Gender-specific difference among socio-demographic determinants of malnutrition and anemia among hospitalized children

Abstract

BACKGROUND:

Malnutrition and anemia are mainly in coexistence with each other and are potent risk factors of delayed growth and development in children. Moreover, both malnutrition and anemia could trigger the disease and prolonged the hospitalization period.

OBJECTIVE:

The purpose of the current study is to determine the prevalence of malnutrition and anemia in patients admitted to Tabriz pediatric hospital in 2017 and also to determine their demographic and social determinants.

METHODS:

A cross-sectional study of 342 children aged 6 months to 13 years including 220 boys and 122 girls admitted to pediatric hospital in Tabriz-Iran in 2017 were recruited. Demographic and anthropometric variables were obtained from medical records. Height for age, weight for age and weight for height Z-scores (HAZ, WAZ, WHZ) were used to evaluate the nutritional status. Routine laboratory records of children in hospital were used to determination of anemia. Anemia was defined based on the WHO criteria as hemoglobin concentrations less than 11 and 11.5 g/dL for children under and over 5 years old respectively.

RESULTS:

The prevalence of severe and moderate wasting among girls were more prevalent than boys (P < 0.05). The moderate stunting was also more prevalent among girls (P = 0.029). Total prevalence of anemia was 31.87%; while this prevalence among children under and over 5 years of old was 31.25% and 33.33% respectively. In children under 5 years, mean age, weight, height and WHZ in anemic children were significantly lower than non-anemic children (P < 0.05). In children over 5 years of age, mean age and weight were also marginally lower among anemic compared with non-anemic children. No statistically significant difference between prevalence of anemia in children under or over 5 years old were identified.

CONCLUSIONS:

High prevalence of malnutrition among girls compared with boys reveals the need for further attention and strategy planning for nutrition education and intervention among vulnerable low-income families.

Keywords

Pediatric anemia hospital underweight stunting wasting

1 Introduction

Malnutrition, defined as the deficiency, excess or imbalance of energy, protein and other nutrients is a major cause of chronic or acute disease among children [1]. Malnutrition is common among all age groups, but its prevalence among children is much higher due to their rapid linear growth [2, 3]. Reducing malnutrition among children will be associated with numerous health benefits for society and reducing malnutrition has been considered across two of the millennium development goals (MDGs) by the world health organization (WHO) [3]. On the other hand, anemia is a major health problem throughout the world and affects both adults and children in developed and developing countries. It has been estimated that 1.62 billion people in the world are affected by anemia with the most prevalence rate of 47.4% in preschool children [4]. The most prevalent form of anemia is iron deficiency anemia while the smaller proportions occur due to deficiencies in other nutrients [5]. The prevalence of anemia in children is of particular importance; children are one of the most susceptible groups to anemia since their rapidly growing tissues and blood cells increase their iron requirements [6]. Iron deficiency anemia has significant negative impacts on mental development, social performance, immunity and linear growth in children [7]. In early childhood, inappropriate feeding behaviors and introducing complementary feeding with poor dietary sources of iron leads to anemia [8 –11]. Iron deficiency anemia is also a major public health in Iran and according to WHO report, Iran is considered to be at the medium level (20%–39%) of anemia prevalence. The overall estimate of anemia prevalence was 13.6 and 29.1% in Iranian pregnant women and children, respectively [12 –15].

There are numerous studies evaluating the prevalence of malnutrition and anemia in children in different areas of Iran [16–17] including Tabriz [18 –20]. Despite the existence of numerous studies on the prevalence of malnutrition in children, assessment the nutritional status in hospitalized children is often neglected. In Tabriz pediatric hospital one study was carried out in 2008 by Mahdavi AM [18] and reported a high prevalence of malnutrition according to the height for age, weight for age and weight for height Z-scores (HAZ, WAZ, WHZ) with preceding percentages of 48.6%, 30.7% and 32.2% respectively. However no other report of the prevalence of anemia in hospitalized children in Tabriz pediatric hospital was found. We have two objectives in the current study: 1) to determine the prevalence of anemia and malnutrition and 2) to identify the socio-demographic and anthropometric factors related with anemia among children hospitalized in Tabriz pediatric hospital.

2 Subjects and methods

This was a cross-sectional study conducted in Tabriz pediatric hospital. This hospital is located in Tabriz city and is the only referral center for children in the northwest of country that delivers secondary and tertiary care for pediatric patients. Three hundred forty two children including 220 boys and 122 girls aged 6 months to 13 years old from surgical, oncology, ear/nose/throat, infectious diseases and internal medicine (gastroenterology, nephrology, respiratory, neurology, cardiology, metabolic disorder) wards were enrolled in the current study between April to July 2017. Patients in emergency, neonatal intensive care and neonatal special care units were excluded from the study.

Information about anthropometric assessments including weight and height measurements was obtained from patient’s medical records. These measurements were carried out at the first day of admission in the hospital by an operator unrelated to the study. HAZ, WAZ, WHZ were calculated using the Epi-Info 2000 Nutristat program (Centers for Disease Control and Prevention, Atlanta, GA, USA) using the CDC 2000 standards. Malnutrition was assessed using standard deviation classification as underweight (weight for age), stunting (height for age) and wasting (weight for height) according to the WHO criteria: severe malnutrition (z-score < –3), moderate malnutrition (z-score ≥ –3 and < –2) adequate (z-score ≥ –2 and < +2) and over-nutrition (z-score ≥ +2) [21].

Patients were categorized according to age into five groups as: 0–2, 2–5, 5–10 and >10 years old. Routine laboratory records of children in hospital were obtained to identify anemia in children. These laboratory tests are performed for all of the children at the time of admission routinely. For patients with multiple complete blood counts (CBC) only the last test was taken into account. Anemia diagnosis was performed based on the WHO criteria as hemoglobin concentrations less than 11 and 11.5 g/dL for children under and over 5 years old respectively [22, 23]. The protocol of the current study has been approved by the ethics committee of Tabriz University of Medical Sciences (The registration number TBZMED-63013).

2.1 Statistical analysis

Statistical analysis was performed by Statistical Package for Social Sciences (PASW Statistics 18 SPSS for Windows, release 18, 30 July 2009, Chicago, IL, USA). Normality of data was analyzed by Kolmogorov-Smirnov test. Comparison of the continuous variables including age, weight, body mass index (BMI) and WHZ, WAZ, HAZ between anemic and non-anemic children was carried out by independent sample t-test. Chi-square analysis was used to compare the relationship of proportions including educational attainment, gender and birth order between groups. A two sided P value less than 0.05 was considered significant.

3 Results

A total of three hundred forty two children were enrolled in the current study. Table 1 presents the socio-demographic characteristics of children according to their gender. As shown in this Table, the majority of children had less than 2 years old (46.2%), were in the first order of birth (54.39%) and were in low literacy level of father (59.94%) and mother (58.18%). No significant difference was observed between boys and girls in terms of socio-demographic determinants. Almost 89.47% of the children were in low-income families. The prevalence of malnutrition and its different stages among hospitalized children is shown in Table 2. As shown, the total prevalence of severe wasting, stunting and underweight were 15.49, 9.35 and 11.11% respectively. The prevalence of severe and moderate wasting among girls was higher than boys (P < 0.05). Accordingly the moderate stunting was also more prevalent among girls (P = 0.029). Underweight was also prevalent among girls although this difference was not statistically significant. Total prevalence of anemia was 31.87%; while this prevalence among children under and over 5 years of old was 31.25% and 33.33% respectively. The comparison of anthropometric and demographic factors among children aged under and over 5 years old are presented in Table 3 and 4 respectively. In children under 5 years old, mean age, weight, height and WHZ in anemic children were significantly lower than non-anemic children (P < 0.05). In children over 5 years of age, mean age and weight were also marginally lower among anemic compared with non-anemic children. No statistically significant difference between prevalence of anemia in children less than 5 years old or over 5 years old among girls and boys were identified.

Table 1
Socio-demographic characteristics of children according to gender

Variable Boys N = 220 Girls N = 122 Total N = 342

Age [n (%)]

0–2 y 93 (42.3) 65 (53.3) 158 (46.2) 0.67

2–5 y 60 (27.3) 22 (18) 82 (24)

5–10 y 50 (22.7) 26 (21.31) 76 (22.2)

≥10 y 17 (7.72) 9 (7.4) 26 (7.6)

Birth order [n (%)]

1st 118 (53.63) 68 (55.73) 186 (54.38) 0.087

2nd 71 (32.27) 36 (29.50) 107 (31.28)

≥3rd 31 (14.09) 18 (14.75) 49 (14.32)

Family members (Mean±SD) 3.89±0.95 3.76±0.91 3.85±0.94 0.34

Household income (Rials*)

≤500000 104 (47.27) 47 (38.52) 151 (44.15) 0.068

500000–1000000 90 (40.90) 65 (53.27) 155 (45.32)

≥1000000 24 (10.90) 12 (9.83) 36 (10.52)

Father’s education

<12 years 132 (60) 73 (59.83) 205 (59.94) 0.27

≥12 years 88 (40) 49 (40.16) 137 (40.05)

Mother’s education

<12 years 131 (59.54) 68(55.73) 199 (58.18) 0.87

≥12 years 89 (40.45) 54 (44.26) 143 (41.81)

Variable	Boys N = 220	Girls N = 122	Total N = 342
Age [n (%)]
0–2 y	93 (42.3)	65 (53.3)	158 (46.2)	0.67
2–5 y	60 (27.3)	22 (18)	82 (24)
5–10 y	50 (22.7)	26 (21.31)	76 (22.2)
≥10 y	17 (7.72)	9 (7.4)	26 (7.6)
Birth order [n (%)]
1st	118 (53.63)	68 (55.73)	186 (54.38)	0.087
2nd	71 (32.27)	36 (29.50)	107 (31.28)
≥3rd	31 (14.09)	18 (14.75)	49 (14.32)
Family members (Mean±SD)	3.89±0.95	3.76±0.91	3.85±0.94	0.34
Household income (Rials*)
≤500000	104 (47.27)	47 (38.52)	151 (44.15)	0.068
500000–1000000	90 (40.90)	65 (53.27)	155 (45.32)
≥1000000	24 (10.90)	12 (9.83)	36 (10.52)
Father’s education
<12 years	132 (60)	73 (59.83)	205 (59.94)	0.27
≥12 years	88 (40)	49 (40.16)	137 (40.05)
Mother’s education
<12 years	131 (59.54)	68(55.73)	199 (58.18)	0.87
≥12 years	89 (40.45)	54 (44.26)	143 (41.81)

Table 2

The prevalence of malnutrition and its different grades stages among hospitalized children

Variable	< –3 S.D.			–3 S.D. to –2 S.D.			–2 to –1 S.D.			≥ –1 S.D.
	Boys n (%)	Girls n (%)	Total n (%)	Boys n (%)	Girls n (%)	Total n (%)	Boys n (%)	Girls n (%)	Total n (%)	Boys n (%)	Girls n (%)	Total n (%)
WHZ	31 (14.09)	22 (18.03)	53 (15.49)	19 (8.63)	8 (6.55)	27 (7.89)	37 (16.81)	26 (21.31)	63 (18.42)	133 (60.45)	66 (54.09)	199 (58.18)
	0.027			0.34			0.045			0.17
HAZ	16 (7.27)	6 (4.91)	32 (9.35)	15 (6.81)	16 (13.11)	31 (9.06)	37 (16.81)	22 (18.03)	59 (17.25)	152 (69.09)	78 (63.93)	230 (67.25)
	0.12			0.029			0.36			0.12
WAZ^*	21 (9.54)	17 (13.93)	38 (11.11)	17 (7.72)	14 (11.47)	31 (9.06)	40 (18.18)	26 (21.13)	66 (19.29)	142 (64.54)	65 (53.27)	207 (60.52)
	0.25			0. 43			0. 43			0.65

^*P = 0.04 in chi-square analysis; WHZ = weight for height Z-score; HAZ = height for age Z-score; WAZ = weight for age Z-score; SD = standard deviation.

Table 3

Comparison of anthropometric and demographic factors among children ages less than five years according to anemia status

Variable	Children Aged ≤5 y [n = 240]
	Hg <11 g/dL N = 75	Hg ≥11 g/dL N = 165	P
Age (Years)	1.83±1.08	2.34±1.36	0.020
Weight (Kg)	10.84±3.36	12.39±4.47	0.024
Height (cm)	83.25±11.83	87.35±1.64	0.050
WHZ	–1.05±0.25	–0.39±0.21	0.019
HAZ	0.06±0.26	–0.20±0.22	0.110
WAZ	–0.95±0.24	–0.65±0.18	0.321
Gender
Male	40 (53.33)	113 (68.48)	0.055
Female	35 (46.66)	52 (31.51)
Birth order [n (%)]
1st	35 (46.66)	93(65.36)	0.047
2nd	25 (33.33)	53(32.12)
≥3rd	15 (20)	20 (12.12)
Father’s education
<12 years	40 (53.33)	102 (61.81)	0.043
≥12 years	35 (46.66)	63 (38.18)
Mother’s education
<12 years	50 (66.66)	83 (50.30)	0.980
≥12 years	25 (33.33)	82 (49.69)

WHZ = weight for height Z-score; HAZ = height for age Z-score; WAZ = weight for age Z-score.

Table 4

Comparison of anthropometric and demographic factors among children ages more than five years according to anemia status

Variable	Children Aged >5 y [n = 102]
	Hg <11.5 g/dL N = 34	Hg ≥11.5 g/dL N = 68	P
Age (Years)	7.56±0.37	8.50±0.30	0.05
Weight (Kg)	25.95±2.02	26.76±1.37	0.670
Height (cm)	122.27±2.72	128.18±2.11	0.046
WHZ	–0.36±0.45	–1.18±0.43	0.491
HAZ	–0.28±0.24	–0.36±0.25	0.493
WAZ	–0.31±0.27	–0.76±0.20	0.271
Gender
Male	20 (58.82)	47 (69.11)	0.590
Female	14 (41.17)	21 (30.88)
Birth order [n (%)]
1st	17 (50)	41(60.29)	0.673
2nd	10 (29.41)	19 (27.94)
≥3rd	7 (20.58)	7 (10.29)
Father’s education
<12 years	20 (58.82)	43 (63.23)	0.341
≥12 years	14 (41.17)	25 (36.76)
Mother’s education
<12 years	24 (70.58)	42 (61.76)	0.590
≥12 years	10 (29.41)	26 (38.23)

WHZ = weight for height Z-score; HAZ = height for age Z-score; WAZ = weight for age Z-score.

4 Discussion

In the current cross-sectional study we found that total prevalence of wasting, stunting and underweight among hospitalized children was 23.39%, 18.42% and 20.17% respectively. The prevalence of severe wasting, stunting and underweight was 15.49, 9.35 and 11.11% respectively. We demonstrated in our previous report that the prevalence of food insecurity was more pronounced in malnourished children [24] and that poor nutritional status is related with food insecurity in preschool children [25]. In the previous report of the prevalence of malnutrition among one hundred and forty hospitalized children in Tabriz pediatric hospital in 2008, higher proportions of malnutrition was reported [18]. This might stem from improvement in the nutritional care process in hospital, although other reasons such as higher sample size in our study and different classification of malnutrition might possibly address these differences. Consistent with our findings, in the study by Mafrginean O et al the prevalence of malnutrition and severe malnutrition among 271 hospitalized children in Romania were 37% and 15% respectively. In other study in South Africa the overall prevalence of malnutrition among hospitalized pediatric patients was 34% [27].

In our study the total prevalence of anemia was 31.87%; the mean weight and WHZ in anemic under 5 year old children were lower than non-anemic children. Same results were found in the Santos study in Brazil [6] reporting 56.6% prevalence of anemia in hospitalized children aged less than 5 years old. They also found a lower weight and age among anemic children (P < 0.05). Other study in Islamabad-Pakistan [28] and India [29] presented higher degrees of anemia reporting 76.1% and 72.79% prevalence of different grades of anemia in children aged 6 months to 12 years admitted to hospital while other study in Turkey presented a lower prevalence (3.2%) [30].

Anemia is in significant association with age of the child, maternal education, birth order and nutritional status of the child [31 –33]. In our study mean age of anemic children in both groups was significantly lower than non-anemic children consistent with several previous reports [28].

We identified significantly lower scores of WHZ in anemic under 5 years old children but not in children over 5 years of age; Anemia usually develops in coexistence of protein-energy under-nutrition which is still prevalent among children of poor communities. Malnutrition is the world’s silent emergency leading to death and disability on a vast scale [28]. Custodio E [32] reported 8.3% coexistence of severe anemia and malnutrition among children below 5 years of age.

In the current study, girls showed significantly higher prevalence of wasting and stunting compared with boys. From gender difference perspective, girls are more prone to develop malnutrition due to household insecurity compared than boys; these all suggest more need for interventional and prevention program among girls in nutritional policy makings [34 –36].

In the current study, no significant difference between the prevalence of anemia between girls and boys was identified; similarly, there are conflicting results on the effect of gender on anemia in different studies. Several studies consistent with our study found no association between gender and anemia [3 –6] or even higher prevalence in boys [29, 30] and some others reported higher prevalence of anemia among girls [37 –39]. Probably the difference in anemia definition, adjustment for covariates and also the ethnic and geographical differences are the underlying reasons of difference; although, further studies are warranted for clear identification of the observed results. In conclusion, the high prevalence of total malnutrition and anemia reported here warrants attention because of possible role of these pathologic conditions in the prolonged hospitalization, growth retardation, delayed wound healing and other adverse clinical outcomes in children. Moreover, higher prevalence of malnutrition among girls rather than boys emphasizes the importance of preventing nutritional deficiencies with proper nutrition education programs or implementing effective strategies for detecting and treatment of malnutrition among them.

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

The current work has been performed by a grant from Student Research Committee, Tabriz University of Medical Sciences.

Footnotes

Acknowledgments

We are thankful from Student Research Committee, Tabriz University of Medical Sciences for their financial support.

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