Original Article Healthline Journal Volume 10 Issue 2 (July - December 2019)

Study on Prevalence of Protein Energy Malnutrition among Children of

3-6 Years of Age in the Study District
1 2
Malay Savalia , Sumit Unadkat
1
Resident Doctor, 2Associate Professor, Shree M. P. Shah Government Medical College, Jamnagar, Gujarat, India
Correspondence : Dr Sumit Unadkat, E mail: [email protected]

Abstract :
Introduction : Children are generally most vulnerable and least able to help themselves. Malnutrition in
its several forms of under nutrition has been coined as “silent emergency” by United Nations Children's Fund
(UNICEF). Rural area shows inequalities in distribution of beneficiaries in form of structure, performance
and pattern of economic growth. Objectives : To estimate prevalence of Protein Energy Malnutrition (PEM),
to find out association between various factors and prevalence of malnutrition and to assess various aspects
of feeding of child with prevalence of malnutrition in children of 3-6 years of age. Method : A community
based cross sectional study was conducted on 3-6 years old children of rural area of study district. Results :
Out of total 894 children, 27.96% children were underweight and 6.71% children were severely
underweight. Malnutrition was seen in 42.78% children amongst those who did not consume calories as per
Recommonded Dietary Allowarce (RDA). Conclusion : Protein energy malnutrition in form of underweight
was present in more than one third children. Higher prevalence of malnutrition was found in children who
had birth weight of less than 2.5 kilograms, having interpregnancy interval of less than 24 months, of birth
order of 4 or more, who were breastfed for a period of 6 to 12 months, to whom complementary feeding was
started before the age of 6 months or who were partially immunized.
Key words : Children of 3-6 years of age, Protein energy malnutrition, Underweight

Introduction : or a nation.[3, 4] Early childhood is a period of rapid

The hearts of most grown-ups melt at the sight of growth and that nutritional insults during this period
[5, 6]
small children who constitute one of the most result into under or over nutrition.
vulnerable sections of society. Children are our Malnutrition in its several forms of under
supreme assets because children of today form the nutrition, namely wasting, stunting and underweight
[1]
human resource of tomorrow. Children need extra has been coined as the “silent emergency” by the
[7]
care because these are generally the most vulnerable United Nations Children's Fund (UNICEF).
and least able to help themselves. Interventions early Malnutrition and infection are the two most
in life can thus have lifelong benefits not just for important factors that affect the growth of children.
[2]
individual but for society as a whole. Under nutrition is associated with impaired immune
It is now an established fact that the brain function and consequent increased susceptibility to
undergoes development and growth within the first infections; infections aggravate undernutrition; if this
five years of a child's life. Therefore, malnutrition of vicious cycle continues it can result in death of the
children under 5 years will surely lead to reduced child. Nutrition plays a key role in physical, mental
mental abilities affecting the intellectual capabilities and emotional development of children and much
of the children when they reach adulthood. It is well emphasis has been given to provide good nutrition to
recognised and documented that preschool children growing populations especially in the formative years
[8]
are a nutritionally vulnerable segment of population of life.
and their growth and nutritional status are useful and The subject gains more importance in rural
sensitive indicators for judging health of a community children, due to certain adverse realities like
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Savalia & Unadkat Prevalence of Protein Energy Malnutrition...

intake, frequent infections, lack of access to health • To find out association between various factors
services, illiteracy, unhygienic personal habits, and prevalence of malnutrition in children of 3-6
adverse cultural practices etc. Major factors which years of age.
modulate nutritional status during early childhood • To assess various aspects of feeding of child with
include birth weight, infant and young child feeding prevalence of malnutrition in children of 3-6
practices, morbidity due to infections, treatment of years of age.
infections, nutrition care during infection and
convalescence. Factors which are responsible for the Method :
higher prevalence of malnutrition comprise low birth Community based cross sectional study was
weight, maternal health problems, delay in conducted from August 2017 to August 2018.
introduction of complementary feeds, faulty child Present study was carried out on 3-6 years old
care and other poor environmental conditions which children of rural area of the study district. All the
[9]
are again more prevalent in rural areas. In children of 3-6 years of age group in the district were
association to neonatal and infant mortality and the target population. Sample size was calculated for
morbidity Low Birth Weight (LBW) is also associated the population of 157556 children as per Census
with growth retardation in children and development 2011 Data. Prevalence of malnutrition among under-
of chronic diseases such as diabetes mellitus, 5 children in rural area of the study district is 33.2%.
cardiovascular diseases and hypertension in adults. [10] [14]
With precision level of 4%, taking design effect of
Anthropometric assessment is widely used and often 1.5 and considering non-response rate around 10%
regarded as the best single measure for health and the final sample size was (n) ≈ 875 children of 3-6
nutritional status in children. [11] years.
Globally 52 million children under 5 years of age Two stage sampling technique was used. In first
are wasted, 17 million are severely wasted and 155 stage, from total 6 talukas of the study district, 35
million are stunted. Around 45% of deaths among villages were selected by cluster sampling technique.
children under-5 years of age are linked to In second stage, from total 35 villages, 25 children of
[12]
undernutrition. According to National Family 3-6 years of age group were selected after obtaining
Health Survey (NFHS) – 4, under-5 mortality in India list of all children in the age group of 3-6 years from
is 50 per 1000 live births, 38.4% children under 5 the anganwadi by simple random sampling
years of age are stunted, 21% are wasted, 7.5% are technique from each village. Thus total 875 children
[13]
severely wasted and 35.7% are underweight. were selected from the study district as samples.
Rural area shows inequalities in the distribution of Data were collected in a predesigned and
the beneficiaries in the form of structure, pretested proforma after getting consent from the
performance and pattern of economic growth. parents and the information was obtained from
Present study was undertaken on a socio-cultural and mother or primary care giver of child. Data collection
economically underprivileged group i.e. children of was divided in to interview schedule and
3-6 years of age of rural area aiming to estimate anthropometric measurements. Close ended
prevalence of Protein Energy Malnutrition (PEM) interview schedule was designed for the mother or
among them. Apart from prevalence attempts are the primary care taker of children.
made to identify relationship of birth outcome, socio
economic status, nutritional status, morbidity Weight, height and mid arm circumference were
pattern, immunization status and factors associated measured of all study subjects as anthropometry is
with those on prevalence of Protein Energy very sensitive and useful tool to measure nutritional
Malnutrition (PEM). status.

Objectives : Data entry was done in EPI INFO software. Z

scores were compared for weight for age using
• To estimate the prevalence of Protein Energy Microsoft Excel software. Data analysis was primarily
Malnutrition (PEM) in children of 3-6 years of age.
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 Healthline Journal Volume 10 Issue 2 (July - December 2019)

carried out in EPI INFO software. EPI INFO software Results :

and Microsoft Excel were used to create graphs for Table 1 shows that about two-fifth of 894 children
present study. Descriptive analysis was done for all
i.e. 363 (40.6%) were in the age group of 4-5 years,
predictor and outcome variables. Chi square test was
used to find association between predictor and followed by 309 (34.56%) in the age group of 3-4
outcome variables. years and 222 (24.83%) in the age group of 5-6 years.
Under nutrition is the outcome variable in the Observation also shows that out of 894 children 463
present study and it was calculated by parameter (51.79%) were males and 431 (48.21%) were
WAZ (weight for age). WHO growth standards were females.
used to define under nutrition. Weight-for-age is a
composite index of height-for-age and weight-for- Table 2 reveals that out of 894 children, 310
height. It takes into account both acute and chronic (34.68%) children were malnourished of whom 250
undernutrition. Children whose weight-for-age Z- (27.96%) were underweight while 60 (6.71%) were
score was below minus two standard deviations (-2
severely underweight. Sex wise distribution of
SD) from the median of the reference population
were classified as underweight. Children whose malnutrition was found to be somewhat higher in
weight-for-age Z-score was below minus three females (35.27%) than males (34.13%).
standard deviations (-3 SD) from the median were
considered severely underweight.

Table 1 : Age and sex wise distribution of children

Male Female Total

Age Group
No. % No. % No. %

3-4 years 157 33.91% 152 35.27% 309 34.56%

4-5 years 195 42.12% 168 38.98% 363 40.60%

5-6 years 111 23.97% 111 25.75% 222 24.83%

Total 463 100.00% 431 100.00% 894 100.00%

Table 2: Distribution of children according to their Weight for Age (Underweight)

Weight for Age Male Female Total

(Underweight) No. % No. % No. %

Normal 305 65.87% 279 64.73% 584 65.32%

≥-2SD
Underweight 135 29.16% 115 26.68% 250 27.96%
< -2SD and ≥-3SD
Severe underweight 23 4.97% 37 8.58% 60 6.71%
< -3SD
Total 463 100.00% 431 100.00% 894 100.00%

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Savalia & Unadkat Prevalence of Protein Energy Malnutrition...

Table 3: Association between consumption of calories as per recommended daily

allowance (RDA) and malnutrition in children
Consumption of calories as Normal PEM Total
per Recommended Daily
Allowance (RDA) No. % No. % No. %

Yes 279 77.29% 82 22.71% 361 100.00%

No 305 57.22% 228 42.78% 533 100.00%

Total 584 65.32% 310 34.68% 894 100.00%

Table 4: Association between various demographic variables and malnutrition in children

Variables Normal (%) PEM (%) Total (%) χ2 value p value

Social class
Upper 260 (73.03%) 96 (26.97%) 356 (100%)
15.522 0.000082
Lower 324 (60.22%) 214 (39.78%) 538 (100%)
Type of family
Nuclear 219 (62.93%) 129 (37.07%) 348 (100%)
4.171
Joint 215 (64.18%) 120 (35.82%) 335 (100%) 0.124

Three generation 150 (71.09%) 61 (28.91%) 211 (100%)

Overcrowding
Present 354 (61.78%) 219 (38.22%) 573 (100%) 8.85
0.00293
Absent 230 (71.65%) 91 (28.35%) 321 (100%)
Literacy status of mother
Illiterate 123 (58.29%) 88 (41.71%) 211 (100%) 6.027
0.0141
Literate 461 (67.5%) 222 (32.5%) 683 (100%)
Occupation of mother
Home maker 467 (67.88%) 221 (32.12%) 688 (100%)

Service 15 (88.24%) 2 (11.76%) 17 (100%)

Business 8 (80%) 2 (20%) 10 (100%) 20.975 0.00032

Labourer 35 (47.95%) 38 (52.05%) 73 (100%)

Agricultural 59 (55.66%) 47 (44.34%) 106 (100%)

According to table 3 prevalence of malnutrition was for their age in comparison to those children who were
higher (42.78%) in children who did not consume consuming calories as per RDA (22.71%). Observed
calories as per Recommended Daily Allowance (RDA) difference was statistically highly significant.
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 Healthline Journal Volume 10 Issue 2 (July - December 2019)

Table 5: Association between various indicators in children and PEM

Table 4 shows association between various children who dwelled in houses where there was no
demographic variables and malnutrition in children. overcrowding. Observed difference was statistically
The prevalence of malnutrition was higher i.e. 39.78% significant. Literacy status of mothers showed that
in children belonging to lower social class compared prevalence of malnutrition was high in children of
to children belonging to upper social class (26.97%). mothers who were illiterate i.e. 41.71%, while
Observed difference was statistically highly prevalence of malnutrition was less (32.5%) in children
significant. Prevalence of malnutrition was higher i.e. of mothers who were literate. Observed difference was
37.07% in children belonging to nuclear families, statistically significant. Prevalence of malnutrition was
followed by 35.82% and 28.91% in children higher among children of mothers who were labourers
belonging joint families and three generation families and involved in agricultural work (52.05% and 44.34%
respectively. Observed difference was statistically not respectively) as compared to those children whose
significant. Distribution of children according to type mothers were home maker (32.12%), doing business
of house revealed that prevalence of malnutrition was (20%) or doing service (11.76%). Observed difference
higher (38.22%) in children who dwelled in was statistically highly significant.
overcrowded houses, while it was lower (28.35%) in
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Savalia & Unadkat Prevalence of Protein Energy Malnutrition...

Table 5 shows association between various study. National Family Health Survey – 4 (2015-
variables related to children and malnutrition in 2016) reported that poor rich ratio was nearly 2.5 for
them. Prevalence of malnutrition was higher i.e. underweight category meaning lowest quintile
54.29% in children who had birth weight of less than group has 2.5 times more prevalence of underweight
2.5 kilograms, as compared to children (33.01%) (48.6%) compared to highest wealth quintile group
who had birth weight of more than 2.5 (20.1%). [15]The results of the present study were
kilograms.Observed difference was statistically slightly different from NFHS – 4. The reason behind
highly significant. In the present study, prevalence of higher number of children being malnourished
malnutrition was highest i.e. 46.08% in children belonging to nuclear families was lack of knowledge
having interpregnancy interval of less than 24 regarding proper feeding habits or working parents.
[16]
months followed by 42.58% and 28.4% in children Mahendraker et al (1996) found similar results in
having interpregnancy interval between 24 to 36 their study that morbidity in children was more
months and more than 36 months respectively. common in overcrowded houses than in non
Observed difference was statistically highly overcrowded house. A. Mittal and S. K. Ahluwalia
significant. The prevalence of malnutrition was high (2007) [17] in their study also found similar results of
i.e. 55.38% in children of birth order of 4 or more high prevalence of malnutrition in children of
followed by 38.53% and 32.63% in children of birth illiterate mothers (60.9%) as compared to children of
order 3 and 1 respectively. The prevalence of mother's education above high school level (21.2%).
[17]
malnutrition was lowest i.e. 31.76% in children of A. Mittal and J. Singh (2007) also found similar
birth order 2. Observed difference was statistically results of high prevalence among children of working
highly significant. Results also revealed that the mothers (46.15%) as compared with housewives
prevalence of malnutrition was 35% in children who (37.8%).
were breastfed for a period of 6 to 12 months as
M. Shafiqur Rahman et al. (2016) [18] found
compared to 34.93% and 23.81% children who were
similar results that the prevalence of malnutrition
breast fed for more than 12 months and less than 6
was high (56.2%) in children with low birth weight as
months respectively. Observed difference was
compared to children (38.1%) having normal birth
statistically not significant. Prevalence of [19]
weight. J. Lakshmi A and K. Begum (2003) in their
malnutrition was less in children to whom
study also found similar results of higher prevalence
complementary feeding was started at or after the
of malnutrition with higher birth order, it was found
age of 6 months (33.49%), whereas it was higher in
34% in birth order 1, 39% in birth order 2-3 and 56%
children to whom complementary feeding was
in birth order more than 4 or more. Victora CG et al.
started before the age of 6 months (50%). Observed
(1984) [20] in their study found that prevalence of
difference was statistically significant. Immunization
malnutrition was smallest in those children breast-
status of children showed that the prevalence of
fed for 3 to 6 months, but after this age nutritional
malnutrition was high in partially immunized
status appeared to be worse in those breast-fed for
children i.e. 72.34%, while it was 32.59% in fully
longer. The results were similar to the present study.
immunized children. Observed difference was
The reason behind more number of children found
statistically highly significant.
being malnourished who were breastfed for the
Discussion: period of 6 to 12 months and for more than 12
months was that proper complementary feeding was
According to National Family Health Survey
not initiated after the age of 6 months. Anita Khokhar
(NFHS) – 4, 35.7% children under 5 years of age were
and S. Singh (2003) [21] in their study also found
underweight and 11% children were severely
similar results that the prevalence of malnutrition
underweight. The results were similar to the present
was high in children weaning early (64.8%) as
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 Healthline Journal Volume 10 Issue 2 (July - December 2019)

compared to children breast feed exclusively up to six complementary feeding and also the quality and
[22]
months (35.2%). S. N. Dwivedi et al (1992) in their quantity of food that can be given after six months of
study found that immunized children experience less age. Health care providers like anganwadi workers,
malnutrition (57.0%) in comparison to ASHA and Female Health Workers need to be
unimmunized children (66.40%). sensitized time to time about infant and young child
feeding. Immunization protects against common
Conclusion:
vaccine preventable diseases and also has protective
Protein energy malnutrition in the form of effects over stunting. Routine immunization
underweight was present in more than one third coverage should be maintained at high level and
children, while some children suffered from severe services need to be strengthened. Regular growth
underweight. Prevalence of malnutrition was monitoring of each and every child by trained and
somewhat higher in female children than in male qualified health care providers is very essential for
children. Prevalence of malnutrition was highest in early detection in growth faltering. Monitoring
the age group of 5 to 6 years and lowest in the age activities for situation of malnutrition and factors
group of 4 to 5 years. Children who did not consume responsible for it at local levels should be
calories as per Recommended Daily Allowance (RDA) strengthened and supervised.
for their age showed higher prevalence of
Declaration:
malnutrition in comparison to those children who
were consuming calories as per RDA. Prevalence of Funding : Nil
malnutrition was more in children belonging to Conflict of Interest : Nil
social class I, belonging to nuclear families, who
dwelled in overcrowded houses, whose mother were References:
illiterate or of mothers who were labourer and 1. K. R. G. Nair. Malnourishment among Children in India: A
Regional Analysis. Economic and Political Weekly. 2007
engaged in agricultural work. Higher prevalence of September; 42(37): p. 3797-3803.
malnutrition was found in children who had birth 2. David Briggs. Making a Difference:Indicators to Improve
weight of less than 2.5 kilograms, having Children's. Imperial College London, Department of
Epidemiology and Public Health; 2003.
interpregnancy interval of less than 24 months, of
3. Assessing Child Malnutrition- Some Basic Issues(Sachdev).pdf
birth order of 4 or more, who were breastfed for a [Internet]. Google Docs. [cited 2019 Aug 27]. Available from:
period of 6 to 12 months, to whom complementary https://drive.google.com/file/d/1teO5FJAV93Ex3OC_SSOF4o
feeding was started before the age of 6 months or PoCVFrh4Sw/view?usp=sharing&usp=embed_facebook

who were partially immunized. 4. Bishnoi P, Sehgal S, Kwatra A, Chernysheva T, Gerasimenko T,

Apukhtina T. Anthropometric measurements of preschool
children as effected by socio-economic factors. :1.
Recommendations:
5. Sen PK. Nutritional status of under five children in an urban
Maternal education is positively related with slum community of Calcutta. Indian J Public Health. 1994 Sep;
38 (3) : 113–4.
child rearing practices and utilization of child health
6. De Onis M, Monteiro C, Akré J, Clugston GA. The Worldwide
services. So, female literacy should be improved for magnitude of protein-energy malnutrition : an overview from
promotion of child health, prevention of malnutrition the WHO Global Database on Child Growth. Bulletin of the World
and associated morbidities and better utilization of Health Organization 1993 ; 71(6) : 703-712 [Internet]. 1993
[ c i t e d 2 0 1 9 A u g 2 7 ] ; Ava i l a b l e f ro m : " h t t p s : / /
services. Mothers should be counselled regarding apps.who.int/iris/handle/10665/51422"https://apps.who.in
young child feeding practices like importance of t/iris/handle/10665/51422
colostrums, initiation of breast feeding, exclusive 7. Bellamy C. The State Of The World's Children. United Nations
Children's Fund (UNICEF), Executive Director; 1998.
breast feeding during antenatal period. Nutritional
8. A. Kumar et al. Nutritional status assessment of under-five
education and time to time counselling of mothers
beneficiaries of Integrated Child Development Services
should be done regarding initiation of
:: 20 ::
Savalia & Unadkat Prevalence of Protein Energy Malnutrition...

program in rural Karnataka. Australian Medical Journal. 2010; 16. Mahendraker et al. A study of medico social profile of under five
3(8): p. 495-498. children suffering from diarrhoeal disease. Indian Journal
9. Malnutrition: a South Asian enigma. | POPLINE.org [Internet]. Maternal and Child Health. 1991; 2(4): p. 127-130.
[cited 2019 Aug 27]. Available from: HYPERLINK 17. A. Mittal et al. Effect of Maternal Factors on Nutritional Status of
" h t t p s : / / w w w. p o p l i n e . o r g / n o d e / 2 7 4 0 8 3 " 1-5-Year-Old Children in Urban Slum Population. Indian Journal
https://www.popline.org/node/274083 of Community Medicine. 2007 October; 32(4): p. 264-267.
10. Tessa Wardlaw et al. Low Birthweight : Country, Regional and 18. M. Shafiqur Rahman et al. Association of Low-Birth Weight with
Global estmates. United Nations Children's Fund (UNICEF) and Malnutrition in Children under Five Years in Bangladesh: Do
World Health Organization (WHO); 2004. Mother's Education, Socio- Economic Status, and Birth Interval
11. M. De Onis. Measuring nutritional status in relation to mortality. Matter? PLOS ONE. 2016 June; 10.
Bulletin of the WHO. 2000: p. 1271-1274. 19. Jyothi Lakshmi A et al. Nutritional status of rural preschool
12. Malnutrition [Internet]. [cited 2019 Aug 27]. Available from: children - mediating factors. The Journal of Family Welfare.
HYPERLINK "https://www.who.int/news-room/fact- 2003 December; 49(2): p. 45-56.
sheets/detail/malnutrition" https://www.who.int/news- 20. Victora CG et al. Is prolonged breast-feeding associated with
room/fact-sheets/detail/malnutrition malnutrition? American Journal of Clinical Nutrition. 1984
13. National Family Health Survey 4 - India Fact Sheet. Mumbai: February; 39(2): p. 307-314.
International Institute for Population Sciences, Ministry of 21. Anita Khokhar et al. A study of malnutrition among children
Health and Family Welfare, Government of India; 2015-2016. aged 6 months to 2 years from a resettlement colony Delhi,
14. National Family Health Survey 4 - Jamnagar District Fact Sheet. Department of community medicine, VVCM & Safadarjang
Mumbai: International Institute for Population Sciences, Hospital. Indian Journal of Medical Sciences. 2003; 57(7): p.
Ministry of Health and Family Welfare, Government of India; 286-289.
2015-2016. 22. S. N. Dwivedi et al. Malnutrition among the children in an urban
15. National Family Health Survey (NFHS-4) 2015-16. Deonar, Indian slum and its associations. Indian Journal of Maternal and
Mumbai 400088: International Institute for Population Child Health. 1992 July-September; 3(3): p. 79-81.
Sciences; December 2017.

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