Including infants in nutrition surveys

Claudine Prudhon is the head of the nutrition department in ACF HQ. Claudine is interested in improving the nutritional management of the under six month infants. The survey she writes about in this article was carried out by Stephanie Hanouet.

Guidelines on nutritional survey methodologies currently stipulate that children between 6 to 59 months should be surveyed. This age group are generally believed to be the most vulnerable to nutritional stress. One of the main reasons for excluding children under six months of age from surveys has been the assumption that malnutrition will be rare amongst this age group as they are predominantly breastfed. However, in some situations malnutrition has been found to be a significant problem amongst infants during their first six months of life. Where nutritional problems are suspected amongst this age group, it may be appropriate to establish prevalence of malnutrition in the under 6 month population and the main factors leading to malnutrition. This is particularly important as the mortality rates of malnourished infants in traditional feeding centres is generally higher than that of the over 6 month feeding centre population suggesting that some other form of care may be more appropriate. However, the assessment of nutritional status of children under 6 months presents practical difficulties with measurements and standards. The interpretation of the results may also be difficult as poor nutritional status in infants may be related to intra-uterine growth retardation or lactation and feeding practice problems which in turn could be due to a variety of factors.

Action Contre la Faim had been running MCH activities, supplementary and therapeutic feeding centres and health education sessions through feeding programmes, in Kabul city during 1998. About 10% of the admissions in the therapeutic feeding centres were children under 6 months, admitted with a weight-height of less than 70 % or too weak to suckle properly. In order to better understand the extent and nature of the malnutrition problems in this age group Action Contre la Faim undertook an evaluation of the nutritional status of children under 6 months, in Kabul city in Afghanistan in January 1999. This survey was carried out in conjunction with an anthropometric survey of 6-59 months old children, using a cluster survey methodology. When a child aged between 1 week and 6 months was present in the surveyed families, their measurements were also taken. Questions about exclusive breast-feeding practices were included in the questionnaire.

Practical difficulties
First of all, it was very difficult to straighten small infants in order to get accurate measurements of height with a standard measuring board. There were no practical problems measuring weight, although using a salter scale with 100 g calibrations, probably led to imprecision given the weight range of the age group. Some of the team members were afraid to take measurements of small babies not being used to handling infants so small and fearing they might hurt them.

The NCHS reference values of weight for height were based on growth curves of bottle-fed children, and there is some evidence that breast-feeding infants may have lower growth rates. Using NCHS standards may therefore be inappropriate. Also, the NCHS reference values have only been calculated for children of 49 cm and above. However, high risk infants less than this height may be encountered who have been severely affected by intra-uterine growth retardation and have extremely low weights.

Another problem emerged to do with sample size. If we wanted to have good precision we would have needed to have measured about 900 infants under 6 months. The Kabul survey only found 132 children in the 900 families surveyed. If we had wanted to survey 900 infants the survey would have been much more time and resource consuming.

Results and comparison with the nutritional status of 6-59 months old
Of the children measured (132), 20 were less than 49 cm. The results show that the nutritional status of children less than 6 months old (table 1) was about the same as that of the older ones (table 2). However, the confidence interval was large. Of the infants under 49 cm, 80% were less than 1 month old. Their mean weight was 2.8 Kg, ranging from 1.7 to 3.7, indicating a low weight in these children. Of the surveyed children 74% were exclusively breastfed. Those on mixed feeding were receiving tea, biscuits, bread, family meal, porridge or milk. The percentage of non exclusively breastfed was higher among the sample of malnourished children, but a causal relationship could not be proven from the data. All children under 49 cm were exclusively breastfed.

Interpretation and action
These results suggest that the nutritional status of children under 6 months of age in Kabul city is no better than the older children. However, more information is required to better interpret these results. Action plans are difficult to formulate precisely as poor nutritional status in this age group may be related to intra-uterine growth retardation or feeding practices after birth. Given this lack of understanding, the best way to deal with the problem at population level may well be to focus resources on both maternal and child health and nutrition in order to prevent intra-uterine growth retardation and the deterioration of the child's nutritional status after birth.

The weight gains of the infants treated in the feeding centres were between 15 and 20 g/kg/day. On discharge from feeding they had ascending growth curves and were breast-feeding sufficiently well to ensure growth. However, there was a high default rate amongst these patients.

There is clearly a need to improve the methodology for both assessing the nutritional status of children under six months of age and the factors leading to poor nutritional status. There is also considerable scope for improving the care of malnourished children under 6 months old, as it appears that traditional feeding centres are probably not the best place to deal with these children.

Table 1 Nutritional status using weight-height index of infants 1 week - 6 months of age, Kabul, January 1999

	SEVERE	GLOBAL
Z-Score	0.0 %	6.1 %
95 % Confidence Interval	-0.3 - 6.8 %	1.8 - 15.7 %
% of the median	1.3%	6.0%
95 % Confidence Interval	-0.2 - 8.2%	1.9 - 14.8 %

No oedema cases were recorded

Table 2 Nutritional status using weight-height index of children from 6 months to 5 years of age, Kabul, January 1999

ACUTE MALNUTRITION	SEVERE	GLOBAL
Z-Score	1.0 %	8.7 %
95 % Confidence interval	0.3 - 2.6 %	6.9 - 10.8 %
% of the median	0.5 %	6.0 %
95 % Confidence interval	0.1 % - 1.9 %	4.1 - 8.8 %

3 oedema (kwashiorkor) and 6 marasmus cases were found

For further information contact: cprudhon@acf.imaginet.fr

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