www.idosr.org
©IDOSR PUBLICATIONS
International Digital Organization for Scientific Research
Kumbowi et al
ISSN: 2579-0781
IDOSR JOURNAL OF EXPERIMENTAL SCIENCES 8(1) 72-81, 2022. Prevalence of Under Nutrition among HIV-Exposed Uninfected Children
Aged 6 to 18 Months in Bushenyi District
ABSTRACT
Under nutrition and poor feeding practices during early childhood affects the quality of life, astheyareassociatedwithcognitiveimpairment,poormotordevelopment,and anincreased risk of morbidity and mortality. HIV-exposed children are vulnerable to under nutrition. Knowledge of feeding practices, prevalence and factors associated with under nutrition among HIV-exposed uninfected children remains the mainstay to elaborate efficient strategies, which can help to reduce the burden of under nutrition among this vulnerable group This was a cross sectional, descriptive and analytical study to determine the prevalence,feedingpracticesandfactorsassociatedwithundernutritionamongHIV-exposed uninfected children aged 6 to 18 months in Bushenyi District, Uganda. The study involved 245 mother-child pairs in four antiretroviral treatment clinics from May to June 2021. Questionnaire interviews were used to obtain socio-demographic, medical, and dietary factorsdata.A digital weighingscale, stadiometerand mid-upper-armcircumference (MUAC) tapewereusedtomeasurebodyweight,length,andMUACofparticipantsrespectively.Under nutrition was defined by either a length-for-age or a weight-for-length or a weight-for-age below -2 SD of the 2006 World Health Organization growth standards for stunting, wasting andunderweight respectively. Data wereenteredandanalyzed using IBMSPSS 27.0statistics for windows. The prevalence of under nutrition and feeding practices indicators were determinedasproportions,whereasbinarylogisticregression was usedtodeterminefactors associated with under nutrition. A p-value <0.05 was considered for statistical significance at multivariable level.Of the 245 participants, 43(17.6%) had under nutrition The prevalence of stunting, wasting and underweight was 11%, 5.3% and 6.5% respectively. Most study participants 235(95.9%) were initiated on breastfeeding during their first hour of life, and 215(87.8%) were exclusively breastfed for 6 months. However, 93(38%) of study participant did not receive an acceptable meal frequency and 188 (76.7%) did not have an acceptable dietary diversity score during the last 24 hours. The prevalence of under nutrition among HIV-exposed uninfected children (6-18 months) in Bushenyi district was relatively low.
Keywords: prevalence, under nutrition, HIV, children, 6-8 months, Uganda.
INTRODUCTION
Under nutrition was first described as a clinical entity since 1930s. Cecily Williams identified a disorder marked by diarrhoea, irritability, changes in skin and hair, and swelling of the hands and feet in African childrenagedsixmonthstofouryears.She first published it under the heading “deficiency diseases”, then “nutritional disease”, “kwashiorkor”, and "malnutrition” [1].Others had reported the symptoms of malnutrition in tropical Africa before Cecily Williams, but she was the first to unite them into a clinical entity
based on aetiological considerations. Kwashiorkor, the most serious and widespread nutritional disorder with a high mortality rate in 1952, was the most serious and widespread nutritional disorder. In many locations, up to half of thechildrenwereunlikelytosurvivetothe age of five years [1]
There is a strong link between HIV and malnutrition [2]. Severe wasting described as ‘slim disease’ was among the first recognizedsymptomsofHIVinfectionand
was first described in Africa in the early 1980s [3]
HIV-exposed uninfected children have been shown to have a higher risk of malnutrition in various studies [4]. The prevalence of under nutrition among HIVexposed children has been reported to be high in most African countries [5; 6]. The global burden of under nutrition and its
Study design
associated determinants among HIVexposed uninfected children remains unknown or underreported including in Uganda.
The study was done to determine the prevalence of under nutrition among HIVexposed uninfected children aged 6 to 18 months in Bushenyi District.
3. METHODOLOGY
This was a health facility-based cross sectional, descriptive andanalyticalstudy, aiming to determine the prevalence, feeding practices and factors associated with undernutrition among HIV-exposed uninfectedchildrenaged6to18monthsin Bushenyi District. A cross- sectional study enables the researcher to collect all the required dataatapoint. Itis rapid andcan measure both exposure and disease outcome simultaneously.
Study site
The research was carried out in four randomly chosen ART centers in Bushenyi district including Kampala International University-Teaching Hospital, Ishaka Adventist Hospital, Comboni Hospital, and Kyabugimbi HC IV.
Target population
Children aged between 6 months to 18 months. The lower limit of 6 months has been chosen because children below 6 months are supposed to be exclusively breastfed, therefore other components of feeding practices assessment considered inthisstudy wouldnot apply to them. The upper limit of 18 months was considered becauseitrepresentsthetimeforexitfrom EMTCT program in most centres.
Eligible population
AllHIV-exposeduninfectedchildrenaged6 to 18 months attending ART Clinic in any of the selected sites (KIU-TH, Ishaka Adventist Hospital, Comboni Hospital and KyabugimbiHealthCenterIV) wereeligible for the study.
Study population
All mother-child pairs, whose child was uninfectedbutexposedtoHIVinuteroand aged 6 to 18 months, attending the four selected ART centres in Bushenyi district.
Study duration
Thisstudywascarriedoutoveraperiodof two months (May to June 2021).
Participants were enrolled during special appointment with HIV-positive mothers at ART clinics.
Sample size determination
For the objective number one, the sample size was calculated using [7]: �� = ��2��(1 ��) ��2
n: Estimated minimum sample size required p: Proportion of a characteristic in a sample e: The acceptable Margin of error set a 5%. z: 1.96 (for 95% confidence interval). In a cross-sectional study done in Tororo District Hospital by [8], the prevalence of under nutrition among HIV-exposed uninfected children was 20%. �� = (1.96)2 ×0.2×(1 0.2) (0.05)2 = 245
For associated factors, the sample size has been calculated using the method for calculating sample size for two proportions: �� = (��1 +��2)22��(1 ��) (��2 ��1)2 And, �� = (��1 +��2) 2 Where; Z1: Z value at 95% level of significance = 1.96, Z2: Z value at 80% power = 0.84, P1: proportion of under nutrition in male childrenP2 isproportionofundernutrition in female children
InalongitudinalstudydoneinRwanda[9], sexwasapredictorof undernutrition with more males being malnourished (30.3%) compared to female babies (11.0%).
P1 isproportionofunderweightmale=30.3 %= 0.3
P2 isproportionofunderweightfemale=11 %= 0.1 �� = (��1 +��2) 2 = 03+01 2 =0.2 �� = (��1 +��2)22��(1 ��) (��2 ��1)2 = (196+086)2 ×2×02×(1 02) (03 01)2 =64
2�� =2×64=128
The sample size calculated using associatedfactors(128)issmallerthanthe one based on prevalence (245). Therefore, the larger sample size (245) was used.
Inclusion criteria
AllHIV-exposeduninfectedchildrenaged6 to 18 months-mother pairs attending the four selected ART centres in Bushenyi district were included in this study.
Exclusion criteria
Children with congenital anomalies that would interfere with study procedures such as anthropometry measurement or interpretation including cerebral palsy or metabolic disorders were excluded from the study.
Sampling technique
Bushenyi district has a total of 15 ART clinics providing eMTCT services. According to the health district records (March 2021), the total number of HIVexposed children was 1219 across the different ART centers (Appendix VII).
Using OpenEpi random numbers (www.openepi.com: Accessed on March 2021) a randomization sequence of the ART has been generated and four ART clinics were selected. These include KIUTH, Ishaka Adventist Hospital, Comboni Hospital and Kyabugimbi HC IV. The number of participants to be recruited fromeachARTclinicwasdeterminedusing proportionatesamplinginaccordancewith the total population of HIV-exposed uninfected children registered at the ART centre (Appendix VIII). The sample size enrolledineachARTclinicwasdetermined using the stratified sample formula:
ni : Number of participants to be enrol in each ART
n: Population size of each ART
N: Population size of all selected ARTs
Ni: Total sample size
Participants were enrolled consecutively until the required sample size in each ART clinic was achieved.
Data collection instruments
Data relative to sociodemographic characteristics, medical factors and feeding practices were captured using a pre-tested and standardized questionnaire written in English and the local language (Runyankole). Each questionnaire had a total of 35 questions (variables) grouped into five sections including child sociodemographic data, mother’s sociodemographic data, medical data, feeding practices, and anthropometry. Medical records of both the mother and child were checked to extract information relativetodateofbirth,child’sPCRresult, and maternal viral load. Body weight was measured using a digital weighing scale (Seca 869, GMBH&Co, designed in German and made in China 874.1021658, maximum capacity 150 Kg; d=0.1Kg).); and an infantometer was used for measuring length. The Mid-Upper Arm Circumference (MUAC) was assessed using a nonstretchable tape specifically designed for this purpose by UNICEF. To minimize errors in measurements, the weight, length,andMUACweretakenatleasttwice. The child’s weight and length measurementswereenteredintotheonline WHO Child Growth Standards calculator which generated the weight-for-length, length-for-age and weight-for-age Z-scores (https://www.infantchart.com.php, accessed from 6th to 8th July 2021) which were then compared to the WHO growth chart (Appendix IV).
Data collection
Data was collected during special appointmentswithHIV-positivemothersat ART clinics. Mothers were contacted at least three days prior to the appointment via phone calls or home visit by a nurse attached to ART clinics, and were
requested to come with their children
Data was collected by the principal investigator and trained research assistants. A unique study number was assigned to each participant to avoid duplication. Interviews, physical examination, and anthropometric measurements were taken in a separate room from other clients to maintain privacy and confidentiality. HIV-positive mothers were asked to give written informedconsenttoanswerastandardised questionnaire about socio-demographic factors, medical factors and feeding practices. The medical records of both the mother and child were accessed by the principal investigator to exclude all HIVexposed infected children basing on the latest Polymerase Chain Reaction (PCR) results, and to complete information such as maternal viral load, after obtaining a special clearance from the Bushenyi DistrictHealthOfficerandthe In-chargeof the hospital. The following information was collected.
Data management
Data from completed questionnaires was organized, summarized and entered using International Busienss Machines Statistical Package for Social Sciences (IBM SPSS) 27.0 statistics for windows (Armonk. NY: IBM Corp). The data was cleaned, checked for errors and corrected, then analysed. The information was stored on a password protectedcomputerandwasaccessedonly by the principal investigations.
Data analysis
Data was analyzed using IBM SPSS 27.0 statistics for windows (Armonk. NY: IBM Corp).
Ethical considerations
Institutional
consent
Ethical approval was sought from the research ethics committee (REC) of Kampala International University, Western Campus (Ref: KIU-2021-13). The study was
registered with Uganda National Council for Science and Technology. Permission to execute the study was obtained from Health District Officer of Bushenyi and Health facility In-charges.
Privacy and confidentiality Privacyof participants wasensuredduring data collection by assessing them in different room and limiting access to their personal information. All questionnaires did not have provisions for participant’s names.Theinterviewswereconductedina separate room to ensure privacy of participants. Completed questionnaires werekeptunderlockandkey,anddatawas passwordprotected;onlyaccessiblebythe principal investigator.
Informed consent
Writteninformed consent was obtained,as well as respect for the participants' voluntary recruitment. An informed consent was signed. A fingerprinter was obtainedforcaregiverswhocouldnotsign. Informed consent from participants was obtained after fully explaining the details ofthestudyinthelanguagethatthey were able to understand.
Respect of individual persons
Written informed consent was obtained before enrolment, and mothers were free to withdraw from the study any time they wished.
Demographic characteristics of study participants
The gender of study participants was evenly distributed as 124 (50.6%) males and 121 (49.4%) females. Study participants were aged 6 to 18 months, with a mean age of 10.5 ± 3.7 months. The mean age for participants with normal nutritional status, stunting, wasting, and underweight was 10.4±3.9, 11.7±3.8, 9.1±3.1 and 10.5±3.8 months respectively. Other baseline demographic characteristics are detailed in Table 1 below.
Table 1: Baseline demographic characteristics of study participants
Variable Frequency Percentage
Sex
Male 124 50.6 Female 121 49.4
Age of child (Months)
6-11 145 59.2 12-18 100 40.8
Residence Urban 45 18.4 Rural 200 81.6
Age of the mother (Years) < 25 87 35.5 ≥25 158 64.5
Tribe
Munyankole 206 84.1 Mukiga 10 4.1 Others 29 11.8
Number of children
<5 211 86.1 ≥5 34 13.9
Marital status Single 81 33.1 Married 164 66.9
Mostmothershadamonthlyincomeofless than200,000UGX(95.1%)andhadattained primary education level (69.8%). Other
baseline socio-economic characteristics are detailed in Table 2 below.
Table 2: Baseline socio-economic characteristics of study participants
Variable Frequency Percentage
Occupation
Non formal 233 95.1 Formal 12 4.9 Religion Christian 204 83.3 Muslim 41 16.7
Monthly income (in UGX)
<200,000 193 78.8 ≥200,000 52 21.2
Education level
Primary 171 69.8 Secondary 50 20.4 Tertiary 24 9.8
www.idosr.org
Most study participants had normal birthweight210(85.7%),while62(25.3%)of thechildrenstudiedhadahistoryofillness in the past two weeks. Other baseline
Kumbowi et almedical characteristics of study children and caregivers are detailed in Table 3 below.
Table 3: Medical characteristics of study participants
Variable Frequency Percentage
Lowbirthweight
Yes 35 14.3 No 210 85.7
Child’s history of illness (in the past two weeks)
Yes 62 25.3 No 183 74.7
Child’shistoryofhospitaladmission
Yes 19 7.8 No 226 92.2
Maternal viral load (copies/µL)
<1000 224 91.5 ≥1000 21 8.5
Maternal under nutrition
Yes 28 11.4 No 217 88.6
Overall, 43(17.6%) of study participants had at least one form of under nutrition.
Out of these, 3(7%) had oedematous malnutrition.
Figure 1: Prevalence of under nutrition among HIV-exposed uninfected children aged 6 to 18 months in Bushenyi district
Prevalence of undernutrition
43(17.6%)
202(82.4%)
Undernutrition Normal
The prevalence of stunting, wasting and underweight was 11.1%, 5.7% and 6.2% respectively. This is shown in table 4 below. Some HIV-exposed children had morethanoneformofundernutrition.The meanz-scoreoflength-for-age, weight-forlength and height-for-age was ‒ 0.4±1.4,
0.2±1.4, ‒ 0.06±1.2 respectively. The proportion of study participants with severestunting, severe wasting and severe underweight was 22.2%, 28.6% and 20% respectively.
Table 4: Prevalence and severity of stunting, wasting and underweight among HIVexposed uninfected children aged 6 to 18 months in Bushenyi district
Form of under nutrition
Stunting (N=27)
Frequency Percentage
Moderate(≥-3 to <-2 SD) 21 77.8 Severe (<-3 SD) 6 22.2
Wasting (N=14)
Moderate(≥-3 to <-2 SD) 10 71.4 Severe (<-3 SD) 4 28.6
Underweight (N=15)
Moderate(≥-3 to <-2 SD) 12 80.0 Severe (<-3 SD) 3 20.0
DISCUSSION
In this study, the prevalence of under nutrition was 17.6%. Overall, the prevalence of stunting, wasting, and underweight was 11%, 5.3%, and 6.5% respectively. Some HIV-exposed uninfected children had more than one form of under nutrition. The prevalence of under nutrition was lower compared to the findings of most previous studies. In central Uganda, studies at Nsambya hospital [10] and Entebbe [11] reported an overall prevalence of 20.2% and 26.1% respectively. Similarly, a cross-sectional study conducted at Tororo District Hospital in Eastern Uganda [8] reported a prevalence of 20%. Through a follow-up study of 2387 HIV-exposed infants, [12] reported a prevalence of 22.9% in Tanzania.
The most plausible explanation for the lower prevalence of under nutrition in the current study is the general improvement in child health due to improved access to ART and widespread utilization of other child survival strategies including feeding practices and immunization coverage. For example, the recommended duration of breastfeeding for HIV-exposed uninfected
children changed from a duration not exceeding 6 months, to 12 months [13,14,15,16,17,19,19,20]. In addition, the proportion of children aged 12-23 months fully vaccinated by 12 months of age has increased over time from 40 % in 2011 to 55%in2016andRotavirusvaccineagainst diarrheal diseases was recently (2018) introduced in Uganda [15,16,21,22,23] Furthermore, this study focused on children aged 6-18 months compared to previous studies that involved a wider age range of under-fives [8,24,25,26]. In addition, there was a high exclusive breastfeeding rate in the first 6 months of life when compared to previous studies. Thiscouldhaveconferredsomeprotection against under nutrition [17,27,28,29,30]. Stunting was the most common form of under nutrition most likely because of the high rate ofintrauterine growth restriction among HIV-exposed children. Wasting was the least common form of undernutrition in this study. Studies have reported that HIV-exposed children tends to be smaller in both length and weight than uninfected children, making them to have a normal weight-for-length [18].
CONCLUSION
The prevalence of under nutrition among HIV-exposed uninfected children (6-18 months) in Bushenyi district was relatively low REFERENCES
1. Rijpma, S. (1996). Malnutrition in the history of tropical Africa, (April 2019).
2. Ivers, L. C., Cullen, K. A., Freedberg, K. A., Block, S. and Webb, P. (2010). Undernutrition and Food Insecurity. National Institute of Health Public Access, 49(7), 1096–1102.
3. Mbori-, D. and Kieffer, M. P. (2006). Handbook on Pædiatric AIDS in Africa Editors, (July).
4. Wambura, J. N. and Marnane, B. (2019). Undernutrition of HEU infants in their first 1000 days of life: A case in the urban-low resource setting of Mukuru Slum, Nairobi, Kenya. Heliyon, 5(7), e02073.
5. Chalashika, P., Essex, C., Mellor, D. and Swift, J. A. (2017). Birthweight , HIV exposure and infant feeding as predictors of malnutrition in Botswanan infants, 2015(1), 1–12.
6. McHenry,M.S.,Apondi,E.,Ayaya,S.O., Yang, Z., Li, W., Tu, W. and Vreeman, R. C. (2019). Growth of young HIVinfected and HIV-exposed children in western Kenya: A retrospective chart review. PLoSONE, 14(12), 1–17.
7. Kish, L. (1965). Survey Sampling. In SurveySampling. New York: John Wiley & Sons, Inc.
8. Osterbauer, B., Kapisi, J., Bigira, V., Mwangwa, F., Kinara, S., Kamya, M. R. and Dorsey, G. (2012). Factors associated with malaria parasitaemia , malnutrition ,and anaemiaamongHIVexposed and unexposed Ugandan infants: a cross-sectional survey, 1–6.
9. Condo, J. U., Gage, A., Mock, N., Rice, J. and Greiner, T. (2015). Sex differences in nutritional status of HIV-exposed children in Rwanda: a longitudinal study, 20(1), 17–23.
10.Magezi, R., Kikafunda, J. and Whitehead, R. (2008). Brief Report Feeding and Nutritional Characteristics of Infants on PMTCT Programs, (August).
11.Muhangi, L., Lule, S. A., Mpairwe, H., Ndibazza, J., Kizza, M., Nampijja, M. and Webb, E. L. (2013). Maternal HIV infection and other factors associated with growth outcomes of HIVuninfectedinfantsinEntebbe,Uganda, 16(9), 1548–1557.
12.Mcdonald,C.M.,Kupka,R.,Manji,K.P., Bosch, R. J., Aboud, S. and Kisenge, R. (2013). Predictors of stunting, wasting, and underweight among Tanzanian children born to HIV-infected women. EurJClinNutr, 66(11), 1265–1276.
13.World Health Organization (2010). Guidelines on HIV and infant feeding. Geneva.
14.Ministry of Health of Uganda (2020a). Consolidated guidelines for the prevention and treatment of HIV and AIDS in Uganda, (February).
15.Uganda Bureau of Statistics (UBOS) and ICF. (2018). Uganda Demographic and Health Survey 2016. Kampala, Uganda and Rockville, Maryland, USA: UBOS and ICF.
16.Uganda Bureau of Statistics (UBOS) and ICF International Inc. (2012). Uganda Demographic and Health Survey 2011. Kampala, Uganda: UBOS and Calverton, Maryland: ICF International Inc.
17.Chepkorir, P., Ogada, I. A., Steenbeek, A., Odinga, G. and Mwachiro, M. M. (2016). Do the feeding practices and nutrition status among HIV-exposed infantslessthan6monthsofagefollow the recommended guidelines in Bomet County , Kenya? BMCNutrition, 1–9.
18.Lane, C. E., Adair, L. S., Bobrow, E. A. and Ndayisaba, G. F. (2019). Determinants of growth in HIV ‐exposedandHIV ‐ uninfectedinfantsin the Kabeho Study. Matern Child Nutr., (E12776), 1–10.
19.N Gloria, AO Yamile, E Agwu (2022). Prevalencepatternsofbacterialurinary tract infections among febrile children under-five years of age at Kampala International University Teaching Hospital. IDOSR Journal of Biology, ChemistryandPharmacy 7 (1), 41-55.
20.B Petrus, E Nzabandora, E Agwu (2022). Evaluation of the bacterial agents associated with PID among women of reproductive age at Kampala International University Teaching Hospital. IDOSR Journal of Biochemistry, Biotechnology and Allied Fields 7 (1), 64-74.
21.OA Hussein, M Joy, JN Musiime (2022).Evaluation of the factors associated with immediate adverse maternal outcomes among referred women in labor at Kampala International University Teaching Hospital. IAA Journal of Biological Sciences 8 (1), 228-238.
22.OA Hussein, M Joy, JN Musiime (2022). Factors associated with Immediate Adverse Maternal Outcomes among Referred Women in Labor attending Kampala International University Teaching Hospital. IAA Journal of Applied Sciences 8 (1), 117-125.
23.MWilberforce,OJohn,KClaude(2022). Evaluation of the Acute Toxicity and Hematological Effect of Aqueous Extract of Albizia chinensis (Osbeck) Merr Stem Bark in Streptozotocininduced Diabetic Wistar rats. IAA Journal of Biological Sciences 9 (1), 146-158.
24.TB Yves, OE Dafiewhare, LA Charles, E Sebatta (2022). Electrocardiographic Pattern among Heart Failure Patients at Kampala International University Teaching Hospital, Ishaka, Uganda. IAA Journal of Biological Sciences 9 (1), 159-165.
25.Hussein Osman Ahmed, Joy Muhumuza and Musiime James Nabaasa (2022). The compositeimmediateadversematernal outcomes among women in labor referred to Kampala International University Teaching Hospital IAA Journal of Scientific Research 8(1):149156.
26.Daniel Asiimwe, Herman Lule and Izimba Daniel (2022). Epidemiology of AssaultInjuriesamongTraumaPatients Presenting at Kampala International University Teaching Hospital and Jinja Regional Referral Hospital. INOSR Applied Sciences 8(1):111-119.
27.E.O.Ikuomola,O.S Akinsonmisoye, R.O. Owolabi and M. B. Okon (2022).
Assessment of Toxicity Potential of SecnidazoleonReproductiveSystemof Male Wistar Rats. INOSR Applied Sciences 8(1):120-133.
28.UgwuOkechukwu,P.C.,Onwe,S.C.and Okon, M. B. (2022). The effect of Methanol Extract of Rauwolfia vomitoria on Lipid Profile of Chloroform intoxicated Wistar Albino Rats.IAAJournalofScientificResearch, 8 (1), 73-82.
29.E.O.Ikuomola,O.S.Akinsonmisoye, R.O. Owolabi and M. B. Okon (2022).Evaluation of the Effect of
Secnidazole on Sperm Motility, Morphology, Viability and Total Sperm Count of Wistar Rats. INOSR Experimental Sciences 8(1): 74-83, 2022.
30.E.O. Ikuomola , O.S Akinsonmisoye, R.O. Owolabi and M. B. Okon (2022).Evaluation of the effect of secnidazole on the histology of the testes and epididymis of male Wistar rats. INOSR Experimental Sciences 8(1): 84-94, 2022.