Transcript Slide 1

THE IRON STATUS OF INFANTS 3-6 MONTHS IN RELATION TO
BREASTFEEDING TYPE AND OTHER ASSOCIATED FACTORS: A CASE
STUDY OF MAMA LUCY KIBAKI HOSPITAL, NAIROBI
BY:
NYAMASEGE KEMUNTO CAROLYNE
RESERCH PROPASAL SUBMITTED IN PARTIAL FULFILMENT OF THE
REQUIREMENT FOR THE DEGREE OF MASTERS OF SCIENCE IN
APPLIED HUMAN NUTRITION OF THE UNIVERSITY OF NAIROBI.

DEPARTMENT OF FOOD SCIENCE, NUTRITION AND TECHNOLOGY.
MARCH 21st 2014
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Prof. Jasper Imungi
and
Prof. Wambui Kogi-Makau
Department of Food Science Nutrition and Technology,
University of Nairobi.
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Table of Contents
DEFINATION OF TERMS
ABBREVIATIONS
CHAPTER ONE
1.0 INTRODUCTION
1.1 Background Information
1.2 Statement of Problem
1.4 Aim of the Study
1.5 Purpose of the study
1.6 Objectives
1.6.1 Main Objective
1.6.2 Sub objective
1.7 Study Hypotheses
1.8 Assumptions
1.9 The Benefits of the Study
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CHAPTER 3
APPENDICES
3.0 METHODOLOGY
3.1 Study Setting
3.2 Study Population
References
3.3 Study Design
3.4 Sampling
Aerial View of MLKH
3.4.1 Sample Size Determination
3.4.2 Sampling Procedure
Budget
3.5 Data Collection
3.5.1 Data collection tools
Chronology of events3.5.2 Recruitment and training research assistants
3.5.3 Pretesting of questionnaires
3.5.4 Data collection procedures and methods (Ghant Chat)
3.6 Ethical Consideration
3.7 Data Quality Assurance
3.8 Data Analyzing
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1.1 Background Information
Nutrition is the most important factor in child health
promotion, growth and development; especially
during the first 2 years of life, (WHO 2006).
Anaemia is a major public health problem in preschool-age
children because it is associated with an increased risk of
death, impaired cognitive development, growth and
immune function.
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
Based on recent estimates from the World Health
Organization (WHO 2008) the prevalence of anaemia is
24.8% globally and the highest rates are found in preschoolage children (67.6%) and pregnant women (57.1%) in subSaharan Africa.

Of the 293.1 million children who suffer from anemia
worldwide, 83 million (28%) are in sub-Saharan Africa,
(McLean et al., 2009; WHO, 2008)

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
World Health Organization (WHO) recommends exclusive
breastfeeding for 6 months. In Kenya EBF is low 32%.

However, IDA is still of concern to EBF infants .(Beard
2007).

The introduction of complementary foods is not accepted
before 6 months.

There is evidence that even children with normal birth
weights, but anemic mothers,

will have low iron reserves at birth and are more likely to
develop anemia (Fall 2004).
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
Current guidelines for iron supplementation in young children
are based on the assumption that:

However, it depends on factors not often present in low-income
countries:


adequate maternal iron status, low birth weights,
adequate birth practices that promote the transfer of a portion of
the birth iron via placental blood i.e (late umblical code
clamping) and

Exclusive breast-feeding that avoids pathological iron loss via
damage to the integrity of the intestinal wall. (Chaparro ,2006).
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
The iron content of human milk is low (0.4-0.8 mg/L in colostrum and
0.2-0.4 mg/L in mature milk and decreases with the length of lactation.

In addition, introducing CF during the first 6 months of life can hinder
absorption of the iron present in breast milk.

Therefore Iron deficiency has been described as the most common
nutritional deficiency in the world.

In a survey of 858 children 6-35 months of age in western Kenya,
Anemia (71.8%) and severe anemia (8.4%) were common. Overall
16.8% of anemia cases were associated with malaria, 8.3% with iron
deficiency, and 6.1% with inflammation (Foote EM 2013).
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
By the fourth month of age, neonatal iron stores are reduced
by half, and exogenous iron is required to maintain the Hb
during the rapid phase of growth above 4 months of age.

Hence the reason of carrying the study on this 3-6 m
infants.

Further, deficiencies are associated with adverse effects on
child
cognitive,
compromised
immunity
and
motor
development among other defects.
(WHO 2006) recommends iron supplementation for anaemic.
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
Hence this study is designed to assess the iron status and the
nutritional status of infants 3-6 months in Mama Lucy Kibaki
Hospital

It will provide baseline information for an intervention to
address anaemia in either exclusively, partially or mixed
breastfed infants.
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It is meant to help implement effective measures for fighting
iron deficiency anaemia in infants below 6months
1.5 Purpose of the study

Generate information on prevalence of Iron deficiency
anaemia in infants 3-6 months and its association with
breastfeeding
type
in
order
to
inform
appropriate
interventions.

To establish other factors associated with Iron Deficiency
Anaemia in infants 3-6 months.
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To assess the hemoglobin concentration in relation to breastfeeding
type and other associated factors among 3-6 months old infants.
1.6.1 Sub objective
1)
To determine socio-economic and socio-demographic characteristics of
study population.
2)
To determine infant feeding practices i.e. if exclusive, partial or mixed
breastfed.
3)
To determine maternal and infant nutritional status
4)
To determine the haemoglobin concentration in infants 3-6 months old.
5)
To determine morbidity experience of the children
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
Breastfeeding types and maternal nutritional status influence
the iron status of infants 3-6 months

The morbidity experience, economic and socio demographic
characteristics are related to the child's development of Iron
Deficiency Anaemia.
1.8 Assumptions
 mothers
will be willing to participate
 Will receive ethical clearance from KNH
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
The study will provide information on the iron status of
infants to researchers as a reference for subsequent studies.

The findings of this study can help relevant agencies like the
policy makers, Ministry of Health in setting up interventions
to curb iron deficiency anaemia.

The study will contribute to information aimed at imparting
knowledge to mothers on prevention of IDA and promotion of
proper Exclusive Breastfeeding.
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CHAPTER 2: LITERATURE REVIEW
2.0 INTRODUCTION
2.1 Overview of Infant Nutrition
2.2 Breastfeeding Types Commonly Practiced on Infants
2.2.1 Exclusive breastfeeding
2.2.2 Mixed Breastfeeding
2.2.3 Partial breastfeeding
2.2.4 Breastfeeding in HIV AID Context
2.3 Iron Deficiency and Anaemia in Infants
2.4 Prevalence of Iron Deficiency Anaemia among under five
2.5 Methods of Measuring Iron Status
2.6 Causes of Iron Deficiency and Anaemia in Infants
2.7 Consequences of Iron Deficiency Anaemia in Infants
2.8 Approaches to Ensure Adequate Iron Status in Early Infancy
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
There is inadequate data in the literature on the prevalence
of anemia among children less than 6 months old, because
of the assumption that at this age breast milk suffices to
provide the necessary iron, irrespective of maternal
nutritional status.
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
CHAPTER 3

3.0 METHODOLOGY

3.1 Study sitting

The study will be conducted at MLKH near Umoja in Embakasi
constituency.

It’s a district hospital owned by the ministry of health.

It’s located on Spine road, Umoja 3, near Kayole off
Kang’undo road, Nairobi County, Kenya.

Its latitude is 1.27373630S and longitude 36.89934310E. .

It’s a new hospital constructed by a China Wiyu company
with a bed capacity of 137 beds.
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
It’s a public hospital

It’s located in a highly populated area of Nairobi serving an
estimated population of two million people.


It began limited operations in 2011
The hospital was officially opened on February 26, 2013 by his
Exellence the former President of Kenya Mwai Kibaki.

Mr Zacharia Lihumbazi the human resources manager indicated
that the facility handles up to 800 outpatients in a
day, 6,000 maternity deliveries.
 Other departments
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
The (MCH) usually receives around 300 mother-child pair
daily.

Most of these children are below 9 months.

Those attending this well baby clinic range from the high to
middle and the low income households which include:

Kayole, Sinai, Mwiki, Kasarani,

Buruburu, Dohnholm, Greenspan, Umoja and as far as
Pipeline estates.
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The population to be studied will be drawn from the mother

child pair visiting the hospital.
It will comprise of children 3-6 months both female and male

and their mothers.
The ethnicity, and the estate they reside in will not be a factor

in determining who to assess.
3.3 Study Design

A cross-sectional survey involving both descriptive and
analytical It will consist of some retrospective components
3.4.1 Sample Size Determination
Sample size determination will be using the Fisher et al., (1991) formula
N = Z2pq
d2
p- 19.1%. According to a micronutrient report on a survey conducted in
Kenya in 1999 by the Micronutrient Initiative and UNICEF,
 q- Expected proportion expected to anaemic (1-p) (1-0.19) =0.81
z- The standard normal deviation set at 1.96 of the 95% confidence
interval.
d- The degree of accuracy desire set at 0.05 significance.
Therefore N= (1.96)2(0.19) (0.81)/ (0.05) 2=236 infants 3-6 months.
(Fishers et al, 1991).
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Nairobi County
Purposive
Sampling
Purposive
Sampling
Mama Lucy Kibaki Hospital
Stratified Sampling
Exclusive Breastfeeding
Mixed Breastfeeding
Partial Breastfeedin
Proportionate
Sampling
78 Mother Child Pair
Systematic
Sampling
n=78
56 Mother Child Pair
n=56
102 Mother Child
Pair
n=102
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3.5.1 Data collection tools
1. A semi structured pre-tested questionnaire, contents
a.
General questionnaire for socio-demographic and socio-economic
information of the households.
b.
Index child information inclusive of breastfeeding types, CF
practises, morbidity experience, Hb levels and anthropometric
measurements.
c.
Maternal nutrition status, iron supplementation status during
pregnancy, incidences of anaemia and the birth process like the
length of time that elapsed before the umbilical cord was clam

2) A food frequency questionnaire for partially breastfed infants.

3) A Key Informant interview guide to interview the head nutritionist
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
Five research assistants will be recruited.

Four of them holders of a nutrition certificate, diploma or
degree while the other one will be a lab technicians.

They should be able to speak fluent English and Kiswahili.
They will be trained for 1 day to equip them with knowledge
on how to administer and fill questionnaires also taking of
anthropometric measurements.
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
Pretesting will be carried out at Kangemi Health Center,
targeting at least 10 mother child pair and the information
collected will be used to modify questions so as to give the
desired results.
3.5.4 Data collection procedures and methods

Activities….
Equipments to be usedHaemocue Anlyzer, Adult Muac Tapes, Stadiometer, electronic
scales, bathroom scales, height boards, Salter scales and
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
The permission to carry out the study will be sought from
KNH/UON-Ethics and Research Committee.

To minimize the discomfort and inconveniences the survey team
will explain the objectives, purposes, and possible benefits of the
study in a

The participant will be given an opportunity to ask questions and
decline participation or participate by signing a consent form.

Safety of the child will be assured by providing adequate
procedures.

Confidentiality and privacy will be maintained and the caregiver
will be assured of this.
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 Calibration
 Frequent
of scales was done on a daily basis.
supervision of the assistants during data collection was
carried out.
 The
completed questionnaire was cross-checked & examined.
 Data
cleaning to remove extreme & wrong entries was done
Field assistants will receive proper training to avoid errors in
recordings.
 To
avoid parallax during reading of measurements an average of
two subsequent readings will be taken.
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
The Chi-square test will be used to determine the difference between
proportions, odds ratios so as to estimate the relative risk.

Correlation will be used to test the strength of the association and estimate
the relation between variables that contribute to development of iron deficiency
and anaemia in infants 3-6 months.

The qualitative and quantitative data obtained will be entered and analyzed
using specific computer packages namely (ENA) for SMART (SPSS) and
nutrisurvey.

Data on Key Informant interview will be analyzed using word-processing
functions with features of special-purpose software designed coding and
creating themes.

Available errors during data entry will be noted and counterchecked using the
questionnaires.
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OBJECTIVE
VARIABLES
DESCRIPTIVE ADVANCED
STATISTICAL STATISTICAL
TEST
TESTS
Demographic
characteristics
Age ,Gender,
etc
Proportions
Infant feeding
practices
EBF,Partial BF Means,Odds,Per
and Mixed BF centages,
Nutritional
status of index
child and the
mother
Current Height Percentages,
Correlation
and Weight
Modes, Means or Regression
Median
Prevalence of
Anaemia in
Infants
Hb
Means,Odds
Chi square tests
Chi square,
Correlation
Regression,
Correlation
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
Beard J ( 2007). Recent evidence from human and animal studies
regarding iron status and infant development. J Nutr;137:524S–30.
Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Liz Cedillo
R, Dewey KG (2006). Effect of timing of umbilical cord
clamping on iron status in Mexican infants: a randomized
controlled trial. Lancet ; 367:1997-2004.

Domellöf MD, Cohen RJ, Rivera LL, Dewey KG, Hernell
O,Lönnerdal B. (2002). Iron supplementation affects growth
and morbidity of breast-fed infants: Results of a randomized
trial in Swedenand Honduras. J Nutr;132:3249-3255.
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
Foote EM, Sullivan KM, Ruth LJ, Oremo J, Sadumah I, Williams TN,
Suchdev PS. (2013) . Determinants of anemia among preschool children
in rural, western Kenya. Am J Trop Med Hyg. 88(4):757-64.

Fall C (2004). Iron requirements and iron status during infancy. In:
International Nutritional Anemia Consultative Group. Report of the 2004
symposium. Iron deficiency in early life: challenges and progress. Lima;
p. 13-6.

World Health Organization (WHO), UNICEF (2006). Planning guide
for national implementation of the global strategy for infant and young
child feeding. Geneva.
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APPENDIX 2 : BUDGET
ITEM
COMPONENT No ITEM
COST TOTAL
DESCRIPTION PER COST in
UNIT KSH
1.0
1.1 Researcher’s
1 8 person days
500*8 4,000
Personnel
Allowance
days
1.2 Supervisor
2
1.3 Training
Research
4
assistant
Assistance -data
1.4 collection
4
2 person days
5,000 10,000
1 person days
300
1,200
7 person days
500
24,000
3,500
1.5 Technologist
7 persons days
500
1
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2.0
2.1 Hire a salter
Equipme
&Weighing scale
nts
2
Lump some
1,500 3,000
2.2 Hire a Length board 1
,,
1,500 1,500
2.3 Hire Stadiometer
1
,,
1,500 1,500
2.4 Buy MUAC tapes
4
,,
250
1,000
2.5 Hire a Hb Analyzer 2
2.6 Curvets
,,
2,000 4,000
A Pack contains
260 50 Curvets
4500 23,400
2.7 Cotton swabs with 1
spirit
Sub Total
A roll
500
500
37,500 35
APPENDIX 2: BUDGET
ITEM
COMPONENT No
3.0
3.1 Questionnaire
Stationary
Photocopying
3.2 Pencils and
rubber
ITEM
COST
DESCRIPT PER
ION
UNIT
TOTAL
COST in
KSH
260
8 page
document
4,160
10
5 pencils 40
&5 rubbers
400
1,350
3,000
16 *260
3.3 Photocopying
Reams for
3
6 copies of 450
final doc.
3.4 Printing toner
1
Lump some 3,000
3.5 Stapler
1
250
250
Sub Total
9, 160 36
Grand Total
103,750
ITEM
4.0
Logistics
Sub Total
COMPONENT No ITEM
COST
DESCRIPTION PER
UNIT
TOTAL
COST
in KSH
4.1 Ethical
Clearance
1
Lump some
2,000
2,000
Research
4.2 Assistants
(Transport)
5
8 persons days
100
4,000
Training
4.3 Refreshments
5
1 day
150
750
4.4 Training Hall
1
1 day
500
500
7,250 37
5.0 Analysis
and
Submission
5.1
5.2
Consultation
of statistician 1
Binding the
Dissertation
6
2 days
1,000*2d 2,000
ays
200
1,200
Sub Total
2,200
Total
98,810
5%
Contingency
4,940
Grand Total
103,750
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MONTH
Jan
Fe
Ma
Ap May
Jun
Jul
Aug
Sep
Oct
Nov Dec
Jan
Feb
Mar
Apr Ma
EVENT
Selection of the research title
Development of the proposal
Defense of research proposal
Application of Ethical
Clearance
Pretesting of Questionnaire
Data Collection
Data Entry and Analysis
Preparation of Project Report
Defense of the Project report
Submission for final
Correction
Final corrections& submission
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 THANK
YOU
 COMMENTS?????
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