566
TRANSACTIONS OF ~nr ROYALSOCIETY OF TROPICALMEDICINE
Risk indicators
of childhood
AND HYGIENE (1992) 86, 566569
undernutrition
in Kingston,
Patricia D. Fletcher, Donald T. Simeon and Sally M. Grantham-McGregor University of the West Indies, Mona, Kingston 7, Jamaica
Jamaica Tropical Metabolism Research Unit,
Abstract In Jamaica, early childhood undernutrition remains a problem; however, the health of all children cannot be monitored due to limited resources. Therefore, there is a need for the early identification of children at risk of undernutrition. A simple screening instrument for use by paraprofessionals in the primary health care system was developed. We conducted a case-control study using 649 children, aged 6 to 48 months. The cases were undernourished (weight-for-age less than 80% of the reference) and identified from a survey. The children’s guardians were given a questionnaire comprising 31 variables thought to be associated with undernutrition and which were present from 6 weeks of age. Nine variables were significantly associated with undernutrition. Multiple logistic regression analysis indicated that low birth weight, short birth spacing, being born at home, poor ante-natal and post-natal clinic attendance, overcrowding and a lack of household possessions were independent predictors of undernutrition. Using these variables, a simple scoring system was developed to identify high risk children. It had a sensitivity and specificity of 56% and 76% respectively and a positive predictive values of 3 1%. This simple screening instrument should be easy to use in the primary health care system. However, its low sensitivity indicates that it is difficult to identify children who are at risk of undernutrition from 6 weeks of age. Subsequent high morbidity and poor child care which were not measured may account for some of the missed cases. Introduction Early childhood protein energy undernutrition remains a public health problem in Jamaica, although there has been some reduction in its prevalence in recent years (SINHA, 1988). The main channel through which the problem is addressed is the primary health care service. This comprises a network of maternal and child health clinics staffed by nurses and community health aides (CHAs, government-employed health paraprofessionals) who visit the children at home when necessary. Unfortunately, at present there are considerable financial and personnel constraints. Therefore, in order to target limited resources more efficiently, there is a need to identify children who are likely to become undernourished from as early as possible. It is well established that undernutrition occurs in families living in poverty; however, the specific characteristics vary between countries and regions (GRANTHAM-MCGREGOR, 1980). In Jamaica, some of these socio-cultural, biological and economic characteristics of families with malnourished children have been described previously (GRANTHAM-MCGREGOR et al., 1977; POWELL & GRANTHAM-MCGREGOR, 1985; DESAI et al., 1970). We conducted a study to develop an inventory to identify children in Kingston from the age of 6 weeks, who were at risk of becoming undernourished at a later age. This inventory is easy for CHAs to use when working with mothers in the field. Methods Study design , A retrospective case-control study was conducted with 649 children, aged 6 to 24 months, who were identified from a cross-sectional survey. The cases were undernourished while the controls were not. Variables which would have been present at the age of 6 weeks were measured using a questionnaire. Sample A house-to-house survey was carried out in 7 poor neighbourhoods rated among the more deprived in Kingston (DAVIES et al., 1989). All children between 6 and 48 months of age were identified. One child from each household was then selected and, when more than one was available, first the oldest and then the youngest were chosen alternately; 649 children were studied. All children had their weights and lengths or heights measured and their mothers or female guardians were given a questionnaire. Author for correspondence: Patricia Fletcher, T.M.R.U., U. W.I., Mona, Kingston 7, Jamaica.
Table
1. Variables
measured
by the questionnaire
Child Age Sex Birth weight Birth order Birth interval (before) Multiple birth . Congenital handicap Maternal
Age
Health status Obstetric history No. of partners Union status Employment Children deaths Education
Paternal Occupation Employment Dead/Alive Lives with child Supports child Housing and economic No. of children under 4 years Crowding Type of toilet Type of water supply Possession of radio Possession of television Possession of refrigerator Type of stove Use of health services First ante-natal visit Post-natal visit Birth place Anthropometry Children were weighed wearing underpants only, on a Detecto@ beam balance, using standard procedures ( JELLIFFE, 1966). Supine lengths were measured using an infantometer in children under 24 months of aae and standing heights were measured in the other children with a stadiometer. The measuring instruments were checked regularly with a standard weight and length.
567 Four CHAs were trained to take anthropometric measurements and to give the questionnaire. Training continued until acceptable measures of reliability were achieved between the trainer and each CHA (i.e., differences of no more than 0.5 cm in height and 0.1 kg in weight, in 10 consecutive measurements). Questionnaire
Questions were formulated which were simple, readily understood by the mothers and required little probing. They covered variables which had been previously found to be associatedwith undernutrition in either Jamaicaor other developing countries (GRANTHAM-MCGREGOR, 1980). These variables are outlined in Table 1. Before the study, all interviewers were observed until they achieved a minimum of 90% concurrence with the trainer in 10 consecutive interviews. Data analysis
Anthropometric measurementswere expressedas percentagesof expected value for ageand sex using the National Center for Health Statistics (NCHS) standards (HAMILL et al., 1979). The prevalencesof moderate to severe stunting and wasting (WATERLOW, 1976) were low (7% and 2% respectively). We therefore focused solely on low weight-for-age. For the purposes of this study less than 80% of expected weight-for-age was defined as being undernourished (ANONYMOUS,1970). It is usually recommended (WATERLOWet al., 1977) that standard scores be used when analysing anthropometric data; however, we used the percentageof the reference median in order to be consistent with the practice of the Jamaican health services. Therefore, the cases were those children whose weights-for-age were lessthan 80% of the reference. The weights-for-age of the controls were above 80% of the latter. The complete data set comprised 3 1 independent variables (Table 1). However, the prevalences of multiple Table
3. Sensitivity,
specificity
Table 2. Distribution undernutrition
Sensitivity 18.3 10.6 24.0 20.4 29.1 2Z 11.5 32.7
associated
Birth weight 6 ppr)b Possessions(none)
of variables
Specificity 89.4 95.6 86.3 89.9 83.5 95.6 89.4 94.3 78.0
with undernutrition
Positive predictive value 24.7 31.4 25.3 28.0 25.2 29.4 31.7 27.9 22.1
Odds ratio 1.9 22:; 2.3 ;:; ::4 1.7
P value 0.03 0.01
0.01 0.004 0.003 0.03 0~0001 0.03 0.02
YXut-off point in parentheses. bppr=Persons per room. births (1%) and children with physical handicaps (1%) were too low to be useful and were not included in the analyses. The data were then examined to determine whether the remaining variables were associated with undernutrition. For simplicity of the final instrument, all variables were dichotomized. Continuous variables were dichotomized by selecting the cut-off point which gavethe highest positive predictive value with a sensitivity of at least 10%. Odds ratios were then calculated for each variable to determine their association with undernutrition. Variables with significant odds ratios (P
TRANSACTIONS OF ~nr ROYALSOCIETY OF TROPICALMEDICINE
Risk indicators
of childhood
AND HYGIENE (1992) 86, 566569
undernutrition
in Kingston,
Patricia D. Fletcher, Donald T. Simeon and Sally M. Grantham-McGregor University of the West Indies, Mona, Kingston 7, Jamaica
Jamaica Tropical Metabolism Research Unit,
Abstract In Jamaica, early childhood undernutrition remains a problem; however, the health of all children cannot be monitored due to limited resources. Therefore, there is a need for the early identification of children at risk of undernutrition. A simple screening instrument for use by paraprofessionals in the primary health care system was developed. We conducted a case-control study using 649 children, aged 6 to 48 months. The cases were undernourished (weight-for-age less than 80% of the reference) and identified from a survey. The children’s guardians were given a questionnaire comprising 31 variables thought to be associated with undernutrition and which were present from 6 weeks of age. Nine variables were significantly associated with undernutrition. Multiple logistic regression analysis indicated that low birth weight, short birth spacing, being born at home, poor ante-natal and post-natal clinic attendance, overcrowding and a lack of household possessions were independent predictors of undernutrition. Using these variables, a simple scoring system was developed to identify high risk children. It had a sensitivity and specificity of 56% and 76% respectively and a positive predictive values of 3 1%. This simple screening instrument should be easy to use in the primary health care system. However, its low sensitivity indicates that it is difficult to identify children who are at risk of undernutrition from 6 weeks of age. Subsequent high morbidity and poor child care which were not measured may account for some of the missed cases. Introduction Early childhood protein energy undernutrition remains a public health problem in Jamaica, although there has been some reduction in its prevalence in recent years (SINHA, 1988). The main channel through which the problem is addressed is the primary health care service. This comprises a network of maternal and child health clinics staffed by nurses and community health aides (CHAs, government-employed health paraprofessionals) who visit the children at home when necessary. Unfortunately, at present there are considerable financial and personnel constraints. Therefore, in order to target limited resources more efficiently, there is a need to identify children who are likely to become undernourished from as early as possible. It is well established that undernutrition occurs in families living in poverty; however, the specific characteristics vary between countries and regions (GRANTHAM-MCGREGOR, 1980). In Jamaica, some of these socio-cultural, biological and economic characteristics of families with malnourished children have been described previously (GRANTHAM-MCGREGOR et al., 1977; POWELL & GRANTHAM-MCGREGOR, 1985; DESAI et al., 1970). We conducted a study to develop an inventory to identify children in Kingston from the age of 6 weeks, who were at risk of becoming undernourished at a later age. This inventory is easy for CHAs to use when working with mothers in the field. Methods Study design , A retrospective case-control study was conducted with 649 children, aged 6 to 24 months, who were identified from a cross-sectional survey. The cases were undernourished while the controls were not. Variables which would have been present at the age of 6 weeks were measured using a questionnaire. Sample A house-to-house survey was carried out in 7 poor neighbourhoods rated among the more deprived in Kingston (DAVIES et al., 1989). All children between 6 and 48 months of age were identified. One child from each household was then selected and, when more than one was available, first the oldest and then the youngest were chosen alternately; 649 children were studied. All children had their weights and lengths or heights measured and their mothers or female guardians were given a questionnaire. Author for correspondence: Patricia Fletcher, T.M.R.U., U. W.I., Mona, Kingston 7, Jamaica.
Table
1. Variables
measured
by the questionnaire
Child Age Sex Birth weight Birth order Birth interval (before) Multiple birth . Congenital handicap Maternal
Age
Health status Obstetric history No. of partners Union status Employment Children deaths Education
Paternal Occupation Employment Dead/Alive Lives with child Supports child Housing and economic No. of children under 4 years Crowding Type of toilet Type of water supply Possession of radio Possession of television Possession of refrigerator Type of stove Use of health services First ante-natal visit Post-natal visit Birth place Anthropometry Children were weighed wearing underpants only, on a Detecto@ beam balance, using standard procedures ( JELLIFFE, 1966). Supine lengths were measured using an infantometer in children under 24 months of aae and standing heights were measured in the other children with a stadiometer. The measuring instruments were checked regularly with a standard weight and length.
567 Four CHAs were trained to take anthropometric measurements and to give the questionnaire. Training continued until acceptable measures of reliability were achieved between the trainer and each CHA (i.e., differences of no more than 0.5 cm in height and 0.1 kg in weight, in 10 consecutive measurements). Questionnaire
Questions were formulated which were simple, readily understood by the mothers and required little probing. They covered variables which had been previously found to be associatedwith undernutrition in either Jamaicaor other developing countries (GRANTHAM-MCGREGOR, 1980). These variables are outlined in Table 1. Before the study, all interviewers were observed until they achieved a minimum of 90% concurrence with the trainer in 10 consecutive interviews. Data analysis
Anthropometric measurementswere expressedas percentagesof expected value for ageand sex using the National Center for Health Statistics (NCHS) standards (HAMILL et al., 1979). The prevalencesof moderate to severe stunting and wasting (WATERLOW, 1976) were low (7% and 2% respectively). We therefore focused solely on low weight-for-age. For the purposes of this study less than 80% of expected weight-for-age was defined as being undernourished (ANONYMOUS,1970). It is usually recommended (WATERLOWet al., 1977) that standard scores be used when analysing anthropometric data; however, we used the percentageof the reference median in order to be consistent with the practice of the Jamaican health services. Therefore, the cases were those children whose weights-for-age were lessthan 80% of the reference. The weights-for-age of the controls were above 80% of the latter. The complete data set comprised 3 1 independent variables (Table 1). However, the prevalences of multiple Table
3. Sensitivity,
specificity
Table 2. Distribution undernutrition
Sensitivity 18.3 10.6 24.0 20.4 29.1 2Z 11.5 32.7
associated
Birth weight 6 ppr)b Possessions(none)
of variables
Specificity 89.4 95.6 86.3 89.9 83.5 95.6 89.4 94.3 78.0
with undernutrition
Positive predictive value 24.7 31.4 25.3 28.0 25.2 29.4 31.7 27.9 22.1
Odds ratio 1.9 22:; 2.3 ;:; ::4 1.7
P value 0.03 0.01
0.01 0.004 0.003 0.03 0~0001 0.03 0.02
YXut-off point in parentheses. bppr=Persons per room. births (1%) and children with physical handicaps (1%) were too low to be useful and were not included in the analyses. The data were then examined to determine whether the remaining variables were associated with undernutrition. For simplicity of the final instrument, all variables were dichotomized. Continuous variables were dichotomized by selecting the cut-off point which gavethe highest positive predictive value with a sensitivity of at least 10%. Odds ratios were then calculated for each variable to determine their association with undernutrition. Variables with significant odds ratios (P
![[The incidence of emergence delirium and risk factors following sevoflurane use in pediatric patients for day case surgery, Kingston, Jamaica].](/assets/img/hold.png)
