title: Diagnosis of undernutrition in the first 6 months of life in Enugu city, southeast Nigeria
Creators: name: Ezeofor, Ifeyinwa Obiageli
Publisher: name: University of Glasgow
Year: 2015
Subjects: subject: Malnutrition, infants (0 - 26 weeks old), screening, skinfolds, growth velocity, growth patterns, morbidity, growth charts, health staff, MUAC.

description: The World Health Organisation (WHO) recommends exclusive breastfeeding during the first six months of life for optimal growth. However, the rapid growth of early infancy is limited by undernutrition, and this has been assumed rare. Nonetheless, there has been reported evidence of this problem, particularly in infants with underlying disease. Identifying infants at the risk of undernutrition using growth charts is simple, quick, invaluable, but suggested ineffective. The possible cause is poor health staff understanding, application and interpretation of growth patterns in early infancy, particularly in developing countries. In Nigeria, little is known about patterns of growth, how growth velocity relate to nutritional status, standardised methods for assessing nutrition risk, and prevalence of undernutrition in infants younger than 6 months, particularly hospitalised infants. Therefore, this project based at the University of Nigeria Teaching Hospital (UNTH), Enugu, set out to answer the following research questions: 1) What is the prevalence of undernutrition in infants younger than 6 months, particularly hospitalised infants? 2) What are the implicated feeding patterns and medical conditions of these infants? 3) Can feeding information and growth patterns be used to predict undernutrition in these infants? 4) Is health staff use of growth patterns in identifying undernutrition in early infancy effective? Methods: Data were collected for the project’s three cross-sectional, observational studies. 1) Feeding information from birth to date of assessment was collected from mothers/carers of healthy infants attending the Infant Welfare Clinic (IWC) of the UNTH, Enugu. Their retrospective weight measurements at birth, 6 weeks, 3 months and 6 months were documented from their mother-held Road-to-Health (RTH) growth charts. 2) Feeding and growth information was collected from infants at admission (from birth to 26 weeks of age) to the Hospital Wards of the UNTH. These data were collected using a structured interviewer-administered questionnaire based on the Subjective Global Nutrition Assessment (SGNA); including anthropometric measures of weight, length, head circumference, mid-upper arm circumference, and skinfolds (triceps and subscapular). 3) Paediatric Health Staff were surveyed in two teaching hospitals and four government-controlled primary health facilities using a structured self-completion questionnaire to: - determine how growth charts are used to detect childhood undernutrition - determine the accuracy in plotting and rating/applying/interpreting weight gain patterns shown on the RTH and WHO growth charts for appropriate action - test the understanding of growth trajectories displayed on charts. Results: Infant Welfare Clinic Study: The retrospective weights of 411 healthy infants (0 – 26 weeks old) attending the IWC of the UNTH, Enugu was compiled and used to generate a reference to compare that of their hospitalised peers in the same hospital. There was a steady weight gain increase in the first half and slower gain in the latter half of first six months of life. During this period, the weight Z-scores distribution of the infants compared well to the WHO Child Growth Standards (WHO-CGS). Moreover, 5% of the infants had -2SD (CWG), setting the 5th percentile as slow weight gain threshold, the reference to compare the weight velocity of their hospitalised peers. Therefore, the data compiled from the IWC was transformed successfully into a dataset qualified as a norm for comparing the data collected from the hospitalised infants. However, suboptimal breastfeeding patterns were observed in the majority (391, 95%) of the infants at assessment. Hospital Ward Study: Assessment of growth was done in 210 infants admitted to the paediatric wards from birth to 6 months, of which 143 (80.6%) were younger than 3 months. These younger infants were most commonly admitted for respiratory tract disorders 39 (18.6%), while the older infants were most commonly admitted for sepsis 21 (10.0%). The least of the morbidities were diarrhoea/vomiting 10 (4.8%) and severe undernutrition 8 (3.8%). SGNA-rating showed that the majority (161, 76.7%) of the infants were at low risk for undernutrition. The mean CWG of the hospitalised infants from birth was low, with 23% of the infants recording weight gain since birth below the 5th percentile for slow weight gain. Around one quarter of the hospitalised infants recorded low anthropometric Z-scores of weight, CWG, length, BMI or MUAC. A reference for skinfolds for under-3-month-olds was not available in the WHO-CGS. On applying a reference developed using the infant Paediatric Yorkhill Malnutrition Screening Group’s UK data (iPYMS Reference), over one third of all the infants recorded low sum of skinfolds. Using crude MUAC measurements, two-thirds of the infants were moderately undernourished (&lt;115mm) and over a half severely undernourished (&lt;110mm), significantly (P&lt;0.0001) decreasing with increase in age of admission. The majority (184, 87.6%) of the infants was initially breastfed, however, only 43 (20.5%) of the infants were exclusively breastfed (breastfed without water or other liquids) at any age. Breastfeeding status was related to the reasons for admission and nutritional status: the mean weight change for exclusively breastfed infants was -0.6 Z-score as compared to -1.1 Z-score for partially breastfed infants. Health Staff Study: Of the 222 health staff that responded to the survey in 2 referral hospitals and 4 government-controlled primary health facilities in Enugu city, 78% were hospital-based, 55% nurses, 46% highly experienced. About a third of the respondents often plotted; 87.8% often interpreted growth charts; over a half often identified and treated undernutrition, 88.7% with confidence. However, low accuracy was observed in recognising slow weight gain, particularly with average size; and fast weight gain was also poorly recognised. The respondents were as likely to be as worried about a small infant growing fast as an average weight infant growing slowly. Growth trajectories were better understood and interpreted on the WHO than RTH chart format. Most correct responses came from the medical doctors and moderately experienced respondents. Conclusions: The growth of young Nigerian infants fit the WHO-CGS well and the SGNA-rated nutrition risk is low, but other measures suggest undernutrition in up to one third of the hospitalised infants. Moreover, faulty breastfeeding patterns were prevalent and need to be addressed in future studies involving this population. Furthermore, the ineffectiveness of health staff understanding, application and interpretation of growth trajectories displayed on growth charts as practical tools, suggests the need for training. © Ifeyinwa Obiageli Ezeofor 2015