MALNUTRITION THESIS

MALNUTRITION

AUTHOR: I. ARUN JOTHI, MSN, COMMUNITY HEALTH NURSING

CHAPTER – I

INTRODUCTION

India’s children still languish in malnutrition in spite of lot of progress in terms of food production, procurement and food security. One of the most dominant problems declining the quality of life of the most Indian citizens is the malnutrition. Malnutrition has been defined as a major public health and nutritional problem in India. It not only leads to childhood morbidity and mortality but also leads to impairment of physical and possibly of mental growth of those who survive.

The nutritional status of a child is usually described in terms of anthropometry, that is body measurement such as weight in relation to age or height, which is reflective of the degree of underweight or wasting of that child, food is the prime necessity of life; life cannot be sustained without an adequate nourishment child needs adequate food for growth and development.

According to WHO, breast milk has the complete nutritional requirements that a baby needs for healthy growth and development in the first six months of life. According to the UNICEF, children who are breast feed in the six months of life have a six times greater chance of survival as opposed to non breast feed children.

Children are malnourished if their diet does not provide adequate nutrients for growth and maintenance or they are unable to fully utilize the food they eat due to illness.

GLOBAL BURDEN OF MALNUTRITION

WORLD

In 2014, approximately 462 million adults worldwide were underweight, while 1.9 billion were either overweight or obese. In 2016, an estimated 155 million children under the age of 5 years were suffering from stunting, while 41 million were overweight or obese.

IN INDIA

India experiences a malnutrition burden among its under-five population. As of 2015, the national prevalence of under-five overweight is 2.4%, which has increased slightly from 1.9% in 2006. The national prevalence of under-five stunting is 37.9%, which is greater than the developing country average of 25%.

TAMIL NADU

Severe Acute Malnutrition (SAM) is high among children (under the age of five) at 8% in Tamil Nadu, according to National Family Health Survey-4 (NFHS) data released in 2017.“If the measurement is below 11.5 cm, it confirms that the child is severely malnourished.

BACKGROUND OF THE STUDY

Malnutrition is a condition which occurs when there is a deficiency of certain vital nutrients in a person’s diet. The deficiency fails to meet the demands of the body leading to effects on the growth, physical health, mood, behaviour and other functions of the body. Malnutrition commonly affects children and the elderly. Malnutrition also entails conditions where diet does not contain the right balance of nutrients. This might mean a diet high on calories but deficient in vitamins and minerals. These second group of individuals may be overweight or obese but are still considered malnourished. Thus being malnourished does not always mean that the person is underweight or thin.

Srivastava Anurag, et al (2012) carried out cross sectional study in selected urban slums of Bareilly district, Uttar Pradesh which showed that 66.3% were malnourished. Nearly 32.5%, 16.9%, 8.4% and 8.4% were suffering from grade I, II, III and IV malnutrition respectively.

Munesh Kumar Sharma et al (2011) showed that on the basis of IAP classification 72.5% were suffering from any form of malnutrition, and 22.4% from grade- III & IV (severe form) malnutrition. Gholamreza Sharifzadeh, et al (2010)23 cross sectional and descriptive analytical study was conducted on children under 6 years old in South Khorasan Iran, showed that weight index was normal in 52.2% children, 34.4% lightly underweight, 11.7% moderately underweight and 1.2% severely underweight.

NEED FOR THE STUDY

In India about 2/3 portion of the under 5 children of our country is malnourished among them 5 to 8% is severely malnourished whole rest fall in the group of mild or moderate malnutrition so it can be said that malnutrition one of the most wide spread condition affecting child health.

In India nearly 75% of the population reside in the village of the total rural populations around 50% is still under the poverty illness. Majority of children in india are not in a position to get adequate nourishment because of very low per capita income of their families. The significant proportion of the children live in economic and social environment which impedes the child’s physical and mental development, this condition include poverty, poor environment sanitation, disease, infections , inadequate access to primary health care, inappropriate child caring feeding practice.

The investigator while posted in the rural area. found many of the under five children to be malnourished. So, the investigator thought of doing a study to assess the knowledge regarding malnutrition among the mothers of under five children in that rural area.

STATEMENT OF THE PROBLEM

A descriptive study to assess the knowledge regarding malnutrition among mothers of under five children in the selected rural area, Thanjavur .

OBJECTIVES

To assess the knowledge regarding malnutrition among mothers of under five children.

ASSUMPTIONS

Mothers of under five children may have inadequate knowledge regarding malnutrition.
Mothers of under five children may have inadequate knowledge regarding the diet of children.

HYPOTHESIS

H1 – There will be a significant association between the knowledge regarding malnutrition among mothers of under five children and their selected demographic variables.

OPERATIONAL DEFINITIONS

MALNUTRITION

In this study it refers to the lesser intake of food for children in terms of quality and quantity to maintain optimum health.

KNOWLEDGE

In this study it refers to the information, awareness and correct response of mothers towards malnutrition.

MOTHERS OF UNDER FIVE CHILDREN

In this study it refers to those who have child of age group from 1 to 5 years.

DELIMITATION

The study is delimited to the mothers of under five children and a period of 1week.

CHAPTER-II

REVIEW OF LITERATURE

Review of literature is one of the most important steps in research process. It is an account of what is already known about a particular phenomenon. The main purpose of literature review is to convey the readers about the work already done and the knowledge and ideas that have been already established on a particular topic of research. A literature review is an account of the previous efforts and achievements of scholars and researchers on a phenomenon.

Theoretical research
Empirical research

THEORETICAL RESEARCH

INTRODUCTION

Malnutrition is a serious condition that occurs when a person’s diet does not contain enough nutrients to meet the demands of their body. This can affect growth, physical health, mood , behavior , and many of the functions of the body .

DEFINITION

The WORLD HEALTH ORGANIZATION (WHO) defines malnutrition as the cellular imbalance between the supply of nutrients and energy and the body’s demand. To ensure growth , maintenance , and specific functions .

Protein-energy malnutrition is an energy deficit due to chronic deficiency of all macronutrients. It commonly includes deficiencies of many micronutrients. PEU can be sudden and total (starvation) or gradual.

CLASSIFICATION OF MALNUTRITION

Gomez Classification: The child’s weight is compared to that of a normal child (50th percentile) of the same age. It is useful for population screening and public health evaluations.

Percent of reference weight for age = [(patient weight) / (weight of normal child of same age)] * 100

Water low Classification: Chronic malnutrition results in stunting. Malnutrition also affects the child’s body proportions eventually resulting in body wastage.

Percent weight for height = [(weight of patient) / (weight of a normal child of the same height)] * 100
Percent height for age = [(height of patient) / (height of a normal child of the same age)] * 100

CAUSES OF MALNUTRITION

Malnutrition can result from the various environmental and medical conditions. Causes of malnutrition include inappropriate dietary choices, a low income, difficulty obtaining food, and various physical and mental health conditions. Under nutrition is one type of malnutrition. It occurs when the body does not get enough food.

Low intake of food

This may be caused by symptoms of an illness, for example , dysphasia, when it is difficult to swallow. Badly fitting dentures may contribute.

Mental health problem

Conditions such as depression , dementia , schizophrenia , anorexia nervosa, and bulimia can lead to malnutrition.

Social and mobility problems

Some people cannot leave the house to buy food or find it physically difficult to prepare meals. Those who live alone and are isolated are more at risk. Some people do not have enough money to spend on food, and others have limited cooking skills.

Digestive disorders and stomach conditions

If the body not absorb nutrients efficiently, even a healthful diet may not prevent malnutrition. People with Crohn’s disease or alternative colitis may need to have part of the small intestine removed to enable them to absorb nutrients.

Celiac disease is a genetic disorder that involves a gluten intolerance . It may result in damage to the lining of the intestines and poor food absorption.

Alcoholism

Addition to alcohol can lead to gastritis or damage to the pancreas. These can make it hard to digest food, absorb certain vitamins , and produce hormones that regulate metabolism.

Alcohol contains calories, so the person may not feel hungry. They may not eat enough proper food to supply the body with essential nutrients

Lack of breastfeeding

Not breastfeeding, especially in the developing world, can lead to malnutrition in infants and children.

RISK FACTORS OF MALNUTRITION

In some parts of the world, widespread and long-term malnutrition can result from a lack

of food.

Older people, especially those who are hospitalized or in long-term institutional care.
Individuals who are socially isolated
People on low incomes
Those who have difficulty absorbing nutrients
People with chronic eating disorders, such as bulimia or anorexia nervosa
People who are recovering from a serious illness or condition

SYMPTOMS OF MALNUTRITION

Loss of weight ,breathing difficulties, depression, higher weakness to feeling cold, longer healing times for wound, longer recovery from infections , slow behavioral problems mental retardation.

DIAGNOSIS

MUST have been designed to identify adults, and especially older people with malnourishment or a high risk of malnutrition.

It is a 5-step plan that can help health care providers diagnose and treat these conditions.

The steps are as follows:

Step 1 measure height and weight , calculate body mass index(BMI), and provide a score .

Step 2 Note the percentage of unplanned weight loss and provide a score. For example, an unplanned loss of 5 to 10 percent of weight would give a score of 1, but a 10 percent loss would score 2.

Step 3 Identify any mental or physical health condition and score. For example, if a person has been acutely ill and taken no food for over 5 days , the score will be 3.

Step 4 Add scores from steps 1, 2 and 3 obtain an overall risk score

Step 5 Use local guidelines to develop a care plan.

If the is at low risk of malnutrition, their overall score will be 0. A score of 1 denote a medium risk and 2 or more indicates a high risk.

MUST is only used identify malnutrition or the risk of malnutrition in adults. It will not identify specific nutritional imbalances or deficiencies.

TREATMENT OF MALNUTRITION

Low risk Recommendations include ongoing screening at the hospital and at home.

Medium risk The person may undergo observation , their dietary intake will be documented for 3 days , and they will receive ongoing screening.

High risk The person will need treatment from a nutritionist and possibly other specialists, and they will undergo ongoing care .

For all risk categories, help and advice on food choices and dietary habits should be offered.

ongoing screening and monitoring
making a dietary plan, which might include taking supplements
treating specific symptoms, such as nausea
treating any infections that may be present
checking for any mouth or swallowing problems
suggesting alternative eating utensils

In severe cases, a person may need to:

spend time in the hospital
gradually start taking in nutrients over a number of days
receive nutrients such as potassium and calcium intravenously

During growth years the requirement of nutrients usually is high and such demands need to be met adequately. Regular visits to the pediatrician for assessment of adequate growth in height and weight is essential.

Malnutrition causes more problems in children than any other age group as they may lead to growth (both physical and mental) retardation and susceptibility to repeated infections. Children with Protein energy malnutrition (PEM) need to be identified. This includes children with Marasmus and Kwashiorkor. These children require aggressive therapy.

Children with long term diseases need therapy for malnutrition as a prophylactic measure. This includes additional nutrients, vitamins and mineral supplements etc. The underlying disease also needs to be treated adequately to prevent malnutrition. Children with severe malnutrition need therapy in the hospital. This includes parenteral nutrition and slow introduction of nutrients by mouth. Once their condition stabilizes then they can gradually be introduced to a normal diet.

TREATMENT OF MALNUTRITION AT HOME

This is suitable for patients who are able to eat and digest food normally. Treatment at home involves:

The diet planner and advisor discuss the diet with the patient and makes recommendations and diet plans to improve nutrient intake.
In most patients with malnutrition the intake of protein, carbohydrates, water, minerals and vitamins need to be gradually increased.
Supplements of vitamins and minerals are often advised.
Those with protein energy malnutrition may need to take protein bars or supplements for correction of the deficiency.
The Body Mass Index is regularly monitored to check for improvement or responsiveness to dietary interventions.
Occupational therapists and a team of physicians of different specialities may be necessary for people with disability who cannot cook or shop for themselves or those who have mental disorders, dementia or long term illnesses.
Those who have difficulty in swallowing, chewing or eating may need to be given very soft or pureed food for easy eating.

TREATMENT OF MALNUTRITION AT THE HOSPITAL

The team of physicians and health care providers who manage malnutrition patients includes a gastroenterologist who specializes in treating digestive conditions, a dietician, a nutrition nurse, a psychologist and a social worker.

Nasogastric tube feeding, PEG feeding and intravenous infusion or parenteral nutrition may be done in the hospital for moderate to severely malnourished patients who are unable to take food via the mouth.

PREVENTION OF MALNUTRITION

To prevent malnutrition, people need to consume a range of nutrients from a variety of food types. There should be intake of carbohydrate, fats, protein, vitamins, and minerals , as well as plenty of fluids , and especially water.

People with ulcerative colitis, Crohn’s disease, alcoholism, and other health issues will receive appropriate treatment for their condition.

EMPIRICAL REVIEW

Guerrant et al.,(1992) although there are clear channels by which poor water quality would affect a child‟s nutritional status, evaluations of effects of improved water supply on malnutrition are virtually nonexistent in the development literature. It is well known that diarrhea is one of the leading causes of malnutrition in India and that clean water is critical to contain the spread of diseases, many of which hinder growth (World Bank, 2002a). Data from Brazil shows that diarrhea hampers gains in weight and height of children and leads to severe malnutrition.

Laxmaiah, et al, (1999) in an assessment of the Mid-Day Meal Program in Karnataka beneficiaries of the program were associated with better educational and nutritional status than non-beneficiaries. Another study using data collected on the school meal program in India(Afridi, 2009) finds that at a cost as low as 3 cents per child per school day, the program had a substantive and significant effect on reducing hunger and protein-energy malnutrition.

RN Mishra et al., (2001) among 520 preschool children in urban slums of Varanasi showed that 75% were malnourished and 20% were severely malnourished.

Bhatia et al., (2002) In summary, evidence from the literature suggests that once one controls for confounding factors and unobserved heterogeneity caused by endogenous program placement, the ICDS scheme does not seem to have a significant effect on child nutrition outcomes. Through its package of services, the ICDS program has the potential to end poverty and malnutrition for future generations. Enhancing the program with other necessary interventions could make it more effective.

Beaver et al (2002) had conducted by study and found out that each region or country has developed its own local diet over many years. Diets have evolved based on available foods which in turn depend on climate, culture , class, and lifestyle. Each diet contains a balance of essential nutrients. A well – balanced diet which includes a variety of food will provide all the vitamins and minerals required for the efficient functioning of the body . it is only when diet becomes restricted in illness or because of food shortages or poor choice of foods that shortages of essential vitamins and minerals will occur.

KD Bhalani et al (2002) conducted a cross sectional study among 30 randomly selected anganwadi centres in Vadodara city which showed that 62.9% were malnourished.

Shally Awasthi, et al.,(2003) among preschool children in uttar Pradesh showed that 67.3% of children were underweight.

Simiyu, et al., (2003) the literature reveals that, while the mothers may have correct knowledge, their accompanying practices are not always appropriate. Knowledge, attitudes and cultural beliefs underlying child care practices and some traditional home care practices can delay the seeking of medical care. Gaps between knowledge and practice in the treatment of childhood illness exist and need to be addressed in a culturally sensitive manner.

Harishankar et al (2004) conducted the study of nutritional status of children under 6 years of age in Allahabad district of UttarPradesh. The prevalence of PEM in under 6 years children was 26.83%.

Harishankar et al., (2004) conducted the study of nutritional status of children under 6 years of age in Allahabad district of Uttar Pradesh which showed that amongst normal grade of nutrition majority 83 (78.30%) of children were in age group 25-36 months (2-3 years). The maximum overall prevalence of malnutrition was recorded 33 (32.02%) in age group 13-24 months. The maximum prevalence of grade I malnutrition was found to be in age 37-72 months. Majority of children having grade II malnutrition were in age group 13- 24 months while maximum grade 46 III malnutrition was recorded in age groups 0-12 months. Maximum grade IV malnourished children were found to be 2 (1.88%) in age group 25-36 months followed by 1 (0.65%) in age group 37-72 months.

Das Gupta et al. (2005) study of 1286 pre-school children in urban, rural and slum areas of Chandigarh shows that the prevalence of protein energy malnutrition is higher among ICDS beneficiaries than nonbeneficiaries. This finding and show that the program has a positive and significant effect on health outcomes. However, once a more rigorous propensity score matching technique is used, the effect is insignificant for ICDS villages compared to similar non- ICDS villages.

Behrman and Hoddinott, (2005) this is not to say that nutrition programs are never found to be effective. In fact, evaluations of nutrition interventions around the world show that supplementary feeding programs can have an influence on indicators of malnutrition. An evaluation of the impact of Programae Education, Saludy Alimentación (PROGRESA), a large Mexican rural anti- poverty program, shows 64 statistically and substantively significant impacts of supplementary nutrition on child height. Incorporating unobserved heterogeneity, the program with a reduced probability of a child between the ages of 1 and 3 years being stunted and an increased growth in height of one sixth.

K. Goel et al.,(2007) in the urban slums of Rohtak, a city in Haryana, on 540 children aged 1-6 years showed that 57.4% of children were malnourished. A study done in 2007 by SP Mitra27 on 540 under five children in urban slums of Kolkata municipal area found that only 38.9% of the under five children were within the normal limit while 61.1% were in different grades of malnutrition.

Ministry of Health and Family Welfare., (2007) The ICDS continues to play an important role in child development and health. According to NFHS-3 data, 81% of Indian children less than six years old 71 reside in areas in which anganwadi services are available. Of these children, 33% receive service(s) of some sort. Supplementary food is provided for 26% of these children, preschool to 23%, immunizations to 20%, and growth monitoring for 18%.

Paramita Sengupta, et al (2010) conducted a cross-sectional survey of 200 randomly selected under-five children to determine the prevalence and risk factors of under-nutrition amongst under-five children living in an urban slum of Ludhiana. The study showed that 74 per cent of the children were stunted and 29.5 per cent of them were under-weight.

Munesh Kumar Sharma et al(2011) showed that on the basis of IAP classification 72.5% were suffering from any form of malnutrition, and 22.4% from grade- III & IV (severe form) malnutrition. Gholamreza Sharifzadeh, et al (2010)23 cross sectional and descriptive analytical study was conducted on children under 6 years old in South Khorasan Iran, showed that weight index was normal in 52.2% children, 34.4% lightly underweight, 11.7% moderately underweight and 1.2% severely underweight.

Srivastava Anurag, et al (2012) carried out cross sectional study in selected urban slums of Bareilly district, Uttar Pradesh which showed that 66.3% were malnourished. Nearly 32.5%, 16.9%, 8.4% and 8.4% were suffering from grade I, II, III and IV malnutrition respectively.

CHAPTER – III

RESEARCH METHODOLOGY

Research methodology is a way to systematically solve the research problem in this chapter the investigator discusses the research approach, research design, variables, setting, population, sample, sample size, sampling technique, criteria for data collection, description of the tool, plan for data analysis and protection of human rights.

RESEARCH APPROACH

Quantitative research approach was used in this study.

RESEARCH DESIGN

Non-experimental (descriptive study) was used in this study.

DEMOGRAPHIC VARIABLES

Age, education, occupation, income, number of children, type of family, dietary habits and previous source of information.

RESEARCH VARIABLE

Knowledge of malnutrition among mothers of under five children.

SETTING OF THE STUDY

The study was conducted among the mothers of under five children in rural area, at Thanjavur.

POPULATION

The population comprised of mothers of under five children.

CRITERIA FOR SAMPLE SELECTION

Inclusion criteria

The mothers who were

Having under five children
Residing in selected rural area
Available at the time of data collection

Exclusion criteria

The mothers who were

Not willing to participate in the study.
Working in health care sector .

SAMPLE

The samples of the study were the mothers of under five children.

SAMPLE SIZE

The sample size comprised of 30 mothers of under five children.

SAMPLING TECHNIQUE

The sample technique used in this study was convenient sampling technique.

DESCRIPTION AND INTERPRETATION OF TOOL

PART 1: Demographic variables such as age of the mother, education of the mother, number of children, and previous source information.

PART 2: Knowledge questionnaire to assess the knowledge regarding malnutrition among mothers of under five children.

SCORING OF THE TOOL

Inadequate knowledge – 0 to 10

Moderately adequate knowledge – 11 to 20

Adequate knowledge – 21 to 30

VALIDITY OF THE TOOL

The validity of the tool was done by review of literature treated by nursing experts. The tool was modified according to the suggestion and recommendations of experts and the tool was finalized.

DATA COLLECTION PROCEDURE

The investigator obtained written permission from the head of the institution and from the authorities of the proposed setting for the conduction of the study. The investigator obtained oral consent from the participants. By convenient sampling, 30 mothers of under five children were selected and their knowledge regarding malnutrition was assessed by the knowledge questionnaire and the results were analyzed by descriptive and inferential statistics.

PLAN FOR DATA ANALYSIS

Collected data was tabulated and analyzed by using descriptive, inferential statistical method.

ETHICAL CONSIDERATION

The permission was obtained from the head of the institutional authorities.
Ethical clearance was obtained from the ethical committee of Our Lady of Health college of nursing .
Oral consent was obtain from each participant.
The subject’s privacy, confidentiality and anonymity were maintained throughout the study.

CHAPTER – IV

DATA ANALYSIS AND INTERPRETATION

This chapter deals with the analysis and interpretation of the collected data from 30 subjects at, Thanjavur among the mothers of under five children.

The collected data was analyzed and interpreted by using both descriptive
and inferential statistics and the data has been tabulated and analyzed according to the objectives and hypothesis of this study.

ORGANIZATION OF DATA

The data has been organized and tabulated as follows

SECTION A

Assessment of demographic variables ( age of the mother, education status of the mother, occupation of mother, family monthly income , number of children, type of family, dietary habits, previous source of information).

SECTION B

Assessment of the level of knowledge regarding malnutrition among mothers of under five children’s at , Thanjavur.

PRESENTATION OF DATA

SECTION A

TABLE 4.1: Represents the frequency and percentage distribution of the demographic variables

S.NO

DEMOGRAPHIC VARIABLES

FREQUENCY

PERCENTAGE

AGE OF THE MOTHER

Below 20 years

21 to 25 years

31 to 35 years

Above 35 years

10%

50%

23.3%

16.7%

EDUCATIONAL STATUS OF THE MOTHER

Illiterate

Primary education

Higher secondary

Graduate

Post graduate

6.7%

30%

20%

30%

13.3%

OCCUPATION OF THE MOTHER

Coolie

Homemaker

Cottage industry

Private sector

Government sector

16.7%

43.3%

6.7%

23.3%

10%

FAMILY MONTHLY INCOME

Less than RS.5000

Rs.5001- Rs.10000

More than Rs.10001

20%

76.7%

3.3%

NUMBER OF CHILDREN

One

Two

Three

Above four

33.3%

46.7%

13.3%

6.7%

TYPE OF FAMILY

Nuclear family

Joint family

30%

70%

DIETARY HABITS

Vegetarian

Non – vegetarian

23.3%

76.7%

PREVIOUS SOURCE OF INFORMATION

Health personnel

Friends and relatives

Mass media

16.7%

50%

33.3%

4.1.1Frequency distribution of the mother age

This figure (4.1.1) was represent by age of mother

4.1.2Frequency distribution of the education status of mother

This figure (4.1.2) was represent by education status of mother

4.1.3Frequency distribution of the mother occupation

This figure (4.1.3) was represent by mother occupation.

Frequency distribution of the family monthly income

This figure (4.1.4) was represent by family monthly income.

4.1.5Frequency distribution of number of children

This figure (4.1.5) was represent by number of children

4.1.6Frequency distribution of the type of family

This figure(4.1.6) was represent by type of family

4.1.7frequency distribution of the dietary habits

This figure(4.1.7) was represent by dietary habits .

4.1.8frequency distribution of previous source of information

This figure (4.1.8) was represent by previous source of information.

SECTION B

Assessment of the level of knowledge regarding malnutrition among mother’s of under five children’s at, Thanjavur.

TABLE: 4.2

Represents the frequency , percentage distribution of the level of knowledge regarding malnutrition among mother’s of under five children ‘s at, Thanjavur.

S.NO

Level of knowledge

Frequency(N)

Percentage (%)

Inadequate knowledge

Moderate adequate knowledge

Adequate knowledge

3.3%

76.7%

20%

This figure (4.2.1) was represent frequency and distribution.

CHAPTER – V

DISCUSSION

This chapter deals with discussion of the study findings the study was done to determined the level of knowledge regarding malnutrition among mothers of under five children’s at , Thanjavur.

A descriptive design was used to conduct the study convenient sampling technique used to select the samples. Which are considered as study participants. Data was collected, analyzed, and study findings revealed the followings.

The first objective of the study was to assess to assess the knowledge regarding malnutrition among mothers of under five children.

The present study showed that the 3.3% are having inadequate knowledge, 76.7% are having moderate adequate knowledge, 20% are having adequate knowledge .

CHAPTER – VI

SUMMARY

The investigator concluded the study to Assess the knowledge regarding malnutrition among mothers of under five children in the rural area, Thanjavur. The study was descriptive study of total of 30 mothers who met the inclusion criteria were selected as the samples.

Descriptive design was selected for this study. The study was conducted among 30 mothers in rural area by using convenient sampling method to select the samples.

The investigator applied both descriptive and inferential statistics and the data has been tabulated and analyzed according to the objectives and hypothesis of this study.

CONCLUSION

NURSING IMPLICATIONS

Nursing is a service oriented profession and it must advance and keep pace with the advancing technology, newer problems, and growing demands of consumers. The findings of the study has implications for nursing practice, nursing education, nursing administration and nursing research , and its implication is not only in the field of nursing but also in other areas like community health, preventive medicine and school health. The present study findings will be helpful for such future studies. In this framework the findings of the study has valuable implications to nursing education, administration and research.

NURSING EDUCATION

Education is the key to the development of excellent nursing practice. Education faces tremendous challenges in keeping pace with changes in nursing practice to maintain is high quality. Nurses must be lifelong learns and they should be given an opportunity for continuing education . Nurses with higher education deliver cost effective care.

Nurses who are equipped with up data knowledge of malnutrition are better persons to impact appropriate knowledge to the nursing students which will help in preventing complications of malnutrition and will lead a highly productive life.

During nursing education , students may be given clinical field assignments the activities may in work to find out the special needs of under five children and other members of the vulnerable group, pregnant and lactating women and to plan and implement various health awareness and nutritional programmes.
Teachers training programmes should include the specific areas like nutrition, classification of nutrients, their functions, sources of nutrients , and what are the common problems in nutrition , malnutrition and preventive of malnutrition in children especially for Anganwadi teachers in the rural areas.
The health care providers are the key personnel in impacting education to the clients. There is need for in-service educational programmes for the health care providers for preparing them to function effectively as a counselor for clients.

NURSING PRACTICE

Mothers need to have adequate knowledge regarding nutrition for under fives and how much it is important for children’s growth and development. The findings imply that there is a need for regular health programmes to be carried out by nurses. Counseling centres may be recognized by nurses in colleges to provide counseling and educate mothers on nutrition. Nurse can also identify family members in the same family who have lack of knowledge regarding nutrition and help them to understand the importance and effects of nutrition for growth and development of child, it helps them to adjust with the reasons for why they should start giving proper nutrition. Nurses should try to fill these lacunaes by participating in the preparation of learning resource material and disseminating these materials through mass media and other ways. Nurse should also involve themselves in counseling mothers to bring changes in their knowledge regarding nutrition for under five.

Health care services are essential components of community health, the role of personnel is to contact nutritional projects and participate in national nutritional programmes.
It is the responsibility of community health personnel to reduce the morbidity and mortality related to malnutrition of children in a defined rural area.

NURSING ADMINISTRATION

In service education to be provided to the nursing personnel at various levels to make them aware of malnutrition problems in children . time should be allotted for all health personnel for dissemination of knowledge and health education to all mothers regarding nutrition knowledge and educate them by making use of our health facilities.

Nurse as an administrator can plan and organize educational programs. Nurse administrator can organize in service education programme for the nurses to increase their knowledge regarding nutrition under for under five. Nurses need to involve more actively in the preventive, educating, and giving more education regarding nutrition for under five. Nurse administrator should encourage nurse to involve themselves in preventive programmes on nutrition for under five at primary , secondary and tertiary. Nurse administrator should also plan or conducting nursing education programmes on various aspects of nutrition , which will help the nurses to take care of individuals with behavioural and physical problems and complications of nutritional deficiencies and disorders.

NURSING RESEARCH

Research plays a vital role in nursing. There is need for extended and intensive research in the area of educating the staff nurses about nutrition for under five. Research can help and increase the body of nursing knowledge, which improves the care provided. Although actual performance is important , use of observation to explore nurse performance is limited in clinical setting. “ the potential of observation in research in this nature has yet to be fully exploited”.

More research needs to be done in this area to find out the nutritional problems faced by under five children and preventive measures taken.
Research needs to be focused on the health problems related to malnutrition among under five children.
Extensive research needs to be conducted on children to find the relationship between nutritional status of children and mothers knowledge level.

SUGGESTIONS

Some educating street play, drama, and other public educating programmes in the community and college should arrange to bring awareness among the mothers and community people regarding nutritional deficiencies.
In kinder garden health education can be given to teachers regarding prevention of growth retardation because of nutritional deficiencies.

Regular in-service / refresher course on universal precautions should be implemented in colleges and community.

In schools, colleges and community health education can be given regarding nutrition.
Nurses should upgrade their knowledge regarding nutrition in order to give excellent nutrition.
Mass media , and other medias should strictly give advertise in favor of nutritional deficiencies or community peoples regarding nutrition and its use in growth and development in under five.

A suitable environment for study could be maintained through provision of adequate education regarding nutrition and its effects on growth and development.

RECOMMENDATIONS

A comparative study on the effectiveness of the currently advocated nutrition should be under taken with a view to develop problem specific protocols.
A study on the knowledge of nursing personnel regarding nutrition may help to the students.
A study on the attitude and willingness of slum people regarding nutrition may be helpful for the community.
A qualitative study on the effectiveness of nursing measures to improve the quality of life of persons living with protein energy malnutrition should be conducted.

REFERENCE

BOOK REFERENCE

1) Sangavi,u.(2001). Journal of tropical paediatrics. Kerala: Assessing potential risk factors for child malnutrition.

2)Cranney A, Horsley T, O Donnell S, et al. (2007) effectiveness and safety of vitamin D in relation to bone health.

3)Yin SA, Yan ZY, Pan L, Lai JQ, et al. (2009) china : effects of nutritional education on improvement of nutritional knowledge of infant’s mothers in rural area in china. national institute for nutrition and food safety , Chinese center for disease control and prevention .

4)Ghosh S, Kilaru A, Ganapathy S (2002)nutrition education and infant growth in rural Indian infants : narrowing the gender gap.

5)Doherty CP, Crofton PM, Sarkar MA, et al.(2002) Malnutrition, zinc supplementation and catch-up growth: changes in insulin-like growth factor I, its binding proteins, bone formation and collagen turnover.

6)Gatheru Z, Kinoti S, Alwar J,et.al. (1998) zinc levels in children with kwashiorkor aged one to three years at Kenyatta National Hospital and the effect of zinc supplementation during recovery.

7)Golden BE, Golden MH.(1992) Effect of zinc on lean tissue synthesis during recovery from malnutrition.

8)Hemalatha P, Bhaskaram P, Khan MM. (1993) Role of zinc supplementation in the rehabilitation of severely malnourished children.

9)Khanum S, Alam AN, Anwar I,et.al, (1988) Effect of zinc supplementation on the dietary intake and weight gain of Bangladeshi children recovering from protein–energy malnutrition.

10)Luque Fernandez M, Delchevalerie P, Van Herp M.(2010) Accuracy of MUAC in the detection of severe wasting with the new WHO growth standards.

11)Berkley J,(2005) Assessment of severe malnutrition among hospitalized children in rural Kenya: comparison of weight for height and mid upper arm circumference.

12)Defourny I, (2009)A large-scale distribution of milk-based fortified spreads: evidence for a new approach in regions with high burden of acute malnutrition.

13)Ciliberto MA, Manary MJ, Ndekha MJ,et.al, (2006)Home-based therapy for oedematous malnutrition with ready-to-use therapeutic food.

14)Linneman Z, Matilsky D, Ndekha M, et.al, (2007) A large-scale operational study of home-based therapy with ready-to-use therapeutic food in childhood malnutrition in Malawi.

15)Manary M, Ndkeha MJ, Ashorn P,et.al, (2004)Home based therapy for severe malnutrition with ready-to use food.

16)Oakley E, (2010) A ready-to-use therapeutic food containing 10% milk is less effective than one with 25% milk in the treatment of severely malnourished children.

17)Amthor R, Cole S, Manary M. (2019)The use of home-based therapy with ready-to-use therapeutic food to treat malnutrition in a rural area during a food crisis.

18)Pust R, Johnson P, Lautenschlager J. (2012)Detecting malnutrition at age 6–12 months: international comparisons of arm circumference v. standard anthropometry.

19)Collins S, Dent N, Binns P,et.al, (2006) Management of severe acute malnutrition in children.

20)Imdad A, Yakoob MY, Sudfeld C,et.al, (2011)Impact of vitamin A supplementation on infant and childhood mortality.

21)Stephensen C, Franchi LM, Hernandez ,et.al,(1998) Adverse effects of high-dose vitamin A supplements in children hospitalized with pneumonia.

22)de Fátima Costa Caminha M, et al.(2008) Serum retinol concentrations in hospitalized severe protein-energy malnourished children.

23)Ashour M, Salem SI, El-Gadban HM, et.al, (1999)Antioxidant status in chidlren with protein-energy malnutrition (PEM) .

24)Mitra A, Alvarez JO, Wahed MA, Fuchs GJ, et.al,(1998) Predictors of serum retinol in children with shigellosis.

25)Mahalanabis D. (1991) Breast feeding and vitamin A deficiency among children attending a diarrhoea treatment centre in Bangladesh: a case-control study.

26)Nacul L, Kirkwood BR, Arthur P,et.al, (1997) Randomised, double blind, placebo controlled clinical trial of efficacy of vitamin A treatment in non-measles childhood pneumonia.

27)Kjolhede C, Chew FJ, Gadomski AM, et.al, (1995)Clinical trial of vitamin A as adjuvant treatment for lower respiratory tract infections.

28)Dibley M, Sadjimin T, Kjolhede CL, et.al, (1996)Vitamin A supplementation fails to reduce incidence of acute respiratory illness and diarrhea in preschool-age Indonesian children.

29)Daulaire N, Starbuck ES, Houston RM, et.al, (1992)Childhood mortality after a high dose of vitamin A in a high risk population.

30)Fawzi W, Mbise R, Spiegelman D, et.al,(2000) Vitamin A supplements and diarrhoeal and respiratory tract infections among children .

JOURNAL REFERENCE

Journal of the association of nurses in malnutrition The journal of association of nurses in AIDS care( JANAC )is edited according to the publication manual of the American (APA, 6^th ed).
American journal of nursing,/community health nursing journal, nursing clincs of north America,nursing 201 X

NET REFERENCE

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