A Study on the Relationship between Nutritional Status and Prevalence of Pneumonia and Diarrhoea among Preschool Children in Kushtia

The prevalence of diarrhoea and pneumonia is quite alarming amongst children under 5 years of age who belong to low socioeconomic status. This study was carried out from January to December (2012) in Kushtia, and the total sample were boys (209) and girls (191). Anthropometric measurements were performed by standard methods National Centre for Health Statistics (NCHS). The prevalence of severe underweight, stunting and wasting (≤ -3 SD) were found in the sample data about 11%, 22% and 17% respectively; whereas the prevalence of pneumonia, diarrhea and both pneumonia & diarrhea was found 53%, 44.50% and 38.75% respectively. The high prevalence of pneumonia (62.72%) and frequency (1.85) were found in under 12 months age group, while diarrhea (48.86%) and both pneumonia & diarrhea (45.45%) were found in 13-24 months age group. A greatest relationship was found between mother and child health status. About 89.26% mothers with poor health status have a sick child. Among the mothers with good health, the percentage of sick children was 45.73%. In this study, 34.25% of children were found to be severe anemic, 40.25% of children were found to be moderately anemic and 25.50% were nonanemic. Our findings underscore the fact that even poor nutrition or marginal malnutrition can predispose children to pneumonia. Anemia also significantly increased the risk of pneumonia in children. Our study revealed that anemia might be a risk factor for lower respiratory tract infections including pneumonia; however further studies with statistical model is needed to confirm. This study also indicated that children with diarrhea were at increased risk of pneumonia.


Introduction
Children under 5 years should be taken a special care because they are most vulnerable and high risk group.Malnutrition, infectious diseases, diarrhea, pneumonia etc are very common in this group.About 12.5-15% of world populations are under 5 years age group and the mortality rate is 25-30% among the developing countries (Majlesi F et al., 2001).
Childhood malnutrition is comparatively high in Southern Asia likely 45-48% in Bangladesh, India and Nepal, 38% in Pakistan and 30% in Sri Lanka (Peiris and Wijesinghe, 2010).More than 50% of child's death occurs due to diarrhoea, pneumonia, acute respiratory illness, malaria, or measles (Amy L. Rice et al., 2000).Pneumonia and diarrhea are the two leading cause of child death in the world (Black RE. et al., 2010;Dickens Onyango et al., 2012; J. Anthony G. Scott et al., 2008).About 21% and 17% deaths occur due to childhood pneumonia and diarrhea respectively (Onyango and Angienda, 2010;Williams BG, Gouws E et al., 2002).Every year more than 1.9 million children die due to pneumonia; whereas diarrhea kills about 4 million children (PIDS and IDSA, 2011;WHO, Media centre, 2012;Dickens Onyango et al., 2012).In the developing countries, annually, at least 1,500 million episodes of diarrhea and more than 150 million episodes of pneumonia occur in young children (Rudan I. et al., 2008;WHO, 1999).According to WHO (2006), an estimated of 98% children live in developing countries who die of pneumonia (WHO, 2006).Malnutrition and Diarrhoea increase the risk of pneumonia among young age group (Sania Ashraf et al., 2013;Coles CL et al., 2005).Dehydration caused by diarrhoea may also increase the risk of respiratory illnesses (Kalhoff H., 2003).Reducing child mortality is one of the eight Millennium Development Goals (MDGs), which are the world's time-bound targets for reducing poverty in its various dimensions by 2015.Achieving this goal will require urgent action to reduce childhood pneumonia and diarrhoea deaths, which at present account for 19 percent of all under-five deaths.In Bangladesh enteric infections, infectious diseases and malnutrition are common, while maternal and infant mortality are extremely high due to the tropical climate, combined with the existence of large open water-bodies, dense population, poverty and poor access for the majority to reliable health services.Low birth weight, underweight, and lack of breastfeeding have been identified as risk factors for pneumonia (Victora CG, Kirkwood BR, Ashworth A, et al., 1999;O'Dempsey TJ, McArdle TF, Morris J et al., 1996).Thus, the aim of this study was to examine the health status of the children in Kushtia district, and observe the impact of malnourishment upon the high prevalence of diarrhoea and pneumonia infection among them.

Methods and Materials
This cross sectional survey was done in Kushtia district with the sample of 400 preschool going children in the session, January to December, 2012.In this study, the sample children (0-60 months) are selected randomly in urban & rural area, and desirable data were collected from both mother and children through oral questionnaires, physical and clinical examination, dietary habit, anthropometric measurements etc, and the various disease associated with malnutrition were evaluated by detailed history & clinical examination.The survey form was prepared in two sections.The first part was conducted in order to assess the nutritional status by taking anthropometric measurement and dietary history of the child, and the second part was prepared for examining the presence of any disease.Over 20 infrastructure items in and around the dwelling were examined in this survey.

Data Analysis
Data was coded and entered into a computer database, summarized and presented descriptively.Z-scores were calculated for height-for-age (H/A), weight-for-height (W/H) and weight-forage (W/A) using Epi Info software.Prevalence of malnutrition i.e. stunting, wasting and underweight was determined using the reference population defined by the National Centre for Health Statistics Deviation scores (SD) usually mentioned as Z -scores was adopted.The cut-off points used for the indicators are "-2 to -2.99 SD" for moderate and "-3SD and below" for severe state (Rosland S. Gibson, 1990).For the determination of nutritional status, a cross sectional study was conducted.It includes their economic and sociodemographic data, cultural practice, food habits, food beliefs and food prices (Derrick B Jelliffe, 1989).Data were analyzed by NCHS reference data.

Result
This study was conducted to investigate the relationship between nutritional status and incidence of pneumonia and diarrhea among under-5 aged rural and urban children with special reference to the socioeconomic status of parents.A total of four hundred children aged between 0-60 months were enrolled in this study.
This table also shows that 30.00% of children height for age Z-score was between -0.99 to +0. 99 SD of the NCHS median which indicates that they were normal.The prevalence of severe stunting (<-3 SD) were found in the sample data about 22.00%, while the prevalence of moderate (-2.99 to-2.00) and mild stunting (-1.99 to -1.00 SD) were 27.00% and 21.00% respectively.It also depicts the distribution of children's weight for height (Z-score) according to age group.Amongst all the children, 17.00% children was found as severely wasted in any age group, and 34.00% were moderately wasted (-2SD to <-3SD).21.00% of the children were mild wasted, W/H-Z-score was between -1.00 to -1.99 SD of the NCHS median and 33% were normal.Figure 1 shows the distribution of children by different ranges of MUAC.In this study 24% of the children were found to be normal (14.5 cm), 14.25%, 36.00%,& 25.75% of the children were found to be mild, moderate and severe malnutrition, respectively in MUAC measurement.find out the relationship between nutritional status and incidence of pneumonia and diarrhea among under-5 years children.This study was conducted on 400 children (0-60 months) of whom 209 were male and 191 were female.
In our study, the parents' educational level was low, only 16.25% have school certificate and 51% of the family income was TK.3000-5000 per month which cannot ensure proper health and nutrition to a medium size family (4-5 persons) in our country.Amongst the study population 39.00% of families lived in tin shed house, whereas 26.25% in mud shed and 34.75% had buildings to live in.Most of the study subjects (58.75%) used the sanitary latrines, and 74% of the households use tube well water for drinking; but none of them boil water before drinking.It has been showed that most of the children were full vaccination schedule (86.25%) and 59.25% of mothers give their children colostrums after birth.
Malnutrition affects a large proportion of children under the age of 5 years.In Kushtia, approximately 49% were stunted (height-for-age Z-score < -2 SD), about 51% were wasted (weight-for-height Zscore < -2 SD) and about 47% were underweight (weight-for-age Z-score < -2 SD).In this study 34.25% of children were found to be severe anemic, 40.25% of children were found to be moderately anemic and 25.50% were non-anemic.A great relationship was found between the mother and child health status.About 89.26% of mothers with poor health status have sick child whereas among the mothers with good health, the percentage of sick child was 45.73%.The prevalence of diarrhoea and pneumonia was found 44.50% and 53% respectively.
Diarrhoea occurs in all age groups especially in the developing countries, but highly prevalent among children in the first two years of life (Patwari AK, Manorama Deb and Ridie Duidyaj, 1993).In our study, the maximum prevalence (48.86%) of diarrhea was found in the age of two.The infants aged less than 12-24 months experienced a higher frequency (1.70) of persistent diarrhoea.A high prevalence of persistent diarrhoea among the young infants in our study may be related to the early exposure to heavy microbial load and immaturity of the gut immune system at early infancy.
UNICEF and WHO have estimated that 1.3 million of child deaths could be averted every year if pneumonia prevention and treatment interventions were universally delivered (UNICEF, June 2012).In our study, the higher prevalence (62.72%) and frequency (1.85) of pneumonia was found in under 12 months of age.The prevalence of both diarrhoea and pneumonia was estimated in 38.75%.Our result demonstrated that the prevalence of diarrhea and pneumonia was found higher in less than 0-24 months aged children than that of 48-60 months.But actually, the prevalence of diarrhoea and pneumonia in 48-60 months aged children should be higher because they already passed more time span of their life.Most of the mothers may forget the occurrence of the disease of their earlier days.Our findings underscore the fact that even poor nutrition or marginal malnutrition can predispose children to pneumonia.Anemia also significantly increases the risk of pneumonia in children (Harris et al. 2011).Anemia also significantly increases the risk of pneumonia in children which indicate that anemia might be a risk factor for lower respiratory tract infections including pneumonia; however further studies are needed to confirm this association.
On the basis of the malnutrition-infection cycle described by Scrimshaw and San Giovanni, increased frequency of diarrhea result in poor nutritional status, which in turn predispose to pneumonia.Our results indicated that children with diarrhea were at increased risk of pneumonia.We have identified potentially modifiable factors that may contribute to the high prevalence of pneumonia in the children living in urban and rural areas: anemia, stunting, and low birth weight.The ddevelopment and implementation of effective antenatal and nutritional intervention programs for children and community-based educational programs for mothers are likely to improve

Figure- 1 :
Figure-1: Percent Distribution of Children by Different Categories of MUAC DiscussionThe prevalence of diarrhoea and pneumonia is quite alarming amongst children under 5 years of age who belong to low socioeconomic status.While it is widely recognized that diarrhea and pneumonia are the major cause of morbidity and mortality among children in developing countries, especially in

Table 3 : Distribution of Mother according to Their Age Group, Maternal Nutrition Knowledge and Its Relation with Child Health (Data Collected from Hospital Report/Diagnostic Report)
_______________ Shaikh Shahinur Rahman, Afroza Khatun, Bably Sabina Azhar, Hafizur Rahman and Sabir Hossain (2014), Pediatrics Research International Journal, DOI: 10.5171/2014.805309