CHAPTER II

REVIEW OF LITERATURE

Review of literature is a written summery of the study conducted previously

study topic. The review of literature is defined as a broad, comprehensive in depth,

systematic and critical review of scholarly publication, unpublished scholarly print

materials, audio-visual materials and personal communication.

Review of literature is a key step in research process. The review of literature in

a research report is a summary of current knowledge about a particular practice problem

and includes what is known and what is not known about a problem. Literature review

is a standard requisition of scientific research. It means reading and writing the pertinent

information of the attempt in research topic to understand better about the proposed

topic. It also supports and explains why proposed topics taken for research and avoid

unnecessary duplication, explore the feasibility and illuminate way to new research.

BT Basavanthappa

The literature review serves to guide the researcher in discussing the result of the

study in term of agreement or non-agreement with other studies.

IN THIS STUDY, REVIEW OF LITERATURE WERE CLASSIFIED UNDER THE

FOLLOWING HEADINGS

1. Literature related to kwashiorkor

2. Literature related to marasmus

3. Literature related to effectiveness of structured teaching programme

The study was conducted on Under nutrition among Under-Five Children in

Western Maharashtra. The aim of this study was to study under nutrition in rural under-

fives. Settings and Design was A cross-sectional study was carried out. The study

included 307 under-five children from a rural area of western Maharashtra. Information

was collected on pretested semi-structured questionnaire after taking informed consent.

The anthropological measurements were taken by standard methods. The statistical tests

were performed and 5% level significance was taken for analysis. Data were analysed

using software: WHO Anthro3.2.2, SPSS 26, and Epi Info v7.2.4.0. Results of the study

was more than half of the under-five children (56.3%) were found to be undernourished.

The prevalence of underweight, stunting, and wasting was found to be 33.5%, 35.5%, and

12.4%, respectively. Logistic regression performed showed prelacteal feed, colostrum,

BPL cardholder status, and per capita income to be significantly associated with under

nutrition. Conclusions was under nutrition still persists to be a major public health

concern in rural areas. Most of the determinants of under nutrition are modifiable. The

preventive and remedial measures should be an on-going process to combat this

problem.18

A study conducted on Malnutrition among under-five children in India and

strategies for control Malnutrition among under-five children is an important concern for

the health authorities in India. The aim of the present review was to assess the burden of

under-nutrition and over-nutrition, its determinants and strategies required to tackle

malnutrition among under-five children in India. Recent data were collected from Google

search, Medline, and others. The information retrieved was reviewed and analysed for
discrepancies. Existing evidence shows that the prevalence of under-nutrition among

under-five children was high and varied widely (under-weight: 39-75%, stunting: 15.4-

74%, wasting: 10.6-42.3%) depending on the assessment methodology adopted. Studies

on assessment of over-nutrition status among under-five children were limited.

Distribution of various types of risk factors and its influence on nutrition status of

children in a given set up should be analysed for planning the control measures.

Strengthening public health interventions for mild malnutrition cases and vulnerable

groups, effective implementation and evaluation of the strategies at regional level,

research on overweight, obesity and its etiological factors and steps for improving

socioeconomic development are the prerequisites for tackling malnutrition among under-

five children in India19

A study conducted on Assessment of Nutritional Status of Under-Five Children in

an Urban Area of South Delhi, India. Objective of the study to estimate the prevalence of

under nutrition among children under five years of age by utilizing the Composite Index

of Anthropometric Failure and the WHO growth charts. Methods was used from January

to March 2020, 1332 children under the age of five years participated in a facility-based,

descriptive, cross-sectional study at Fatehpur Beri, Urban Primary Health Centre. An

anthropometric assessment for each participant was done as per the WHO criteria. The

data were entered into a Microsoft Office Excel spread sheet (Microsoft Corporation,

Redmond, WA) and analysed with WHO Anthro software (WHO, Geneva, Switzerland)

and a licensed version of SPSS 21 (IBM Corp., Armonk, NY). Continuous data were

expressed using appropriate measures of central tendency, while categorical data were

expressed in either frequency or proportions. The results was mean age of the study
participants was 23.04 ± 18.24 months, and males (53.3%) were more than (46.7%)

females. The prevalence of being underweight was 24.5% (327/1332), of which 24.1%

(79/327) of children were severely underweight. Of the total study participants, 27.3%

(362/1332) were stunted, and 17.8% (237/1332) were wasted, of which 29.1% (69/237)

were severely wasted. The prevalence of anthropometric failure was 45%. Conclusions

were according to the findings of this study, the prevalence of under nutrition among the

study participants was substantial. Furthermore, considering weight for age as the sole

criterion may underestimate the true prevalence of malnutrition. The findings have

critical implications for future interventions and initiatives among children in India.20

A study conducted on Prevalence and determinants of undernutrition among

under-five children residing in urban slums and rural area, Maharashtra, India a

community-based cross-sectional study. The present study was carried out to assess the

prevalence and determinants of under nutrition in children under five in Maharashtra,

India. Methods was used a community-based cross-sectional study was conducted in 16

randomly selected clusters in two districts of Maharashtra state, India. Data were

collected through house-to-house survey by interviewing mothers of under five children.

Total 2929 mothers and their 3671 under five children were covered. Multivariate logistic

regression analysis was carried out to identify the determinants of child nutritional status

separately in urban and rural areas. Results where the mean age of the children was 2.38

years (±SD 1.36) and mean age of mothers was 24.25 years (± SD 6.37). Overall

prevalence of stuntingamong children under five was 45.9%, wasting was 17.1 and

35.4% children were underweight. Prevalence of wasting, stunting and underweight were

more seen in an urban slum than a rural area. In the rural areas exclusive breast feeding (p
< 0.001) and acute diarrhoea (p = 0.001) were associated with wasting, children with

birth order 2 or less than 2 were associated with stunting and exclusive breast feeding (p

< 0.05) and low maternal education were associated with underweight. Whereas in the

urban slums exclusive breast feeding (p < 0.05) was associated with wasting, sex of the

child (p < 0.05) and type of family (p < 0.05) were associated with stunting, and low

income of the family (p < 0.05) was associated with underweight. Conclusions of the

study Factors like sex of the child, birth order, exclusive breast feeding, economic status

of the family, type of family, acute diarrhoea and maternal education have influence on

nutritional status of the child. Improvement of maternal education will improve the

nutritional status of the child. Strategies are needed to improve the economic status of the

community.21

A study was conducted on the status of research on malnutrition among children

under 5 years in Southern Africa: a systematic review. The literature search was

conducted in multiple electronic databases, including Google Scholar, PubMed, and

Research Gate. A large proportion of the literature focused on determining factors

associated with malnutrition. Similarities were found amongst various articles with

findings highlighting household food insecurity as a major threat that leads to inadequate

feeding practices and consequently resulting in under nutrition. This review assessed the

state of knowledge on malnutrition in Southern Africa. The authors identified knowledge

gaps that should be considered for future research. We did not come across any

evaluation studies assessing food security interventions in response to malnutrition.

Moreover, sanitation in relation to malnutrition is not broadly researched. We

recommend future studies to apply a cross-sectional analytic design with mixed methods,
combining survey data, geographical data, and household and key informant interviews.

There is a need to map the prevalence of malnutrition in children under five years and

providing more knowledge on vulnerability and contexts that influence malnutrition

including socio-economic, environmental and infrastructural conditions. We further

recommend the use of GIS databases to generate information on spatio-temporal patterns

of malnutrition.22

2. Literature related to marasmus

A study was conducted on the Prevalence and Associated Factors of Protein

Energy Malnutrition Among Under Five-Year Children in Paediatric Opd of Public

Health Institution in Yirgalem Town, Southern Ethiopia. The main objective of this study

was to assess the prevalence and associated factors of protein energy malnutrition among

under-five children in paediatric OPDs of public health institutions at Yirgalem town,

Dale woreda, Sidama zone, SNNPR, Ethiopia from September 18-26, 2017.

Methodology was used institutional based cross-sectional study was conducted in

paediatric OPDs of public health institutions in Yirgalem town, on a total of 204 children

age less than five years from September 18-26, 2017. Study subjects were selected by

using quota sampling technique. Interviewer administered structured questionnaire and

anthropometric measurements were used to collect data. Data was analysed using SPSS

version 20.0statistical software. Result were this study indicated that the prevalence of

stunting wasting and Underweight was 41.2%, 1.7% and 25% respectively. Factors

showed statistically significant association in multivariate analysis were family planning

use by mother; children eat together with older siblings and exclusive breast feeding with

P-value (0.02), (0.036) and (0.002) respectively. Conclusion was this study reviled that
the prevalence of stunting, wasting and under-weight were higher among under–five

children participated in this study.23

A study was conducted on INCAP studies of kwashiorkor and marasmus. Food

and nutrition bulletin. The report findings from a cross-sectional exploration of serum

one-carbon metabolites in Malawian children. Methods was used i. e. Blood was

collected from children aged 12–60 months before nutritional rehabilitation: kwashiorkor

(N = 94), marasmic-kwashiorkor (N = 43) marasmus (N = 118), moderate acute

malnutrition (N = 56) and controls (N = 46). Serum concentrations of 16 onecarbon

metabolites were quantified using LC/MS techniques, and then compared across

participant groups. Findings were Twelve of 16 measured one-carbon metabolites

differed significantly between participant groups. Measured outputs of one-carbon

metabolism, asymmetric dimethylarginine (ADMA) and cysteine, were lower in

marasmic-kwashiorkor (median μmol/L (± SD): 0·549 (± 0·217) P = 0·00045 & 90 (±

40) P < 0·0001, respectively) and kwashiorkor (0·557 (± 0·195) P < 0·0001 & 115 (± 50)

P < 0·0001), relative to marasmus (0·698 (± 0·212) & 153 (± 42)). ADMA and cysteine

were well correlated with methionine in both kwashiorkor and marasmic-kwashiorkor.

Interpretation were Kwashiorkor and marasmickwashiorkor were distinguished by

evidence of one-carbon metabolism dysfunction. Correlative observations suggest that

methionine deficiency drives this dysfunction, which is implicated in the syndrome's

pathogenesis. 24

A cross sectional study was conducted on One-carbon metabolism in children

with marasmus and kwashiorkor. Methods Blood was collected from children aged 1260

months before nutritional rehabilitation: kwashiorkor (N = 94), marasmic-kwashiorkor (N

Serum concentrations of 16 one-carbon metabolites were quantified using LC/MS

techniques, and then compared across participant groups. Findings Twelve of 16

measured one-carbon metabolites differed significantly between participant groups.

Measured outputs of one-carbon metabolism, asymmetric dimethylarginine (ADMA) and

cysteine, were lower in marasmic-kwashiorkor (median μmol/L (§ SD): 0¢549 (§ 0¢217)

P = 0¢00045 & 90 ( 40) P < 0¢0001, respectively) and kwashiorkor (0¢557 (§ 0¢195) P <

0¢0001 & 115 ( 50) P < 0¢0001), relative to marasmus (0¢698 (§ 0¢212) & 153 (§ 42)).

ADMA and cysteine were well correlated with methionine in both kwashiorkor and

marasmic kwashiorkor. Interpretation Kwashiorkor and marasmic-kwashiorkor were

distinguished by evidence of one-carbon metabolism dysfunction. Correlative

observations suggest that methionine deficiency drives this dysfunction, which is

implicated in the syndrome’s pathogenesis.25

An article published on Marasmus: An Update and Review of Literature Review

Article Marasmus is a form of severe malnutrition in children mostly occurring in

developing countries. Marasmic children are vulnerable to various complications

including various infectious disease, diarrhoea, hypoglycaemia, hypothermia,

micronutrient deficiency (vitamin A, zinc, copper, iron etc.). Marasmic children must be

treated appropriately to prevent morbidity and mortality. Forty cases of management of

marasmus are in important cause of treatment failure and consequently case fatality.

Marasmic children without complication can be managed by community-based

management. While Marasmic with complication where death rate is very high should be

managed preferably at facility treatment at felicity-based management comprises 7-steps

based care. In community children are given therapeutic food and routine medicine to

treat simple medical condition at an outpatient community-based centre. Appropriate case

management of marasmus by standard protocoled management with or without

complication can reduces case fatality and improves health status Marasmic children.26

A study conducted on Risk Factors of Protein Energy Malnutrition " Kwashiorkor

and Marasmus " among Children Under Five Years of Age in Assiut University Children

Hospital. The aim of the study is to identify the risk factors of protein energy malnutrition

among children under five years of age in Assiut university children hospital. A

correlation descriptive research design was chosen for this study. A convenient sampling

design was followed to include children suffering from protein energy malnutrition aged

below 5 years. Control group was purposively selected to be nearly age and sex matched.

A total of 150 study and 150 control were included. The results revealed that PEM was

more found in children in families of middle and low socioeconomic status with

statistically significant differences, history of malnutrition in other sibling and younger

age than others, statistically significant differences between practices of mothers in the

cases than the control groups were found regarding breast feeding, artificial feeding and

additional and adult food with low level of satisfactory practices observed among

mothers in the cases than those in the control groups. From this study it can be concluded

that several risk factors were found to be associated with PEM including, lower education

level of the mother, number of children in the family as the number of children in the

family decreased, the prevalence of PEM increased, low and middle family

socioeconomic status, age of the child. children with the younger age are more vulnerable
to have PEM than those of older age and mothers' practices regarding feeding of their

children (breast feeding, artificial feeding as well as additional and adult food)

unsatisfactory practices of mothers regarding feeding of their children increase the

prevalence of PEM among their children.27

A study conducted on Protein Energy Malnutrition Among Children Less Than

Five Years and the Clinical Management Protocol at Mohammed Elameen Hamid

Hospital for Children. The aims of this study to assess protein energy malnutrition among

children less than 5 years and identify the clinical management protocol treatment for the

affected children at Mohammed Elameen Hamid. Methods and Material: This study

targeting PEM children and health professionals at the hospital. Fifty (50) all

professionals were interview (working staff) in malnourished children wards at

Mohammed Elameen Hamid Hospital for Children.140 children less than 5 years

admitted to the hospital with PEM during the collection of data convincingly selected.

The tool used to collect data in the study was questionnaire. Result: 80% of the health

professionals are female. (50%) of the professional's respondent confirm that the major

causes of malnutrition were parent's awareness, economic status and culture. (90%) of the

professional’s respondent agree that national and international treatment protocols have

been applying at the hospital. (90%) were sure that undergo enough treatment and flow

up for malnutrition child at the hospitals. (56%) agree about the number of children with

malnutrition admitted to the hospitals in the past five years increases year after year. 66%

of the professionals were revealed that suitable treatment for children with malnutrition

are includes drugs, balance diet, and ORS (oral dehydration solutions). 43.6% of children

their age 12-24 month, 58% are male, 80% of them weaned gradually, 92.1 % take 3-4
meals/day, 58.6 % of them are Marasmic, 55.0% have deficiency Anemia's, Pneumonia,

Acute Bronchitis before get malnourished. Fathers and mothers’ education level was

basic education (44.3%) and (46.4) respectively. Conclusion was Hospital has been using

national and international treatment protocols. Affected children admitted to hospital

increase year after year. Level of education of fathers and mothers, illness and diseases

before PEM and inadequate intake of food and the economic situation are the main

factors to caused PEM.28

3. Literature related to effectiveness of structured teaching programme

A study was conducted on a study to assess the effectiveness of structured

teaching programme on knowledge regarding prevention of protein energy malnutrition

among mothers of under five children at block bhalwal, jammu India. A pre-experimental

one group pre-test and post-test method was used in this study. The samples were

selected by purposive sampling technique. The sample size was 40. A structured

questionnaire was used to assess the knowledge regarding prevention of protein energy

malnutrition. The responses in pre-test showed that 34 (85%) had inadequate knowledge,

4 (10%) had moderate knowledge and 2 (5%) had adequate knowledge. After structured

teaching programme, post test result showed that 20 (50%) had adequate knowledge and

20 (50%) had moderate knowledge. There was no significant association between the

post-test knowledge and demographic variables like age, socio economic status, and

educational status, type of occupation, number of children, breastfeeding and

vaccination.29

A study was conducted on effectiveness of structured teaching programme on

knowledge and expressed practice regarding sanitary napkin among school girls those
who attained menarche at a selected school in Kancheepuram district. By using purposive

sampling technique, a total of 50 samples were included for the study. The result showed

that the age at menarche 26(52%) and 24(48%) participants were aged between 12.1-13

years and 13.1-14 years respectively Regarding nature of practice during menstruation,

25(50%) used cloth, 20(40%) used sanitary napkins and, 5(10%) used others. While

looking the frequency of changing napkin per day, most of them 25(50%) change the

napkin once a day, 17(34%) change the napkin twice a day,8(16%) changes the napkin

thrice a day and above. Regarding perception of pain during menstruation it was found

that 25(50%) never feels pain, 17(34%) sometimes feels pain and 8(16%) always feels

pain. The most of the study participants 25(50%) had the source of water supply from

well,18(36%) had from the municipal water,7(14%) had from bore water. Regarding

methods of disposal 25(50%) were directly burn,15(30%) was thrown outside and

10(20%) were dumped. With regard to usage of toilet practices 30(60%) adapted open

field defecation and 20(40%) adapted sanitary latrine practices.30