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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 31-37

Prevalence of and risk factors for fetal malnutrition in term babies delivered at a Tertiary Hospital in Southern Nigeria


1 Department of Paediatrics, Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria
2 Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria

Date of Web Publication6-Feb-2018

Correspondence Address:
Dr. Peace Ibo Opara
Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_98_17

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  Abstract 


Introduction: Fetal malnutrition (FM) is a “clinical state of a baby of any birth weight, characterized by obvious intrauterine loss or failure to acquire normal amounts of subcutaneous fat and muscle mass, manifesting as wasting, shortfalls in weight, length and other anthropometric measurements.” It is associated with increased morbidity and mortality in the newborn. Aim: The aim of this study was to determine the prevalence of and risk factors associated with FM in Port Harcourt, Nigeria. Subjects and Methods: This was a prospective hospital-based study, carried out at the labor Wards of a tertiary hospital in Southern Nigeria. Baby-mother pairs who met the inclusion criteria for the study were recruited consecutively. Relevant biodata was recorded, and babies' nutritional status was assessed using the Clinical Assessment of Nutritional Status Score chart. Data were entered into a Microsoft Excel sheet and analyzed using standard statistical tools. Results: Of 300 newborns studied, 176 (58.7%) were male and 124 (41.3%) females with a male:female ratio of 1.4:1. The prevalence of FM was (16.7%). Babies with FM had significantly lower anthropometric indices (length, occipitofrontal circumference, and mid-upper arm circumference) than their counterparts (P = 0.00). Being small for gestational age and nonuse of at least one dose of intermittent preventive treatment for malaria in pregnancy were significantly associated with the occurrence of FM (P < 0.005). Conclusion: The prevalence of FM in Port Harcourt is high and highlights the need for evolving appropriate interventions and strategies for its prevention.

Keywords: Fetal malnutrition, prevalence, risk factors


How to cite this article:
Josiah AE, Opara PI, Nte AR. Prevalence of and risk factors for fetal malnutrition in term babies delivered at a Tertiary Hospital in Southern Nigeria. J Clin Neonatol 2018;7:31-7

How to cite this URL:
Josiah AE, Opara PI, Nte AR. Prevalence of and risk factors for fetal malnutrition in term babies delivered at a Tertiary Hospital in Southern Nigeria. J Clin Neonatol [serial online] 2018 [cited 2020 Jun 4];7:31-7. Available from: http://www.jcnonweb.com/text.asp?2018/7/1/31/224818




  Introduction Top


FM is defined as “a clinical state of a baby of any birth weight (BW) and gestational age (GA) characterized by obvious intrauterine loss of or failure to acquire normal amounts of subcutaneous fat and muscle mass.[1],[2],[3] Babies with FM may have low BW (LBW) or be small or even appropriate for GA.[4] Fetal growth is determined by individual constitutional growth potentials, adequate nutrition, placental functional status, and absence of factors that retard growth.[5] These result in differences in birth sizes and wide variations in nutritional status at birth.[6] The period of intrauterine growth and development is very vulnerable in humans and determines the quality of later life.[7],[8]

Identifying prevailing risk factors and preventing them may improve fetal outcomes. This study aimed to determine the prevalence of and identify risk factors for FM in Southern Nigeria.


  Subjects and Methods Top


The study was carried out at the labor ward, postnatal wards, and special care baby unit of a tertiary medical facility. It was a prospective, longitudinal study of term new-borns delivered to mothers who received antenatal care in and delivered in the hospital. Mother-infant pairs resident in the locality were recruited consecutively from the booked labor wards shortly after delivery over an 11-week period. Babies were singleton term births with no obvious congenital anomalies. Socioeconomic stratification was done using the method by Oyedeji.[9]

Anthropometric measurements were carried out on babies using standard methods as soon after birth as possible and within 24 h. These included weight, occipitofrontal circumference, mid-upper arm circumference, and supine length. GA was assessed using the Dubowitz Scoring system,[10] and values obtained compared with those generated using the last menstrual period, as well as records from ultrasonographic imaging, where available. Where there was a disparity, the Dubowitz score was used. Babies were further classified using the Intrauterine growth chart by Olowe [11] as small for GA (SGA), appropriate for GA (AGA), and large for GA (LGA).[11]

Nutritional status of babies was assessed using the Metcoff's Clinical Assessment of Nutritional Status Score (CANSCORE) Chart.[12] The chart contains scores for nine “superficial” and readily detectable signs of FM. Scoring was based on inspection and hands-on estimation of degree of loss of subcutaneous tissue and muscles. For each point of assessment, the degree of loss of subcutaneous fat was scored by applying a maximum score of four for no evidence of malnutrition, and the lowest score of one for the worst evidence of malnutrition. Babies with total score below 25 were classified as having FM.[12]

Babies were also examined, and other biodata such as sex, BW, length, and APGAR scores were obtained and documented.

Information obtained from the maternal records including dates of antenatal clinic (ANC) booking, number of visits; past medical, obstetric and surgical histories; presence or otherwise of proteinuria, other diseases in pregnancy; use of routine antenatal drugs, intermittent preventive therapy (IPT) for malaria (sulfadoxine/pyrimethamine combination); use or otherwise of long-lasting insecticide-treated nets; and highest maternal blood pressure, weight, and packed cell volume (PCV) during pregnancy.

Chronic hypertension was taken as systolic blood pressure of at least140 mmHg and a diastolic of at least 90 mmHg before and after 20 weeks GA.[13] Preeclampsia, on the other hand, was taken as raised blood pressure (at least 140/90 mmHg) after 20 weeks GA taken twice, 6 h apart in a pregnant woman in addition to pedal edema and protienuria.[14],[15]

Mothers were weighed within 24 h of delivery, and their heights were measured using a nonstretchable meter rule. Body mass indices (BMIs) were calculated using the formula: BMI = weight (in kg)/height 2 (in meters)[16] and interpreted as follows: underweight = <18.5 kg/m 2, normal weight = 18.5–24.9 kg/m 2, overweight = 25–29.9 kg/m 2, and obesity as 30 kg/m 2 and above.[16]

Blood samples were collected from each mother for PCV estimation and blood film for malaria parasites (MP).

Data were collected on a pro forma designed for the study, and results were analyzed using the SPSS software version 17 (IBM, Chicago: SPSS Inc.). Descriptive statistics were computed using simple frequency tables and charts. Spearman's Chi-square test or the Fisher's exact test (FET) of significance was used to determine statistical significance. A comparative analysis of the continuous variables, such as weights and lengths, was done, using the student's t-test and analysis of variance to get the means and standard deviations. The confidence interval was set at 95% and P < 0.05 was considered statistically significant.

Ethical clearance was obtained from the Ethics committee of the Hospital and informed consent from the mothers.


  Results Top


Three hundred mother-infant pairs participated in the study. The babies comprised of 176 (58.7%) males and 124 (41.3%) females giving a male:female ratio of 1.4:1. 292 (97.3%) mothers were married and eight (2.7%) single. Ninety (30.0%) babies belonged to families from high socioeconomic classes, 125 (41.7%) middle, while 85 (28.3%) belonged to the low socioeconomic class.

The general characteristics of the babies are shown in [Table 1]. BWs ranged from 1550.0 g to 4700.0 g with a mean of 3281.8 ± 505.1 g, lengths ranged from 44.0 cm to 54.0 cm with a mean ± standard deviation (SD) of 49.8 ± 1.8 cm, and the CANSCORE values ranged from 18.0 to 36.0 (mean ± SD of 28.0 ± 3.6).
Table 1: General characteristics of the babies

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Fifty babies had features of FM, giving a prevalence rate of 16.7%. There were statistically significant differences in the anthropometric measurements of babies with FM and without FM as shown in [Table 2].
Table 2: Anthropometric indices of babies with and without fetal malnutrition

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Weight-for-gestational-age and nutritional status

Of the 300 babies, 185 (61.7%) were AGA, 57 (19.0%) SGA, and 58 (19.3%) LGA. The mean CANSCORE of babies were 24.5 ± 2.97, 28.0 ± 2.91, and 31.6 ± 2.66 for SGA, AGA and LGA babies, respectively. Of the 50 babies that had FM, 31 (62.0%) and 19 (38.0%) were SGA and AGA, respectively. FM was statistically, significantly more common in babies who were SGA than those who were AGA (χ2 = 89.23; df = 2; P < 0.01). No LGA baby had features of FM.

Maternal age

Twenty-two (7.3%) babies were born to mothers aged 15–24 years and 5 (22.7%) had FM, while 126 (42.0%) were delivered by mothers aged 25–29 years out of whom 23 (18.3%) had FM. Although the younger mothers had proportionally, more babies with FM, there was no statistically significant association between maternal age and FM (P = 0.66, χ2 = 1.60, df = 3) [Table 3].
Table 3: Relationship between maternal age and the nutritional status of the babies

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Maternal educational level

One hundred and thirty mothers (43.3%) had university education. Of these, 18 (13.8%) had babies with FM, while 29 (18.8%) of the 154 others with secondary or postsecondary level of education had babies with FM. The mean CANSCORE of the babies of mothers with different levels of education was 28.40 ± 3.51 for university level, 27.69 ± 3.71 for secondary/postsecondary level below university, and 28.25 ± 3.64 for mothers with primary/no education. There was no statistically significant relationship between educational level of the mothers and FM.

Socioeconomic status

The mean CANSCORES were 28.8 ± 3.9, 27.9 ± 3.4, and 28.0 ± 3.6 for babies from high-, middle- and low-socioeconomic classes, respectively. Of the 90 babies delivered by mothers from high socioeconomic class, 17 (5.7%) compared to 18 (6.0%) of 125 in the middle socioeconomic class, and 15 (5.0%) of the 85 from low socioeconomic class families, respectively, had FM. There was no statistically significant relationship between the socioeconomic class and FM (χ2 = 0.84; df = 2; P= 0.66) as shown in [Table 4].
Table 4: Relationship between socioeconomic class of family and nutritional status of the babies

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Parity

The relationship between parity and the nutritional status of the babies is shown in [Table 5]. Fetal malnutrition occured most 28 (21.7%) in babies of primiparous mothers, but there was no significant relationship between parity and FM (χ2 = 12.20; df = 3; P= 0.58).
Table 5: Relationship between parity and nutritional status

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Alcohol and tobacco use history

Thirty-six (12.0%) mothers were “social drinkers” during the index pregnancy. Of these, 6 (16.7%) had babies with FM compared to 44 (16.7%) who did not take alcohol but had babies with FM. There was an equal proportion of babies delivered with FM, to both groups of mothers (P = 0.11).

Timing of antenatal clinic booking and frequency of antenatal visits

The GAs at ANC registration ranged from four to 36 weeks with a mean of 20.3 ± 7.7 weeks. Seventy-one (23.7%), 122 (40.7%), and 107 (35.7%) mothers booked in the first, second, and third trimesters, respectively. There was no significant relationship between the time of registration and occurrence of fetal malnutrition (χ2 = 4.30; df = 2; P= 0.62). The mean number of ANC visits was 7.7 ± 2.8. Although the nutritional status of the babies appeared better with more frequent ANC visits, the observed difference was not statistically significant (χ2 = 4.06; df = 3; P= 0.26).

Maternal anemia

The antenatal hemoglobin (Hb) levels ranged between 7.0 g/dl and 16.3 g/dl, with a mean ± SD of 11.1 ± 1.2 g/dl. Thirty-three (11.0%) mothers were anemic with antenatal Hb levels <10.0 g/dl. Postpartum, the Hb levels ranged between 6.0 g/dl and 15.3 g/dl, with a mean and SD of 10.8 ± 1.9 g/dl. However, the mean antenatal Hb of mothers whose babies had FM was 11.1 ± 1.6 g/dl while that for the mothers whose babies did not have FM was 10.9 ± 1.7 g/dl. The mean Hb of both groups were similar (P = 0.45; t = 0.75).

Maternal HIV infection

Antenatal screening for HIV showed that 25 (8.3%) mothers were HIV positive (all were on highly active antiretroviral therapy). Of these, two (8.0%) had babies with FM, compared with 48 (17.5%) of 275 HIV-negative mothers. There was no significant difference in the occurrence of FM in both groups (χ2 = 1.51; df = 1; P= 0.22).

Antenatal maternal malaria parasitemia

Nineteen (76.0%) mothers had positive malaria parasitemia. Of the 19, nine (47.4%) had babies with FM. Overall, a higher proportion of mothers of babies with FM had positive malaria parasitemia, but the difference was not statistically significant (FET-derived P= 0.2).

Malaria prevention strategy

Two hundred and seventy-eight (92.7%) mothers received at least one dose of Intermittent Preventive Therapy for malaria in pregnancy (IPTp) (IPTp-1), while 22 (7.3%) had none (IPTp-0). Of the 278 mothers who received IPTp, 41 (14.7%) had FM while of those who never received IPTp, nine (40.9%) had babies with FM. Furthermore, 16 (17.8%) of the 90 mothers who had only IPTp-1 had babies with FM compared with 24 (13.1%) of the 183 who had at least two doses of IPTp (IPT-2,3). Mothers who did not receive IPT were more likely to have babies with FM (likelihood ratio of 0.03) [Table 6].
Table 6: Relationship between use of one dose of IPTp and the nutritional status of the babies

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Maternal body mass index

The BMI of mothers ranged from 19.5 kg/m 2 to 42.8 kg/m 2 with a mean of 29.0 ± 4.3 kg/m 2 Obesity and overweight were found in 128 (42.7%) and 129 (43.0%), respectively, while 43 (14.3%) mothers had normal BMI; none had a low BMI. Of the 43 mothers that had normal BMI, 12 (27.9%) had babies with FM compared with 23 (17.8%) and 15 (11.7%) of the overweight and obese mothers, respectively. The mean BMI of mothers with babies who had FM was 28.2 ± 4.3 kg/m 2 lower than that of mothers whose babies did not have FM (29.3 ± 4.3 kg/m 2). The difference was not statistically significant (Student's t-test = −1.59; P= 0.12).


  Discussion Top


The 16.7% prevalence rate of FM in this study is similar to the 18.8% by Adebami and Owa [8] in Ilesha South-West, Nigeria and the 19.0% reported by Jayant and Rajkumar in India,[2] but lower than the 24.0% by Soundarya et al.,[17] in Manipal, India, 27.4% by Kumari et al.,[18] and the 40.0% by Mehta et al.,[19] in New Delhi, all in India. It was however, higher than the 8.3% reported by Kashyap and Dwivedi,[20] in Bhopal, India, and the 10.9% reported by Metcoff,[12] in an American study in Oklahoma city. The similarity in the prevalence of FM in the present study with that of Adebami et al.[8] may be attributable to the similarities in the environment and the socioeconomic characteristics of the study populations since the two studies were tertiary healthcare-based surveys in comparable Nigerian settings. On the other hand, the low prevalence recorded in the American study may be explained by the higher socioeconomic circumstances, generally better nutritional status of mothers in that environment and the reported lower corresponding prevalence of LBW (8.0%) in term deliveries in the developed countries compared to a LBW prevalence of 15.0% in Nigeria in 2012.[21] High prevalence in the current study and that of Adebami et al.,[22] which is also reflected in Indian studies [17],[23],[24] show that FM is more common in developing countries. There has not been a significant change in the prevalence of FM in Nigeria between 2004 when Adebami et al.[8] reported (18.8%) and the present study despite a documented reduction in poverty levels over the years.[25],[26]

In earlier reports, risk factors for FM included maternal factors such as age, educational level, socioeconomic class, nutritional status, presence of severe anemia, malaria, hypertension, and other chronic illnesses in pregnancy.[1],[8],[22],[27] The contrast in maternal age as a risk factor in this study was probably because most of the mothers in the current study were not in their teens, an age group reported to be more at risk for having LBW, SGA, and FM babies.[28],[29] The lack of a significant relationship between socioeconomic class and FM has been demonstrated by Lawoyin and Oyediran in Ibadan, South-Western Nigeria.[30] This, however, is at variance with the findings of Adebami et al.[31] in Ilesha, and Harrison [32] in Zaria, Northern Nigeria who showed that maternal education and antenatal care reduced the prevalence of LBW from 26.0% to 8.0% and perinatal mortality from 258/1000 live births to 30/1000 live births. Harrison also reported that socioeconomic and cultural factors, rather than deficiencies in maternity services were responsible for adverse pregnancy outcomes.[32] The study by Adebami et al.[31] had a sizeable proportion (46.7%) of families in the lower socioeconomic class, unlike what obtained in the present study.

Previous reports suggested that higher maternal parity was associated with higher BW and nutritional status of the babies.[33],[34] The contrasting results may be due to the high proportion of low parity in our study population. However, earlier multivariate analyses by Oni [35] and Barua et al.[36] showed that parity did not significantly affect the occurrence of LBW in Nigeria and Bangladesh, respectively.

Tobacco and illicit drug use in pregnancy previously reported as significant etiological factors in FM [37],[38] did not emerge as risk factors in the present study probably because of the low rate of their usage among the women which limited the assessment of their impact on the occurrence of FM. The low use of these substances may be attributed in part, to culture-related/traditional stigma attached to tobacco smoking and use of illicit drugs.

Similarly, the timing of ANC registration and frequencies of ANC visits did not show any significant relationship with the nutritional status of the babies, contrary to other reports.[39],[40],[41] These authors reported that early ( first trimester) registration and more frequent ANC visits allowed for nutritional supplementation for the mothers with low BMI and had a corresponding significant positive influence on the nutritional status and BW of the babies. Furthermore, maternal anemia an important determinant of the baby's nutritional status because of the potentially low oxygen-carrying capacity (by anemic mothers) for placental transfer to the fetus [3],[42],[43] did not statistically significantly affect fetal nutritional status in the current study. This finding is in accord with the findings from a previous study by Nte et a1.[44] The small number of mothers with anemia in the present study and that of Nte et al.[44] may partly account for this. Furthermore, the fact that all the mothers in this study were booked and took their routine ANC drugs regularly could have contributed to the low prevalence of maternal anemia.

Similarly, pregnancy-induced and chronic systemic hypertension in the mother which had earlier been reported to adversely affect the nutritional status of babies,[12],[43] were not established to be statistically significant risk factors for FM in the study. This may also be ascribed to the low prevalence of hypertension in the mothers.

The finding of maternal malaria parasitemia (postpartum) as a risk factor for FM in this study agrees with earlier reports.[45],[46],[47],[48],[49],[50] The study location is in the malaria holoendemic zone. Antenatal malaria parasitaemia did not show a significant relationship with the occurrence of FM, probably because most women with febrile illnesses were routinely treated for malaria without a confirmatory laboratory tests for MP. Furthermore, the nonutilization of malaria prevention strategy during pregnancy (IPT) was statistically significantly associated with the occurence of FM. This is similar to the findings by other authors in earlier studies.[44],[45],[51],[52]

Maternal BMI as a measure of the nutritional status of the mothers was expected to influence the nutritional status of their babies as documented by Adebami et al.[31] and Soundarya et al.[17] These studies, however, did not state which maternal weights (prepregnancy, pregnancy or immediate postpartum) were used to determine the BMI. This is in view of the inevitable pregnancy-related fluid accumulation and the consequent weight increase and higher BMI value in various stages of pregnancy. The prepregnancy weight and BMI would have been more reliable to use but were unfortunately not available in the current study.


  Conclusion Top


The prevalence of FM in Port Harcourt is high. Significant risk factors include being small for GA, nonutilization of malaria prevention strategy during pregnancy and highlights the need for evolving appropriate interventions and strategies for its prevention.

Acknowledgement

The authors would like to thank staff of labor wards of the Department of Obstetrics and Gynaecology and Special Care Baby Unit of the Department of Paediatrics, University of Port Harcourt Teaching Hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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