Prevalence of wasting and associated factors among 6 to 23 months old children in the Sahel Region of Burkina Faso

Introduction Despite the efforts of nutrition stakeholders in Burkina Faso to improve infant and young child feeding (IYCF) practices, the country is still struggling to stem undernutrition. Wasting, or acute malnutrition, is the form of malnutrition that has the most harmful short-term consequences for children. The objective of our study was to estimate the prevalence of wasting in children aged 6-23 months in the Sahel region of Burkina Faso and to identify its associated factors. Methods We conducted a secondary analysis of data from the 2015 National Nutrition Survey. The factors associated with wasting in the studied population were identified using a logistic regression. Results A total of 956 children participated in the study. The prevalence of wasting was 25% (95% CI [22.28, 27.87]) in the Sahel region. Only 24.37% of children received a minimum meal frequency and 13.38% received a minimum dietary diversification the day before the survey. In the multivariate analysis, being male (aOR = 1.99; 95% CI [1.46, 2.72]), breastfeeding the day before the survey (aOR = 2.43; 95% CI [1.13, 5.22]), and having a history of illness (aOR = 2.32; 95% CI [1.67, 3.21]) significantly increased the risk of acute malnutrition. Conclusion In 2015, the prevalence of wasting among children was high in the Sahel region and good IYCF practices were still inadequate. There is an urgent need to implement good IYCF practices and strengthen interventions to improve infant health in this region.


Introduction
Malnutrition remains a public health concern for developing countries.
The prevalence of different forms of malnutrition (acute malnutrition or wasting, stunting, and underweight) remains high, especially among children under 5 years of age [1]. Malnutrition weakens intellectual capacity, limits productivity in adulthood, increases vulnerability to certain diseases, and is the underlying cause of about 45% of all deaths in children under 5 years of age worldwide [2,3].
Wasting is the type of malnutrition that has the most harmful short-term consequences for children. Child wasting is defined by a weight-to-height ratio less than 2 standard deviations (SDs). It is driven by infectious diseases and an inadequate diet. It is a direct cause of mortality among children under 5 years of age [4]. The prevalence of wasting in children under 5 years old in 2015 was estimated at 7.4% worldwide and 8.9% in West Africa [5]. Despite the efforts of the government and nongovernmental organizations to improve infant and young child feeding (IYCF), wasting among children under 5 years of age remains a concern in Burkina Faso. To obtain reliable and up-to-date data on the nutritional status of children, Burkina Faso's Ministry of Health has annually conducted the National Nutrition Survey (NNS) since 2008. The NNS is carried out according to the Standardized Monitoring and Assessment of Relief Transition (SMART) methodology [6]. The surveys reported a steady decline from 11.3% in 2009 to 8.6% in 2014 in the national prevalence of wasting among children under 5 years of age [6][7][8].
However, the NNS carried out in November 2015, during the harvest period and the drop in the malaria peak, showed a reversal of this trend, with a prevalence of 10.4% [8]. The prevalence in the Sahel region, where the highest prevalence was reported (15.7% in 2015 versus 11.7% in 2014), was above the emergency threshold of 15% set by the World Health Organization (WHO) [7][8][9]. Nutrition stakeholders have sought explanations about the prevalence's peak in 2015. However the risk factors for wasting were still poorly documented in this region of Burkina Faso. The objective of our study was to describe the feeding practices of children aged 6-23 months old in the Sahel region and to identify the factors associated with wasting in 2015.

Methods
Type and period of study: we conducted a secondary analysis of the 2015 NNS data. The 2015 NNS was a cross-sectional study based on SMART methodology with a national coverage [8,10]. Data collected: for our study, we extracted the children's anthropometric (weight and height), sociodemographic (age and sex), food, and clinical data (history of illness through the onset of fever or diarrhea 2 weeks before the survey and deworming with mebendazole). We also extracted mothers' education level. The weight measurement was conducted using uniscale weight scales (also called seca electronic weight scales) with an accuracy up to 100 g. The kilogram (kg) was the unit of measurement used. All of the children were weighed naked. Their heights were measured using a shorr measuring board (in wood) graduated in centimeters and accurate to the millimeter. The centimeter (cm) was the unit of measure. Children under 2 years of age were measured in the supine position. Wasting was defined according to WHO 2006 standards. A weight-to-height z-score (WHZ) less than <2 standard deviations (SDs) was considered as wasting (with severe wasting defined as a z-score less than <3 SDs). The data collected on infant feeding included the following: early initiation of breastfeeding (put to the breast within one hour of birth), the continuation of breastfeeding (breastfeeding the day before the survey), and the food groups Ethical and regulatory aspects: during each NNS, the informed consent of the head of the household is needed to collect the children's data. Each child was assigned a unique number to maintain confidentiality during our study.

Results
In the Sahel region, 973 children aged 6-23 months were included in the 2015 NNS. The anthropometric data were unavailable for 17 children, which led to their exclusion from our analyses. In total, we conducted analyses on 956 children. And 57.9% of children presented a history of illness (fever and or diarrhea) the last 2 weeks before the survey (Table 1).

Sociodemographic and anthropometric characteristics
Factors associated with infant emaciation: in a univariate analysis, deworming, male sex, continued breastfeeding, and history of illness in the last 2 weeks were significantly associated with acute malnutrition in children 6-23 months of age (  Table 3). There was no interaction between the variables.

Discussion
Our study showed a high prevalence (25%) of wasting in children  [24,25]. In fact, the relationship between the continuation of breastfeeding and the infant's height-weight index depends on the quality and the amount of additional food received by the child [26]. However, the MDD and MAD were good in less than 15% of children. This result may be explained by the mothers' misconception about the need to introduce complementary foods at the age of 6 months and by the low access to quality food [25]. The promotion of continued breastfeeding should go hand in hand with improved access to complementary foods and mothers' education about good infant feeding practices. We showed that a history of illness (through diarrhea and/or fever) 2 weeks before the survey significantly increased the risk of emaciation. These results could be explained by inadequate hygiene practices during breastfeeding and during infant feeding. In the Sahel region, in the pastoral zone specifically, the current practice is to feed children with fresh, unpasteurized animal milk. This practice may transmit pathogens to the infant, leading to diarrheal diseases, which have a direct effect on the infant's nutritional status [24]. Additionally, the population of the arid Sahel region has difficulties accessing drinking water. Thus, a study carried out in Bamako, Mali (also in the Sahel region), demonstrated the association between hygiene practices, access to drinking water, and child malnutrition [17].
In our study, we did not show a statistically significant association between the indicators of IYCF (MDD and MMF) and wasting. This lack of association has been reported by previous studies [25,[27][28][29][30][31].
This result may be explained by the high frequency of misclassifying an adequate diet when administering the IYCF questionnaire. The simplicity of the WHO IYCF indicators might simplify the complexity inherent in children's complementary feeding. Thus, the IYCF indicators may miss some contextual facts and therefore lack specificity [27]. For example, an infant received the equivalent of a teaspoon of rice with a palm oil sauce containing a small piece of fish.
Is it sufficient to consider this meal as one containing 4 food groups; cereals, nuts, vegetables rich in vitamin A, and meat products consumed by the child? If that is the case according to the respondent, the indicators will not properly express the quantity and quality of the food consumed and will lack specificity. There is a need

Conclusion
Our study showed that during the 2015 NNS, the prevalence of wasting in children aged 6-23 months was higher in the Sahel region than in others. Additionally, it showed that several factors were associated with the growth of children. Our results suggest that despite the IYCF promotion programs, good IYCF practices were not sufficient there. There is an urgent need to implement good IYCF practices and strengthen interventions to improve infant health in this region. It is important to evaluate the real effectiveness of IYCF awareness activities on mothers' practices when feeding their children. 84.2 % = Percent; SD = Standard Deviation *Good= Breastfed children who received solid, semi-solid or soft foods the at least two times for children 6-8 months and three times for children 9-23 months the day before the survey, and non-breastfed children 6-23 months who received solid, semi-solid or soft foods or milk feeds at least four times per day. 0.09 n = number of wasted children; N =Total; OR = Odds ratio; CI95% = 95% confidence interval; p = degree of significance; *: Value with a significant p (below the threshold of 0.05) 0.05 n = number of wasted children; N =Total; aOR= adjusted Odds Ratio; CI 95 % = 95% confidence interval; p = degree of significance; *: Associated value after adjustment in the final multi-variate logistic model; Adjustment in the final model was done on sex, continuation of breastfeeding and illness (diarrhea and fever) the last 2 weeks before the survey. There was no interaction.