Feeding difficulties in disabled children leads to malnutrition: experience in an Indian slum

High burden of wasting among children under-five with hydrocephalus receiving care at CURE children's hospital in Uganda: a cross-sectional study

BACKGROUND

Hydrocephalus is one of the most common neurological disabilities presenting in children. Although there are limited studies on its association with wasting, neurological comorbidities such as dysphagia have been associated with an increased risk of wasting in children. In this study, we aimed to determine the prevalence and factors associated with wasting in children less than five years with hydrocephalus.

METHODS

We conducted a cross-sectional study at various satellite clinics of CURE Children's Hospital in Uganda between September and November 2021. Children with hydrocephalus were identified at the outpatient departments of the satellite clinics of the Cure Children's Hospital and these include Mbale, Gulu, Lira, Jinja and Katalemwa. A structured questionnaire was used to collect information on several variables including (1) for the mother: socio-demographic characteristics, partner support, and wealth index (2) for the child: socio-demographic characteristics, clinical symptoms, feeding difficulties and neural comorbidity. Anthropometric measurements were also taken and these included the mid-upper arm circumference. Data were analysed using Stata version 14. We estimated adjusted odds ratios and their corresponding 95% confidence intervals while relying on multivariable logistic regression models.

RESULTS

The prevalence of wasting among children with hydrocephalus was 23.2% (n = 89/384) (95%CI: 19 - 27.7%). Their mean age was 19.5 months (SD 16.8). Most of the children were below 12 months (47.9%) and were male (57.5%). The factors associated with wasting among children with hydrocephalus included: having; difficulty in chewing and swallowing (AOR = 2.6, (95%CI:1.05-3.94), a poor appetite (AOR = 1.74, (95%CI: 1.31-2.32), difficulty in breathing (AOR = 1.9, (95%CI: 1.18-3.16), chocking on food (AOR = 1.42, (95%CI:1.1-1.9) and attending the Mbale satellite clinic (AOR = 2.1 (95% CI 1.19-3.7). Children under 5 years of age with hydrocephalus that were born to women whose highest level of education was 7 to 10 years of formal schooling (AOR = 0.32, 95%CI: (0.12-0.87) were less likely to be wasted.

CONCLUSIONS AND RECOMMENDATIONS

The prevalence of wasting among children with hydrocephalus was high. The factors associated with wasting were mainly feeding challenges. We recommend that children with hydrocephalus should be given greater attention regarding their nutrition especially those with various forms of feeding difficulties. The caregivers of children with hydrocephalus should receive counseling on nutrition and on the best modalities to rely on while feeding their children.

Feeding Difficulties Among Children With Special Needs: A Cross-Sectional Study From India

Deficits in feeding can lead to impairments in occupational performance for children with special needs. This correlational study assessed the relationship between oromotor deficits, behavior problems related to feeding, and caregiver perception of the behavior in children with special needs. We included children with neurodevelopmental disorders (n=79), between 2 and 12 years of chronological age, and their caregivers. Those fulfilling the selection criteria were administered the Behavioral Pediatric Feeding Assessment Scale (BPFAS) and Schedule for Oromotor Assessment (SOMA). More than half the sample had skill deficits and behavioral problems related to feeding. There was a statistically significant correlation of oromotor deficits with specific food consistencies and feeding-related behavior problems. Children with special needs have impaired participation in feeding. Deficits at the body system level are associated with parental and cultural factors, which would have to be mitigated to optimize performance.

Caregiver experiences of feeding children with developmental disabilities: a qualitative study using interpretative phenomenological analysis from India

OBJECTIVE

We aimed to explore caregiver experiences of feeding children with developmental disabilities, in the context of it being influenced by biological, personal and social factors.

DESIGN

This study applied a qualitative study design through focus group discussions (FGDs), using interpretative phenomenological analysis. Data were analysed using thematic content analysis.

SETTING

This study was conducted at the Child Psychiatry Unit of a tertiary care centre in South India, between March and November 2020.

PARTICIPANTS

Seventeen mothers of children with developmental disabilities, who provided written informed consent, participated in four FGDs.

RESULTS

Three over-arching themes were identified. Feeding experience: (a) a tedious, confusing task; (b) disproportionate onus on mothers; (c) influenced by sociocultural norms.

CONCLUSION

Feeding can be a stressful activity for both caregiver and child, influenced by family structure and sociocultural belief systems. Considering caregivers' emotional status, facilitatory and hindering environmental factors, and actively exploring strategies to promote the generalisation of strategies learnt into real-life outcomes are essential in tailoring deficit-specific feeding interventions.

A comparison of nutritional status between children with and without disabilities: A community-based study

Background:

Children with disabilities are expected to have poor nutritional status in comparison to children without disabilities. However, limited data on nutritional status of children with and without disabilities in rural settings in India.

Objective:

To assess and compare the nutritional status of children with and without disability.

Methods:

A cross-sectional study among children aged 5–15 years was conducted in the rural practise area of a medical college in Karnataka. 290 children (145 with and 145 children without disability) of similar age and sex were studied. Age and sex-specific World Health Organization (WHO) BMI centiles, 24 h dietary calorie and protein intakes were assessed and compared. Median and interquartile ranges were calculated for quantitative variables. Mann–Whitney U test was used to assess the differences in quantitative variables among the two groups.

Results:

As per WHO BMI centiles, 33.1% with and 37.20% without disabilities were undernourished. The median calorie consumed by children with disabilities was 1169.0 (946.5–1586.0) significantly lower compared to that of children without disability, that is, 1362.0 (1167.0–1641.0). The median protein consumed by children with disabilities was 28.0 (22.5–38.0) significantly lower compared to that of children without disability, that is, 32.0 (28.0–40.0).

Conclusions:

Children with disabilities had similar rates of undernutrition as that of their non-disabled peers and their lesser dietary intake in terms of calories and proteins.

The association between malnutrition and childhood disability in low- and middle- income countries: systematic review and meta-analysis of observational studies

OBJECTIVE

The aim of this study was to evaluate the association between childhood disability and malnutrition in low- and middle- income countries (LMICs).

METHODS

Articles were identified from 1990 to August 2017 by searching nine electronic databases. Epidemiological studies, undertaken in LMICs that compared the prevalence of malnutrition in children with disabilities to children without disabilities were eligible for inclusion. Titles, abstracts, and full texts were screened by two reviewers, and data were extracted using a structured table for eligible papers. Meta-analyses for the association between childhood disability and undernutrition were performed.

RESULTS

The search generated 4678 results, from which 17 articles were eligible. Fifty-three per cent of these studies showed a positive association between childhood disability and undernutrition. Results varied when disaggregated by type of disability, with positive associations identified for 44% of studies focussed on neurodevelopmental disability, 60% of general disability studies and 67% of studies on hearing impairment. Only four studies were identified that considered overnutrition outcomes, and these showed variable results. Eighteen per cent of eligible studies were considered at low risk of bias, 53% had a medium risk, and 29% had a high risk of bias. Pooled ORs showed that children with disabilities were almost three times more likely to be underweight (OR 2.97, 95% CI 2.33, 3.79), and nearly twice as likely to experience stunting and wasting (Stunting: 1.82, 1.40, 2.36; Wasting: 1.90, 1.32-2.75), compared to controls.

CONCLUSIONS

Children with disabilities may be a vulnerable group for undernutrition in LMICs, which should be reflected in disability and nutritional programming and policy-making.

Evaluating the impact of a community-based parent training programme for children with cerebral palsy in Ghana

BACKGROUND

In low and middle-income settings, where access to support and rehabilitation services for children with disabilities are often lacking, the evidence base for community initiatives is limited. This study aimed to explore the impact of a community-based training programme for caregivers of children with cerebral palsy in Ghana.

METHODS

A pre and post evaluation of an 11-month participatory training programme ("Getting to Know Cerebral Palsy") offered through a parent group model, was conducted. Eight community groups, consisting of a total of 75 caregivers and their children with cerebral palsy (aged 18 months-12 years), were enrolled from 8 districts across Ghana. Caregivers were interviewed at baseline, and again at 2 months after the completion of the programme, to assess: quality of life (PedsQL™ Family Impact Module); knowledge about their child's condition; child health indicators; feeding practices. Severity of cerebral palsy, reported illness, and anthropometric measurements were also assessed.

RESULTS

Of the child-caregiver pairs, 64 (84%) were included in final analysis. There were significant improvements in caregiver quality of life score (QoL) (median total QoL 12.5 at baseline to 51.4 at endline, P<0.001). Caregivers reported significant improvements in knowledge and confidence in caring for their child (p<0.001), in some aspects of child feeding practices (p<0.001) and in their child's physical and emotional heath (p< 0.001). Actual frequency of reported serious illness over 12-months remained high (67%) among children, however, a small reduction in recent illness episodes (past 2 weeks) was seen (64% to 50% p < 0.05). Malnutrition was common at both time points; 63% and 65% of children were classified as underweight at baseline and endline respectively (p = 0.5).

CONCLUSION

Children with cerebral palsy have complex care and support needs which in low and middle-income settings need to be met by their family. This study demonstrates that a participatory training, delivered through the establishment of a local support group, with an emphasis on caregiver empowerment, resulted in improved caregiver QoL. Despite less effect on effect on child health and no clear effect on nutritional status, this alone is an important outcome. Whilst further development of these programmes would be helpful, and is underway, there is clear need for wider scale-up of an intervention which provides support to families.

The effect of a practical nutrition education programme on feeding skills of caregivers of children with cerebral palsy at Muhimbili National Hospital, in Tanzania

BACKGROUND

Feeding children with cerebral palsy (CP) is challenging and can lead to poor health outcomes. Using a facility-based intervention, we assessed the effect of a practical nutrition programme on feeding skills in caregivers of children with CP attending a pediatric clinic in urban Tanzania.

METHODS

A randomized-controlled intervention study, involving 2-block stratified sample of under-5 CP children attending a specialized pediatric clinic at the Muhimbili National Hospital was done. One hundred ten moderate-to-severe, new and follow-up cases of children with CP were randomly allocated to the intervention (N = 63) and control groups (N = 47). A short nutrition education on feeding and positioning skills was provided to caregivers and occupational therapy sessions to CP children. Bivariate and multivariable logistic regression analyses of collected data were done. Statistical significance was assessed at p < .05.

FINDINGS

The intervention significantly improved feeding skills of caregiver in the select indicators assessed. More caregivers appropriately positioned the children (AOR = 5.29; 95% CI: 2.00-13.96), fed children slowly (AOR: 5.17, 95% CI: 1.99-13.44), and involved the child during the feeding process (AOR = 3.46; 95% CI: 1.42-8.44). During feeding, caregiver's reported being less stressed (AOR = 2.53, 95% CI: 1.04-6.13) and the child's mood was more likely to be reported as improved (AOR = 3.15, 95% CI: 1.33-7.474). Although changes were observed in oral motor feeding skills (AOR = 1.67; 95% CI: 0.72-3.91) and functional feeding skills (AOR = 2.28; 95% CI: 0.86-6.06), they did not reach statistical significance in the multivariable models.

CONCLUSION

Strengthening nutrition education and services for caregivers of children with CP has great value in the care of children with special needs and may improve the health outcomes of children as well as reduce stress among parents/caregivers.

Childhood disability in Turkana, Kenya: Understanding how carers cope in a complex humanitarian setting

BACKGROUND

Although the consequences of disability are magnified in humanitarian contexts, research into the difficulties of caring for children with a disability in such settings has received limited attention.

METHODS

Based on in-depth interviews with 31 families, key informants and focus group discussions in Turkana, Kenya, this article explores the lives of families caring for children with a range of impairments (hearing, vision, physical and intellectual) in a complex humanitarian context characterised by drought, flooding, armed conflict, poverty and historical marginalisation.

RESULTS

The challenging environmental and social conditions of Turkana magnified not only the impact of impairment on children, but also the burden of caregiving. The remoteness of Turkana, along with the paucity and fragmentation of health, rehabilitation and social services, posed major challenges and created opportunity costs for families. Disability-related stigma isolated mothers of children with disabilities, especially, increasing their burden of care and further limiting their access to services and humanitarian programmes. In a context where social systems are already stressed, the combination of these factors compounded the vulnerabilities faced by children with disabilities and their families.

CONCLUSION

The needs of children with disabilities and their carers in Turkana are not being met by either community social support systems or humanitarian aid programmes. There is an urgent need to mainstream disability into Turkana services and programmes.

Oropharyngeal dysphagia in children with cerebral palsy: comparisons between a high- and low-resource country

PURPOSE

There is paucity of research investigating oropharyngeal dysphagia (OPD) in young children with cerebral palsy (CP), and most studies explore OPD in high-resource countries. This study aimed at determining the proportion and severity of OPD in preschool children with CP in Bangladesh, compared to Australia.

METHOD

Cross-sectional, comparison of two cohorts. Two hundred and eleven children with CP aged 18-36 months, 81 in Bangladesh (mean = 27.6 months, 61.7% males), and 130 in Australia (mean = 27.4 months, 62.3% males). The Dysphagia Disorders Survey (DDS) - Part 2 was the primary OPD outcome for proportion and severity of OPD. Gross motor skills were classified using the Gross Motor Function Classification System (GMFCS), motor type/distribution.

RESULTS

(i) Bangladesh sample: proportion OPD = 68.1%; severity = 10.4 SD = 7.9. Australia sample: proportion OPD = 55.7%; severity = 7.0 SD = 7.5. (ii) There were no differences in the proportion or severity of OPD between samples when stratified for GMFCS (OR = 2.4, p = 0.051 and β = 1.2, p = 0.08, respectively).

CONCLUSIONS

Despite overall differences in patterns of OPD between Bangladesh and Australia, proportion and severity of OPD (when adjusted for the functional gross motor severity of the samples) were equivalent. This provides support for the robust association between functional motor severity and OPD proportion/severity in children with CP, regardless of the resource context. Implications for Rehabilitation The proportion and severity of OPD according to gross motor function level were equivalent between high- and low-resource countries (LCs). Literature from high-resource countries may be usefully interpreted by rehabilitation professionals for low-resource contexts using the GMFCS as a framework. The GMFCS is a useful classification in LCs to improve earlier detection of children at risk of OPD and streamline management pathways for optimal nutritional outcomes. Rehabilitation professionals working in LCs are likely to have a caseload weighted towards GMFCS III-V, with less compensatory OPD management options available (such as non-oral nutrition through tubes).

Malnutrition and Childhood Disability in Turkana, Kenya: Results from a Case-Control Study

BACKGROUND

Children with disabilities may be particularly vulnerable to malnutrition, as a result of exclusions and feeding difficulties. However, there is limited evidence currently available on this subject.

METHODS

A population-based case-control study was conducted in Turkana County, Kenya, between July and August 2013. Key informants in the community identified children aged 6 months to 10 years who they believed may have a disability. These children were screened by a questionnaire (UNICEF-Washington Group) and assessed by a paediatrician to confirm whether they had a disability and the type. Two controls without disabilities were selected per case: A sibling control (sibling nearest in age) and a neighbourhood control (nearest neighbour within one year of age). The caregiver completed a questionnaire on behalf of the child (e.g. information on feeding, poverty, illness, education), and anthropometric measures were taken. We undertook multivariable logistic and linear regression analyses to estimate the relationship between disability and malnutrition.

RESULTS

The study included 311 cases with disabilities, 196 sibling controls and 300 neighbour controls. Children with disabilities were more likely to report a range of feeding difficulties. They were 1.6-2.9 times more likely to have malnutrition in comparison to neighbour controls or family controls, including general malnutrition (low weight for age), stunting (low height for age), low body mass index (BMI) or low mid upper arm circumference (MUAC) for age. Children with disabilities were almost twice as likely to have wasting (low weight for height) in comparison to neighbour controls (OR = 1.9, 95% CI 1.1-3.2), but this difference was not apparent compared with siblings (OR = 1.5, 95% CI 0.8-2.7). Children with disabilities also faced other exclusions. For instance those aged 5+ were much more likely not to attend school than neighbour controls (OR = 8.5, 95% CI 4.3-16.9).

CONCLUSIONS

Children with disabilities were particularly vulnerable to malnutrition, even within this area of food insecurity and widespread malnutrition. Efforts need to be made to include children with disabilities within food supplementation programmes, and school based programmes alone may be inadequate to meet this need. Exclusion of children with disabilities from education is also a priority area to be addressed.

Percutaneous Endoscopic Gastrostomy in Children: Caregivers' Perspectives

We aimed to study caregivers' perspectives on percutaneous endoscopic gastrostomy (PEG). We interviewed the caregivers of 33 children who were fed via PEG and that, of these caregivers, those who believed that they received adequate information prior to and after PEG insertion had a better quality of life. Furthermore, 65% would proceed for an earlier PEG insertion which was associated with several factors including lower educational level, lower household income, and longer traveling time from their residence to our institution. Data from our study may help improve understanding caregivers' perspectives and concerns in children who already or will have PEG.

The development of a feeding, swallowing and oral care program using the PRECEDE-PROCEED model in an orphanage-hospital in Guatemala

PURPOSE

The purpose of this study was to evaluate a long-term on-going international academic service-learning (I-ASL) intervention. Its goal was to improve swallowing, feeding and oral care technique of medical staff in an orphanage in Guatemala to children who are medically complex and have special needs.

METHOD

The PRECEDE-PROCEED model was used as the conceptual framework of the program. Five major target areas were identified during the diagnosis, assessment, implementation and evaluation phases of the model: knowledge and skills, feeding equipment, feeding and oral care technique, positioning and communication. Verbal instruction, modelling and small group training was provided by the research team across all visits. A five-day intervention designed to increase feeders' knowledge of feeding and oral care technique, signs and symptoms and complications of dysphagia and to improve their feeding, positioning and oral care technique was implemented and evaluated.

RESULT

Statistical analyses showed significant increases in knowledge and appropriate feeding, positioning and oral care technique.

CONCLUSION

As a consequence of the intervention, a trusting and mutually supportive relationship was built between the I-ASL team and the host organization.

The impact of disability on the lives of children; cross-sectional data including 8,900 children with disabilities and 898,834 children without disabilities across 30 countries

Background

Children with disabilities are widely believed to be less likely to attend school or access health care, and more vulnerable to poverty. There is currently little large-scale or internationally comparable evidence to support these claims. The aim of this study was to investigate the impact of disability on the lives of children sponsored by Plan International across 30 countries.

Methods and Findings

We conducted a cross-sectional survey including 907,734 children aged 0–17 participating in the Plan International Sponsorship Programme across 30 countries in 2012. Parents/guardians were interviewed using standardised questionnaires including information on: age, sex, health, education, poverty, and water and sanitation facilities. Disability was assessed through a single question and information was collected on type of impairment. The dataset included 8,900 children with reported disabilities across 30 countries. The prevalence of disability ranged from 0.4%–3.0% and was higher in boys than girls in 22 of the 30 countries assessed – generally in the range of 1.3–1.4 fold higher. Children with disabilities were much less likely to attend formal education in comparison to children without disabilities in each of the 30 countries, with age-sex adjusted odds ratios exceeding 10 for nearly half of the countries. This relationship varied by impairment type. Among those attending school, children with disabilities were at a lower level of schooling for their age compared to children without disabilities. Children with disabilities were more likely to report experiencing a serious illness in the last 12 months, except in Niger. There was no clear relationship between disability and poverty.

Conclusions

Children with disabilities are at risk of not fulfilling their educational potential and are more vulnerable to serious illness. This exclusion is likely to have a long-term deleterious impact on their lives unless services are adapted to promote their inclusion.

Identification of feeding risk factors for impaired nutrition status in paediatric patients with cerebral palsy

AIM

To assess the nutrition status of children with CP, applying WHO growth standards, to indentify feeding risk factors and to evaluate their impact on the growth of children with CP.

METHODS

In 42 paediatric patients (mean age 8.00 ± 4.00 years), anthropometry and food intake records were assessed. z-scores were calculated using WHO Anthro software. Intake to requirements ratio (I/R) was calculated, and patients were classified according to their feeding ability (PFA). Overall diet quality was assessed using the Diet Quality Index International (DQI-I).

RESULTS

Based on WAz, 15 patients (38.1%) were undernourished. No association was found between I/R ratio and BMI z-score, while PFA and DQI-I displayed a significant correlation to both (p < 0.05). Diet Quality Index International was also correlated with macronutrient distribution (p < 0.05). Patients with CP were undernourished in a considerable proportion. Malnutrition in patients with CP is not associated with the intake of estimated energy requirements. Among the other feeding risk factors studied, PFA and DQI-I represented important parameters associated with malnutrition.

CONCLUSION

WHO z-scores represent accurate parameters for the assessment of malnutrition in patients with CP. Together with anthropometry and PFA evaluation, the use of the DQI-I would add prognostic value to both the initial growth assessment and the patients' growth monitoring.

Predictors of early-onset permanent hearing loss in malnourished infants in Sub-Saharan Africa

The objective of this study was to determine the predictors of early-onset permanent hearing loss (EPHL) among undernourished infants in a low-income country where routine screening for developmental disabilities in early childhood is currently unattainable. All infants attending four community-based clinics for routine immunization who met the criteria for undernutrition by the Growth Standards of the World Health Organization (WHO) based on weight-for-age, weight-for-length and body-mass-index-for-age were enlisted. EPHL was determined after two-stage screening with transient-evoked otoacoustic emissions, automated auditory brainstem response and diagnostic evaluation. Factors predictive of EPHL were explored with multivariable logistic regression analysis. Some 39 (1.7%) infants from 2254 undernourished infants were confirmed with hearing loss (>30 dB HL). Bilateral EPHL was mild in 7 (17.9%) and moderate-to-profound in 26 (66.7%). EPHL was unilateral in 6 (15.4%). Multiparity, chronological age of more than 30 days, the absence of skilled attendant at birth and severe neonatal jaundice were associated with an increased risk of EPHL while having a Christian mother and exclusive breast feeding had protective effect against EPHL. EPHL is highly prevalent among undernourished infants and associated with modifiable risk factors that can be addressed at the community-level and used as a basis for targeted intervention in resource-poor countries.

Is undernutrition a risk factor for sensorineural hearing loss in early infancy?

The present cross-sectional study set out to determine the nutritional status of infants aged 0–3 months with the WHO Multicentre Growth Reference (WHO-MGR) and examine the relationship between undernutrition and congenital or early-onset sensorineural hearing loss (CESHL) rarely reported for developing countries. The nutritional status of all infants attending community-based clinics for routine Bacille de Calmette-Guérin (BCG) immunisation from July 2005 to December 2006 was determined by weight-for-age, weight-for-length and BMI-for-age based on the WHO-MGR. Hearing loss status was determined by tympanometry, auditory brainstem response (ABR) and visual response audiometry after a two-stage screening with transient evoked otoacoustic emissions and automated ABR. The relationship between nutritional status and CESHL were explored after adjusting for potentially confounding maternal and infant characteristics using multivariable logistic regression analyses. Of the 3386 infants who completed the hearing evaluation protocol, seventy-one were confirmed with hearing loss (>30 dB hearing level). More than one-third (37·9 %) of all infants and over half (54·9 %) of those with CESHL were undernourished by at least one measure of growth. Stunting (35·3 %) was the most prevalent nutritional deficit in infants with CESHL. In the final logistic model, infants with any undernourished physical state were significantly likely to have CESHL (OR 1·67; 95 % CI 1·03, 2·77) and of a severe-to-profound degree (OR 3·92; 95 % CI 1·38, 11·17) compared with infants without any undernourishment. Prospective studies to establish the full spectrum of the relationship between undernutrition and CESHL, particularly in resource-poor countries, are therefore warranted.