Under nutrition and Associated factors among infants and young children age 6-23 months attending Minilik II Hospital, Ethiopia, 2021.

Globally, 47 million children young age were wasted, 14.3 million are severely wasted and 144 million are stunted. Around 45% of deaths among children are linked to undernutrition. The impact undernutrition is more severe among children age 6–23 months as this period is critical for child development, and irreversible damages can occur due to nutritional deciencies. Hence aimed to assess magnitude of under nutrition and associated factors among infants and young children age 6–23 months attending Minilik II hospital, Addis Ababa, Ethiopia. Hospital based cross-sectional study was conducted among 377 Infant and young children age 6–23 months were selected using simple random sampling method. Data was collected using face-to-face interview with family and anthropometric measurement was taken. The anthropometric measurements of children were evaluated using WHO standard Antro software. Descriptive statistics was used to describe the characteristics of study population. Logistic regression was tted to identify factors associated with under nutrition. The study revealed about 34.1% of young age children were under nutrition while 28.8% of them stunted, underweight 10.2% and 4.7% of them were wasted. Working condition of 95% education status of the mother household rent (AOR 95% illness/disease (AOR inappropriate complementary feeding (AOR = 3.10, 95% breast receiving vitamin A (AOR = 0.17, 95% CI: 0.08–0.34) and growth monitoring (AOR = 0.288 at 95% CI (0.14–0.58) were found to have statistically signicant association with children under nutrition.


Introduction
Undernutrition continues to affect the lives of millions of children and women worldwide and every country is affected by some form of nutrition problem (1). Globally, 47 million children young age were wasted, 14.3 million are severely wasted and 144 million are stunted and mostly occur in low-and middleincome countries (2).
About half of all stunted children lived in Asia and over one third in Africa and approximately two thirds of all wasted children lived in Asia and almost one third in Africa, with similar proportions for severely wasted children (3). At least one in three children is not getting the nutrition they need to grow well, particularly in the crucial rst 1,000 days -from conception to the child's second birthday -and often beyond(4).
Young age children undernutrition continues to be the leading public health problem in developing countries (5). Africa has experienced the smallest relative decrease, with underweight from 23-17%. This means Africa was likely fall meet the MDG, reaching about only half of the targeted reduction (3). Africa has one of the highest levels of child undernutrition, Stunting was highest in Burundi (57.7%) and Malawi (47.1%) in East Africa; Niger (43.9%), in West Africa; Democratic Republic of Congo (42.7%), Chad (39.9%) in Central Africa and Ethiopia (8.70%) in East Africa (6).
In Ethiopia, from the year 2005 to 2016, there is a decrease in stunting from 47-39%, but the prevalence of wasting changed little over the same time period (11-10%) (7). Undernutrition among young children was one of the public health problems in Ethiopia. The prevalence of stunting, wasting, and underweight were 38.3%, 10.1%, and 23.3%, respectively (8). About 19.47% of children were both stunted and underweighted, and only 3.87% of children had all the three conditions(8).
In Addis Ababa, the prevalence of malnutrition and classi es it according its degree which is 55.1%, 57.7% and 49.26% measured with weight for age, weight for height and mid upper arm circumference respectively (9).
Poor nutrition in the rst 1,000 days of a child's life can lead to stunted growth, which is irreversible and associated with impaired cognitive ability and reduced school and work performance(10). Under nutrition may be a consequence of energy de cit or micronutrient de ciency. It is considered the most relevant risk factor for illness and death, particularly in developing countries like Ethiopia (11).
Inadequate nutrition during the rst two years of life may lead to childhood morbidity and mortality, as well as inadequate brain development (12).
Infants and children undernutrition remains one of the major public health problems in many parts of the world, especially in a developing country, in which young age children are more vulnerable group to undernutrition (13).
The developmental, economic, social, and medical impacts of the global burden of undernutrition are serious and lasting, for individuals and their families, for communities and for countries (2). As recent report indicates Around 45% of deaths among children young age are linked to undernutrition (2). Similarly, In Ethiopia, undernutrition is a leading cause of child illness and death (5).
According to 2018 global nutritional report undernutrition was major bottlenecks for economic development (14). The study on economic impact of disease-related undernutrition at hospital admission determinants of cost deviation shows that the cost of treating a nutritionally-at-risk patient is 20% higher than the average of the respectively (15).
The hospital staying of undernourished young age children is long when compared with well-nourished. But also, incidence of complication and high-cost hospitality that has an impact directly or indirect on economy and other crisis on the family(16).
Undernutrition puts children at greater risk of dying from common infections, increases the frequency and severity of such infections, and contributes to delayed recovery due to potentially decrease immunity(10-11). Additionally, the interaction between undernutrition and infection can create a potentially lethal cycle of worsening illness and deteriorating nutritional status(10).
Inappropriate complementary feeding practices among children aged 6-23 months is major cause of under nutrition (17). Breast feeding, sociodemographic condition, hygiene of food are also most At hospital under child health service growth monitoring and screening nutritional status service are the major nutritional concern service.

Study design
Hospital based cross sectional study was conducted through quantitative approach.

Source of population
All infants and young children age 6-23 months who come to hospital for different services.

Study population
All Infant and young children 6-23 months whose tted inclusion criteria but not excluded by exclusion criteria.

Inclusion criteria
Infants and children between 6-23 months those come to hospital during data collection period. associated factors with undernutrition of young age group children(18).
The impact undernutrition is more severe among children age 6-23 months as this period is critical for child development, and irreversible damages can occur due to nutritional de ciencies (19). For instance, undernutrition lacking brain development that lead to lack of attention (poor attention span), reducing academical performance and lowering the IQ level of the children (20). Generally, undernutrition can reduce physical (growth), mental and social development of young age children (21).
The consequence of the problems can affect the children, the family and the development of the country by lowering growth domestic product, economic level, complicating health service when aggregated and complicated.

Exclusive criteria
Children or infants or mothers/caregiver who were critically sick and in life threaten situation and unable to talk or hear.
Children having physical disabilities that can interfere the anthropometric measurement.
The infants or children who known as undernutrition and held in treatment of clinical nutrition to avoid exaggeration of result.

Sample size determination
The sample size (n) required for the study was calculated using the formula to estimate a single population proportion by considering the following assumptions.
Zα/2 = critical value for normal distribution at 95% CI to 1.96 (Z value at alpha = 0.05). According to the study conducted in 2019 at Tigray region was about 33.7%, 15.7% and 4.8% of young children were stunting, underweight and wasting respectively (22). The sample was calculated by double population proportion through online web (www.openinfo.com) by considering power (1-β) that is 80%, signi cance level(Zα/2) that is 0.05 since 95% CI, allocation ration (exposed to unexposed) that is equal ration 1:1 was taken and effect size(proportion) was taken from community based cross-sectional study conducted in Ethiopia near Dabata (23). Finally, the obtained sample and odd ration was presented in Table 1. Therefore, our largest sample was the sample size calculated for stunting it was 377.

Sampling Technique
The sample was collected for 25 days, more than 30 under two years come to hospital every day. To cover 377 sample within 25 days, more than 15 children were selected from expected department. So, half of children were included every day by lottery method. There three departments to expected to serve the children, immunization departments serve more than 50 children means more than 8 children per day.
Among those 8 children 4 children were selected by lottery method (rolled paper coded with 0(off) and The proportion of children aged 6-23 months who received 4 or more food items among the seven food groups (24).

Diarrhea
Children with a history of ≥ 3 times loose stool or watery diarrhea per day for two weeks prior to the study (24).

Stunting
Length for age < − 2SD of the WHO growth standard(24).

Underweight
Weight for age less than − 2SD of the WHO growth standard (24).

Wasting
Weight for length < − 2SD of the WHO growth standard (24).

Under nutrition
According to this study, any children recording one or more measurement indices less than − 2SD of Length for age, weight for age or weight for length against WHO growth standard is considered as undernutrition.

Data collection tools and methods
Data were collected using structured questionnaire that adapted from FAO (2016) for socio-demographic and nutritional related data.
Data were collected by trained data collectors through face-to-face interview with family or care giver of candidate infants and young children. The length of a child was measured using a horizontal wooden length board in recumbent position, and read to the nearest 0.

Data Quality control
To ensure quality of data questionnaire was translated to local language (Amharic) and back translated to English for consistency by expertise for clarity. Training was given for data collectors and supervisors on the purpose of the study, methods of data collection, how to take anthropometric measurements and ensure ethical issues. Overall work of data collection procedures and process was followed by investigator. Pre-test was done on 5% sample out of the study area. Necessary correction was made based on the result of pretest data analysis. Data were checked and then lled in to epidata software since the software has pre-set rule to reduce error.

Data processing and analysis
Data were checked for completeness and consistencies and then it was cleaned, coded, and entered using Logistic regression was tted to identify the association between dependent (under nutrition) and independent variables. The analysis was conducted to select candidate variables to the initial multivariable model. Those variables that show association with under nutrition at a p-value less than 0.2 was included in an initial multivariable logistic regression model. Both crude and adjusted odds ratios with their corresponding 95% con dence interval was used to determine the strength of association.
Assumptions of logistic regression was checked before nal multivariable analysis using probability Bivariable graph and collinearity diagnostic (Variance in ation factor and correlation matrix

Feeding practice of mothers/caregiver of infants and young children
Of the total, 292(80.9%) of the mothers were currently feeding breast their children and 296(82%) of mother used bottle feeding. 280(77.6%) of mothers feed their child by appropriate frequency, feeding amount 279(77.3%) and 174(48.2%) of mothers feeding appropriate type of food with respect to their age.
199(55.1%) of children were not feed appropriate complementary feeding. 251(69 children were feed by their mothers or caregiver and only 6(1.7%) of children were feed by their fathers. 266(59.8%) of children were received vitamin A supplements during past six months (Table 3).

Food hygiene and safety practice of mother/caregiver
Based on self-report of mothers/caregiver of children, 361(100%) all mother/caregiver wash their hand before give meal for child but only 181(50.1%) of them wash their hand by soap. 336(93.1%) mother/caregiver give fresh and home prepared food for their child (Table 4).   (Fig. 2).

Factors associated with under nutrition among infant and young children
Bivariable logistic regression was conducted to select candidate variables with P value less than 0.2. In Bivariable analysis working condition of mother, educational status of mother, living in rent house, bottle feeding, appropriate meal frequency, appropriate feeding amount, Food variety, appropriate complementary, Receiving Vitamin, a Growth monitoring, currently on breast feeding and Sickness were associated with outcome variable at P value less than 0.2. Accordingly, all the twelve variables were included in the initial multivariable logistic regression model, which eight of the were found to have independent and statistically signi cant association with dependent variable at 5% level of signi cance.
The working condition of the mothers was found to be statistically  (Table 6).
Wasting is acute form of under nutrition by measuring weight with respect to length of the children, 4.7% (at 95% (CI 2.4-7.4%)) of young age children were reported as wasted. The report was agreed with study conducted in Tanzania(26) and was very less when compared with study conducted in Nigeria (25) and Tigray region (27), while nearest to the study conducted and nearly half of study conducted in India (23).
The variation may be due to geographical variation or economic status of the community.
The prevalence of undernutrition was high among male children (37.1%) when compared with female (30.5%). Similarly stunting (30.5%) and wasting (14.2%) also high among male when compared with female 26.8%, 5.5% respectively. This nding is relatively consistent with study conducted in Tigray region (29). In contrast, children 12-23 months were more under nourished and wasted while children 6-11 months were more underweight.
Working condition and educational status of the mothers were signi cantly associated with under nutrition. Employed mother were far from their child during working hours that had potential to reduce feeding practice of children and care. In this study children from employed mothers were six times more likely being undernutrition or half of children from employed mothers were under nutrition. This nding is consistent with study conducted in Ethiopian government hospitals(18).
Educational status was found to be associated factor of child undernutrition. in this study maternal illiteracy was increasing odd of children undernutrition. This nding was consistent by increasing odd with study conducted in Ethiopa (18) and Tanzania (25).
Appropriate complementary feeding is including, appropriate time, appropriate amount, appropriate frequency, appropriate type and safe food. Inappropriate complementary feeding was another factor that odd of under nutrition. In this study the children who did not feed appropriate complementary were three times more likely to being undernutrition. this nding is consistent with study conducted in Burkina Faso (26), Nigeria (25), Tanzania (27) and East Ethiopia Somali region (12).
Micronutrient supplementation another important predictor for undernutrition. in this study children received vitamin A supplement within past six months were less likely undernutrition. This nding was consistent with report of study conducted East Belesa District, northwest Ethiopia (29).
Breast feeding another important predictor of children undernutrition. in this study Currently on breast feeding was decreasing odd of undernutrition while not breast feeding was increasing odd by 3.9 times.
This nding of study were agreed with study conducted in Tanzania which is breast feeding were increasing odd by 3.7(29) (30) and consistent with study conducted in East Ethiopia(Somalia region) (12). Another study conducted in Ethiopia also showed short duration of breast feeding increase odd of under nutrition (31).
Disease condition increase odd of under nutrition. In this study sick children were 5.6 times more likely being under nutrition while health children were less likely under nutrition. This nding was agreed with report of study conducted in Burkina Faso (34) and Granada, Nicaragua (35). In this report most prevalent disease were diarrhea, cough and fever as like as study conducted in Granada,Nicaragua. This nding indicated 77.8% of children infected with diarrheal disease and 71.4% of children infected with respiratory disease were under nutrition. This indicated how disease increase the risk of undernutrition. this nding was consistent with study conducted in Ethiopia (28), (29).
Living in rent house is found to be another predictor, this may be related with economic why because the report indicated 24.4% of household living in rent house were exhausted to buy food due to over payment for rent house. In this study the children from household living rent house were three times more likely to being undernutrition.
Growth monitoring an important program which used to monitoring the nutritional status of children from time to time. This variable is not addressed by many studies. In this study growth monitoring were found decreasing odd of children under nutrition and children who did not hold under the program were 3.4 times more likely being under nutrition.

Conclusion
The magnitude of undernutrition found to be high, particularly the magnitude of stunted was higher than previous ndings. Working condition of mothers, educational status of mothers, living in rent house and disease condition were found to be increasing odd of undernutrition while Appropriate complementary feeding, receiving vitamin A, growth monitoring and Breast feeding were reducing odd of undernutrition.

Recommendation
Health education and promotion are important for mothers and caregiver to improving concept of nutritional status, young age feeding practice and food safety. Receiving vitamin, A supplements based on program and growth monitoring of children at health facilities is suggested. Appropriate complementary feeding after 6 months and optimum breast feeding until two-year age are recommended. Necessary strategy and program are needed to solve the problem raised with undernutrition. Further investigation is suggested by considering qualitative data and variables not considered by many studies like renting house and etc.

Declarations
Ethical clearance was taken from Addis Ababa public health research and emergency directorate after request letter obtained from Rift Valley University Abichu Compus. Permission letter was taken from Minilik II hospital administrative o ce. The informed consent was obtained with family of infants and children. The collected data was intended only for the purpose this study. No right or bene t taken away from non-response family because of they refuse to response.

Consent for Publication
'Not applicable'.

Availability of Data and Materials
The nding of this study is generated from the data collected and analyzed based on stated methods and materials.
The original data supporting this nding are available from the corresponding author on reasonable request.

Competing Interests
The authors declare that they have no competing interests.

Authors' Contributions
Lelisa Worku, Desta Asse e, participated in the design of the study, performed the data collection and the statistical analysis and served as the corresponding author of the manuscript. Dube jara give constructive advice, assist analysis and interpretation of the data. Addisu Tadesse supervised the study, ensured quality of the data All authors read and approved the manuscript.
Authors' Information LW is Nutritionist, Nurse professional and chief medical laboratory technician at private sector, Lega Tafo, Oromia region, Ethiopia.
DA is nutritionist and Senior nurse professional at Menelik II hospital, Addis Ababa, Ethiopia.
DJ is PhD candidate and vice dean of postgraduate at Rift valley university, Addis Ababa, Ethiopia.
AT is senior nurse professional and TB focal person at Kimbibit Woreda Health o ce, Oromia region, Ethiopia. Magnitude of under nutrition among infants and young children age 6-23 months attending Minilik II Hospital, Ethiopia, 2021.