CHAPTER TWO
2.0 INTRODUCTION
This chapter comprises of literature review theoretical frame work and empirical review.
2.1 Literature Review
A negative relationship between mother's age and Malnutrition is expected because
physiological condition of younger mother is expected to be better than that of the older
mother's.
Nutritional awareness of the mother help them to have better knowledge on nutrition and they
may allocate there resources more effectively and more efficiently in improving their children's
nutritional condition. Therefore a negative relationship between Malnutrition of children and
mother's knowledge on nutrition is expected (Bemji et al 2009).
Mother's interest in the media especially television and radio programs help to improve level of
education and health awareness of mother's and it may have a positive effect by improving health
condition of their children's
On the other hand when mothers allocate more time on media it has a negative effect as it
reduces the time available for child care and income generating activities.
Because of that, depending on the relative magnitude of these factors either a negative or
positive relationship between mother's interest in the media and Malnutrition is expected (Daily
trust February 2019)
Malnutrition is a broad term which means under-nutrition (sub nutrition) and over nutrition
(obesity). The diseases that fall under improper consumption of nutrients are kwashiorkor and
marasmus while over consumption of nutrient like fat and carbohydrate can lead to obesity.
The World Health Organization (WHO) (2015) defines malnutrition as the cellular imbalance
between supply of nutrient and energy and the bodys demand for them to ensure growth,
maintenance and specific functions.
According to Rawson et. al (2013) define malnutrition as the poor nutrition to the cells. The primary
supply metabolic needs which is due to the eating food available for consumption or utilization in
the body. Basavanthappa (2011) described malnutrition as a reduction in quality and quantity of food
taken. There are good components which are very necessary and are needed daily by the body. When
these components are not supplied adequately they breakdown with problems of malnutrition.
Malnutrition has been identified as a major silent killer in Nigeria which is responsible for over
especially those under five (Hossain, 2009).
Malnutrition is a health problem found in all developing countries under-nutrition or lack of
adequate diet is a form of malnutrition which is most widespread. The causes of under nutrition are
many and often interrelated (Bamji et al., 2009).
Some of the factors that causes malnutrition may include: poverty, geographical areas, ignorance of
the relation of food to health, overcrowding, insanitary environment conditions, poor hygiene,
contaminated water supply, decrease resistance to infections e.g. diarrhea, hormonal changes,
erroneous eating habits, lack of outdoor play, genetic predisposition, etc (Datta, 2014).
The major nutritional challenges facing Nigeria especially in children is kwashiorkor and marasmus
(PEM) with less incidence of obesity (UNICEF, 2015).
Incidence of malnutrition
Malnutrition affects people in every country. Around 1.9billion adults worldwide are overweight,
while 462million are underweight. Estimated 41million children under the age of 5years are
overweight or obese, while some 159million are stunted and 50million are wasted. Adding to this
burden are the 528million or 29% of women of reproductive age around the world affected by
anemia for which approximately half would be amenable to iron supplementation (WHO, 2015).
Punch (October 2018) reported that 500,000 children suffering from malnutrition in Kano State.
Daily trust (May 2019) reported that the survey report presented by the organization revealed that 58
in every 100 malnourished children in Kano state are at risk of stunting as a result of imbalance in
their dietary intake.
The executive secretary of Computer Science University of Nigeria Nsukka, Beatrice Eluaka said
stunting has increased in Kano by more than 5% in the last four years in spite of the efforts of the
state government to addressing the plight of malnourished children in the state. Data from Multiple
Indicator Cluster Surveys (MICS, 2018) puts the stunting rate at 58%, underweight 40.3%.
According to the United Nation Childrens Fund (UNICEF) about 11million Nigerian children are
presently suffering from malnutrition and the World Health Organization (WHO, 2015) at so affirms
that 35% of deaths among children under the age of five are caused by malnutrition, consequently,
41% of Nigerian children under the age of five suffer stunted growth as a result of malnutrition and
also increase death rate among children in that age bracket.
Worse still, Global Alliance for Improved Nutrition (GAIN) (2014) reported that 29.5% of children
in Nigeria suffer vitamin A deficiency that causes childhood blindness while half of women of child
bearing age are anemic.
Another survey conducted by the Ministry across all the states in Nigeria, equally indicates that
malnutrition, a condition which result from insufficiency and imbalance in the intake of nutrients, is
widespread among children, particularly in all Northern states, amounting to about 80% of child
population.
Overview of Kwashiorkor, Marasmus and Obesity
Kwashiorkor
Kwashiorkor is a term used by Cicely William in 1934 to describe this condition while working in
West Africa. Kwashiorkor means the sickness a child develops when another baby is born
according to language spoken in Ghana the term was said to mean red boy due to characteristic
pigmentary changes.
By the early 1950s kwashiorkor had become accepted as coherent entity, a moment marked by a
prominent World Health Organization (WHO, 2015) report that declared it the most serious and
widespread nutritional disorder known to medical science accompanied by a detailed scholars.
The name kwashiorkor derived from the language of coastal Ghana, translated as the new baby
comes.
Causes of Kwashiorkor
According to Ahmad, H. J. (2017) the causes of Kwashiorkor are insufficient protein consumption
by the child or inability of the body to utilize protein. Some of the reasons include: -
Poverty: - This is inability of the parent to supply the qualitative and quantitative food
because of the financial constrain.
Low level of education: - An individual may have food but lacks knowledge to protein
consume and maintain health.
Clinical manifestations of Kwashiorkor
According to Waugh and Grant (2014) the clinical manifestations of Kwashiorkor include:
Oedema: - Is one of the most cardinal sign of kwashiorkor which occur at the face, abdomen
and limbs. The plasma osmotic pressure is maintained by the plasma protein. In this
condition there is deficiency of protein which leads to low osmotic pressure and result to
collection of fluid in the abdomen, limbs and face.
Muscle wasting: - Due to low protein to the tissue.
Failure to grow: - Growth is dependent to the proteneous food.
Psychomotor change: - The child with kwashiorkor is a pathetic, miserable, sluggish
withdrawn and anorexia. The child will have psychomotor retardation.
Hair changes: - The hair changes vary greatly from one part of the world to another. Hair
changes are found as light coloured hair or reddish brown colour hair which become thin,
dry, coarse and silky with easy pluckability.
Other conditions that might have kwashiorkor as complication may potentially be an under
lying causes of kwashiorkor. Example Alzheimer disease, measles, whooping cough etc.
Medical Management of Kwashiorkor
According to Mudambi and Rajagopal (2012) the medical management of Kwashiorkor include:
Prescribing vitamins supplement drug e.g. Slow-K.
Treating infection with antibiotics e.g. Gentamycin.
Prescribing intravenous fluid.
Prescribing blood transfusion in case of anemia.
Prescribing appropriate diet.
Nursing Management of Kwashiorkor
According to Mudambi and Rajagopal (2012) the Nursing management of Kwashiorkor include:
Administration of proteinous diet.
Educating mothers on adequate diet.
Daily weighing of the child.
Observation of patients vital sign.
Determining the process of nutritional status of child using arm circumference measurement.
Reassure the mother.
Administration of prescribed medication.
Care of Oedematous skin.
Marasmus
Marasmus Is from Greek word Marainen to waste away. It is also termed as infantile atrophy or
athrepsia. It is a condition of chronic undernourishment occurring commonly in infants may be
found in toddlers and even in later life. It occurs when both protein and calorie (energy) are
insufficient over prolonged period (Sandige, et al., 2014).
Causes of Marasmus
According to Ahmad, H. J. (2017) the causes of Marasmus are inefficient protein consumption by
the child or inability of the body to utilize protein. Some of the reasons include: -
Failure to breastfeed: - Due to death of mother or abandonment of the child or due to
malformation of mouth and nose cleft lip and palate.
Poor weaning habit: - In the course of weaning habits are committed like depriving of child from
parent to someone else, using traditional concoctions and feeding of child with poorly nourishing
diet.
Poverty: - Is another cause of marasmus.
Disease conditions: - Like measles, malaria, diarrhea can cause the occurrence of marasmus.
Clinical manifestation of Marasmus
According to Waugh and Grant (2014) the clinical manifestations of Marasmus include:
Growth failure shown by body weight which is extremely low for age. Growth retardation with less
than 60% of expected weight for age and subnormal height.
Gross wasting of muscles and subcutaneous fat as the protein from body tissues is used up as energy.
The child looks like an old man face in appearance.
The child has an alert and hungry expression but may not necessarily look miserable.
Marked stunting and absence of oedema.
Medical Management of Marasmus
According to Mudambi and Rajagopal (2012) the medical management of Marasmus include:
Prescribing micronutrient e.g Iron supplement.
Prescribing antibiotics e.g Augumentin.
Prescribing intravenous fluid infusion e.g. Pediatric saline.
Nursing Management of Marasmus
According to Mudambi and Rajagopal (2012) the Nursing management of Marasmus include:
Educating mothers on the cause and treatment of the disease.
Reassure the mother.
Feeding via NG tube as the case maybe.
Observation of patients vital sign 4 times a day.
Daily weighing of patient to assess progress of the management.
Administration of prescribed medication e.g Antibiotics.
Obesity
Obesity is not a common problem in Nigerian child, where nutritional deficiencies are mostly found.
But changes in lifestyle and child rearing practices are contributing towards this problem. Children
of affluent family are more prone to develop obesity.
Obesity occurs when the energy intake exceeds expenditure, the excess is deposited as fat. Obesity is
known to be predisposing factor for a number of health problems e.g. Diabetes mellitus,
cardiovascular disease etc (Rawson et al., 2013).
Causes of Obesity
According to Ahmad, H. J. (2017) the causes of Obesity include:
Hormonal changes.
Erroneous eating habit (chocolates, sweets, candies, snacks, ice cream).
Lack of outdoor play.
Excessive television watching.
Over protective parenting.
Genetic predisposition.
Clinical manifestations of Obesity
According to Waugh and Grant (2014) the clinical manifestations of Obesity include:
Obese children have low esteemed and emotional problems.
Excessive appetite and more food intake causing further obesity.
Medical and Surgical Managements of Obesity
According to Mudambi and Rajagopal (2012) the medical and surgical managements of Obesity
include:
Prescribing weight loss medications e.g. orlistat, naltrexone.
Gastric bypass surgery.
Gastric sleeve.
Vagal nerve blockage.
Nursing Management of Obesity
According to Mudambi and Rajagopal (2012) the Nursing management of Obesity include:
Dietary regulation and supervision.
Physical exercise.
Encouragement and supervision.
Behavior change.
Administration of prescribed medication.
Observation of vital sign.
Daily weighing of patient.
Health education to mothers.
2.2 THEORETICAL FRAME WORK
The Indian Academy of Pediatrics (IAP, 2016) proposed 2 theories:
1- Free radical theory of Kwashiorkor.
2- Aflatoxin theory of Malnutrition
Free Radical Theory of Kwashiorkor
Free oxygen radicals are potentially toxic to cell membrane and are produced during various
infections.
These oxides are normally buffered by proteins and neutralized by anti oxidants such as vitamin
A, C & E and Selenium.
In malnourished child, deficiency of these nutrients in the presence of infection or aflatoxin may
result in the accumulation of toxic free radicals.
These may damage liver cells giving rise to kwashiorkor.
2. Aflatoxin Theory of Malnutrition
The theory stated that;
Aflatoxin contribute to malnutrition by interfering with intestinal integrity and hepatic metabolism,
this leads to malabsorption, micronutrients deficiencies, impaired immune function and vulnerability
to gut infection which all lead to impaired growth and Malnutrition.
These theories are related to the research topic in the sense that they focus on types of malnutrition
in children which include:
Kwashiorkor.
Marasmus.
Marasmic kwashiorkor.
Stunting.
They also focus on causes of malnutrition including:
Deficiency of antioxidants e.g vitamin A, C & E and Selenium.
Infections.
Insufficient nutrients as low protein diet, very low protein diet.
The theories also focus on the signs and symptoms of malnutrition:
Liver damage.
Growth stops.
Anorexia.
Weight loss.
Both theories highlight the consequences of not knowing and or utilizing good nutritional practices
hence adequate knowledge is required.
2.3 EMPIRICAL REVIEW
A research was conducted at Tudun Wada C of Nassarawa local Government area of Kano
State, to assess mothers knowledge on the effects of malnutrition among Children, in the year
2019 By Nabila Abubakar.
The study described malnutrition and the extent to which it occur both in the place of study,
state, country and worldwide, including preventive measures and control. It also tells about
method adopted in conducting the research which is a descriptive research, described the data
analysis, interpretation and presentation using frequency distribution tables, bar charts and pie
charts showing Mothers knowledge on malnutrition, effects of malnutrition and how to prevent
malnutrition among Children
Based on the fact that malnutrition is the insufficient excessive or imbalance consumption of
nutrients or results from overfeeding or underfeeding, it was necessary to carry out this study to
assess Mothers knowledge on the effects of malnutrition in Children from the data analyzed it
can be concluded that: Majority of the study population understand the cause of malnutrition in
Children (50% of the respondents indicated that malnutrition is caused by poor hygienic
condition in preparing the childs food, poverty, unsafe water, diseases and infections are the
causes of malnutrition).
Majority of the Mothers did not understand the sign and symptoms of malnutrition in Children
(only 40% said skin may become thin, inelastic, long term recovery from infection and illnesses
as the sign and symptoms of malnutrition).
Prevention of malnutrition is well known by the Mothers as 67% of the respondents believed that
mothers should have adequate knowledge on malnutrition, feeding the child with food that
contains nutrients, making the child to sleep and rest are measure to prevent malnutrition.
2.4 SUMMARY OF RELATED LITERATURE
Malnutrition is a broad term which means under-nutrition (sub nutrition) and over nutrition
(obesity). The diseases that fall under improper consumption of nutrients are kwashiorkor and
marasmus while over consumption of nutrient like fat and carbohydrate can lead to obesity. The
WHO defines malnutrition as the cellular imbalance between supply of nutrient and energy and the
bodys demand for them to ensure growth, maintenance and specific functions.
Some of the factors that cause malnutrition may include: poverty, ignorance of the relation of food to
health, genetic predisposition, etc.
Kwashiorkor and Marasmus (PEM) are the major challenges facing Nigeria especially in children 0-
5years with less incidence of obesity. Kwashiorkor, Marasmus and Obesity were discussed including
their causes, clinical manifestations, nursing, medical and surgical managements.
Theoretical framework take a look at free radical theory of kwashiorkor and aflatoxin theory and the
theories were related to the research topic.
