What’s known on this subject
What this study adds
Background
Methodology
Study procedure
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Project Announcement: We encouraged parents living in the geographical area served by the faculty hospital to bring their healthy preschool children. We designed invitations including the project's aim, the weekly working day's date and time, participation benefits, and contact for inquiry. We sent invitations using social media, e.g., the hospital's official website and social groups in the city. In addition, we designed a Google form, and its link was added to the invitations for literate parents to register their children. We also used posters at target points in the hospital, namely the entrance and the pediatrics clinic.
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Screening phase: a campaign was conducted on a fixed pre-announced weekly day at the hospital when the other outpatient activities were absent to provide enough space without overcrowding. First, the planned project activities were presented to the parents in the waiting area to ensure their cooperation and acceptance of the time spent. Secondly, children and their parents went through separate stations for registration, anthropometric assessment, medical and dietetic History taking, detailed clinical examination, and nutrition awareness session. Finally, a blood sample was drawn for laboratory testing. Parents were requested to come again on the next working day of the project to obtain the assessment result, a copy of the laboratory results, and a follow-up card when required.
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◦ Demographic data: The children's age was calculated from the date of birth on their birth certificate and date of measurement. Also, the gender, residence, and contact information were documented.
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◦ History taking: emphasizing the medical History of the perinatal period, breastfeeding details, weaning, vaccination, developmental milestones, birth measures when available, physical activity, and sleep characteristics. We also reported the History of the current nutritional intake.
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◦ Anthropometric assessment: Two trained team members helped each other. The measurer held the child and took the measurements, and the other assisted with the process and recorded the measurements on the documentary sheet. We used uninflated colorful balloons to calm the children. Weight and height were measured using a stadiometer while the child was barefoot with minimum clothing. The weights of frightened children were measured by subtracting the mother's weight holding her infant in her arms from the total weight. Height was measured while the child looked straight ahead (at his mother who stood in front of him), the child's line of sight parallel with the ground, and the measurer's left hand under the child's chin, his shoulders at the same level, and his hands at his sides. Ensuring that the head, shoulder blades, and buttocks were against the measuring scale, the measurer lowered the headpiece on the child's head with his right hand. After that, BMI was calculated by dividing the weight measured in kg by the height in squared meters. Measures were plotted using the CDC growth charts for ages 2–20. Children with weight below the 3rd percentile or BMI below the 5th percentile for age & sex were labeled with undernutrition, and then classified to stunting or wasting as mentioned below. Children having BMI between 85th & 95th percentiles were considered overweight & those above 95th were considered obese [5]. Children with a height below the 3rd percentile for age & sex, and not underweight were labeled as short stature, with no further discussion being not our study aim. During data analysis, the Z scores for anthropometric measures were calculated online [6], and cases were categorized accordingly to the international classification of malnutrition.
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◦ Clinical examination: particularly concerned about vitamin deficiency signs, systemic affection, and complications in children with obesity. The temperature was measured before entry, and febrile children were deferred for another appointment. Blood pressure was measured for cases of obesity using a sphygmomanometer with a suitable-sized cuff.
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◦ Nutrition awareness: flyers with details about healthy diet for preschoolers were distributed.
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◦ Laboratory testing: A 3 ml blood sample was obtained for all screened children to perform a complete blood count. In cases with anemia, we measured serum ferritin levels and CRP to assess the infection status.
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Definitions applied
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1. Undernutrition: for children up to 19 years [7]:UndernutritionUnderweightStuntingWasting/ Thinness aIndicators specific to a child’s genderWeight-for-ageHeight-for-ageWeight-for-height or BMI for ageZ score classification:- Possible abnormality> + 1> + 3< + 2 to > + 1b- Normal< + 1 to ≥ -2< + 3 to ≥ -2< + 1 to ≥ -2- Moderate< -2 to ≥ -3< -2 to ≥ -3< -2 to ≥ -3- SevereBelow > -3Below > -3Below > -3
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a)Stunting: Indicates that a child does not reach their required growth potential. It reflects chronic malnutrition for over three months, affecting the height velocity [8] . It could be moderate or severe.b)Wasting: Indicates that a child is skinny as regards their height. It is one of the indicators of acute malnutrition in children. It is either moderate or severe. Severe wasting can also be described as nutritional marasmus.c)Underweight: Indicates that a child's weight is less than expected for a well-nourished, healthy child of the same age and gender. It indicates stunting or wasting without precise differentiation. It reflects either weight loss or inappropriate weight gain.
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2. Overweight and obesity: for similar height and gender, overweight usually reflects excess weight from muscle, bone, fat, water, or a combination of them, while obesity usually reflects excess body fat [7]:
Overweight /Obesity
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Age | Up to 5 years | 5 to 19 years |
Indicator: | Weight-for-height | BMI |
Z score classification:
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Overweight | > + 2 to ≤ + 3 | < + 2 to > + 1 |
Obesity | > + 3 | > + 2 |
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3. Anemia: was defined when the hemoglobin level is below 11 gm% up to the age of 4 and 11.5% for ages 4–6 years [9]. Iron deficiency anemia was suspected when the mean corpuscular volume “MCV” was < 70 μm3, and red diameter width “RDW” > 15.
Statistical analysis
Results
Variable | Values |
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Age in years; mean ± SD [min–max] | 3.8 ± 1.4 [1.02 – 7] |
Categories; N (%): Up to 5 years | 391 (77.4) |
Above 5 years | 114 (22.6) |
Gender; N (%): Male | 259 (51.3) |
Female | 246 (48.7) |
History of neonatal period and infancy | |
Physiologic jaundice; N (%): | 140 (27.7) |
Neonatal intensive care "NICU" admission; N (%): | 98 (19.4) |
Initial cause of admission: | |
- Respiratory distress | 57 (58.2) |
- Jaundice | 40 (40.8) |
- Hypoglycemia | 1 (1) |
Duration of stay in days; median (IQR) [min–max] | 5.5 (4 -10) [1 – 60] |
Oxygen administration more than 4 weeks; N (%) | 3 (0.6) |
Blood transfusion at NICU | 1 (0.2) |
Type of feeding; N (%): | |
- Exclusive Breast On demand | 337 6.7) |
- Exclusive Breast then formula | 2 (0.4) |
- Breast & formula | 75 (14.9) |
- Breast & Animal | 3 (0.6) |
- Formula | 88 (17.4) |
Exclusive breast feeding duration in months (n = 339): mean ± SD [min–max] | 5.9 ± 1.97 [1–12] |
Total duration of breast and/or bottle feeding in months; median (IQR) [min–max] | 6 (5—7) [1.5 – 24] |
Number of daily bottles (n = 168); N (%) | |
- Once or twice | 34 (20.2) |
- From two to 5 | 71 (42.3) |
- More than 5 | 63 (37.5) |
Taken all vaccination; N (%) | 491 (97.2) |
Missed vaccination; N (%) | 14 (2.8) |
- Not vaccinated at all | 4 (0.8) |
- Missed 4 months | 1 (0.2) |
- Missed 9 months | 1 (0.2) |
- Missed 18 months | 8 (1.6) |
History of pregnancy and delivery | |
Maternal infection; N (%): | |
- Undiagnosed infection | 2 (0.4) |
- Hepatitis C viral infection | 3 (0.6) |
- Herpes simplex viral infection | 1 (0.2) |
Maternal disease; N (%): | |
- Hypertension "HTN" ± preeclampsia | 16 (3.2) |
- Gestational Diabetes Millitus "DM" | 6 (1.2) |
- DM & HTN | 5 (1) |
- Hypothyroidism | 3 (0.6) |
- Renal stone | 1 (0.2) |
- Urinary tract infection "UTI" | 1 (0.2) |
Maternal treatment; N (%): | |
- Antihypertensive | 16 (3.2) |
- Insulin | 6 (1.2) |
- Insulin & anti-hypertensive | 5 (1) |
- Thyroxin | 3 (0.6) |
- Antibiotics | 2 (0.4) |
- Anticoagulant | 1 (0.2) |
Regular maternal intake of supplements (vitamins & iron); N (%): | 158 (31.3) |
Mode of delivery; N (%): | |
- Vaginal | 161 (31.9) |
- Cesarian section "CS" | 344 (68.1) |
Eventful delivery; N (%): | |
- Premature rupture membranes | 5 (1) |
- Breech presentation | 3 (0.6) |
- Blood transfusion after post-partum bleeding | 2 (0.4) |
- Difficulty due to presence of uterine tumor | 1 (0.2) |
Variable | Values |
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Anthropometric measures | |
Weight in Kg; mean ± SD [min–max] | 15.5 ± 4.02 [6 – 48] |
Z score of weight; median (IQR) | -0.28 (-0.95 – 0.5) [-6.6 – 3.3] |
Weight percentiles; median (IQR) | 39 (17.3 – 68.3) [0 – 100] |
Height in cm; mean ± SD | 97.5 ± 11.02 [71 – 136] |
Z score of height; median (IQR) | -0.5 (-1.2 – 0.2) [-5.4 – 3.8] |
Height percentiles; median (IQR) | 30.2 (12.3 – 58.1) [0 – 100] |
BMI; mean ± SD | 16.1 ± 2 [9.1 – 30.2] |
Z score of BMI; median (IQR) | 0.2 (-0.6 – 0.99) [-7.7 – 3.9] |
BMI percentiles; median (IQR) | 56.7 (27.95 – 84) [0 – 100] |
Q95 (> 5 years); mean ± SD | 18.3 ± 0.4 [17.8 – 20.1] |
BMI p95; mean ± SD | 0.9 ± 0.1 [0.6 – 1.6] |
Examination findings | |
Signs of vitamins deficiencies; N (%): | |
- Pallor | 119 (23.6) |
- Signs of rickets | 10 (2) |
- Dermatitis | 8 (1.6) |
- Acro-orificial rash | 5 (1) |
- Mucositis & chelitis | 3 (0.6) |
- Alopecia areata | 2 (0.4) |
- Spooning of the nail | 1 (0.2) |
Laboratory findings | |
Total leukocytic count "TLC" (× 103/cmm); Mean ± SD [min–max] | 8.2 ± 2.9 [2.64 – 21.2] |
Hemoglobin "HB" (mg/dl); Mean ± SD [min–max] | 11.7 ± 1.1 [8.10 – 14.6] |
Platelet "PLT" (× 103/ul); Mean ± SD [min–max] | 382.15 ± 105 [101 – 750] |
Mean corpuscular volume "MCV" in fl; Mean ± SD [min–max] | 73 ± 6.1 [56.9 – 84.6] |
Screened group N = 505 | Age classification | |||
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Up to 5 years (n = 391) | At or above 5 years (n = 114) | P value | ||
Gender; N (%): | ||||
- Male | 259 (51.3) | 203 (51.9) | 56 (49.1) | 0.7 |
- Female | 246 (48.7) | 188 (48.1) | 58 (50.9) | |
Overall screening results; N (%): | ||||
- Normal | 228 (45.1) | 175 (44.8) | 53 (46.5) | 0.7 |
- Abnormal | 277 (54.9) | 216 (55.2) | 61 (53.5) | |
Anthropometric measures; N (%): | ||||
- Normal | 319 (63.2) | 252 (64.5) | 80 (70.2) | 0.3 |
- Abnormal | 186 (36.8) | 139 (35.5) | 34 (29.8) | |
Abnormal anthropometry; N (%): | ||||
Undernutrition: | 48 (9.5) | 38 (9.7) | 10 (8.8) | 0.7 |
- Underweight | ◦ 33 (6.6) | ◦ 27 (6.9) | ◦ 6 (5.3) | ◦ 0.7 |
- Wasting | ◦ 33 (6.6) | ◦ 28 (7.2) | ◦ 5 (4.4) | ◦ 0.4 |
- Stunting | ◦ 15 (3) | ◦ 10 (2.6) | ◦ 5 (4.4) | ◦ 0.3 |
Over-nutrition | 125 (24.8) | 101 (25.8) | 24 (21.1) | 0.3 |
- Overweight | ◦ 43 (8.5) | ◦ 26 (6.6) | ◦ 17 (14.9) | ◦ < 0.001* |
- Obesity | ◦ 12 (2.4) | ◦ 5 (1.3) | ◦ 7 (6.1) | ◦ < 0.001* |
- Possible high abnormality | ◦ 70 (13.9) | ◦ 70 (17.9) | ◦ 0 | ◦ < 0.001* |
Short stature | 29 (5.7) | 27 (6.9) | 2 (1.8) | 0.04* |
- With normal BMI | ◦ 13 (2.6) | ◦ 13 (3.3) | ◦ 0 | ◦ 0.08 |
- With overweight/obesity | ◦ 6 (1.2) | ◦ 4 (1) | ◦ 2 (1.8) | ◦ 0.6 |
- With possible overweight | ◦ 10 (1.98) | ◦ 10 (2.6) | ◦ 0 | ◦ 0.1 |
Presence of Anemia; N (%): | 141 (27.9) | 100 (25.6) | 41 (36) | 0.03* |
Having both anemia & abnormal anthropometry; N (%): | 50 (9.9) | 36 (9.2) | 14 (12.3) | 0.4 |
Normal Hemoglobin (N = 364) | Anemia (N = 141) | P Value | |
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Age; mean ± SD | 3.6 ± 1.4 | 4.1 ± 1.3 | < 0.001* |
• Below 4 years | 291 (79.9) | 100 (70.9) | 0.03* |
• Below 4 years | 227 (62.4) | 58 (41.1) | < 0.001* |
Gender; N (%): | |||
• Male | 189 (51.9) | 70 (49.6) | 0.6 |
• Female | 175 (48.1) | 71 (50.4) | |
Normal anthropometry; N (%): | 228 (62.6) | 91 (64.5) | 0.8 |
Abnormal anthropometry; N (%): | |||
• Undernutrition: | 40 (11) | 8 (5.7) | 0.09 |
◦ Underweight | ◦ 29 (72.5) | ◦ 4 (50) | 0.04* |
◦ Wasting | ◦ 27 (67.5) | ◦ 6 (75) | 0.2 |
◦ Stunting | ◦ 14 (35) | ◦ 1 (12.5) | 0.08 |
• Over-nutrition | 86 (23.6) | 39 (27.7) | 0.4 |
◦ Overweight / Obesity | ◦ 34 (39.5) | ◦ 21 (53.8) | 0.08 |
◦ Possible high abnormality | ◦ 52 (60.5) | ◦ 18 (46.2) | 0.7 |
• Short stature | 20 (5.5) | 9 (6.4) | 0.8 |
◦ With normal BMI | ◦ 10 (50) | ◦ 3 (33.3) | 0.8 |
◦ With overweight/obesity | ◦ 3 (15) | ◦ 3 (33.3) | 0.4 |
◦ With possible overweight | ◦ 7 (35) | ◦ 3 (33.3) | 0.9 |