|Year : 2014 | Volume
| Issue : 2 | Page : 77-81
Evaluation of some Laboratory Parameters of Malnourished Children in Magaria District, Zinder, Niger Republic
YA Mahaman1, SA Akuyam2, B Danborno3, OM Galadima4, M Belemsigri4, SM Moussa5
1 Department of Human Anatomy, Ahmadu Bello Univeresity, Zaria, Nigeria,
2 Department of Chemical Pathology, Ahmadu Bello Univeresity Teaching Hospital, Zaria, Nigeria
3 Department of Human Anatomy, Ahmadu Bello Univeresity, Zaria, Nigeria
4 Department of Paediatric Unit, Magaria Distric Hospital, Nigeria, Republic of Niger
5 Department of Paediatrics, Zinder National Hospital, Republic of Niger
|Date of Submission||01-Nov-2013|
|Date of Acceptance||23-Feb-2014|
|Date of Web Publication||16-Jul-2014|
S A Akuyam
Department of Chemical Pathology, Ahmadu Bello Univeresity Teaching Hospital, Zaria, Nigeria
Background and Aim : Protein energy malnutrition (PEM) is the most common nutritional disorder affecting children in developing countries including Niger Republic and continues to be a major health burden in these countries. There is paucity of data on the pattern of laboratory parameters among malnourished children in Niger Republic. The aim of the present study was to evaluate the pattern of some laboratory parameters among under-five malnourished children in Magaria District, Zinder, Niger Republic. Materials and Methods : A total of 220 malnourished children and 220 age- and sex-matched well-fed apparently healthy (controls) children were recruited for the study. Albumin, glucose, calcium, phosphorus and hemoglobin were estimated in the subjects and the data were analysed using Sigma-Stat 2.0 for Windows (San Rafael, CA). Results : Serum albumin, calcium, phosphorus and hemoglobin were significantly lower (P < 0.001) in PEM children compared to the controls. The serum levels of albumin and hemoglobin were also found to be significantly lower (P < 0.03) in children with edematous PEM than in children with non-edematous PEM. Conclusion : PEM children had reduced serum levels of the measured laboratory parameters when compared to apparently healthy well-fed children with resultant hypoalbuminaemia and anaemia, with more marked reduction in edematous than in non-edematous PEM children. This suggests that routine measurement of these laboratory parameters and their subsequent supplementation in PEM children could improve the management of this group of patients.
Keywords: Biochemical parameters, malnourished children, PEM children, protein-energy malnutrition, well-fed children
|How to cite this article:|
Mahaman Y A, Akuyam S A, Danborno B, Galadima O M, Belemsigri M, Moussa S M. Evaluation of some Laboratory Parameters of Malnourished Children in Magaria District, Zinder, Niger Republic. Sub-Saharan Afr J Med 2014;1:77-81
|How to cite this URL:|
Mahaman Y A, Akuyam S A, Danborno B, Galadima O M, Belemsigri M, Moussa S M. Evaluation of some Laboratory Parameters of Malnourished Children in Magaria District, Zinder, Niger Republic. Sub-Saharan Afr J Med [serial online] 2014 [cited 2020 May 31];1:77-81. Available from: http://www.ssajm.org/text.asp?2014/1/2/77/136816
| Introduction|| |
Malnutrition is a complex problem which results from a long chain of interrelated events. It continues to be a major health burden in developing countries and affects mostly infants, young children and lactating mothers.  Protein-energy malnutrition (PEM) previously referred to as protein-calorie malnutrition (PCM) describes the severe form of malnutrition seen in childhood (kwashiorkor, marasmic-kwashiorkor, marasmus and underweight) and the nutritionally determined growth retardation that precedes this clinical syndrome.  It is the most common nutritional disorder affecting children in developing countries and the third most common disease of childhood in such countries.  It manifests primarily by inadequate dietary intake of protein and energy, and always accompanied by deficiencies of other nutrients. 
Worldwide, an estimated 852 million people are undernourished with most (815 million) living in developing countries , and about 150 million under-five children are still malnourished although considerable progress has been achieved in reducing child malnutrition in developing world as a whole.  Despite improved medical care, it has been reported that mortality of children with severe PEM remains high at 10-20%. 
Several reports across the world showed that PEM is associated with a significant reduction of most of the body's important nutrients including albumin, calcium and phosphorus and in the blood and tissues. ,,,,,,,,,,,, Serum protein concentrations are decreased in PEM and this is mainly due to hypoalbuminaemia.  Life-threatening hypoglycaemia has been reported in severe PEM.  It was also reported that the mean serum calcium concentrations in PEM was significantly low and the levels correlated significantly with weight-for-height. , The low serum calcium and phosphorus explains the radiological findings of poor mineralization of long bones in PEM patients as reported by Soliman et al. 
PEM has a great impact on the health care system, resulting in reduced quality of life of the affected patients and added financial costs to the institutions where the patients are receiving care. In view of its public health related problem, emphasis should be placed on the timely assessment of PEM. This involves the need to search and update the clinical and laboratory approaches for the assessment of malnourished children in Nigerien hospitals. These should include a comprehensive laboratory evaluation of serum laboratory parameters with a view to including them as part of patient's management.
There is paucity of data on the pattern of serum concentrations of most of the important laboratory parameters including glucose, calcium, phosphorus and hemoglobin among others in Niger Republic. Estimation of serum albumin is usually the most routinely requested biochemical test for the assessment of PEM patients in most of the Nigerien hospitals. This has some limitations including being non-specific and non-sensitive for malnutrition. Therefore, there is the need to consider the estimation of other parameters which are readily available and more reliable for the assessment of PEM in our hospitals. This could improve the management of this group of subjects and hence reduce the morbidity and mortality from PEM. The aim of the present study was therefore to evaluate the pattern of serum concentrations of albumin, glucose, calcium, phosphorus and hemoglobin among children with PEM in Magaria District hospital, Niger Republic, with a view to knowing the pattern of these parameters in this part of the world, and this could improve the laboratory investigations of PEM.
| Materials and methods|| |
This is a descriptive study conducted in Magaria District Hospital, Zinder, Niger Republic. A total of 440 subjects were recruited for the study. These consisted of 220 malnourished and 220 age- and sex-matched children.
The two hundred and twenty (220) malnourished children aged 6 to 36 months (mean age 16.67 ± 7.94) recruited for the study was made up of 129 males (mean age 16.35 ± 7.88) and 111 females (mean age 17.04 ± 8.04). These consisted of 80 patients (mean age 15.44 ± 7.16) with marasmus, 51 patients (mean age 24.09 ± 11.33) with marasmic-kwashiorkor, 41 patients (mean age 16.83 ± 8.35) with underweight and 48 patients (mean age 23.39 ± 6.19) with kwashiorkor. Similarly, the two hundred and twenty (220) apparently healthy well-fed children who were age- and sex-matched with the patients were recruited as control.
The study was approved by the Ethical Committee of Magaria District Hospital, Zindar, Niger Republic. All children with apparent deformities that affect anthropometric measures like limb deformity were excluded. All children whose parents/guardians declined to give consent for inclusion were also excluded from the study. Informed consent for inclusion into the study was sought from the parents/guardians of the selected children and was granted.
At the clinic, children who satisfied the study inclusion criteria were consecutively selected using simple random technique. A full medical history was obtained from the parents/guardians of the selected children. This was followed by a detailed physical examination, anthropometric measurements and collection of blood samples. The main findings were documented in the study proforma. For each child with PEM consecutively recruited, an age- and sex-matched control was consecutively selected.
At the point of first presentation or subsequent presentation during treatment of the children, blood specimens (5 ml each) were collected from peripheral vein by veinepuncture into a plain container using a sterile technique. These were centrifuged for 5 min at 1000 g. The sera were separated from the cells and were transferred to sample bottles and then analysed for serum albumin, glucose, calcium, phosphorus and hemoglobin on the same day of blood collection. However, in a situation when it is not possible to carry out the analysis on the day of specimens' collection due to logistic problem, they used to be kept frozen at -20° C until the following day.
The chemicals for the measurements of serum albumin, glucose, calcium, phosphorus and hemoglobin were procured from RANDOX laboratories Ltd. (United Kingdom). All the chemicals were of analytical grade or higher. Hettich Universal 32 Centrifuge (Germany) was used to spin the blood specimens. ESSE-3-2007 FAST chemistry analyzer (Italy) was used for the measurements of serum albumin, calcium, phosphorus and glucose concentrations, while HemoCue ® B-hemoglobin (HB 201 + ) photometer (Sweden) was used for measuring hemoglobin concentrations.
Serum albumin (ALB) concentration was measured using method of Doumas et al.,  while glucose (GLU) was measured by GLU oxidase method.  Serum calcium (CAL) was measured by the method of Ray and Chauhan,  while phosphorus (PHOS) was measured by the method of Gomorri, as modified by Henry.  The hemoglobin concentrations were measured by the method of Vanzetti. 
The data were expressed as mean±standard deviation (Mean ± SD) and were analysed using Sigma-Stat 2.0 for Windows (San Rafael, CA). Student's t-test was used to assess differences between data from malnourished and apparently healthy well-fed children, as well as edematous from non-edematous PEM children. One way analysis of variance (ANOVA) was applied to assess differences between data from different classes of malnutrition. A P-value of equal to or less than 0.05 (P ≤ 0.05) was considered as statistically significant.
| Results|| |
The results of laboratory parameters of the malnourished and well-fed children were shown in [Table 1]. Most of parameters were significantly lower (P < 0.001) in PEM children compared to the well-fed ones except glucose which was slightly lower in PEM than in well-fed children.
|Table 1: Biochemical parameters (Mean ± SD) of malnourished and well-fed children|
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The results of laboratory parameters according to different classes of malnutrition are presented in [Table 2]. The results in this table showed that there were significant differences (P < 0.03) and P < 0.00) in albumin and hemoglobin levels, respectively, between the four different classes of PEM. Post hoc analysis has shown that the values were significantly lower in kwashiorkor compared with marasmus and underweight, and also lower in marasmic-kwashiorkor compared with underweight. The values were not significantly different between kwashiorkor and marasmic-kwashiorkor, as well as between marasmus and underweight. The finding was confirmed when the two groups comparison was carried out by combining the data from kwashiorkor and marasmic-kwashiorkor (edematous PEM) children and marasmus and underweight (non-edematous PEM) children as shown in [Table 3]. The results in this table showed that serum albumin and hemoglobin levels were significantly lower (P < 0.03, P < 0.00, respectively) in edematous PEM children compared to the non-edematous ones. Serum calcium and phosphorus levels were not significantly different between edematous and non-edematous PEM children.
|Table 2: Biochemical parameters (Mean ± SD) of malnourished children by class of PEM|
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|Table 3: Biochemical parameters (Mean ± SD) of malnourished children by edema status|
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| Discussion|| |
The present study has evaluated the pattern of some laboratory parameters among children with protein-energy malnutrition (PEM) in Magaria District, Zinder, Niger Republic. The results of this study showed that all laboratory parameters studied were lower in PEM patients than in the well-fed control group. However, with exception of hemoglobin, all the other results were low-normal that is close to the lower limit of the reference ranges. This finding agrees with previous reports by Soliman et al.,  Rahman and Begum,  Adegbusi and Sule,  Kalra et al.,  and Waterlow  who found that serum total calcium and phosphorus concentrations were markedly decreased according to the type of PEM. Nassar et al., reported that calcium and phosphorus levels were within reference ranges in non-edematous and edematous groups of PEM patients but lower in the edematous than non-edematous patients.
The occurrence of reduced levels of serum calcium and phosphorus in malnourished children could be due to dietary deficiency of these nutrients or infection owing to increased metabolic loses. The dietary deficiency of calcium could be as a result of intake of calcium-free diet such as gruel which is often prepared from phytates-containing cereals (whole-grain cereals), as it is known that most weaning diets in Zinder community are gruel. It was observed that diets made from products containing phytates which limit calcium availability can lead to calcium deficiency. 
An overall prevalence of hypophosphataemia of 86% at presentation and of severe hypophophataemia of 6% was observed among PEM children by Kimutai et al.  The occurrence of hypophosphataemia in PEM children could be due to long term low dietary phosphate intake or increased lost of the phosphate iron in the urine owing to excessive catabolic release from intracellular compartment. This is because during starvation, in order to maintain normal phosphate levels there is catabolic release of phosphate from intracellular stores which is subsequently lost in urine and therefore significant total body phosphate depletion can occur despite normal serum phosphate levels.  Again, severely malnourished children could have a long term relatively low phosphate intake and this predisposes them to significant total phosphate depletion.
The slightly reduced serum glucose levels among PEM children observed in the present study is in agreement with previous reports by Reddy  who reported that the fasting blood glucose levels were lower in malnourished than in normal children, but Mishra et al., reported that the mean glucose concentrations in PEM and control subjects were not significantly different. In Indian children, blood glucose levels were reported to be normal but glucose tolerance was impaired, suggesting impaired utilization in PEM patients.  The slight reduction of serum glucose in PEM children agrees with previous report by Buchanan et al., who observed impaired glycogenolysis in severe kwashiorkor leading to hypoglycaemia. In different studies, hypoglycaemia has also been reported in severe PEM.  The decreased serum glucose could be due to reduced intake, infection or some metabolic abnormalities such as impaired glycogenolysis and gluconeogenesis.
Hemoglobin concentrations were found to be significantly decreased in the malnourished compared to the well-fed children. Anaemia was observed in all classes of PEM in this study which is more pronounced in edematous than non-edematous PEM children. This is in agreement with the findings of El-Nawawy et al.,  who reported anaemia in PEM and suggested that it is a result of ineffective erythropoiesis. Some degrees of anaemia which is more pronounced in the marasmic-kwashiorkor patients than in other forms of PEM were also observed in the previous studies.  The presence of anaemia as found in the present and previous studies could also be related to the nutritional deficiency of iron and other essential minerals and vitamins, as well as infections.
| Conclusion|| |
Concentrations of albumin, calcium, phosphorus, glucose and hemoglobin were significantly reduced in PEM children compared with apparently healthy well-fed controls with resultant hypoalbuminaemia and anaemia, and the reductions were more pronounced in edematous than non-edematous PEM children. This suggests that routine measurement of these laboratory parameters and their subsequent supplementation in PEM children could improve the management of this group of patients. Moreover, the community should be educated on the use of locally available rich sources of the above mentioned nutrients. Adhering to these recommendations could reduce morbidity and mortality from PEM in Niger Republic and probably elsewhere in the world.
| Acknowledgement|| |
The authors acknowledge and appreciate the support given by Mrs Mariama Aboubacar, Mrs Hadiza Mahaman Yacoubou, Mr Mahaman Yacoubou, Mr Mahaman Yacoubou Abdoul Kader, Mr Nassirou Nazongo and Mr Abdou Salam of the Magaria district Hospital in the area of blood collection and anthropometric measurement. The authors also thank Mr Lawan Ousman and Mr Issoufou Abdou of Zinder National Hospital for their assistance in the area of laboratory sample analysis for the biochemical parameters.
| References|| |
|1.||Muller O, Krawinkel M. Malnutrition and health in developing countries. Can Med Ass J 2005;171:279-93. |
|2.||Wellcome Trust Working Party. Classification of protein-energy malnutrition. Lancet 1970;2:302-3. |
|3.||Jancen AA, Mannet WT. Assessment of nutritional status: A comparison of methods. J Trop Pediatr 1982;28:38-40. |
|4.||Nassar MF, Dina AA, Salwa RE, Soad MG. Markers of bone metabolism in Protein Energy Malnutrition. Intern J Food Nutr Public Health 2010;3:59-70. |
|5.||World Health Organisation. Reducing risks and producing healthy life. World Health Report, 2002, 1211 Geneva 27, Switzerland. http://www.who.int |
|6.||Food and Agricultural Organization (FAO). The state of food insecurity in the world, Monitoring Progress towards the World Summit and Millennium Development Goals. Food and Agricultural Organization of the United Nations, Viale delle Terme di Caracalla, 00100 Rome, Italy, 2004. http://www.ftp.fao.org. |
|7.||World Health Organisation. United Nations High Commissioner for Refugees, International Federation of Red Cross and Red Crescent Societies and World Food Programme. The Management of Nutrition in Major Emergencies. World Health Organization, Geneva, Switzerland, 2000. http://www.whqlibdoc.who.int. |
|8.||Central Bureau of Statistics (CBS), Ministry of Health (MOH), Kenya. Kenya Demographic and Health Survey Data, Nairobi, 2003. Calverton, Maryland: CBS, MOH and ORC Macro. http://dhsprogram.com. |
|9.||Johnson AM. Low levels of plasma protein: malnutrition or inflammation? Clin Chem Lab Med 1999;37:91-6. |
|10.||Reddy V. Protein-energy malnutrition. In: Standfield P, Brueton M, Chan M, Waterston T, editors. Diseases of children in the subtropics and tropics. 4 th ed. London: ELBS with Edward Arnold; 1993. p. 335-57. |
|11.||Mishra SK, Bastola SP, Jha B. Biochemical nutritional indicators in children with protein energy malnutrition attending Kanti Children Hospital, Kathmandu, Nepal. Kathmandu Univ Med J 2009;7:129-34. |
|12.||Soliman AT, Madina EH, Morsi MR. Radiological, biochemical and hormonal changes in malnourished children with rachitic manifestations. J Trop Paediatr 1996;42:34-7. |
|13.||Reddy V. Protein-energy malnutrition. In: Stanfield P, Brueton M, Chan M, Waterston T, editors. Diseases of children in the subtropics and tropics. 4 th ed. London: Edward Arnold; 1991. p. 335-8. |
|14.||Ighogboja IS, Okonjo MC, Onyeocha BK. Serum calcium, inorganic phosphorus and magnesium levels in malnourished pre-school children. Niger J Paeditr 1996;23:336. |
|15.||Doumas BT, Watson WA, Biggs HG. Albumin standard and the measurement of serum albumin with bromocresol green. Clin Chim Acta 1971;31:87-96. |
|16.||Trinder P. Determination of glucose in blood using glucose oxidase with an alternative oxygen acceptor. Ann Clin Biochem 1969;6:24-7. |
|17.||Ray SB, Chauhan C. Estimation of calcium in plasma. Ann Biochem 1967;20:155-9. |
|18.||Henry RJ. Clinical Chemistry, Principles and Techniques. 2 nd ed. Harper and Row; London: Lang Medical Books/McGraw-Hill, Medical Publishing Division; 1974. p. 525. |
|19.||Vanzetti G. Hemoglobin estimation. J Lab Clin Med 1966;67:116. |
|20.||Rahman MZ, Begum BA. Serum total protein, albumin and A/G ratio in different grades of protein energy malnutrition. Mymensingh Med J 2005;l: 38-40. |
|21.||Adegbusi HS, Sule MS. Anthropometric and biochemical assessment among under five children in Kusada Local Government Area, Katsina State, Nigeria. Bayero J Pure Appl Sci 2011;4:137-40. |
|22.||Kalra K, Mital VP, Pal R, Goyal RK, Dayal RS. Serum electrolyte studies in malnutrition. Indian Paediatr 1975;9:1135-9. |
|23.||Waterlow JC. Summary of causes and mechanisms of linear growth retardation. Eur J Clin Nutr 1994;48:S210. |
|24.||de Vizia B. Calcium and phosphorus metabolism in infants and growing child. In: Annales Nestle. Vol. 45. Switzerland: Vevey/Roven Press Ltd.; 1987. p. 36-44. |
|25.||Kimutai D, Maleche-Obimbo E, Kamenwa R, Murila F. Hypo-phosphataemia in children under five years with kwashiorkor and marasmic kwashiorkwor. East Afr Med J 2009;86:330-6. |
|26.||Berkelhammer C, Bear RA. A clinical approach to common electrolyte problems: Hypophosphataemia. Can Med Assoc 1984;130:17-23. |
|27.||Buchanan N, Moodley G, Eyberg-Bloom SR, Hansen JD. Hypoglycaemia associated with severe kwashiorkor. South Afr Med J 2003;50:1442-6. |
|28.||El-Nawawy A, Barakat S, Elwalily T, Abdel-Moneim DA, Hussein M. Evaluation of erythropoiesis in protein energy malnutrition. East Mediterr Health J 2002;8:281-9. |
|29.||Etukudo MH, Agbedana EO, Akinyinka OO, Osifo BO. Plasma electrolytes, total cholesterol, liver enzymes and selected anti-oxidant status in protein-energy malnutrition. Afr J Med Sci 1999;28:81-5. |
[Table 1], [Table 2], [Table 3]