ASSESSMENT OF THE FEEDING PRACTICES VITAMIN A IRON ZINC AND ANTHROPOMETRICS STATUS OF UNDER FIVE CHILDREN IN ORPHANAGES OF FEDERAL CAPITAL TERRITORY ABUJA NIGERIA

ABSTRACT

The study was undertaken to assess the feeding practices, anthropometric indices, vitamin A, zinc and iron status of under-five orphans living in Federal Capital Territory orphanages, Abuja. A cross sectional descriptive study was conducted using 200 orphans (96 males and 104 females) aged between 0-5 years living in ten orphanages. The subjects were purposively selected for the study and 20% of sub-sample was randomly selected for biochemical analysis and weighed food intake assessment. Haemoglobin (Hb) and serum ferritin were used to assess anaemia and iron status, respectively. Serum retinol was used to assess vitamin A status and serum zinc was used to assess zinc status. The subjects were screened for malaria parasites and worm infection to determine their possible impact on anaemia. C-reactive protein (CRP) was used as an indicator for inflammation. Anthropometric information was assessed using height, weight and mid upper arm circumference. Feeding practices and socioeconomic information were assessed using questionnaires. Dietary intake was determined  using both food frequency questionnaire and weighed food intake techniques. The values obtained from nutrient intakes were compared with FAO/WHO recommended nutrients intake. Anaemia cut off was Hb < 11.0mg/dl, iron deficiency cut off was serum ferritin levels below 12ug/dl and serum retinol < 20µg/dl showed marginal vitamin A deficiency. Zinc deficiency was defined as a reading bellow 80µg/dl. There was high prevalence of zinc deficiency (60.0%) in relation to 30.0% of iron and 20.0% of vitamin A deficiencies among the under-five children. The prevalence of anaemia was 42.5%.  The children met the mean daily energy, protein, calcium, iron, thiamin and riboflavin intake. Zinc, vitamin A, niacin and ascorbate were below the recommended allowance. When dietary iron, zinc and vitamin A intake were correlated with the biochemical status of the children, adequate dietary iron intake significantly (P<0.05) correlated with good ferritin and zinc status of the children.

Inadequate dietary zinc intake was significant (P<0.05) and correlated with inadequate zinc and ferritin status of the children. Adequate dietary zinc intake was significant (P<0.05) with serum zinc  status.  Adequate  dietary  vitamin  A  intake  reflected  significantly  (P<0.05)  with  serum retinol. Inadequate vitamin A intake significantly (P<0.05) correlated with serum zinc. The study recorded a low prevalence (7.5%) of inflammatory disorders. Malaria parasite and worm infestations were also low in the children (12.5% and 10.0%, respectively). Anaemia was significantly  associated  with  helminthes  infestation  as  well  as  malaria  parasite.  The  study showed that the caregivers practiced a faulty feeding practice. The under-five children were feed infrequently as against the recommended frequency of meal feeds across various age groups. The children were not fed “responsively”. About 45.5% of the children were underweight. About 63.5% of the children were stunted and 47.5% were wasted. These deficiencies were associated with poor feeding practices, low caregiver to child ratio (1:5) and low socio-economic status. The study shows that protein energy malnutrition and micronutrient deficiency are still of public health important in Nigeria.

CHAPTER ONE

1.0       INTRODUCTION

1.1 Background to the study

‘Today’s children are tomorrow’s leaders’. This slogan is raising a massive wave of concern throughout the world. However,  children all over the world  are deprived of many facilities.  Children  need  various  types  of  support  ranging  from  those  things  necessary  for survival, such as food, adequate nutrition and health care, to those interventions that will provide a better quality of life in the future such as education, psychosocial care and economic self- sufficiency. Ideally, all children should have access to these high quality services. Realistically, this is not the case because most children residing in developing countries, especially orphans are malnourished, sick, without shelter and proper education.

Child malnutrition is the most widely spread disorder in Sub-Sahara Africa. Malnutrition is recognized as a consequence of poverty. It is viewed in the context of violation of child’s human rights.  Malnutrition is caused by inadequacy or over-consumption of one or more of the essential nutrients necessary for survival, growth and reproduction (Smith & Haddad, 2000). Under nutrition in all its forms is a significant public health concern. It is the underlying factor in over 50% of the deaths from under five preventable diseases annually (UNICEF, 2001). Poor nutrition severely hinders personal, social and national development.  In many regions of the world, the onset of stunting is within the first few months of life. Wasting and under nutrition progressively continue through the first two years of life. About one-third of the children less than five years of age are short and underweight for their ages (Jones, Steketee, Black, Bhutta & Morris, 2003). Studies have shown that, this is the peak age for growth faltering, deficiencies of most micronutrients, and common childhood illnesses such as diarrhoea (Martorell, Kettel & Schroeder, 1994). To grow, the children need to consume adequate amounts of energy, protein, calcium, iron, zinc and other nutrients. Failure to provide the extra nutrients precipitates deficiency  of  essential  micronutrients  prevalent  among  children  in  developing  countries, including Nigeria. Under nourished under-fives are unable to learn and this is carried to adult life. The most devastating to under-fives is micronutrient deficiencies of vitamin A, iron and zinc. These combined can cause impaired growth, impaired mental development and learning capacity. The brain, central nervous system and immune systems are all affected when iron and zinc are deficient, other effects includes stunting wasting and underweight.

Nutrition is linked to most of, if not all the Millennium Development Goals (MDG), which are closely interlinked. The right to food and good nutrition for all is fundamental to achieving  the  MDGs  (United  Nations,  2002).  The  first  goal  (MDG-1)  is  emphatic  on  the eradication of extreme hunger and poverty. The prevalence of underweight in under-five children is an indicator for achieving this goal. MDG-4 talks about reduction of child mortality. Malnutrition which is preventable, accounts for up to 53% of all deaths in under-five children and remains the underlying cause of most child mortality. To achieve the Millennium Development Goals (MDG-1) for child survival and the prevention of malnutrition (MDG-4), adequate nutrition and health during the first few years of life is fundamental (United Nation, 2002). Poor feeding practices, coupled with high rates of infectious diseases, are the principal proximate causes of malnutrition during the first few years of life (WHO, 2005).

Infant feeding is a critical aspect of caring for infants and young children. An appropriate feeding practice during infancy and early childhood is fundamental to the development of each child’s full human potential. Economic analyses suggest that the challenge of achieving optimal feeding for infants and toddlers is often as much related to ignorance about feeding and food choices as to scarcity of food (Global Health Council, 2006).  Infant and young child’s feeding practices such as breastfeeding and complementary feeding are major child survival strategies especially in developing world. Improving the quality of infant feeding practices was cited as one of the most cost-effective strategies for improving health and reducing morbidity and mortality in young children (UNICEF, 2007). Studies indicated that, nearly one-third of child deaths could be prevented by a combination of exclusive breastfeeding for 6 months, optimal complementary feeding practices, iron, zinc and vitamin A supplementation (Shrimpton, et al., 2006).

Micronutrients  are  nutrients  required  by the  body in  small  amount  for proper  body functions (Sandstrom, 2001). Micronutrients which include vitamins and minerals play vital roles in body growth and development, reproduction, brain functions and resistance to diseases among others. Vitamin A, iron, iodine and recently zinc are the major micronutrients of public

health  importance  especially  in  developing  country  like  Nigeria  (UNICEF,  2007).  This  is because of the magnitude and seriousness of their deficiencies and consequences on health, learning capacities and productivity of affected people. Micronutrient deficiencies increase morbidity and  mortality rates  not  only in  children  under-five  years,  pregnant  and  lactating mothers, who are more vulnerable but also to the general populace including vibrant adolescents (Bryce, Boschi-Pinto, Shibuya & Black, 2005). It is generally known that the prevalence of malnutrition and micronutrients deficiency increases rapidly in under-five children because of rapid growth and development, therefore deficiency of these nutrients jeopardises the normal health, growth and development of the child. Children may look healthy and their diets may provide adequate energy and protein but are lacking in micronutrients. This is referred to as “hidden hunger”.

Iron is one of the trace mineral that play a vital role in the body. It is an integral part of many proteins and enzymes that maintain good health. It is an essential component of protein responsible for distributing oxygen throughout the body. It plays a central role in metabolic processes involving oxygen transport and storage as well as oxidative metabolism and cellular growth (Serene, Jack, & James, 2003). Iron deficiency most commonly manifest as anaemia. In Africa iron  deficiency occurs  more often  amongst  premature infants,  growing  children  and pregnant women. Studies have shown iron deficiency anaemia to be associated with increased morbidity and mortality rates (UNICEF, 2009).

Anaemia prevalence is high in children and its cause is frequently multifactorial. It has been estimated that about 40% of the world’s population (more than 2 billion individuals) suffer from anaemia with a prevalence of 48% in school-aged children (Shell-Duncan & Mcdade, 2005).  Anaemia  occurs  as  a  result  of  abnormally  low  haemoglobin  due  to  pathological

conditions. Iron deficiency is one of the most common causes of anaemia, other causes include chronic infections such as malaria, worm infestation, hereditary haemoglobinopathies and other micronutrient deficiency particularly folic acid and vitamin C (WHO, 1999).

Vitamin A is a fat soluble vitamin that is of great significance to the body especially its role as immune booster and for health eye sight. Vitamin A deficiency (VAD) is a major public health problem. The most vulnerable group for VAD includes under-five children and pregnant women in low-income countries. In children, VAD is the leading cause of preventable visual impairment and blindness. Twenty six percent of vitamin A–deficient children live in Africa, with the largest number in Ethiopia (UNICEF, 2009). VAD affects almost 1 in every 3 children in Nigeria (WHO, 2007). World Health Organization has classified Nigeria among 34 countries in the world with serious problem of VAD related nutritional blindness and xerophathalmia (WHO, 2007). VAD significantly increases the risk of severe illness and death from common childhood infections, particularly diarrheal diseases and measles (FAO/WHO, 1992).

Zinc is a trace mineral needed by human body in small quantity but of great importance for  child  survival.  Zinc  deficiency  is  wide  spread  in  developing  countries  and  the  most vulnerable  groups  are  infant,  children,  pregnant  women  and  lactating  mothers  (ACC/SCN,

2000). It is marked by growth retardation or stunting. In period of rapid growth zinc requirement is normally high and where this demand is not met, problems like growth retardation may arise (Micronutrient Initiative, 1998). Zinc enhances the transport of vitamin A in and out of the cells and its deficiency is thought to have a close link with iron deficiency. Zinc participates in carbohydrate and protein metabolism, DNA and RNA synthesis among other functions (FAO/WHO, 1992).

Globally, nutritional status is considered the best indicator of the well being of young children and a parameter for monitoring progress towards the Millennium Development Goals (MDGs). Nutrition and health status have powerful influence on a child’s learning and how well a child performs in school. The nutritional status of under-five children is of particular concern because, their early years of life are crucial for future growth and development (Prechulek, Aldau

& Hasan, 1999). Apart from chronic undernutrition experienced by under-five children, they also suffer from parasitic infections and hunger (SCN, 2000). Hunger is the physiological state that results due to inadequate food to meet the energy needs. Chronic hunger leads to undernutrition, causes growth failure and weakness. Hunger reduces energy and strength; it diminishes concentration, impairs a child’s ability to learn and equally affects the health of the child (Carol, Gaile, Donna & Jacqueline, 2009).

Over 140 million children under the age of 18 in the developing world have lost one or both of their parents. In sub-Saharan Africa alone there are 43 million orphans, representing more than 12% of all children (UNAIDS, UNICEF & USAID, 2004). Sub-Saharan African countries are already struggling to eradicate extreme poverty. This unprecedented burden of orphan populations is further reducing resources within households and communities. As a result, orphans are made vulnerable to a variety of risks, including poverty, school dropout, malnutrition,  micronutrient  deficiency  and  other  forms  of  child  deprivation.  For  Nigerian children,  the  impact  of  the  attendant  challenges  in  the  health  sector  especially HIV/AIDS, education and social welfare has occasioned situations of neglect of basic rights leading to increased  vulnerability  of  over  69  million  population  under  eighteen  years  in  the  country (Federal Ministry of Women affaires and Social Development, 2007).

Nigeria like many developing countries in Africa is still far from reducing the rates of infant and under-five mortality. Nigeria is a signatory to the United Nation’s Convention on the Rights of the Child (CRC) and the African Union Charter on Rights and Welfare of Children (AUCRWC). The two declarations emphatically require signatory State Parties to ensure the recognition  and  enforcement  of  the  rights  of  children  to  life,  name,  home  and  family environment, adequate nutrition, health, education as well as protection from all forms of abuse, exploitation, inhumane treatment, and the freedom of self expression, privacy and leisure. These rights are extended to all children including the orphans (United Nation, 1986; UNICEF, 2004). Orphans risk losing opportunities for adequate education, health care and proper nutrition. This is because most orphans live without care, love, affection and security available within a family environment. They are exposed to neglect, violence, exploitation and all forms of abuse (John, Lori, Neff   & Roland, 2011). Although empirical evidence examining the negative effects of orphanhood is growing, there remains much uncertainty as to how it affects child nutritional status. Only a handful of studies have been published that examined the effect of orphanhood on child nutritional status. One of the major challenges facing governments, international organizations and NGOs in their response to orphanhood is the lack of data on the situation of orphans. This has made it difficult in designing quality interventions tailored at improving the well being of the orphans.

1.2 Statement of the problem

Infants and young children are one of the vulnerable groups in the society. They are more vulnerable when they are denied their rights to proper feeding and good nutrition. Nigeria ranks

14th in global assessment of under-five mortality rate and approximately one million children die

annually in Nigeria before their 5th birthday (UNICEF, 2006). Nigeria is among the 20 countries

in the world that account for 80% of undernourished children. The causes of this public health problem in Nigeria are complex and multidisciplinary. However, poor quality and quantity of foods given to children play a major role (Bryce, Boschi-Pinto, Shibuya & Black, 2008). There are more orphanages in the country presently than before.

A study of orphanages conducted by the Federal Ministry of Women Affairs & Social Development (FMWA & SD) in 2007 showed that over 150 orphanages exist in Nigeria and the establishment of half of these orphanages occurred over a period of 50 years (1940 – 1990). It took only 15 years (1991-2000) to establish the other half. This indicates that more orphanages were founded in recent times than previously. They are distributed across the thirty six states of the country including the Federal Capital Territory (FMWA & SD, 2007). Basic indicators as indicated by the Nigeria Demographic and Health Survey reveal no significant improvement on the health status of the Nigerian children between 2003 and 2008 (NDHS, 2003; NDHS, 2008).

About 50% of the current 138 deaths per 1000 live births could have been averted if the children were not malnourished. FCT under-five mortality rate is 152 deaths per 1000 lives birth (MICS, 2011). The prevalence of malnutrition among orphans and vulnerable children under- five years of age in Nigeria is as follows: 22 percent of orphans are underweight, 33 percents of them are stunted while 11 percent are wasted (NDHS, 2008). A survey conducted by MICS (2011) showed the prevalence of malnutrition among under-five children in the FCT as follows

46.8% of the children were moderately underweight, while 22.0% of them were severally underweight. 65.1% of the children were moderately stunted while 40.5% of the children were severely stunted. On the other hand, 14.2% of them were moderately wasted while 4.8% of them were severally wasted. From field experience about 35% of children seen in rural communities of the FCT are malnourished.

The prevalence of vitamin A deficiency in the country for under-five children is 29.5%. About 27.5% of children under-five in Nigeria were iron deficient while 20.0% of the under-five children were zinc deficient (Maziya Dixon et al., 2004). It is worthy to note that this survey was conducted on non-orphans. No large scale surveys have been conducted in respect to micronutrient status of orphans in the FCT. Only a few studies have examined the impact of orphan status on child health and nutrition. Children under-five are particularly more vulnerable to  the  effects  of  orphan  hood  because  they are  undergoing  rapid  development  and  require nurturing, proper care, and adequate access to food and health care services.

Inconsistent findings make it difficult to assess if orphans have specific nutritional needs separate from those children that are not orphaned (FMWA & SD, 2007). Out of 37, 532 orphans who participated in a survey conducted by FMWA & SD in 2008, 12.4% of the children assessed went to bed hungry in the four weeks preceding the survey. The reason for this was lack of food. This is the only information reported on nutrition in this National survey. A study conducted by World Bank noted that, orphaned children are more likely to have stunted growth and overall poor health, mainly because of unmet nutritional needs (World Bank, 1997). In Uganda, studies showed that orphans’ health and nutrition status were worse than that of non-orphans (Wakhawenya, 2002). However, there is also some research showing no significant difference in child well-being between orphans and non-orphans (Ainsworth, Martha and Innocent, 2002).

Despite the inconsistencies in these findings, there are compelling reasons to hypothesize that children whose parents are deceased face unique vulnerabilities, including fear, instability, insecurity, lack of basic education, proper care, poor health and nutrition. Information on the nutritional status of orphans in Nigeria is limited and is much more limited in the FCT. There is need for nutritional inputs in intervention programmes for orphans in FCT orphanages and

indeed the whole country. It is only an evidenced based data that will propel such interventions. In view of this, a study into the feeding practices of the orphans as well as their nutritional status including micronutrients status becomes pertinent.

1.3       Objectives of the study:

The general objective of the study was to assess the feeding practices, anthropometric, vitamin A, iron and zinc status of the under-five children in the orphanages of Federal Capital Territory. The specific objectives were to:

1.    assess the feeding practices of under-five children in FCT orphanages.

2.   assess the anthropometric status of the under five children in FCT orphanages using weight, height/length and mid upper arm circumference.

3.   assess vitamin A, iron and zinc status of under-five children in FCT orphanages using biochemical method

4.   assess the nutrient intake of the under-five children using weighed food intake.

5.   determine the relationship between the dietary intakes of zinc, vitamin A and iron  with the biochemical status of the under-five children

6.   determine the relationship between anthropometrics indices with biochemical status of the children

7.   determine factors in the orphanages that influence the nutritional status of the children

1.4       Significance of the study:

This study would provide information on the nutritional status of the under-five children in the orphanages of FCT as well as their feeding practices. It will provide data on the micronutrients status (vitamin A, iron and zinc) of the under-five children in orphanages of FCT. The generated data and information will be an evidence for strong advocacies to policy makers and stakeholder, which   will   subsequently   inform   their   decisions   on,   appropriate   nutrition   intervention programmes geared towards improvement of the lives of orphans in FCT and Nigeria as a whole. It will also form a based line data for other researchers that would want to work on under-five nutritional status especially among orphans and vulnerable children.

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