To determine the etiological factors responsible for severe acute malnutrition in children admitted to Nutritional Rehabilitation Centre.

According to WHO definition of malnutrition refers to deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients.1 Undernutrition is one of the most concerning health and development issues in India as in other parts of the world. Undernutrition encompasses stunting (chronic malnutrition), wasting (acute malnutrition) and deficiencies of micronutrients (essential vitamins and minerals).2

The high mortality and disease burden resulting from undernutrition call for urgent imple-mentation of interventions to reduce their occurrence and consequences and this would include determined action on the social determinants of undernutrition.2

In 2022, an estimated 148 million children under 5 years of age globally were affected by stunting (too short for age) and 45 million were affected by wasting (too thin for height), revealing the vast extent of under nutrition among the youngest population.3

The global prevalence of stunting is 22.3% in 2022, and the prevalence of wasting is 6.8%. The prevalence of wasting continued to be the highest across all who regions despite having declined from 17.1% in 1990 to 14.7% in 2022.3

Malnutrition is the leading cause of immunodeficiency across the globe. In India, weight-for-age measurements tend to be lower compared to international benchmarks, reflecting widespread nutritional concerns. This trend highlights the prevalence of undernutrition, which can lead to issues like stunting, wasting, and underweight conditions, significantly impacting overall health and development.4

A significant number of children affected by undernutrition experience mild to moderate forms that often go unnoticed. Early childhood is particularly vulnerable, and malnutrition at this stage can lead to irreversible effects on growth and development.5&6

In the present study an attempt will be made to determine the underlying factors contributing to severe acute malnutrition and impact of nutritional rehabilitation center.

Study Design: prospective observational study.

Approval was obtained from the Institutional Scientific and Ethical Committee of Koppal Institute of Medical Sciences, Koppal. Children admitted to Nutritional Rehabilitation Centre at District Teaching Hospital, Koppal, during the study period will be evaluated for inclusion and exclusion criteria. Those meeting the criteria will be enrolled in the study following the acquisition of informed consent.

•              Etiological factors were gathered through the use of history. An extensive his-tory was taken, along with a clinical and systemic examination.

•              Anthropometric data (weight, height/length, mid upper arm circumference, weight for height, edema) taken at admission were used to determine the nutritional status.

Sources of data: Children admitted to Nutritional Rehabilitation Centre at District Teaching Hospital, Koppal.

Participants Inclusion Criteria:

Children aged 6 months - 5 years with presence of any of the following

a.       Weight for length/height<-3 standard deviation (SD) [World Health Organisation (WHO) median height].

b.       Bilateral pedal edema.

c.        Grossly visible severe wasting.

d.       Mid upper arm circumference.

Exclusion criteria:

Children with non-nutritional causes of Severe acute malnutrition:

Table No.1: Father’s and mother’s educational status wise distribution

The majority of children's fathers and mothers had an educational level of illiteracy, with 20 (40.0%) and 18 (36.0%) respectively. This was followed by 14 (28.0%) fathers and 17 (34.0%) mothers who had completed higher secondary education.

Table No.2: Father’s occupation wise distribution of children

The majority of fathers (40.0%) held occupations as unskilled workers, followed by 32.0% who were involved in farming, and 20.0% who were skilled workers. It is evident that a significant portion of fathers in the study were employed in manual labor or agricultural roles.

Table No.3: Socio-economic status wise distribution

The majority of children from lower-class families make up 64.0% of the sample. Additionally, 28.0% of children come from lower-middle-class families, while 8.0% belong to the middle class. Interestingly, no children from upper-class or up­per-middle-class families were included in the study. This distribution highlights the soci­oeconomic diversity within the sample population.

Table No.4: Chief complaints wise distribution of children.

The most prevalent complaints reported by participants. Fever was the most common complaint, with 25 individuals (50.0%) experiencing this symptom. Loose stools followed closely behind, with 21 individuals (42.0%) reporting this issue. Vomiting was reported by 11 individuals (22.0%), while cold and cough were experienced by 10 in­dividuals (20.0%). Poor weight gain was the least common complaint, with only 5 indi­viduals (10.0%) reporting this symptom.

Table No.5: Maternal and neonatal history wise distribution

The maternal and neonatal history of children in the study. It was ob­served that 17 out of 50 mothers (34.0%) were aged 20 years or younger, 29 out of 50 mothers (58.0%) were married at the age of 20 or younger, and 34 out of 50 babies (68.0%) were first or second in birth order. All 50 children (100.0%) had a normal birth weight, and none of them were admitted to the Neonatal Intensive Care Unit (NICU). Additionally, 31 babies (62.0%) were breastfed within the first hour of life, while only 9 babies (18.0%) received prelacteal feeds. Fur­thermore, 15 babies (30.0%) were observed to have faulty feeding practices. A majority of the babies, 36 out of 50 (72.0%), were exclusively breastfed for the first 6 months of life. Moreover, 44 children (88.0%) were fully immunized, while 6 children (12.0%) were only partially immunized. All 50 children (100.0%) were found to be devel­oping normally.

In the present study, the majority of children (36.0%) were between the ages of 12 to 23 months. This was followed by 30.0% in the 24 to 35-month age group, while 28.0% were aged between 6 and 11 months. A smaller proportion, only 6.0%, were between 36 to 59 months. The youngest child was 8 months old and the oldest was 52 months, with the mean age recorded as 19.64 months7.

These findings are consistent with the study conducted by Kumar et al., who observed that 40.2% of children with Severe Acute Malnutrition (SAM) were within the age range of 6–23 months, underscoring the heightened vulnerability during early childhood due to increased nutritional needs and transitional feeding practices. Their data also indicated a slightly higher prevalence of SAM in children aged 6–11 months (35.0%) compared to the current study (28.0%), possibly reflecting regional variations in breastfeeding patterns and early nutritional interventions8.

Our study revealed that a significant proportion of fathers (40.0%) and mothers (36.0%) were illiterate, with 28.0% of fathers and 34.0% of mothers having completed higher secondary education. Occupational data indicated that the majority of fathers were en-gaged as unskilled workers (40.0%), followed by those in farming (32.0%) and skilled labor (20.0%), suggesting a predominantly labour intensive livelihood. Most mothers were housewives (74.0%), with a smaller proportion involved as daily wage workers (12.0%) or in agriculture (8.0%), reflecting limited economic engagement among mothers. In terms of socioeconomic classification, a substantial 64.0% of the children be-longed to lower-class families, followed by 28.0% from lower-middle-class and 8.0% from the middle class, with no representation from upper or upper-middle socioeconomic strata. This distribution underscores the strong association between lower socio-economic status and the incidence of Severe Acute Malnutrition in children.

A study by Arya et al.9 similarly reported that the majority of children with Severe Acute Malnutrition (SAM) belonged to the upper lower (44%) and lower (23%) socio-economic classes, with only 1% from the upper class. Regarding maternal education, 66% of mothers were either illiterate (31%) or had received only primary education (35%), reflecting limited educational attainment. Most fathers were engaged in manual labour, including farming or unskilled work (63.5%), followed by those in service or business (29.5%), with a small proportion being skilled professionals (7%).

Other studies have also found that SAM is more prevalent among children whose mothers are either illiterate or have only primary education and whose fathers are labourers findings consistent with other reports10-11. This pattern may be attributed to a lack of aware-ness and inadequate knowledge among lower socioeconomic groups regarding essential child nutrition practices such as exclusive breastfeeding, timely initiation of complementary feeding, and the importance of protein-rich diets.

Our study illustrates that fever was the most commonly reported presenting complaint among children admitted to the Nutrition Rehabilitation Centre (NRC), with 25 individuals (50.0%) experiencing this symptom. Loose stools were the second most common complaint, reported by 21 individuals (42.0%). Vomiting was experienced by 11 children (22.0%), followed by cold and cough in 10 children (20.0%). Poor weight gain was the least frequently reported complaint, noted in only 5 children (10.0%).

According to Verma DK et al.12, the most common presenting symptoms among children admitted to NRCs were fever and diarrhea, each affecting 46.0% of the sample. Fever was reported in 44.2% of girls and 43.7% of boys, while diarrhea was slightly more prevalent among girls (47.7%) than boys (40.1%). Anorexia was observed in 24.7% of children (25.6% of girls and 21.4% of boys), followed by respiratory symptoms in 12.6% and vomiting in 12.1%.

Our study observed that 34.0% of mothers (17 out of 50) were aged 20 years or younger, and 58.0% (29 out of 50) were married by the age of 20. Regarding birth order, 68.0% of babies (34 out of 50) were first or second in the birth order. All 50 children (100.0%) had a normal birth weight, and none required admission to the Neonatal Intensive Care Unit (NICU).

Breastfeeding practices were also evaluated: 62.0% of infants (31 out of 50) were breast-fed within the first hour of life, while 18.0% (9 out of 50) received prelacteal feeds.

Faulty feeding practices were noted in 30.0% (15 out of 50) of cases. A majority of infants (72.0%, or 36 out of 50) were exclusively breastfed for the first six months. Immunization rates were high, with 88.0% (44 out of 50) fully immunized and 12.0% (6 out of 50) partially immunized. All 50 children were found to be developing normally. In contrast, Solanki TK et al.13 reported that among 90 children, 15 were unimmunized (including 3 with Severe Acute Malnutrition [SAM], 1 with Moderate Acute Malnutrition [MAM], and 1 normal), 65 were partially immunized (3 SAM, 60 MAM, 2 normal), and 10 were completely immunized (none with SAM or normal status). Statistical analysis showed no significant association between immunization status and nutritional outcome (p = 0.365), and notably, no child from the completely immunized group was categorized as having SAM or normal nutrition. Sen S et al.14 reported poor adherence to recommended infant feeding practices: only 6.5% of children were exclusively breastfed for six months, and 30.1% received prelacteal feeds. A large proportion (79.6%) were bottle-fed. Complementary feeding began before 6 months in 1.1% of children, at 6 months in 11.8%, between 6–7 months in 63.9%, and after 7 months in 21.9%15.

Severe acute malnutrition (SAM) is most prevalent in rural children aged 6–35 months. Faulty feeding practices and delayed breastfeeding initiation worsen nutritional status. Infections (fever, diarrhea) are major comorbidities in malnourished children. Low Parental Education, Poverty and unskilled labor contribute significantly to malnutrition. Early Intervention proper, feeding and IYCF feeding practices can reduces SAM cases.

1.       WHO guideline on the prevention and management of wasting and nutritional oedema in infants and children under 5 years, 2023.

2.       Operational Guidelines on Facility Based Management of Children with Severe Acute Malnutrition, Ministry of Health and Family Welfare Government of India, 2011.

3.       Levels and trends in child malnutrition: UNICEF/WHO/World Bank Group joint child malnutrition estimates: key findings of the 2023 edition. Geneva: World Health Organization, United Nations Children’s Fund, International Bank for Re-construction and Development/The World Bank; 2023 (https://iris.who.int/han-dle/10665/368038). Licence: CC BY NC-SA 3.0 IGO.

4.       National Family Health Survey(NFHS-5),India, 2019-2021. Ministry of Health And Family Welfare, Govt Of India, International Institute for Population Sci-ences Deonar, Mumbai

5.       Naandi foundation,HUNGaMA fighting hunger and malnutrition:the HUNGaMA survey report-2012 Naandi foundation Hyderabad ;2012

6.       Strobel S and Ferguson, A. 2005. Immune function, food allergies and food intolerances, Human Nutrition. 11th ed. pp. United Kingdom: Elsevier Churchill Livingstone.

7.       Kumar R, Singh J, Joshi K, Singh HP, Bijesh S. Co-morbidities in hospitalized children with severe acute malnutrition. Indian Pediatr. 2014 Feb;51(2):125-7. doi: 10.1007/s13312-014-0343-x. Epub 2013 Aug 5. PMID: 23999679.

8.       Seema Shah, Nisha Prajapati. Anaemia among SAM children and its effect on outcome in nutritional rehabilitation centre at tertiary care centre of Gujarat. MedPulse International Journal of Pediatrics. November 2020; 16(2): 21-24. http://medpulse.in/Pediatrics/index.php

9.       S. Chakraborty, S.B.Gupta, B. Chaturvedi. A study of protein energy malnutri-tion in children in a rural population of Jhansi district (U.P.). Indian Journal of community medicine. 2006;31:4.

10.    Das S, Paul DK, Bhattacharya M, Basu S, Chatterjee A, Sen S and Bhakta S. Clinicoepidemiological Profile, Risk Factors and Outcome of Severe Acute Mal-nutrition Children at the Nutritional Rehabilitation Centre of a Tertiary Care Centre in Eastern India- A 4 Years Experience. Adv Res Gastroentero Hepatol 2017; 5(2): 555659. DOI: 10.19080/ARGH.2017.05.555659.

11.    Arun Kumar Arya, Pavika Lal, Pramod Kumar. Co-morbidities in children with severe acute malnutrition - a tertiary care centre experience. International Journal of Contemporary Medical Research 2017;4 (5):1086-1088

12.    Verma DK, Varghese A, Agarwal M, Singh VK, Chandrakanta. Outcome of Nutritional Rehabilitation Centre based care for children with Severe Acute Malnutrition in Uttar Pradesh, India: Cross sectional Study. International Journal of Health and Allied Sciences. 2022;11(1):22-26. Available from: https://rescon.jssuni.edu.in/ijhas/vol11/iss1/3. doi: 10.55691/2278-344X.1003

13.    Solanki TK, Kushwaha VS, Kumar V, Bure D. To Study the Community Fol-low-Up of Severely Acute Malnourished Children: A Prospective Cohort Study. International Journal of Current Pharmaceutical Review and Research 2025; 17(4); 1445-1451

14.    Sen S, Chatterjee K, Dutta A. Determinants and Outcome of Severe Acute Mal-nutrition of Children in Nutrition Rehabilitation Centre in Eastern India. Ann. Int. Med. Den. Res. 2020; 6(2):PE16-PE21.

15.    Saka A.O., Saka M J, Ojuavo A, Abdul Karim A., Bilamin S., Latubosun L, Adeboye Man. Hematological profile in children with protein energy malnutri-tion in North Central Nigeria. Global Journal of Medical Research. 2012, May. Volume12, Issue 4.