https://doi.org/10.22502/jlmc.v5i2.

145 Original Research Article

Nutritional Assessment of Under Five

Children Attending Pediatric Clinic in a
Tertiary Care Hospital in the Capital of Nepal
Uma Devi Chhetri,a,b Sujan Sayami,a,c Prabha Mainalia,c

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ABSTRACT:
Introduction: There has been a decreasing trend in malnutrition (stunting, wasting, and under-weight) in Nepal
from 2001 till 2016 according to Nepal demographic health survey 2016. We tried to study whether these national
survey data equally reflect the nutritional status of children visiting hospitals in the capital city of our country. The
objective of the study was to evaluate the nutritional status of children less than five years of age brought to a hospital
in Kathmandu. Methods: Anthropometric measurements (height/length and weight), other demographic details, and
morbidity of all children, six months to five years of age, visiting the hospital over the period of three months were
collected from the out-patient register. Height-for-age, weight-for-height, and weight-for-age were calculated and
expressed as standard deviation units as compared to the median of reference data taken from WHO Multicentre
Growth Reference Study Group (2007). Association between morbidity and various anthropometric values were
calculated. Results: A total of 424 children were included in the study. There were 2.1% severely stunted, 8% stunted,
2.8% tall, and 1.7% very tall children. Similarly, 6.4% were severely wasted, 14.4% wasted, 4.7% severely under-
weight, and 12.3% under-weight. The anthropometric values were significantly associated with morbidity (acute Vs
chronic) but not associated with whether they were from within Kathmandu or form outside, and individual morbidity.
Conclusion: Wasting and severe wasting in under five children from and nearby Kathmandu of Nepal is higher while
stunting and severe stunting is lower as compared to previous National reports.

Keywords: children • nutrition • nutritional status • stunting • underweight

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INTRODUCTION:
Good nutrition allows children to grow, years. Based on Nepal demographic health survey
develop, learn, play, participate, and contribute 2016, trends of nutritional status of children under
while malnutrition robs children of their futures five from 2001 to 2016 are: Stunting 57% in 2001
and leaves young lives hanging in the balance. The to 36% in 2016, wasting 11% in 2001 to 10% in
high rate of child under-nutrition in Nepal remains 2016, and underweight 43% in 2001 to 27% in
a major problem despite a steady decline in recent 2016. Anemic children decreased from 48% in
2006 to 46% in 2011.[1] We would like to study
___________________________________________________________________________________
whether these national survey data equally reflect
a - Consultant Pediatrics the nutritional status of children visiting hospitals in
b- Lumbini Medical college Teaching Hospital, Palpa, Nepal the capital city of our country, Nepal. The objective
c- Manmohan Memorial Hospital, Kathmandu, Nepal
of the study was to evaluate the nutritional status
Corresponding Author: of children less than five years of age brought to
Uma Devi Chhetri a hospital in Kathmandu. The secondary objective
e-mail: [email protected] was to analyze the relationship between nutritional
ORCID: https://orcid.org/0000-0002-7896-5393
status and several demographic factors.
How to cite this article:
Chhetri UD, Sayami S, Mainali P. Nutritional assessment of under METHODS:
five children attending pediatric clinic in a tertiary care hospital
in the capital of Nepal. Journal of Lumbini Medical College. It was a retrospective, observational, cross-
2017;5(2):49-53. doi: 10.22502/jlmc.v5i1.145. Epub: 2017 Dec 1.
___________________________________________________________________________________
Licensed under CC BY 4.0 International License
which permits use, distribution and reproduction in any
J. Lumbini. Med. Coll. Vol 5, No 2, July-Dec 2017 49 medium, provided the original work is properly cited.
 Chhetri UD. et al. Nutritional assessment of under five children

sectional, and analytical study done in pediatric clinic chronic depending on the diagnosis. Acute morbidity
of Manmohan Memorial Hospital in Kathmandu, included URTI, fever less than two weeks, chest
Nepal. Anthropometric measurements (height and infection less than two weeks, acute gastroenteritis
weight), other demographic details, and morbidity (AGE/dysentery). Chronic morbidity include fever
of all children from six months to five years were more than two weeks, recurrent cough (RAD/
collected from the out-patient register. Children with asthma) among other.
incomplete data were excluded. The study was done Descriptive statistics were presented in term
over the period of three months from 16th July 2016 of frequency and percentage. Chi-square test and
to 15th October 2016. The study was approved by the Fisher-exact test were applied as appropriate to
institutional review committee of the hospital. estimate the association between various factors with
Weight in kilogram (kg), length (for less normal or abnormal anthropometric values. P value
than two years) in centimeter (cm), or height (for less than 0.05 was consider statistically significant.
two years or above) in centimeter were measured
in standardized weighing scale (bathroom scale, RESULTS:
infant-meter or stadio-meter). The three indices: Four hundred twenty four children aged six
Height-for-age, weight-for-height, and weight- months to 60 months were included in the study.
for-age were expressed as standard deviation units There were 230 (54.2%) male and 194 (45.8%)
as compared to the median of reference data. The female. Abnormal height-for-age was found in
reference data was taken from WHO Multicentre 14.6% (n = 62), abnormal weight-for-height in 23.6%
Growth Reference Study Group (2007).[2] Data (n = 100) and abnormal weight-for-age in 19.8%
were entered into Microsoft Excel™ 2010 and then (n = 84). Relationship between gender and these
imported into SPSS™-17 (Statistical Package for three anthropometric values were not statistically
the Social Sciences, version 17). Data in SPSS were significant (For height-for-age Vs gender: X2[N
compared to the reference data using WHO Child =424, df=1] = 2.2, p = 0.12; for weight-for-height
Growth Standards SPSS Syntax File (igrowup.sps). Vs gender: X2[N=424, df=1] = 0.16, p = 0.69; for
[3] The syntax file produces sex- and age-specific weight-for-age Vs gender: X2[N=424, df=1] = 3.3, p
estimates for the prevalence of under/over nutrition = 0.07). Details of all the anthropometric values for
and summary statistics (mean and SD) of the z-scores both gender is enlisted in Table 1.
for each indicator. Three hundred sixty-six (86.8%) children
Children who fell below minus two standard were from Kathmandu valley and the rest 58
deviations (-2 SD) from the median of the reference (13.7%) from various 22 districts outside the valley.
population were regarded as malnourished, while Relationship between anthropometric values and
those below minus three standard deviations (-3 whether the children were from Kathmandu valley
SD) as severely malnourished. Height-for-age is a did not showed a significant difference (For height-
measure of linear growth. A child who fell below for-age Vs from-valley: X2[N=424, df=1] = 1.02, p
minus two standard deviations (-2 SD) for height- = 0.31; for weight-for-height Vs from-valley: X2[N
for-age was considered short for his or her age, or =424, df=1] = 0.01, p = 0.92; for weight-for-age Vs
stunted while below three standard deviations (SD) from-valley: X2[N=424, df=1] = 0.03, p = 0.86).
was considered severely stunted. Children above 2 Anthropometric values for acute and chronic
SD were considered tall and above 3 SD very tall. morbidity are presented in Table 2. There was a
Weight-for-height describes current nutritional significant association between all anthropometric
status. A child who was below minus two standard values and acute and chronic morbidity (For height-
deviations for weight-for-height was considered for-age Vs morbidity: X2[N=424, df=1] = 5.23, p
thin for his or her height, or wasted, a condition = 0.02; for weight-for-height Vs morbidity: X2[N
reflecting acute or recent nutritional deficits. A child =424, df=1] = 34, p <0.001; for weight-for-age Vs
who was below minus three standard deviations was morbidity: X2[N=424, df=1] = 21.65, p < 0.001).
considered very thin or severely wasted. Weight- Anthropometric values for several
for-age below -2 SD was considered underweight morbidities are presented in Table 3 . We applied Chi-
whereas below -3 SD severely underweight. If square test (or Fisher Exact ) to see the association
weight-for-age was more than +1 SD, we followed between them but found all of them to be statistically
weight-for-height-for-age chart.[4] insignificant (P value for each morbidity and each
Morbidity was classified as acute and anthropometric value were less than 0.05).

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 Chhetri UD. et al. Nutritional assessment of under five children

Table 1: Anthropometric values for both gender. (N = 424)

Height-for-age Weight-for-height Weight-for-age
Gender Female Male Female Male Female Male
n (%) n (%) n (%) n (%) n (%) n (%)
Very low (<-3 SD) 2 (1) 7 (3) 13 (6.7) 14 (6.1) 6 (3.1) 14 (6.1)
Low (< -2 SD) 8 (4.1) 26 (11.3) 27 (13.9) 34 (14.8) 22 (11.3) 30 (13)
Normal 171 (88.1) 191 (83) 150 (77.3) 174 (75.7) 163 (84) 177 (77)
High (>2 SD) 8 (4.1) 4 (1.7) 3 (1.5) 7 (3) 3 (1.5) 9 (3.9)
Very high (>3 SD) 5 (2.6) 2 (0.9) 1 (0.5) 1 (0.4) 0 0
Total 194 230 194 230 194 230

Table 2: Anthropometric measurement (normal or abnormal) for acute or chronic morbidity.

Height-for-age Weight-for-Height Weight-for-age Total
Morbidity Normal Abnormal Normal Abnormal Normal Abnormal
Acute, n (%) 287 (87.5) 41 (12.5) 272 (83) 56 (17) 279 (85) 49 (15) 328
Chronic, n (%) 75 (78.1) 21 (21.9) 52 (54.2) 44 (45.8) 61 (63.5) 35 (36.5) 96

Table 3: Percentage of children with normal and abnormal anthropometry with morbidities.
Height-for-age Weight-for-Height Weight-for-age
Morbidity Normal Abnormal Normal Abnormal Normal Abnormal
URTI 85.2 14.8 75.4 24.6 81.1 18.9
RAD 84.4 15.2 75.8 24.2 72.7 27.3
Pneumonia 72.2 27.8 94.4 5.6 83.3 16.7
AGE/dysentry 71.4 28.6 64.3 35.7 71.4 28.6
Anemia 92.3 7.7 69.2 30.8 84.6 15.4
Pain abdomen 92.3 7.7 92.3 7.7 84.6 15.4
PUO 76.9 23.1 76.9 23.1 76.9 23.1
Enteric. fever 90 10 100 0 100 0
UTI 100 0 88.9 11.1 100 0
Sepsis 85.7 14.3 85.7 14.3 71.4 28.6
Koch’s infection. 100 0 25 75 75 25
RAD = reactive airway disease, AGE = acute gastroenteritis, PUO = pyrexia of unknown origin, UTI = urinary tract infection.
URTI = Acute pharyngo-tonsillitis

DISCUSSION:
This study revealed that wasting and were wasted (male 14.8% and female 13.9%). These
severe wasting was higher in children under five as figures were little higher than reported in the Annual
compared to National health survey report, 2016.[1] report of Nepal 2016.[1] Similarly, these figures are
Africa and Asia bear the greatest share of all forms higher than the rate shown in other studies done
of malnutrition. More than two thirds of all wasted in Pokhara,[6] Dolakha,[7] Humla,[8] and Ilam[9]
children under five lived in Asia (69%) in 2016. but lower than the studies done in Kathmandu and
Thirty-five point nine million (9.9%) children under Eastern Terai.[10,11] The 14.39% population with
five in Asia are wasted of which 12.6 million are wasting in this study was slightly higher than 11%
severely wasted.[5] In our study, 6.37% were severely shown in the national data.[1] This prevalence
wasted (male 6.1% and female 6.7%) and 14.39% was comparable to 14.3% in Vietnam,[12] higher

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 Chhetri UD. et al. Nutritional assessment of under five children

than that of 11.1% in NW Ethiopia,[13] but lower Underweight under five population in the
than that of Ethiopia (16%),[14] and North West study was 12.3% and severe underweight were 4.7%.
Tanzania (17.8%).[15] Severely wasted population This was much lower compared to underweight
in this study was 6.36% which is higher than that in under five population in Terai region of Nepal: 27%
Philippines.[16] in Kapilbastu,[17] and 34% in eastern Terai.[11]
The findings revealed that stunting and Underweight under five population were lower in
severe stunting were lower in under five children as this study compared to studies in other countries
compared to National health survey report, 2016. In like Thailand (27.8%) and Ethiopia Tigray (37.4%).
2016, more than half of all stunted children under five [14,20]. But it was also similar to the prevalence in
lived in Asia (56%). Globally, stunting is declining NW Ethiopia (14.3%),[19] Bangkok (5.74%),[20]
too slowly. Stunted population in 2000 was 198.4 and Philippines (21.2%),[16].
million (32.7%) which decreased to 154 million Prevalence of anemia in the study was 3.06%
(22.9%) in 2016. In Asia, stunted children under five while the national data shows 46% for children
have decreased from 133.9 million (38.2%) to 86.5 between 6-59 months and 69% for children between
million (23.9%).[5] This study showed no statistical 6-23 months.[1] Anemic children slightly decreased
difference between nutritional status of children from 48% in 2006 to 46% in 2011. Though the rate of
living in Kathmandu valley and those from outside anemia was low in this study, the need of government
the valley. Very stunted population in the study level iron prophylaxis program for children should
was 2.1% (3% male and 1% female) and stunted not be underestimated.
population were 8% (11.3% male and 4.1% female). In this study, there was no statistical
Global estimates of stunted under five population significance between various anthropometric values
were 22.9% (154.8 million in 2016), 56% of whom with gender and with individual morbidity studied
resided in Asia.[ 5 The 8% prevalence of stunting in but there was significant association between acute
this study is lower than studies done in other parts and chronic conditions with weight-for-height (p <
of Nepal.[7,8,17,18]. These findings suggest that 0.001) and height-for-age (p < 0.001). Abnormal
children in the capital city have a better nutritional values tend to be more frequent among children
status compared to other parts of the country. Stunted with chronic conditions. This would suggest that
under five children in our study was much lower common chronic conditions are associated with the
compared to other areas of the world like Ethiopia nutritional status of children under five and these
(57.5),[19] Philippines (34%),[16] North Vietnam have to be identified and treated timely to improve
(29.8%),[13] NW Ethiopia (24.9%),[12] and quality of life of these children.
Thailand (19.9%).[20] This difference could be due
to inclusion of children from the capital, Kathmandu CONCLUSION:
and surrounding districts only. Wasting and severe wasting in under five
Overweight children are increasing at an children from and nearby Kathmandu, the capital of
alarming rate globally. Almost half of all overweight
Nepal, is higher while stunting and severe stunting
children under five lived in Asia (49%) and one
is lower as compared to previous National reports.
quarter lived in Africa (24%). Overweight population
Overweight and obesity are emerging. Anemia is
was 30.4 million (5%) in 2000, that increased to 40.4
still a common problems in children under five years
million (6%) in 2016.[5] This study also shows that
of age. Chronic morbidities are associated with poor
the number of overweight children are increasing.
Overweight and obese children in this study were nutritional status of under five children.
2.8% and zero respectively. This was low compared
to 6% (40.6 million) overweight children under
five globally.[5] A study in Thailand showed 8.3%
obesity and another study in NW Ethiopia showed Conflict of interest: None declared
35.5% overweight children under five.[12,20] A
study done in Ilam, Nepal showed 17.5% overweight
children in 2015.[18] This suggests that the problem
of overweight and obesity is comparatively less in Funding: None
and around Kathmandu compared to other places of
Nepal and different other countries.

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 Chhetri UD. et al. Nutritional assessment of under five children

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