November 1984, Volume 34, Issue 11

Original Article

Nutritional Risk Factors in a Well Baby Clinic

S. Ahmed  ( Department of Paediatrics, Civil Hospital and Dow Medical College, Karachi. )
D.S. Akram  ( Department of Paediatrics, Civil Hospital and Dow Medical College, Karachi. )


Cross sectional data from a “Well Baby” (immunisation) clinic over a period of 1 year and certain associated environmental factors were studied to establish if any of these “risk factors” were significant in causing malnutrition. Thus the concept of “at risk” child has been highlighted for the under priviledged paediatric population (JPMA 34: 335, 1984).


Protein Calorie/energy Malnutrition (PEM) is a significant problem in Pakistan. According to a Planning Commission study 60% of our children need some nutritional intervention. Out of these 7% are severely malnourished.1
A previous retrospective analysis of data from the irnmunisation clinic revealed that over fifty percent of otherwise well babies were malnourished2 and the percentage and degree of malnutrition increased with age. PEM largely contributes to the morbidity and mortality of children. It is recognised now that intervention should be initiated before malnutrition becomes overt to be more effective. Children at risk for developing PEM should be identified and kept under close supervision to prevent malnutrition.
The concept of ‘ at risk ‘ childrenv3 was evolved to provide concentrated care to children who are exposed to certain environmental disadvantages before or after birth. This type of care is more cost-effective, in the limited facilities in underdeveloped countries can be concentrated towards the care of a smaller number of children.
If a sample of children is followed from birth onwards, some of them are found to do well whereas others loose weight and have an increased incidence of illness and mortality. Various workers, have studied such children in under-privileged populations4. In St.Lucia5, West Africa6 and India7 well nourished and malnourished children were studied to establish environmental factors which seemed to affect malnourished children. Factors present predominantly in children who did poorly, were then called Risk Factors (R.F.). They can be defined as environmental variables that expose the child to a greater risk of developing PEM and having a higher morbidity and mortality.
Some of these factors are common to all populations, but others vary with the environment specific to each region. This preliminary study was undertaken to identify the risk variables in karachi population.

Material and Methods

This prospective study started in December, 1982 and will be completed by December.. 1985. The cross-sectional data presented here is based on initial measurements recorded on all babies from December, December, 1983. The main objectives were identification of possible environmental factors which could lead to malnutrition in babies. These ‘risk factors’ were hypothesised and their effect on the nutrition and health of the child has been studied.
Initially, every mother was interviewed by a doctor to identify the baby’s exposure to each risk factor. Then a physical examination was done and the infant’s weight and height measured and recorded. On subsequent visits the above measure ments and the number ot episodes of illness were recorded. Illness was defmed as fever and/or respiratory and/or gastrointestinal symptoms.
Gomez’s criteria was used to classify children into grades of malnutrition8 and frequency distribution to determine the prevalence of malnutrition. A CM-square test of significance was used to show significant association of risk-factors with malnutrition.

Results and Discussion

A total of 2947 children were recorded with a sex ratio of 1: 1. 1. The percentage of children with normal weight for age was 52, whereas 48% were malnourished. There were 29.47% with Grade-I PEM, 15,48% Grade-lI and 2.95% Grade-Ill. Similar frequency has previously been reported from our unit. The frequency distribution of children with PEM is given in fig. 1 and 2 which show that although P.E.M.

is present even between 0-3 months of age, its frequency and severity increases with age, and becomes maximum at 13-36 months which pro bably reflects delayed and improper weaning.

Table 1 shows Risk Factors that were hypothesised and Table-II

the risk factors (R.F.) found to affect nutrition significantly. They are given in order of their significance (weighted). Of fifteen hypothesised variables, ten were found to affect nutrition.

In Table III these factors have again been studied by comparing the populations that were exposed to these risk factors and those not exposed to them. A total of six variables were found to be statistically significant (given in order of their significance or weight). A further analysis was carried out to evaluate if any of the risk factors affected the severity of malnutrition. This was not statistically proven.

In Table IV a comparison has been made between the risk factors identified in West Africa5 Most of these were also found to be significant in the present study, but some were specific to our environment.
Babies can be exposed to two or three of these environmental factors at one time. Whether simultaneous exposure to more than one risk factor multiplies their risk of developing malnutrition, remains to be studied.
To make delivery of preventive care more effective, babies attending immunisation clinics should be evaluated initially’ for the determined risk factors. Babies ‘at risk’ should then be given special attention with nutritional advise and close supervision. Such measures would hopefully prevent malnutrition and decrease morbidity, metality and cost of health care delivery.


1. Micro-Nutrient Survey, Planning Commission, “Percent prevalence of need for intervention in children under 5 years”. In Statistical Profile of Children of Pakistan. Planning Commission Divi sion, 1980; p. 38.
2. Ahmed, S. and Akrain, D.S. Prevalenceof malnutrition in a well baby clinic. Pakistan Paediatr. J., 1984; 8: 46.
3. Stanfield, J.P. The ‘at risk concepts’. J.Trop. Pediat., 1968; 14: 201.
4. Morley, D. The ‘at risk child’ in paediatric priorities in the developing world. Edited by Butterworths, 1979; p. 158.
5. Lees, R.E. Malnutrition; the infant at risk. West IndianMed.J., 1966; 15:211.
6. Morley, D.C., Woodland. “Heights and Weights of West African Village Children from birth to age of five”. West Afr. Med. J., 17 : 18.
7. Langesen, B.M. Presentation at workshop on Under-fives clinics, Hyderabad, 1972.
8. Gomez, F., Galum, R.P. and Frenck. “Criteria for grading malnutrition”. J. Trop. Pediat., 1968; 2: 77.

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