Study of risk factors of severe acute malnutrition (SAM) in children 6 months to 5 years of age and evaluation of effect of micronutrient supplementation (WHO protocol) on serum zinc and magnesium levels: a case control study


  • Kamatham Madhusudhan Department of Pediatrics, Gandhi Medical college, Secunderabad, Telangana, India
  • Rajeev P.K Department of Pediatrics, Gandhi Medical college, Secunderabad, Telangana, India
  • Shireesha A Department of Pediatrics, Gandhi Medical college, Secunderabad, Telangana, India
  • Gummadi Vandana Ushashree Department of Pediatrics, Gandhi Medical college, Secunderabad, Telangana, India



Breast feeding, Illiteracy, Immunization, Magnesium, Severe acute malnutrition, Zinc


Background: Although risk factors for malnutrition have been identified earlier, individual factors potentially change in specific areas over time and a current characterization of risk factors provide the basis for preventative intervention strategies. No guidelines in relation to duration of micronutrient supplementation for treatment of SAM are available. Thus, the study was done to know the adequacy of dose of micronutrients that are presently being supplemented (WHO Protocols) for treating SAM.

Methods: It is a case-control study involving 100 cases with severe acute malnutrition and 100 controls having normal nutrition status 6 months to 5 years of age. Detailed clinical data (using a predesigned questionnaire) and anthropometric measurements were recorded for analysis. Blood assay of Zinc, Magnesium and serum Proteins were done on the day of admission (day 1) and again after 2 weeks of treatment with nutritional supplementation (WHO protocols).

Results: Out of 100 SAM Cases, 42% were from rural area whereas 76% of controls belonged to urban region (p value 0.03). Twenty-four (24%) mothers of SAM cases were Illiterate, whereas only 6 % of mothers in controls were illiterate. 57 % SAM cases were given breast feeding after 4 hours of life, where as 61% controls were given their first feed within 1 hour of birth with p value <0.01. Eighty-eight controls (88%) were given colostrum, whereas only 62 % SAM cases were given colostrum feeds with p value <0.01. Seventy controls (70%) were given exclusive breast feeding for 6 months whereas only 40% of cases (SAM) was given exclusive breast feeding till 6months of age (p value of <0.01). 57% of top fed cases were given over diluted feeds, only 27% of top fed controls were given over diluted feeds (p value 0.02). 53% of cases were bottle fed and 14% of controls were bottle fed with p value <0.01. Mean value of magnesium and zinc before supplementation was 2.4 mg/dl and 117 mcg/dl respectively with no significant rise after supplementation.

Conclusions: Here is a correlation of severe acute malnutrition with rural area, maternal Illiteracy and low socioeconomic status, deprivation of colostrums feeding, lack of exclusive breast feeding for 6 months, over dilution of top feeds and use of bottle feeding. There is no correlation between SAM and immunization status and demographic parameters like age, sex and religion. SAM is inversely related to duration of exclusive breast feeding. 23% of severely malnourished children had delay of developmental milestones. No significant rise of serum levels was seen with WHO recommended doses of micronutrient supplementation


International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NHFS-3), 2005-06: Mumbai. IIPS. India; 2007:1.

Elizebeth KE, Nutrition and child development.4th edition. Hyderabad: Paras medical publisher; 2006.

Food and Agriculture Organization of the United Nations (FAO). Undernourishment around the world. The state of food insecurity in the world. Rome: The Organization; 2004.

Rice AL, Sacco L, Hyder A, Black R. Malnutrition as an underlying cause of childhood deaths associated with infectious diseases in developing countries. Bull World Health Organ. 2000;78:07-21.

Infant and young child feeding. A tool for assessing national practices, policies and programmes. WHO; 2003.

Dhatrak PP, Pitale S, Kasturwar NB, Nayse J, Relwani N. Prevalence and Epidemiological Determinants of Malnutrition among Under-Fives in an Urban Slum, Nagpur. Natl J Community Med. 2013;4(1):91-5.

Kwena A, Terlouw D, De Vlas S, Phillips Howard P, Hawley W, Friedman J. Prevalence and severity of malnutrition in pre-school children in a rural area of western Kenya. Am J Trop Med Hyg. 2003;68(4):94-9.

Müller O, Garenne M, Kouyaté B, Becher H. The association between protein-energy malnutrition, malaria morbidity and all-cause mortality in West African children. Trop Med Int Health. 2003;8:507-11.

Hossain IM, Yasmin R, Kabir I. Nutritional and immunization status, weaning practices and socio-economic conditions of under five children in three villages of Bangladesh. Ind J Pub Health. 1999;43(1):37-41.

Abate G, Makau KW, Muroki NM. Hygiene and health-seeking behaviors of households as predictors of nutritional insecurity among preschool children in urban slums in Ethiopia the case of Addis Ababa. South African J Clinic Nutrit. 2001; 14(2):56-60.

Amsalu S, Tigabu Z. Risk factors for severe acute malnutrition in children under the age of five-A case-control study. Ethiop. J. Health Dev. 2008;22(1).

Sengupta P, Philip N, Benjamin AI. Epidemiological correlates of under-nutrition in under-5 years children in an urban slum of Ludhiana. HPPI. 2010;33(1):1-9.

Jamro B, Junejo AA, Lal S, Bouk GR, Jamro S. Risk factors for severe acute malnutrition in children under the age of five year in Sukkur. Pak J Med Res. 2012;51(4):111.

Labadarios D, Steyn NP, Maunder E, MacIntryre U, Gericke G, Swart R, et al. The National Food Consumption Survey (NFCS) South Africa. 1999. Public Health Nutrition. Cambridge University Press. 2005;8(5):533-43.

Goyal S, Agrawal N. Risk factors for severe acute malnutrition in central India. Inter J Medical Sci Res Prac. 2015;2(2):70-2.

Benjamin AI, Zachariah P. Nutritional status and feeding practices in under-3 years old children in a rural community in Ludhiana, Punjab. Health and Population-Perspectives and Issues. 1993;16(1 and 2):3-21.

Kleynhans IC, MacIntyre UE, Albertse EC. Stunting among young black children and the socio-economic and health status of their mothers/caregivers in poor areas of rural Limpopo and urban Gauteng the Nutri Gro Study. South African J Clinic Nutrit. 2006;19(4):163-72.

Kumar D, Goel NK, Poonam C, Mittal, Misra P. Influence of Infant-feeding Practices on Nutritional Status of Under-five Children. Indian J Pediatr. 2006;73(5):417-21.

Khokar A, Singh S, Talwar R. A study of malnutrition among children aged 6 months to 2 years from a resettlement colony of Delhi. Ind J Med Sci. 2003;57(7):286-89.

Hadian MA, Soleymani GM. Evaluation of serum zinc level in children under 5 years with malnutrition. J Shahid Sadoughi. University of Medical Sciences and Health Services. 2007;15(2):45-9.

Ugwuja EI, Nwosu KO, Ugwu NC, Okonji M. Serum zinc and copper levels in malnourished pre-school age children in Jos, North Central Nigeria. Pak J Nutrit. 2007;6(4):349-54.

Zafar S, Butt A, Ayesha H, Malik BA. Serum magnesium level. comparison between healthy and malnourished children. Professional Med J. 2010; 17(2):279-85.

Karla K, Mital VP, Pai R, Goyal RK, Dayal RS. Serum electrolyte studies in malnutrition. Ind Pediatr. 1975;12(11);1135-40.






Original Research Articles