district of residence, sex of the child and not feeding colostrum) were common predictors in the two groups. Understanding the factors associated with acute malnutrition may help improve in prevention and management of future post discharge relapse. Nutrition programs should invest in improving nutrition counseling and education, especially focusing on IYCF practices, as well as the hygienic practices to protect children against post-discharge relapse of acute malnutrition.

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