Nutritional status of children living within institution-based care: a retrospective analysis with funnel plots and control charts for programme monitoring

Abstract

ObjectivesThe aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries.DesignA retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status.SettingWe conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines.ParticipantsDeidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information.ResultsAt initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. Many had underlying conditions: low birth weight, 514 (57.5%); prematurity, 294 (42.2%) and disabilities, 739 (25.3%). Children with disabilities had higher prevalence of malnutrition compared with counterparts without disabilities at baseline and 1-year screenings. There was marked intersite variation. Funnel plots highlight sites with malnutrition prevalence outside expected limits for this specific population taking into consideration natural variation at baseline and at 1 year. Control charts show changes in site mean z-scores over time in relation to site control limits.ConclusionsMalnutrition is prevalent among children living within IBC, notably different forms of undernutrition (stunting, underweight, wasting). Underlying risk factors are also common: prematurity, low birth weight and disability. Nutrition interventions should take into account the needs of this vulnerable population, especially for infants and those with disabilities. Using control charts to present data could be especially useful to programme managers as sites outside control limits could represent: problems to be investigated; good practices to be shared.

Feeding practices of children within institution‐based care: A retrospective analysis of surveillance data

“…Suboptimal feeding practices were observed, such as poor positioning, limited handwashing and inappropriate pacing of meals. These findings have rarely been described in this population and might explain the increased prevalence of malnutrition in this population (DeLacey et al, 2020;DeLacey et al, 2021;Ernst et al, 2021).…”

“…Anaemia is common in this population (DeLacey et al, 2021;Ernst et al, 2021). Frequent illnesses or anaemia can have consequences for children's development and impact brain functioning (Black et al, 2013;Victora et al, 2021).…”

“…to have a low BMI, which may be related to the third of children who presented feeding difficulties (DeLacey et al, 2020;DeLacey et al, 2021;Ernst et al, 2021;Kuper et al, 2015).…”

“…Children in IBC, especially young children and those with disabilities, are particularly at risk for infections, illnesses, anaemia, micronutrient deficiencies and malnutrition (Black et al, 2013;DeLacey et al, 2020;DeLacey et al, 2021; The World Bank Group Producer, 2019; UNICEF Producer, 2019; Victora et al, 2021).…”

“…Malnutrition impacts millions of children worldwide who have limited access to nutritious food or the resources and support needed to safely and successfully eat. Nutritional intake is especially important throughout childhood because of critical periods of growth and development, during which unaddressed malnutrition can have long‐term consequences to children's development (Black et al, 2013 ; DeLacey et al, 2021 ; Yang, 2017 ). Feeding practices are an especially important factor in children's nutritional intake, and are defined as the interactions between a child and caregiver during mealtimes and can be influenced by various factors, such as socioeconomic status or a child's ability, age or cultural beliefs and practices (Reilly, 1996 ; B. N. S. Silva et al, 2017 ; Yang, 2017 ).…”