Bahri University

Faculty of Medicine
Community Medicine Department
:

PREVALENCE OF MALNUTRITION AMONG UNDER 5

YEARS CHILDREN AT AL DAMAZAIN TEACHING
HOSPITAL IN BLUE NILE REGION SUDAN MAY 2024

Proposal Submitted for partial fulfillment for requirement of

MBBS

SUBMITTED BY:
Tibyan Elzzaldin Ahmed Mohammed
Nwafil Abdallh Hassan Abalmajid

SUPERVISED BY :
Dr. HAMZA OMER HAMZA

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Table of Contents:

Contents Page Number

Title page 1
Chapter One
1.1 Introduction and Background 3
1.2 Proplem Statement 4
1.3 Justifications 4
1.4 Objectives 4
1.4.1General 4
1.4.2 specific 4

Chapter Two : Literature review 5

General
Specific
Chapter Three: Materials and Methods 7
3.1 Study design 8
3.2 Study area 8
3.3 Study period 8
3.4 study population 8
3.4.1 Inclusion criteria 8
3.4.2 Exclusion criteria 8
3.5 Sample size 9
3.6 Sampling Technique 10
3.7 Data collection methods and tools 10
3.9.1 Data analysis 10
3.9.2 Ethical considerations 10

Time frame 11
Budget 11
References 12
Appendices 15

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Chapter One
1.1Introduction and Background
Malnutrition continues to be one of the most common causes of morbidity and
mortality among children throughout the world contributing to one third of childhood
deaths (WHO1999 ).
It has been directly or indirectly linked to 60% of the 10.9million deaths annually
of children under five years old Malnutrition is defined as deficiency or excess of
nutrition consumption, encompassing under-nutrition and over-nutrition, contributing to a
significant portion of child deaths, with multifaceted causes at various levels.[1]

The main symptom of malnutrition is unintentional weight loss, but this is not always
obvious. decreased appetite or loss of appetite and drinking constantly feeling tired or
feeling weak frequent illness and long recovery period after injuries long recovery time,
extreme poverty , constant chills, bad mood, sadness and depression .
Malnutrition among under-five children in East Africa is prevalent, with stunting
affecting 34.7%, underweight 14.8%, and wasting 5.1%. Interventions targeting
education and socioeconomic status are crucial for improvement.[2]

According to NFHS-4, under-5 children about 27% are stunted, 20% are wasted and
24% are underweight in Tamil Nadu] WHO says, 45% of child deaths is associated
with under nutrition and 47 million children under 5 years are wasted. Under nutrition
among malnutrition has three factors ; underweight, stunting and wasting. malnutrition
can be detected by checking wasting (weight for height).[3]

1.3 Problem statement

There was an increase in the number of malnutrition cases in Al-Damazain Teaching

Hospital in the Blue Nile Region in the period from March, when the total number of
cases was 125, to April, when the number of cases exceeded 220 cases, by more than
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80%. als0 , malnutrition cases are increasing after war in Sudan and the incidence is
expected to increase due low socioeconomic status and lose of jobs and homes.

1.4 Justifications
Malnutrition is one of leading causes of death in pediatric and There is no available data
and researches that studied malnutrition specially in this region.

2. Objectives
2.1: General objective
To study Prevalence of Malnutrition Among Children Under 5 Years Old .
2.2: Specific Objectives
- To estimate the prevalence of stunting , wasting and underweight.
- To determine the important risk factors .
-To assess the impact of malnutrition on family and health system .
- To reflect the importance of malnutrition as a problem that the community and health
system to to use the findings on prevalence and contributing factors to design effective
programs to combat malnutrition in children under 5. This could involve strategies for

improving access to food, healthcare, or education.

Chapter Two : Literature review

General Literature review :.

Worldwide, malnutrition is common and is responsible directly or indirectly for about
a third of all deaths of children under 5 years of age. Primary malnutrition also continues
to occur in developed countries as a result of poverty, parental neglect or poor education.
Specific nutritional deficiencies, particularly of iron, remain common in developed

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countries. Restrictive diets may be iatrogenic as a result of exclusion diets or parental
food fads, or may be self-inflicted.
Malnutrition also occurs in 20–40% of children in specialist children’s hospitals. At
particular risk are those with chronic illness: e.g. the preterm, congenital heart
disease, malignant disease during chemotherapy or bone marrow transplantation, chronic
gastrointestinal conditions such as short gut syndrome following extensive bowel
resection or inflammatory bowel disease, chronic renal failure or cerebral palsy.
Malnutrition results from a combination of anorexia, malabsorption and increased energy
requirements because of infection or inflammation. Malnutrition in older children and
adolescents may also result from eating disorders. .[4]

Assessment of nutritional status

Malnutrition must be recognized and accurately defined for rational decisions to be
made a bout reefed ing. Evaluation is divided into assessment of past and present
dietary intake, anthropomorphic and laboratory assessments..[4]

Dietary assessment
Parents are asked to record the food the child eats during several days. This gives a
guide to food intake..[4]
Anthropometry
In addition to weight and height, skin fold thickness of the triceps reflects
subcutaneous fat stores and can be assessed by measuring it. While it is difficult to
measure skin fold thickness accurately in young children, mid upper arm
circumference, which is related to skeletal muscle mass, can be measured easily and
repeatedly and is independent of age in children 6 months to 6 years. It is especially
useful for screening children for malnutrition in the community ..[4]

Laboratory investigations
These are useful in the detection of early physiological adaptation to malnutrition, but
clinical history, examination and anthropometry are of greater value than any single
biochemical or immunological measurement..[4]

Consequences of malnutrition
Malnutrition is a multi system disorder. When severe, immunity is impaired, wound
healing is delayed and operative morbidity and mortality increased. Malnutrition
worsens the outcome of illness, e.g. respiratory muscle dysfunction may delay a child
being weaned from mechanical ventilation. Malnourished children are less active, less
exploratory and more apathetic. These behavioral abnormalities are rapidly reversed
with proper feeding, but prolonged and profound malnutrition can cause permanent delay
in intellectual development ..[4]

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 Marasmus and kwashiorkor
Globally, over one-third of childhood deaths are attributable to under nutrition,
which leaves the child susceptible and unable to survive common infections.
The World Health Organization recommends that nutritional status is expressed as
• Weight for height – a measure of wasting and an index of acute malnutrition .
Severe malnutrition is defined as a weight for height more than −3 standard deviations
below the median plotted on the WHO standard growth chart. This corresponds to a
weight for height <70% below the median.
• Mid upper-arm circumference (MUAC) – <115 mm is severe malnutrition
• Height for age – a measure of stunting and an index of chronic
malnutrition Severe protein-energy malnutrition in children usually leads to
marasmus, with a weight for height more than −3 standard deviations below the
median, corresponding to <70% weight for height, and a wasted, wizened
appearance . Oedema is not present. Skin fold thickness and mid-arm circumference are
markedly reduced, and affected children are often withdrawn and apathetic.
Kwashiorkor is another manifestation of severe protein malnutrition , in which there is
generalized oedema as well as severe wasting. Because of the oedema, the weight may
not be as severely reduced. In addition, there may be:
• a ‘flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation
• a distended abdomen and enlarged liver (usually due to fatty infiltration)
• angular stomatitis
• hair which is sparse and depigmented
• diarrhoea, hypothermia, bradycardia and hypotension
• low plasma albumin, potassium, glucose and magnesium. It is unclear why
some children with protein-energy malnutrition develop kwashiorkor and others
develop marasmus. Kwashiorkor is a feature of children reared in traditional,
polygamous societies, where infants are not weaned from the breast until about 12
months of age. The subsequent diet tends to be relatively high in starch. Kwashiorkor
often develops after an acute inter current infection, such as measles or gastroenteritis.
There is some evidence that kwashiorkor is a manifestation of primary protein deficiency
with energy intake relatively well maintained or, alternatively, that it results from
excess generation of free radicals..[4]

Management
Severe acute malnutrition has a high mortality; about 30% in children require hospital
care. In addition to protein and energy deficiency, there is electrolyte and mineral
deficiency (potassium, zinc, magnesium) as well as micro nutrient and vitamin
deficiency (vitamin A). Acute management includes:
• Hypoglycaemia – common; correct urgently, particularly if coma or severely ill.
• Hypothermia – wrap, especially at night.
• Dehydration – correct, but avoid being overzealous with intravenous fluids, as may
lead to heart failure. • Electrolytes – correct deficiencies, especially potassium.

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 • Infection – give antibiotics; fever and other signs may be absent. Treat oral
candida if present.
• Micro nutrients – give vitamin A and other vitamins
• Initiate feeding – small volumes, frequently,
including through the night. Children with no appetite or medical complications
need hospital care. Otherwise care can be community based. Although protein
deficient, diet is initially low in protein as high protein feeds are not tolerated. Too
rapid feeding may result in diarrhoea. Specialized feeds are widely available. Initially
Formula 75 (75 k cal/100 ml), subsequently Formula 100 (100 k cal/ 100 ml) or
Ready-to-Use Therapeutic Food (RUTF). During recovery phase, growth is monitored,
sensory stimulation should be provided and discharge preparation undertaken. .[4]

Specific literature review:

Malnutrition is a common disease in developing countries and remains a leading cause
of illness and death among children worldwide.
A 2016 cross-sectional study on the prevalence of malnutrition and associated factors
in children under five years of age in Sindh, Pakistan: a case study. 3964 children under
the age of five participated in the study and the results showed that the prevalence of
physical activity, stunting and wasting was 48.2% (95% CI: 47.1–50.3), 16.2% (95% CI:
15.5–17). showed that it was. and 39.5% (95% CI: 38.4-41.5), as well as food/nutrition
practices and good hygiene practices and household resources need to be addressed to
achieve malnutrition within the study area and within the country..[5]
In 2018, a cross-sectional household survey was conducted on the distribution and
identification of drug use among children under five years of age in rural areas of
Northern Sudan in four regions of the RNS. Using the Multistage Cluster model, 1635
children under 5 years of age participated. Among the 1447 children interviewed, the

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prevalence of stunting, wasting, and falls were 42.5%, 32.7%, and 21%. Growth
retardation was seen at the highest rate in the 48-60 month group (82.5%). Boys had
more indicators of malnutrition than girls. Among the Berbers, geography was quite
dominant. Infectious diseases (gastroenteritis and respiratory symptoms) and incomplete
vaccination were associated with dropouts (P = 0.007, P = 0.013, and P = 0.008). Poor
economic situation (P = 0.043), poor home hygiene (P = 0.022), large family size, lack of
family meetings and early breastfeeding of babies were evaluated as causes of
malnutrition. Improve children's health in this region..[6]
Additionally, an in-depth study of under-five malnutrition in Okrika, Nigeria, obtained
socio-demographic and nutritional history data from 410 selected child caregivers in
2019. 410 children were between 0 and 59 months old. 14 (10.5%) of the patients were
underweight, 56 (13.6%) were obese, 36 (8.8%) were obese and 6 (1.5%) were
overweight. No statistically significant difference was found between the prevalence of
weight gain, weight gain and weight loss in men and women under the age of five
(p>0.05). Foods that support their children's growth and development..[7]

Also in 2021, a population survey conducted in Debre Berhan city examined the
prevalence of malnutrition and associated factors in Ethiopia's children under five years
of age. Three hundred eighty-five children under the age of five, selected using a random
sampling technique, were included in this study. The overall prevalence of malnutrition
in children under 5 years of age across the sample was 61 (15.8%). Figures related to
overachievers were discontinued. and shots were 26%, 41% and 33%. Factors
contributing to under-five malnutrition include illiteracy, exclusive breastfeeding,
premature birth, lack of prenatal care, exposure to infectious diseases and diarrhoea. He
noted that Debre Berhan city has high rates of malnutrition (41%), wasting (33%), and
underweight (26%) compared to national (Ethiopian) or regional (Amhara) malnutrition.
Illiteracy, age of the child, exclusive breastfeeding, lack of ANC, exposure to diarrhea,
premature birth, lack of vaccination and lack of hand washing care were identified as risk
factors for under-five malnutrition. Education and training for parents on exclusive
breastfeeding, child care, and communicable disease prevention should be provided and
emphasized at the community level. An ANC program for all pregnant women should be

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promoted and implemented at all levels. Policymakers should pay more attention to
policies to reduce under-five malnutrition. , but because the study had a randomized
design, causal inferences cannot be made between the results and the independent
variables. It should be noted that errors in breastfeeding practice, nutritional differences,
and reporting of past childhood illnesses also hinder the reporting..[8]

Finslly, a study on the prevalence of malnutrition among older children in Kassala

State, Sudan, was conducted in 2021 and found that the prevalence of overall obesity and
obesity was 22.1% and 32.3%. It is a primary school study conducted among 3004
children. Of the 3004 children, were excluded, 366 (12.18%) due to chronic diseases or
missing data, the remaining 2638 (87.82%) were boys and girls with a mean age of 10.4
± 2.4 years: 1:1,2. Most were parents with a good social life; Only 13.2% of fathers had
good education compared to 8.0% of mothers; Family sizes ranged from 2 to 17 years
old and averaged 7 people. There are different rules in their families; 42.2% of them were
first or second in line in the family. Most of the children live in rural areas 1606
(60.9%). They used different water sources every day for drinking and feeding. They
receive 2-3 meals a day and 419 (15.88%) children do not eat anything at the school
table during the day. This study revealed the prevalence of various forms of malnutrition
among school children; this will provide basic information about school health in the
state. There is a need for increased attention from nutrition decision makers at this level
through improving school nutrition, improving the school environment, parent education,
and regular health screenings..[9]

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3. RESEARCH METHODOLOGY
3.1: Study design
A cross-sectional study will be conduct at Al damazin teaching hospital .
3.2: Study setting
Aldamazain Teaching Hospital is located in the Blue Nile State, in the middle of
Aldamazain city. It was established in 1965 with three departments: Internal Medicine,
Surgery, and Obstetrics and Gynecology. In the 1970s, a Pediatrics department was
added, and in the early 21st century, a Nutrition department was established. Currently,
the hospital has seven departments: Internal Medicine, Surgery, Obstetrics and
Gynecology, Pediatrics, Child Nutrition, Urology, and Ear, Nose, and Throat (ENT).
In 2021, Doctors Without Borders (MSF) joined the Nutrition department, which now has
5 wards and over 250 beds.

3.3 Study peroid

From 20 of April to 5 of may 2024

3.3: Study population

All malnutrition causes Under 5 years old at Aldamazain teaching hospital .

3.3.1: Inclusion criteria

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 Males and females Patients from 1 - 5 years whom admitted to the hospital for more
than 24 hours .

3.3.2: Exclusion criteria

Patients whom had secondary malnutrition due to chronic diseases and malignancy ,
in addition to people with communication difficulties

3.4: Sample size

Obtaining the Number of Malnutrition Cases in Aldamazain teaching hospital Using
Solvin's Formula : n = N/1+N×e^2
n: sample size
N = Population size = 220
e = Margin of error = 0.05
Sample Size = 141.94

3.5: Sampling techneqe

All the data will be collected by simple random sampling.

3.6: Data collection

3.6.1: Tool
Data will be collect from these patients using a questionnaire that provides some
information concerning the subject of our research.

3.7: Data analysis

Data will be analyze using a statistical package for social sciences (SPSS)

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4: Ethical considerations
The participation will be voluntary and under informed consent, with confidentiality
and the result will be communicated with the participants.

6: Study timetable
TASK days
1 2 3 4
Literature review
Pre-test
Data collection
Data entry
Data analysis
Draft report
Final draft

7: Budget
ITEM UNIT COST (SDP) BUDGET (SDP)
copying 10000 10000
TRANSPORTATION 5000 5000
Questionnaire 2000 2000
OTHERS 2000 2000

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8: References

1-Tariku, Laelago, Ersado., Tariku, Laelago, Ersado. Causes of Malnutrition. (2023).

doi: 10.5772/intechopen.104458
2-Ann-Marie, Raphail. Multilevel multivariate modeling on the association between
undernutrition indices of under-five children in East Africa countries: evidence from
recent demographic health survey (DHS) data. BMC Nutrition, (2023). doi:
10.1186/s40795-023-00741-w.
3-Naresh S, Maiya GR. A cross-sectional study to assess acute malnutrition among
under-5 children in the field practise area of a teaching hospital in Chennai. J Family Med
Prim Care. 2021 Jan;10(1):218-222. doi: 10.4103/jfmpc.jfmpc_1656_20. Epub 2021 Jan
30. PMID: 34017729; PMCID: PMC8132749.
4-APA. Lissauer, T. (2017). Illustrated textbook of paediatrics (5th ed.). Elsevier Science
5-Menghwar B, Laghari ZA, Memon SF, Warsi J, Shaikh SA, Baig NM. Prevalence of
malnutrition in children under five years' age in District Tharparkar Sindh, Pakistan. J
Pak Med Assoc. 2022 Jan;72(1):33-36. doi: 10.47391/JPMA.20-540. PMID: 35099434.
6-Sulaiman AA, Bushara SO, Elmadhoun WM, Noor SK, Abdelkarim M, Aldeen IN,
Osman MM, Almobarak AO, Awadalla H, Ahmed MH. Prevalence and determinants of
undernutrition among children under 5-year-old in rural areas: A cross-sectional survey
in North Sudan. J Family Med Prim Care. 2018 Jan-Feb;7(1):104-110. doi:
10.4103/jfmpc.jfmpc_73_17. PMID: 29915742; PMCID: PMC5958549.
7-Okari, T. G., Nte, A. R., & Frank-Briggs, A. I. (2019). Prevalence of malnutrition
among under-fives in Okrika Town, Nigeria. IOSR Journal of Dental and Medical
Sciences (IOSR-JDMS), 18(1), 40-45.

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8-Menalu MM, Bayleyegn AD, Tizazu MA, Amare NS. Assessment of Prevalence and
Factors Associated with Malnutrition Among Under-Five Children in Debre Berhan
Town, Ethiopia. Int J Gen Med. 2021 May 3;14:1683-1697. doi: 10.2147/IJGM.S307026.
PMID: 33976568; PMCID: PMC8104975.
9-Abu-Manga M, Al-Jawaldeh A, Qureshi AB, Ali AME, Pizzol D, Dureab F. Nutrition
Assessment of Under-Five Children in Sudan: Tracking the Achievement of the Global
Nutrition Targets. Children (Basel). 2021 May 1;8(5):363. doi: 10.3390/children8050363.
PMID: 34062925; PMCID: PMC8147258.

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 Questionnaire:
Will be conducted as a structured questionnaire with a close-ended and open question
and it will be authorized in three sections.

THIS QUESTIONNAIRE IS CONDUCTED BY MEDICAL STUDENT TO STUDY

THE PREVALENCE OF MALNUTRITION AMONG UNDER 5 YEARS CHILDREN
AT AL DAMAZAIN TEACHING HOSPITAL IN BLUE NILE REGION SUDAN MAY
2024

*it is voluntary to participate in this questionnaire and there is no need to write your name
so if you are willing to participate

Section 1:
Child’s Sex
Child’s Age
Mother’s age
Mother’s educational level
Socioeconomic status ( family income)
Family members

Section :
1. Has (name) ever been breastfed?
*yes
*no
*don’t know

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2. for how long has (name) been breastfed?

3. Did you give (name) the first milk that comes out of the breast (colostrum)?
*yes
*no
*don’t know
4. Is the breast milk the only source of food?
Yes
No.
If no,
When did (name) start other foods? Age in months
Is he/she still being breastfed?
What were the reasons for not breastfeeding?

5. Has (name) had repeated infections in the last two weeks ?

6.what types of symptoms would cause you to take your child to a health facility right
away?

7.has (name) ever been given any “vaccination drops in the mouth” To protect him/her
from getting diseases ?
*yes
*no
*don’t know
8. Has (name) ever received a vitamin a capsule (supplement) like this one?
*Yes
*No
*Don’t Know

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9. Does (name) attend any organized learning or early childhood education programme,
such as a private or government facility, including kindergarten or community child
care?
*Yes
*No
*Don’t Know

Section 3:
Anthropometry module
Child’s weight
Child’s length or height.
Child’s MUAC

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