Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh

Summary of research¹

Location: Urban slum, Bangladesh

What we know already: Both severe acute malnutrition (wasting) and severe chronic malnutrition (stunting) are prevalent and co-exist in children. Routine screening and interventions offered at primary health care facilities typically prioritise identification and treatment of wasting.

What this study adds: Amongst children presenting to primary health care facilities in an urban slum, nearly one in 20 were severely wasted and one in 5 were severely stunted. Nearly half of the severely wasted children were also severely stunted. Routine screening for stunting as well as wasting, and adapted packages of care that consider socio-economic/food security as well as medical factors are needed to deal with this significant burden.

In order to generate crucial data on combined severe forms of malnutrition in the Bangladesh urban slum context, Médecins Sans Frontières (MSF) undertook a study to determine both the prevalence of severe acute malnutrition (SAM) and severe chronic malnutrition (SCM) among children aged 6-59 months presenting for medical care in the two MSF-supported primary health care facilities, and the extent of overlap between SAM and SCM in these children. This was a retrospective study using routinely collected facility-based programme data.

Dhaka, the capital city, is host to over 13 million people. The study focused on the sub-district, Kamrangirchar, to the west of Dhaka City, with a surface area of 3.68 km² on the bank of the Buriganga River and home to an estimated population of 400,000. The majority of the population are migrants. Kamrangirchar provides a temporary abode for this population, as the cost of living is cheaper than in the other slums of Dhaka. Kamrangirchar is divided into nine wards and 39 villages. In a population-based survey in Kamrangirchar in 2011, the prevalence of SCM was 22.7% (95% confidence interval [CI] 19.7- 25.7) whereas that of SAM was 2.2% (95% CI 1.3-3.1; unpublished data, MSF Bangladesh).

The MSF project in Kamrangirchar started its activity in 2010, providing primary health care (PHC) services for children <5 years of age. The health services are provided free of charge through two clinics. Since the beginning of the project, over 1000 paediatric consultations per month have been conducted in these health facilities. All children attending the PHC clinics for curative or preventive care are screened for SAM by evaluation of height, weight and mid-upper arm circumference (MUAC). Anthropometric measurements and data on age and sex are recorded in a register. Children found to have SAM without complications and MAM with medical complications are admitted to the ambulatory therapeutic feeding centre. To address medical complications, children are admitted to an in-patient therapeutic feeding centre in an assigned private hospital. No routine screening for SCM is done at the PHC clinics.

Study method

All children aged 6-59 months who attended an MSF PHC with any ailment for the first time from April to September 2011 were eligible for inclusion in the study. Weight for height and height for age Z-scores were calculated using the 2006 WHO growth standard charts. Children were classified by presence or absence of SAM and/or SCM. Prevalence of SAM and SCM was compared by age group and sex. The ?2 test was used to compare differences in proportions. P < 0.05 was taken as statistically significant. Risk ratios (RR) and corresponding 95% CIs were calculated where differences were statistically significant.

Findings

During the study period, 7481 children meeting the inclusion criteria presented for care at the two MSF supported health facilities. All records were reviewed. Of these, 163 children (2%) were excluded as one or more anthropometric measurements were missing. Among the remaining 7318 patients, 52% were males, 25% were aged between 6 and 12 months, 27% were aged between 12 and 24 months and half were aged between 24 and 59 months Of the children who sought care, 322 (4%) had SAM, 1698 (23%) had SCM .and 176 (2%) had both SAM and SCM. There was no significant association of age or sex with SAM. The proportion of children with SCM was higher among males than females (RR 1.7, 95% CI 1.5-1.8) and the prevalence was significantly different between age groups, with the highest prevalence in those aged 13-24 months compared with those aged 6-12 months (RR 1.8, 95% CI 1.6-2.0).

Nearly half of the children with SAM (n=322) also had SCM, as compared with only one fifth of those without SAM (RR 3.4, 95% CI 2.7- 4.1). The proportion of children with both SAM and SCM was higher among children aged ?24 months compared to those aged >24 months (RR 1.6, 95% CI 1.1-2.3). This overlap was not associated with sex.

Discussion and conclusions

This first report on the extent of overlap between SAM and SCM in children in an urban slum setting in Bangladesh indicates a high prevalence of SCM among children with SAM. These data confirm other findings. Among children attending a basic health unit situated in another Asian slum, in Pakistan, about 6.4% had SAM (severe wasting) and 43.6% had severe stunting. The extent of overlap in this study (nearly half of SAM children had SCM) is greater than observed in n a study from a rural PHC in India, where 29% of children accompanied by their mothers presented with both wasting and stunting (<-2 Z scores). Similarly, in the Paediatric Department of the Civil Hospital of Pakistan, 42% of admitted SAM children were identified with SCM.

This study represents a first step in offering an adapted package of care to children suffering from SAM and SCM co-morbidity in a Bangladesh urban slum. The results of the study have a number of policy and management implications for slums and other similar settings.

First, large numbers of children in slum-based health facilities have SCM. Despite the acknowledged relatively high risk of having concurrent SAM, and its adverse consequences among these children, the presence of SCM is not routinely assessed in such health care services. The affected children had a treatable condition that, if undetected, would lead to chronic and irreversible health problems. The failure to identify and manage SCM at this stage represents a clearly missed opportunity for prevention of childhood morbidity and mortality.

Second, a large proportion of children with SAM require additional management for SCM. Management of these children under the current nutrition rehabilitation programme focuses predominantly on nutritional support of acute malnutrition, which urgently needs to be assessed for its adequacy in ensuring survival in these children in the long term.

Third, there appear to be substantial proportions of children with both SAM and SCM in this urban slum of Bangladesh, indicating a period of insecurity of quality food locally among these children. A joint survey in 2009 by UNICEF, the World Food Programme and the Institute of Public Health Nutrition also revealed that severe malnutrition in Bangladesh is associated with food insecurity due to increases in food prices. Management of SCM requires recognition and correction of both medical and other socio-economic problems. If these problems are not addressed, the child is unlikely to improve and may relapse.

In conclusion, this study shows that among children presenting to the health facilities in an urban slum in Bangladesh, nearly one in every 20 children had SAM and one in five had SCM; half of the children with SAM also had SCM. There is an urgent need to prioritise SCM in addition to SAM, and to develop effective interventions aiming to improve the overall nutritional status of children in such contexts in Bangladesh.

¹Shams. Z et al (2012). Severe malnutrition in children presenting to health facilities in an urban slum in Bangladesh. Health solutions for the poor. Vol 2 No 4. Published 21 December 2012. http://dx.doi.org/10.5588/pha.12.0039