Association of Undernutrition with Acute Diarrhoea and Recent Hospitalisation Among Primary School Children in Nnewi, Southeast Nigeria

Background: Undernutrition is a major predisposing factor to common childhood infectious diseases. It contributes to about half of the deaths of children worldwide, especially in low-income countries. The prevalence of childhood undernutrition is still high despite implementing informed and directed interventional strategies. It is plausible some important aetiological factors may not yet be in focus. Objective: To explore the relationship between acute diarrhoea and a history of recent hospitalisation for common childhood diseases and undernutrition. Methods: This observational, cross-sectional study was conducted on 244 primary school pupils aged 6-12 years in Nnewi, southeast Nigeria. Socio-demographic and other relevant clinical details related to recent diarrhoeal episodes and hospitalisations were collected using an interviewer-administered questionnaire. The anthropometric parameters were used to determine the nutritional status using the World Health Organization (WHO) growth charts. Results: More than half (133; 55.3%) of the participants were males, and most (106; 43.5%) belonged to the low socio-economic classes (SEC). More than half (135; 54.5%) were aged 6-8 years. Low SEC, acute diarrhoea and hospital admission in the preceding six weeks were significantly associated with undernutrition (p <0.001). Conclusion: Acute diarrhoea and recent hospitalisation in the preceding six weeks were associated with undernutrition among primary school children in Nnewi, southeast Nigeria. Prompt treatment of acute diarrhoea to reduce its duration and prevention of common ailments that lead to hospitalisation may help reduce the incidence of childhood undernutrition.


Introduction
According to the World Health Organization (WHO), undernutrition is defined as deficiencies of macro and micronutrients that result in childhood underweight, stunting, wasting and micronutrient deficiencies. 1Undernutrition contributes to more than half of childhood deaths worldwide, especially in low-income countries. 2,37][8][9] According to WHO, acute diarrhoea is caused by poor personal and food hygiene and various levels of nutritional negligence, which are predominant in developing countries, Nigeria inclusive. 10Acute diarrhoea disease leads to increased catabolism, nutrient sequestration, malabsorption and decreased nutrient intake.Therefore, this disease increases the incidence of undernutrition through a predisposition to negative energy balance with increased loss of both macro and micronutrients needed for adequate growth and development. 10,11spitalisation refers to allowing an ill individual to stay in the hospital to access medical care for any disease or ailment. 12,13Hospital admission is a known risk factor for childhood undernutrition as increased metabolic demand caused by the disease state on a sick child with associated reduced dietary intake predisposes to undernutrition. 14,15This can further worsen a child's nutritional status with a predisposition to undernutrition. 15The common ailments that can lead to hospitalisation in children include fever with diarrhoea, fever with cough/catarrh, fever with micturitional pain, and fever with convulsion/loss of consciousness.

14,16
Furthermore, the duration of hospital stay may also worsen a child's nutritional status, as longer hospital stay portrays the severity grade of the ailments, with its known adverse sequelae on nutritional status. 17evious studies have established chronic childhood diseases like tuberculosis, 18 HIV/AIDS 19,20 and childhood cancer, 21 as major risk factors of undernutrition.Surprisingly, the menace of childhood undernutrition is still high in our setting despite implementing dietary and chronic disease-related interventional strategies for childhood undernutrition. 22Also, the school feeding program in the public schools was instituted as part of interventions for childhood undernutrition. 23 -25e WHO reported that acute diarrhoea with other acute childhood diseases is responsible for up to one-third of global childhood undernutrition and, consequently, death. 26,27 he Low-and Middle-Income Countries (LMIC) carry a disproportionately high share of this global burden. 28,29 herefore, the need to determine the association of acute diarrhoea and recent hospitalisation with childhood undernutrition is germane.This study examined the relationship between acute diarrhoea, duration of acute diarrhoea, recent hospitalisation, hospital stay and undernutrition among school-aged children in Nnewi, southeast Nigeria.

Study Site
The study was conducted in Primary Schools in the Nnewi metropolis.Nnewi is the second largest city in Anambra State, southeast Nigeria. 30Nnewi metropolis comprises four autonomous communities: Otolo, Uruagu, Umudim and Nnewichi. 30As of 2006, Nnewi has an estimated population of 391,227, according to the Nigerian census. 30The city spans over 2789Km 2 . 30Trading and farming are the major occupations of the indigenes of Nnewi.At the same time, a few are civil servants. 30,31 ach of the four autonomous communities in Nnewi has about two to three of each of the public and private types of primary schools, respectively.

Study Population
The study population included six-to twelveyear-old primary school pupils in Nnewi, southeast Nigeria.

Study design
The observational, cross-sectional study consecutively recruited 244 primary school pupils who met the inclusion criteria.The participants were selected using a multi-stage sampling technique.Children with known risk factors of childhood undernutrition, such as poor dietary intake, those from large family sizes, those who were not immunised, and those who had not been dewormed in the past six months of the data collection, were excluded from the study.Also, children with known chronic diseases, such as chronic kidney disease, chronic diarrhoeal diseases, sickle cell disease, congenital malformations, childhood cancers, seizure disorders and other diseases that, by their nature, may contribute to undernutrition, were excluded from the study.Similarly, childhood diseases that may be predisposed to frequent hospital visits and or hospitalisation were excluded from the study.Children who were overweight or obese were also excluded from the anthropometric measurements.Furthermore, children whose parents were not available to provide the required information during the periods of data collection were also excluded from the study.

Sample size determination
The sample size was calculated using the formulae for cross-sectional, observational studies thus: n = z 2 pq/d 2 . 32,33 ere: n = The desired minimum sample size when the population exceeds 10,000.z = The standard normal deviation, usually set at 1.96.p = The proportion in the target population estimated to have a particular characteristic.The prevalence of normal-weight primary school children in Anambra state was 85.2%, so the prevalence of malnutrition among these children was 14.8%. 34Therefore, q = 1.0-p; q =1.0-0.148= =q =0.852.d = degree of desired accuracy set at 0.05.
Therefore n = (1.96) 2 x 0.148x 0.852/ (0.05) 2 n = 194.Since some children selected for the study may not agree to participate, so a response rate of 80% was allowed.The adjusted sample size (Ns) was = n/0.8. 33ns= 194/0.8= 243.The minimum sample size for this study was 243, but 244 participants who met the eligibility criteria were included in the final data analysis.

Ethical considerations
Ethical approval was obtained from the Ethics Committee of Nnamdi Azikiwe University Teaching Hospital, Nnewi, with reference number CS/66/Vol.11/132/2018/067,before the commencement of the study.The study procedure was revised per the institution's ethical standards, and the Helsinki Declaration of 1975. 35ermission was obtained from the Ministry of Education in Anambra State (Anambra State Universal Basic Education Board-ASUBEB) before the commencement of the study.Written informed consent was obtained from the School Parent Teacher Association and parents/caregivers of each participant before recruitment into the study.Also, written informed assent was obtained from the participants aged seven years or more before enrolment into the study.The parents/caregivers of the identified malnourished children were engaged in nutritional counselling sessions on the need for immediate nutritional rehabilitation.In contrast, the malnourished children were referred to the Paediatric Gastroenterology/ Nutrition Clinic in Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, for appropriate management and follow-up.

Sampling technique
The participants were selected using stratified multistage sampling methods: the 302 primary schools in Nnewi comprised 30 public schools and 272 private schools with a ratio of 1: 9.
For convenience, ten primary schools were selected from the 302 primary schools sampling frame, in the proportion of 1:9 (public -to private).In stage one of multi-stage sampling, one and nine private primary schools were randomly selected from 30 public and 272 private primary schools. 36n stage 2, the number of participants drawn from each of the selected ten primary schools was determined using a proportionate stratified sampling allocation formulae as follows : 37 (Total population of index school/ Total population of all the selected schools) × Calculated sample size For adequate representation of the different age groups, the allocated sample size for each of the selected 10 primary schools was equally divided among the six grades of each school (stage 3).The allotted sample size for each grade was also divided equally among the number of classes in each grade (stage 4).The number of participants allotted to each class was selected from the class register by a simple random method until the required number of participants for each class had been chosen (stage 5).Participants were identified by codes, and the school record of birth certificates was used to establish the age of each participant.

Data Collection
Three research assistants (Health workers) were involved in data collection following training by the investigator.During data collection, the parents/caregivers of the selected participants were met individually after school dismissal for data collection as they arrived to take their wards home.
A pre-tested, standardised, semi-structured questionnaire was used to obtain the required information.The questionnaire was intervieweradministered, and the following data were collected: age, gender, parents/caregivers occupation and the highest level of education for socio-economic classification using Oyedeji's method. 38The research assistants participated in administering questionnaires and measuring anthropometric parameters.The height and weight measurements were used to derive each child's nutritional status using the WHO growth reference charts for school-age children and adolescents. 39The nutritional status included stunting, defined as Height for Age Z score (HAZ) <-2, wasting defined as BMI for age Z score < -2, underweight defined as Weight for Age Z score (WAZ) <-2 and normal nutritional status, defined as Weight for Age Z-score between > -2 and < +2. 40,41 ormation concerning the occurrence of diarrhoea, including the duration of the illness, in the preceding six weeks was obtained.The hospitalisation details for childhood diseases/ailments were also documented in the prior six weeks.This was confirmed by sighting the child's hospital admission cards.The researcher conducted a thorough clinical physical examination to identify the presence/absence of signs of undernutrition.

Weight measurement
The body weight was measured according to WHO protocol for weight measurement using a sensitive Medical flat weighing scale. . [42]The scale was placed on a flat surface and adjusted to zero before every measurement.Body weight was measured without shoes, but the child was allowed to wear light clothing.The weight of each child was measured twice to the nearest 0.1kg, and the average was recorded for each child.The weighing scales were calibrated using two standardised objects weighing 10kg and 20kg each day prior to data collection.The height was measured according to WHO protocol using a standardised portable wallmounted stadiometer. 43each child's height was taken without footwear or head covers.Each child usually stood with hands hanging at their sides, with the back of the head, heels together, buttocks and shoulders all leaning against a wall, with a horizontal line of sight.The headpiece was lowered from the top to the head, compressing the hair to make contact with the scalp, and the reading was taken when the respondent took full inspiration.The reading was recorded to the nearest 0.1cm.The stadiometer was standardised after every five measurements using a one-meter length ruler.

Data analysis
All completed questionnaires and proforma were coded before entry into the Statistical Package for Social Science (SPSS) software version 21.0 Windows for analysis.Frequencies and percentages were used to summarise categorical variables.The outcome variable was undernutrition, classified as underweight, stunting, or wasting.It was compared with normal nutritional status in terms of its association with each of the independent variables.Categorical variables were tested for association with undernutrition (dependent/outcome variables) using Pearson's Chi-square test (or Fisher's Exact test where appropriate) for bivariate analysis.Probability p-value <0.05 was considered statistically significant.

Results
A total of 272 eligible children were enrolled into the study, but only the 244 children with complete data were analysed.The socio-demographic characteristics of the children are shown in Tables Ia to Ic.One hundred and thirty-three (54.5%) were males, while 111 (45.5%) were females giving a male-to-female ratio of 1.1:1.Majority belonged to the lower SEC (106; 43.4%), and more than half (135; 55.3%) were aged 6-8 years.The age distribution of the participants had right (positive) skewness with the median age of 7 years.

Socioeconomic class (SEC)
Table II shows that most of the children with undernutrition belonged to the low SEC (45; 56.3%).The influence of SEC on the occurrence of undernutrition was 19.6% (p = 0.009).
Children from low SEC were nine times more likely to have undernutrition than children from higher SEC.

Association of acute diarrhoea and hospitalisation with childhood undernutrition
In Table III, 76 (95%) of children with undernutrition had a recent history of diarrhoea with statistical significance (p<0.001).Diarrhoea lasted for one to three days in most of the participants (57; 71.3%), and this was also significantly associated with undernutrition (p<0.001).Fifty-seven (71.3%) children with a recent history of hospitalisation had undernutrition, and this accounted for 47% of all children with undernutrition (p<0.001).

Discussion
This study aimed to determine the association of acute diarrhoea and recent hospitalisation with undernutrition among school-aged children in Nnewi.From this study, a recent acute diarrhoea was associated with undernutrition.This is similar to the reports by Bantamen et al. in Ethiopia, 44 Wong et al. in Malaysia, 45 Abera et al. in Ethiopia 46 and Owoaje et al.in Ibadan, Nigeria . [47]From the current study, children with acute diarrhoea had higher odds of developing undernutrition, unlike the finding by Abera et al. in Ethiopia. 46This difference may be due to the differences in the methodologies adopted.This present study focused on the occurrence of acute diarrhoea in the preceding six weeks; this period is long enough for the manifestation of the effects of diarrhoeal disease on the child's nutritional status.On the other hand, Abera et al. noted the occurrence of acute diarrhoea two weeks before the study.In addition, the present study was done among older children who were able to recall the history of acute diarrhoea in the past six weeks and the duration of the diarrhoea before resolution, unlike in under-fives that are totally dependent on the caregivers. 48e pathogenesis of diarrhoea-induced undernutrition could be explained by negative energy balance from increased metabolic demand and increased nutritional loss from diarrhoea, which was not adequately compensated by nutrient intake.Most ill children usually have anorexia, limiting their nutrient intake during ill health.Also, decreased nutrient absorption due to the loss of absorptive surface from the erosion of the villi/ epithelial lining of the intestine by the infective agents of diarrhoeal disease may be contributory.Furthermore, there is a bidirectional relationship between diarrhoea and undernutrition; while diarrhoea can result in undernutrition and electrolyte imbalance, malnourished children are also more predisposed to diarrhoea. 49,50om the present study, the history of recent hospitalisation was associated with undernutrition.These children were 53.8 times more likely to develop undernutrition.This result was similar to Quadros et al. 51 and Lee et al. 52 The illnesses warranting hospitalisation in the present study were gastrointestinal and respiratory.Owoaje et al. found similar symptoms among children in Ibadan, southwest Nigeria. 47Similar findings were reported from Ethiopia by Gelu et al., 53 Bantamen et al. 44 and from Botswana by Etienne et al. 54 In variance to this finding, Abera et al. 53 noted that children with childhood illness were 59% less likely to have underweight than those who were not ill.The duration of the disease could account for these differences.This study noted the presence of childhood illnesses requiring hospitalisation in the preceding six weeks, which is longer and enough for the full manifestation of the disease severity on a child's nutritional status, unlike the two weeks adopted in the study done by Abera et al.Furthermore, this study noted that these childhood illnesses were severe enough to require hospitalisation.This is because severe childhood illness usually mounts increased metabolic demand, causing a deficit in the child's energy store. 55When the child cannot replenish energy deficit following associated anorexia that usually occurs in such a situation, undernutrition becomes inevitable. 38lso, the managing medical team may not have made provisions to take care of the increased energy demand of a sick child and replenish it by increasing the total energy Recommended Daily Allowance (RDA) for a hospitalised ill child. 46is study also found that the commonest symptoms necessitating hospital admission were fever, vomiting, and diarrhoea, followed by fever and convulsion.Therefore, there is a great need to intensify the campaign on preventing and promptly managing acute childhood illnesses characterised by fever and diarrhoea to help mitigate their contributions to childhood undernutrition.Limitation A longitudinal study would have been more helpful in establishing causal relationships between recent diarrhoea, recent hospitalisation for an acute illness, and nutritional status.Recall bias was also a major limitation of the present study.However, this was averted to a reasonable extent by making it mandatory that the parents/caregivers were present during data collection and with the hospital card of their ward(s).

Conclusion
Acute diarrhoea and a history of hospitalisation in the preceding six weeks may be associated with undernutrition among school-aged children in Nnewi, southeast Nigeria.It is expected that the longer the duration of acute diarrhoea and the longer the duration of hospitalisation, the higher the risk of childhood undernutrition.Parents should be encouraged to bring their sick wards early to the hospital for immediate intervention to limit the impact of the illnesses on their nutrition.Hospital administrators and healthcare providers should ensure adequate total energy requirements for the hospitalised sick child to limit the negative effect of energy deficit on nutritional status.Health education should focus on preventive measures for acute diarrhoeal diseases and other common childhood illnesses.

Association of Undernutrition with Acute Diarrhoea and Recent Hospitalisation Among Primary School Children in Nnewi, Southeast Nigeria ©Niger
J Paediatr.Volume 51, Issue No. 2, 2024_____________________________________________119