Prevalence, level and factors associated with malnutrition in children under-five years of age and their parents’ awareness about children nutrition in Quetta city

Background: Malnutrition continues to be a major public health problem in developing countries. It is the most important risk factor for the burden of diseases. There was lack of information regarding the prevalence, level and factors associated with malnutrition among children of under-fi ve years of age from Baluchistan, Pakistan. Objective: Therefore, the current study was conducted to evaluate the prevalence, associated factors and parents’ awareness with malnutrition among children of under-fi ve years of age. Methods: This cross-sectional analytical study was carried out at Basic Health Unit (BHU), Nawa Killi, BHU Killi Deba, BHU Spini Road, Mubarak Chowk, Sheikh Zahid Hospital Quetta, Rehnuma Center Satellite Town Quetta. A self-developed validated questionnaire was used to evaluate the parents’ awareness regarding children nutrition status. The mean mid upper-arm circumference (MUAC) value of the children was used to categorize the children nutritional status. Children with MUAC value < 12 cm were classifi ed as malnourished, MUAC value =11-12 cm was considered as Moderate Acute Malnutrition (MAM) and, MUAC value < 11 cm was considered as Severely Acute Malnutrition (SAM). Data was analyzed by using Statistical Package for Social Sciences (SPSS version 20). Multivariate binary logistic regression was used to fi nd factors associated with the presence of malnutrition. A p-value <0.05 was considered statistically signifi cant. Results: A total of 205 children and their parents were included in the study. Majority of studied children were baby boys (60.4%) and belonged to the age group of 0-12 months (74.6%). Majority of the fathers of evaluated children were laborers (42%) and had a family monthly income of between 10000-20000 Pakistani Rupees. Majority of respondents were not well-known about the colostrum milk (63.9%), had not been informed or taught about nutrition (73.7%) and considered children vaccination necessary of disease prevention (91.7%), and had vaccinated their children (97.1%). prevalence of malnutrition in children who were not breastfed was 55.99 times higher than those who were breast fed (p-value <0.001, OR=55.99, 95%CI=13.524-231.842). Conclusion: The undernutrition in children is comparable to the national fi gures. Although our study found that absence of formal education, big family size, late and early weaning, absence of exclusive breast feeding and poverty were the factors associated with undernutrition in children, they could cause increase in under nutrition in future if not improved. Research Article Prevalence, level and factors associated with malnutrition in children under-fi ve years of age and their parents’ awareness about children nutrition in Quetta city Musa Bin Bashir1, Muqadim Sadiq2*, Mirwais Khan3, Asad Khan4, Adlin Ho5 and Syed Muhammad Younas2 cXian Jiaotong University, China 2Faculty of Pharmacy and Health Sciences, University of Balochistan, Quetta, Pakistan 3Balochistan Institute of Psychiatry, Quetta, Pakistan 4Bolan University of Medical & Health Sciences, Public university in Quetta, Pakistan 5Xi’an Jiao tong University School of Medicine, PR China Received: 03 May, 2021 Accepted: 31 May, 2021 Published: 05 June, 2021 *Corresponding author: Muqadim Sadiq, Faculty of Pharmacy and Health Sciences, University of Balochistan Quetta, Pakistan, Tel: 00923342318008; E-mail:


Results
presents the socio-demographic characteristics of the total 205 children and their parents included in the study. Mean age of the children included was, majority of them were baby boys (60.4%) and belonged to the age group of 0-12 months (74.6%). Majority of the fathers of evaluated children were laborers (42%) and had a family monthly income of between 10000-20000 Pakistani Rupees (PKR) (81%). Furthermore, majority of the interviewed parents of the children were uneducated (44.4%). Table 2 presents information about parents' awareness about children nutrition and caring practices. A total of 96.1% of the parents' interviewed were considering proper nutrition an important aspect of children life. Majority of them were not well-known about the colostrum milk (63.9%), had not been informed or taught about nutrition (73.7%) and considered

Introduction
Child undernutrition in all its forms is a global health concern [1]. Underweight, stunting and wasting are reported to be serious problems affecting developing countries [2].
Pediatric malnutrition is a major public health problem worldwide and globally a major contributive factor to nearly 45% of all mortality in childhood [3]. Malnutrition is a chronic and extensive situation, diffi cult to cope typical of developing countries [4]. On the other hand, it is usually a result of acute or chronic diseases in developed countries [5]. Assessment of pediatric malnutrition is based on objective anthropometric measurements such as Z-score, weight-for-height (wasting index), height-for-age (stunting index), weight-for-age (underweight index), and head circumference, body mass index, midupper arm circumference and skin fold thickness [6]. However it is diffi cult to determine malnutrition in childhood with a single index [7,8]. Recently, World Health Organization (WHO) recommended new growth standards for children under 5 years and attached more indicators (e.g. body mass index for age) to describe optimal early childhood growth [9]. In addition, several investigations have been performed for testing the WHO charts in different countries, which have showed disagreements in prevalence compared with existing standards, the WHO standards generally accepted for clinical assessment of malnutrition in children worldwide [10].
The National Nutrition Survey (NNS) conducted in Pakistan in 2011 demonstrated that the proportion of stunted and wasted children less than fi ve years of age was 43.7% and 15.1% respectively [11]. Pakistan has developed and implemented a number of programs in order to reduce child undernutrition such as infant and young child feeding, sanitation, deworming, vitamin A supplementation and health education [12]. Despite these programs, child undernutrition is still a challenge [13].
The prevalence of stunting, wasting and severe wasting in children less than fi ve years of age is 52.2%, 16% and 7% respectively in Baluchistan, which is the highest as compared to other provinces [14]. This paper presents recent status of malnutrition in children from Quetta City.

Methodology
Cross-sectional analytical design was adopted for the current study. A structured questionnaire was used to collect data about nutritional status of children and anthropometric measurements. The validation of this questionnaire was not done by any organization, but by self and fi eld experts as there were no such bodies with registered versions of such questionnaires. This study was carried out at different Basic Health Units of the City. All the children with age of less than fi ve years who were presented to the study sites for different treatment and vaccination purposes the parents of whom agreed to participate in the study by giving a written or oral consent were included in the study . The mean mid upperarm circumference (MUAC) value of the children was used to categorize the children nutritional status. Children with MUAC value < 12 cm were classifi ed as malnourished, MUAC value =11-12 cm was considered as Moderate Acute Malnutrition newborns should be breastfed right after birth and for initial two years of life respectively. Most of the parents (49.8%) replied that they do not know about the micronutrients essential for children health, only 88.3% parents replied that they wash hand before feeding the children and 48.3% thought that their child is malnourished.

Children
and their parents' sociodemographic characteristics were cross-tabulated against the nutritional status of the children. The results of the chi-square test revealed statistically signifi cant association between children age and the presence of malnutrition (p-value <0.001). Children of age between 0-12 months were comparatively more malnourished (34%) than those of age between 12.1-24 months (32.5%) and > 24 months. Children with a monthly family income of 10000-20000 PKR were signifi cantly (p-value <0.001) more malnourished (72.3%) than those with a monthly family income of >20000 PKR (20.5%). Similarly, the family size was also signifi cantly associated with the presence of malnutrition (p-value <0.001). The pr evalence of malnutrition increased from 28.5% in a family of less than fi ve persons to 75.6% in children having a family size of 6-10 persons. The chi-square test also revealed statistically signifi cant (p-value <0.001) association between the parents' source of income.

Discussion
The prevalence of malnutrition among children, right from birth up to 12 months of age, as most of subjects lay within the said range, is fi rst ever study conducted in a socioeconomically compromised province of Pakistan i.e. Baluchistan Quetta.
In this study some statistically attractive fi ndings were encountered. Socioeconomic status of the families and literacy rate of parents were two important dragging forces, as 81% of the parents of the subjects had a monthly income between 10000 to 20000 PKR and were lacking any sort of formal education. 62.4% of the children were malnourished.   Colostrum milk is most important for the child health because of having healthy constituents which helps in developing better immune system. Reason behind this is traditional norm in some areas of Baluchistan as they do not consider the colostrum milk clean milk so that's why they don't feed their child colostrum milk. Because they are not familiar to the advantages of the colostrums milk because of lack of awareness and education.
As data of my research also reveals that 73.3% of the parents haven't had any information or proper education about child nutrition which is considered as fundamental unit of life for every child. This is an alarming situation that our education system lacks providing information about the better nourishment of child. Furthermore, 59% of the parents had answered NO to a question that newborns should be breastfed right after birth and for initial two years of life respectively. This is also a major problem in increased prevalence of malnutrition in child's health because it is considered that a child should be fed with mothers' milk till two years as it helps in child's proper growth. Most of the parents (48.3%) replied that they don't think so that their child is malnourished though their children were in process of treatment for the malnutrition.
According to the results multivariate analysis, parents' income and way of breast feeding were major factors associated with malnutrition. The study revealed that 73.3% of parents who had malnourished children were not breastfed by their mothers. In the total population of interviewed samples only 17.5% were breastfed. A study in Ludhiana India found a signifi cant relationship in those children who were not breast fed in their fi rst 4 months were malnourished [17].
A stud y conducted in Kamaiyas city of Nepal also mentioned breast feeding a major factor which is cause of malnutrition in under fi ve-year-old children Eight percent of children did not receive colostrum which is produced in mother's milk right after birth of child [18,19].
The collected data also presents shocking results that most of malnourished child's were associated with families who had low income which was a great barrier in providing quality food to their children. It also reveals that 72.3% of parents had low income which was in between to 10k to 20 k and 20.5% were   [20,21].

Concl usion
The current study evaluated the prevalence and factors associated with malnutrition among children below fi ve years in multiple health centers of Quetta city. Furthermore, it also evaluated parents' awareness regarding children nutrition.
Parents' education regarding children nutrition particularly about breast milk and signifi cance of colostrum are suggested to improve the worse situation of children malnutrition.

Recommendations
Under nutrition prevention efforts should target the younger age groups and there is need to improve the immunization coverage because the immunization status of children is very poor. Supplementary feeding centers and fortifi ed food must be available on large scale for the community. There is a need to establish a nutrition surveillance system to monitor any progression of the nutritional situation.

Ethical consideration
This study was approved by Research and Ethic committee of Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta. The ap proval of this study was submitted with the research sites where they allowed the researchers to conduct study. Informed consent was also taken from the parents of the children.

Study limitation
Cross-sectional designs, enrollment of participants only in Quetta, non-probability sampling, lack of information of about micro-nutrients were the signifi cant limitations associated with the current study. A large multicenter study with the evaluation of micro-nutrients is recommended to confi rm fi ndings of the current study. (Appendix)