Nutritional status of children 7–36 months old from millet consuming communities of Masindi District, Western Uganda

Study setting

The study was cross-sectional and analytical. Masindi District was purposively chosen because 53.1% of children aged 7–24 months consume millet porridge [10], it is also one of the most rural based districts in Western Uganda and it is characterised by low income households and common occurrence of infections among children [8]. Two highest millet producing sub counties in Masindi District namely Budongo and Bwijanga were chosen [8]. Fisher’s Equation [15] was used to calculate the sample size: n = Z²pq/d². Where n = minimum sample size, z = the standard normal deviate at 1.96 for a confidence level of 95%, p = proportion of stunted children below 5 years in Western Uganda [5], q = the proportion of children below 5 years who are not stunted in Western Uganda, d = the degree of accuracy desired, set at 0.05. The study subjects and respondents were children aged 7–36 months and their mothers/caretakers respectively. A sample size of 636 households was recruited by random cluster sampling method. Children aged 7–36 months were recruited from 23 villages (n = 10 in Budongo and n = 13 in Bwijanga). This matched the national distribution and was representative of Bujenje County of Western Uganda [8]. Only the youngest child in the household was included in the study and in case of twins in the household, both were included for cultural reasons. Each household was visited twice over a period of 1 month and only children from households with mothers/caretakers present were recruited.

Data collection and management

Self-administered questionnaires were used to collect data on socioeconomic and demographic characteristics of households as well as morbidity status and dietary practices of children.

Anthropometric measurements were taken using calibrated equipment and standardized techniques [16]. Standing height/ length was taken using Short’s Height Measuring Board (Short Productions, Woonsocket, RI) and recorded to the nearest 0.1 cm. Body weight was taken using light weight SECA mother–infant scales with a digital screen that were designed and manufactured under the guidance of UNICEF. Mid Upper Arm Circumference (MUAC) was measured basing on WHO guidelines and recorded to the nearest 0.1 cm [17]. All measurements were taken in duplicate with the children in light clothing and without shoes. Each measurement was taken by the same person to eliminate inter examiner error.

Statistical analysis

Descriptive statistics were compiled. Pearson’s Chi-square tests using Cross tabulations were done to establish the influence of demographic and socioeconomic characteristics, and morbidity patterns on children’s nutritional status. Correlation between nutritional status and amounts of millet porridges consumed by children was established using Pearson’s correlation coefficient analysis. A p-value of < 0.05 was accepted as indicating statistical significance.

Ethical approval

This study was reviewed by The Aids Support Organisation (TASO) internal review board (TASOIRC/029/13-UG-IRC-009) and approved by the Uganda National Council of Science and Technology (HS 1315). Verbal and written consent were obtained from the parents of the study children.

Socioeconomic and demographic characteristics of the population studied

Nutritional status of the studied children

Nutrient intake from millet porridges

Knowledge and healthcare practices for children with diarrhea

Demographic and socioeconomic characteristics of the studied population

Majority of households in Bujenje County lived on less than $2 per day. This reflects an extreme state of poverty which could negatively influence the nutrition status of children. Child malnutrition in Uganda, just like in most developing countries is strongly associated with poverty [2, 5, 20, 21]. Many mothers were taking care of their own children instead of employing caretakers possibly because this is a rural based community. Such a good practice could enhance proper care which is a key aspect in child growth and development [22]. Reported low levels of education among majority of mothers limit utilisation of the already limited resources to improve children’s nutritional status especially given the fact that more than half of the children were either first or second born, probably mothers lacked experience in childcare [22]. Majority of the mothers of the studied children had a normal Body Mass Index (BMI). This is very crucial if mothers are to care for the health and nutritional needs of their children well. Breast milk production has been reported to be low among malnourished mothers and association of BMI with poor child nutrition status has also been reported [22].

Prevalence of stunting, underweight and wasting among the studied children

Stunting estimates were higher than the global percentages of 25% while underweight and wasting estimates were less than the global estimates of 15 and 8% respectively [23]. Stunting, underweight and wasting levels were comparable to national figures of 29, 11 and 4% respectively and those of Bunyoro sub region (34.5, 9.1 and 3.8% respectively) of children below 5 years. The levels were also close to 26.6, 13.9 and 10.1% stunting, underweight and wasting respectively reported among children below 5 years in cassava consuming communities of Nambale, Busia of Western Kenya [13]. According to the World Health Organisation classification of children’s nutritional status, such percentages of stunted and underweight children reflect serious malnutrition conditions [3]. The prevalence of wasting among these children is ranked as that which demands for interventions [17]. Stunting represents failure of children to receive adequate nutrition over a long period of time and is affected by recurrent and chronic illnesses [3]. Underweight takes into account both chronic and acute under nutrition and it is an overall indicator of a population’s nutritional health [6]. Wasting represents failure of children to receive adequate nutrition in the period immediately preceding the study and this was due to inadequate food intake or a recent episode of diarrhoea or both. Acutely malnourished children who are not immediately treated are likely to develop clinical conditions requiring hospitalisation. Such conditions can cause irreversible damage to mental development [3]. Many health centres tend to be crowded with severely malnourished children and this presents a heavy cost to governments and individuals in the process of treating complications associated with severe acute malnutrition [3].

Stunting and wasting levels were significantly higher in males than females just like in the national reports [6]. This has been reported by other studies and is quite common in the absence of discriminatory measures, but its mechanism is not clear [24, 25]. However it has also been observed that most girl children are trained to be close to their mothers’ right from the early stages of life for cultural reasons, this closeness could attract some privileges like food, especially when there is shortage of food.

The proportion of stunted and underweight children was highest between the ages of 12–23 months which was the weaning period for most of the studied children. This has been reported to be the common age for stunting in most communities with poor quality complementary foods [2]. Weaning children with less nutritious foods affects them since this age group is characterised by high nutrient requirements and limited gastric capacity [26]. The situation is even made worse when infections set in [10]. Increase of stunting with age is consistent with other studies [27] and might also be due to reduced care as some mothers tend to become very busy with economic activities outside the household as children are weaned [28]. The percentage of children who met the recommended nutrient intake (RNI) tended to decrease with age due to increased nutrient requirements as children grew. Most mothers were still relying heavily on porridges without introducing other foods to children and this could have negatively affected the children.

Factors influencing the nutritional status of the studied children

Our previous findings among children aged 7–24 months in this area showed that majority of these children had inadequate nutrient intake [10]. Children were fed on bulky plant foods with minimal animal products, fruits and vegetables, contrary to World Health Organisation’s recommendations for complementary feeding [10]. Millet porridges formed the bulk of these children’s feeding and were very thin contributing less than 60% of the daily recommended nutrient intake for energy, protein, iron and zinc. The fact that millet porridges had no vitamin A calls for interventions to provide vitamin A in supplements form in order for children to grow as required. Weight-for Height Z scores (WHZ) were positively associated with the amounts of millet porridges taken by children meaning that these porridges are still key players in improving the nutritional status of children in this community. Millet porridges have been reported by some scholars as the most nutritious food among cereals [11]. However there is need to improve the nutritive value of millet porridges if under nutrition among children living in these places is to be addressed. Height-for-Age Z scores were negatively associated with the amount of porridges taken. This was because majority of stunted children were 12–36 months old, where in addition to porridges, mothers were supposed to give other nutritious solid foods. Majority of stunted and underweight children had diarrhoea in the 2 weeks preceding the study and they were more likely to be stunted with low weight. Although WHO recommends increased intake of both food and fluids when children have diarrhoea, many mothers did the contrary perhaps because of lack of knowledge. Uganda Demographic and Health Surveys have also reported feeding practices for children with diarrhoea as being contrary to World Health Organisation’s recommendations. Infections affect dietary intake and utilization and this has a negative effect on the nutritional status of children [22]. After an acute infection, weight gain may be relatively rapid but linear growth is slower, and where infections occur frequently, linear growth recovery may never occur resulting in persistent stunting [3]. In Uganda diarrhoea is a common cause of under nutrition among children and accounts for about 40–50% lower intake for energy and protein among children [3]. We have previously reported that most mothers kept millet porridges for long periods under unhygienic conditions before feeding the children, such a practice could easily attract infections [10]. Many mothers were also involved in digging or providing casual labour to sugar cane plantations where they carry their children along. Such practices could easily result in children picking infections as their immunity is not yet fully developed [3].

Households with few members had majority of their children underweight especially those households comprising mainly of children. This could be due to the dependency burden since majority of the study population were peasant farmers. It also reflects the aspect of proper childcare which is very important in the early stages of growth and development. A study on the nutritional status of children in Gabon also showed better Weight-for-Height Z scores among children from households with many members [29]. Since young children have limited gastric capacity, there is need for feeding them frequently and this can only be possible with availability of parent/caretaker. Essential practices like being hygienic, visiting a health facility/provider when sick, giving vitamin A supplements as recommended and de-worming can only be possible if caretakers are available.

Majority of mothers though knowledgeable about Oral Rehydration Salts (ORS) had poor feeding practices during diarrhoea. This could have been responsible for the high wasting levels compared to national figures especially since the period data was collected was a rainy season when infections are high. Caretakers need to be educated on the recommended healthcare practices during diarrhoea. There is need to get an affordable and sustainable solution to the poor healthcare and feeding practices in these rural communities if good nutritional status is to be achieved among children. This perhaps can be done by improving the value of millet porridge, since it is locally available and affordable by most households.