Assessment of Nutritional Rickets Among Acute Malnourished Children 6-59 Months in Mbagathi Hospital, Nairobi, Kenya.

Abstract

Introduction: Globally, in the years between 1940 and 1970 nutritional rickets had been phased out following the discovery of vitamin D from ultra violet sun rays and with increased vitamin D food fortification practices. It was also considered rare in cases of acute malnutrition as it is a disease related to growth. However, in the 2000s, there has been a resurgence globally, with cases of rickets being reported among both chronic and acutely malnourished children. The resurgence has mainly been observed among children in urban areas as a result of minimal sunlight exposure, air pollution and other confounding dietary and maternal factors. Aim: This study sought to assess the burden of nutritional rickets among acutely malnourished children aged 6 to 59 months at Mbagathi hospital in Nairobi and to explore associated maternal, child and health system risk factors. Materials and Methodology: This was an analytical cross-sectional study targeting acute malnourished children 6-59 months. It was carried out at Mbagathi Hospital which is a referral hospital in Nairobi County, mainly serving households from the urban poor and middle class. Simple random sampling was used to select the study participants. The study utilized mixed methods to collect quantitative and qualitative data on child and maternal characteristics, knowledge, attitude and practices and; infant and young feeding practices were collected through the Kobo toolbox ODK platform. Nutritional rickets was defined as positive biochemical results of alkaline phosphatase (ALP) more than 400 IU/500IU/L, calcium less than 2 mmol/L, phosphate less than 1.45 mmol/L, 25 hydroxyvitamin D (OH) D level is below 20 ng/ mL) and/or the presence of radiological changes of cupping or fraying and/ or metaphyseal thickening. Data collection methods included interviews with the caregivers and health care providers, focus group discussions XIII with select caregivers and a review of the policy guidelines used in the management of acute malnutrition in Kenya. Data analysis was conducted using SPSS version 23, ENA for Standardized Monitoring and Assessment of Relief Transitions software and excel. Qualitative data was analyzed through theme categorization excel. Results: A total of 362 children 6 to 59 months were enrolled in this study. However, only 352 questionnaires were used in analysis. The proportion of acute malnourished children with nutritional rickets was 53.7%, 56.6% of which were not enrolled in nutritional rehabilitation programmes. The odds of testing positive for nutritional rickets reduced if the sex of the child was female, the child was still breastfeeding, had consumed infant formula and, consumed blue band/margarine in the past 7 days at 0.6, 0.6, 0.2 and 0.4 times respectively holding all other predictor variables constant. The odds of testing positive for nutritional rickets increased 4.1, 1.9, 1.6 and 1.9 times if the child was mainly taken care of by another person who was not the mother, the mother had not heard about vitamin D, the child was not supplemented with calcium or the child was exposed to less than one hours daily respectively for each predictor holding all other predictor variables constant. The proportion of children with severe acute malnutrition, stunting and underweight among the rickets cases were at 47.1%, 34.9% and 69.3% respectively. Conclusions: More than half of the acute malnourished children enrolled in this study had a positive rickets test result. However, the cases are missed out as clinical assessment is not done at admission and follow up due to lack of a clinician based at the nutrition clinic; and the registration fees required before receiving services at the Pediatric outpatient clinic. Continued breastfeeding, consumption of infant formula, consumption of blue band/ margarine in the 7 days preceding the interview, knowledge on vitamin D, main household breadwinner and main caregiver during the day were found to be associated with nutritional rickets. Increasing population in Nairobi County XIV has led to congestion of both storey and non storey houses due to limited space. This has in turn led to low penetration of sunshine in houses. Further, high cost of living has led to caregivers being required to work all day to fend for the family which affects child care practices for instance not having time to sit out with their children and dietary diversity among others. Among acute malnourished children, there are many missed opportunities in prevention and early diagnosis of nutritional rickets at the community and nutrition clinics level. Therefore, there needs to be more deliberate effort to address nutritional rickets in children. Policy and Practice Recommendations: There is need to improve prevention of nutritional rickets through health education and; active screening and treatment for nutritional rickets at both the community and facility level. Further, there is need to make medical assessment for acute malnourished children admitted in nutrition programs free and mandatory. This could be achieved by having a registration fee wavering system for all management of acute malnutrition beneficiaries in all the clinics and hospitals. Nutritional rickets screening and other growth disorders should be captured in the IMAM guidelines to ensure holistic treatment for beneficiaries.