Prevalence and seasonal variation of severe childhood protein calorie malnutrition in Khartoum : implication for brain function

Protein calorie malnutrition (PCM) is one of the most serious public health problems in the developing world, including Sudan. This condition was investigated through studies which examined three main areas: prevalence and seasonal variation, influencing demographic factors and impact on brain function with use of electroencephalogram (EEG) assessment before and after clinical and nutritional interventions. All 466 children admitted to the Khartoum Teaching Hospital and Ibn Oaf Children Emergency Hospital during July to September 2009 (the wet season) and during February to April 2010 (the dry season) were eligible for the study on the prevalence, seasonal variation and demographic factors influencing which influence the incidence of PCM. Questionnaires were employed to collect pertinent demographic, nutritional and anthropometric data. The impact of PCM on brain function were examined through a case-control study of 48 children admitted to the Ibn oaf Children Hospital in Khartoum between July 2011 to July 2012 (16 underweight, 16 with kwashiorkor, and 16 with marasmus), The data obtained were compared with those of 12 healthy and well-nourished children. EEGs, clinical and neuropsychological assessment were performed on admission and at two time points after discharge (week 4 and 12). The overall prevalence of PCM was 1.15%, and the distribution of marasmus, kwashiorkor and marasmic kwashiorkor 67.0, 23.0 and 10.0% respectively. Analysis of the 24-hour dietary recall revealed that the protein (p= 0.001), fat (p= 0.020), carbohydrates (p= 0.005) and energy (p=0.0028) consumption were statistically significantly lower than the recommended daily allowances. The coefficient of interaction between seasons and cofactors indicated that the wet season influenced significantly (p<0.0001) the incidence of PCM when the length of residence, paternal education, and sugar consumption were taken into consideration individually. In terms of demographic factors, mothers who delivered their first baby before they were 18 years old, mothers with a BMI of less than 18.5 Kg /m2 , a birth interval of less than 2 years, children aged 6-11 months (for marasmus), children aged 12-23 months (for kwashiorkor), children whose mid-upper arm circumference was less than 12.5cm and the number of children in a family were all highly associated with the incidence of PCM (p<0.001). Neuro-cognitive investigation of the children showed that 70.8% had abnormal EEG patterns and 50-70% neuropsychological abnormalities. However, after four weeks treatment, 84.4% of the protein calorie malnourished children exhibited normal EEG patterns. In conclusion, this study has revealed a high prevalence of PCM in Sudanese children with more cases during the wet season than the dry season. In addition, it has identified a number of predisposing demographic factors which must be addressed in order to help reduce the prevalence the disorder. Clinical and nutritional treatment of the children improved considerably clinical, neuropsychological and EEG outcomes. A more promising strategy to improve PCM outcomes may be to tackle the major risk factors for PCM: seasonality and demographic factors. It is envisaged that earlier intervention with the treatments would be beneficial. Future programmes should investigate the long-term impact of PCM on cognitive function including school performance. This study has generated important information about the prevalence of protein calorie malnutrition and pre-disposing socio-economic factors. Nevertheless it has some limitations. The main limitations are: first, there is potential recall bias among respondents answering questions relating to household food consumption, and events happening in the past, such as the child’s history of illness and breastfeeding patterns immediately after birth and then after. Second, information on some important confounding variables such as infection was not collected which could cause problems in interpreting the results. Third, the non-truly statement of the subjects regarding income which may cause bias was another limitation. Lastly, Lack of an address system limited follow-up with some patients. Overall, the findings have important implications for research policy and programme efforts towards improved growth monitoring and designing of interventions to mitigate protein calorie malnutrition and its determinants.