Exploring the Nutrition status of Children affected by Nodding Syndrome (NS) in Western Equatoria State of South Sudan 公开

Mindra, Godwin (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/xs55mc21v?locale=zh
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Abstract


Nodding Syndrome (NS) is a novel form of epilepsy seen predominantly among
children aged 5-18 years and characterized by head nodding, cognitive
impairment, mental retardation and physical growth deterioration. To date the
cause of nodding syndrome remains unknown. Apart from South Sudan, nodding
syndrome has been reported in northern Uganda, bordering South Sudan to the
South and southern Tanzania. The condition's characteristic head nodding is
usually stimulated by either food and/or cold weather. The age at onset of
nodding syndrome is commonly reported in children between 3 and 5 years but
observed current age of cases range up to 23 years in Mundri and Maridi counties
of Western Equatoria State.

The purpose of this study was to investigate the nutrition status of children
affected by nodding syndrome exploring acute and chronic (stunting) nutrition
patterns. Case-control technique was used to investigate the growth pattern of
children affected by nodding syndrome. Anthropometric measurements were
used to assess nutritional status in cases and controls. Twenty-three percent
(23.7%) of all nodding syndrome cases were severely stunted (HFA z-score while the rate of wasting in nodding syndrome cases and their controls was not
different (p=0.06). Nodding syndrome cases enrolled in the study showed strong
correlation (r=0.41) between duration of the condition and stunting level.

Chronic malnutrition (stunting) is found to be frequent in children affected by
nodding syndrome enrolled in the study. Critical to the management of children
with nodding syndrome is targeted feeding program, education to parents on
appropriate feeding of children, improve hygiene and sanitation, control of
seizures and provide psychosocial support to children and parents.

Table of Contents


TABLE OF CONTENTS
ABSTRACT ................................................................................................... ii
ACKNOWLEDGMENTS ................................................................................ iv
LIST OF APPENDIXES .............................................................................. viii
LIST OF TABLES ....................................................................................... viii
LIST OF FIGURES ..................................................................................... viii
ABBREVIATIONS ....................................................................................... ix

CHAPTER 1 ................................................................................................... 1
INTRODUCTION ........................................................................................... 1
1.1. BACKGROUND ....................................................................................... 1
1.2. PROBLEM STATEMENT ........................................................................ 3
1.4 SPECIFIC STUDY OBJECTIVES .............................................................. 4
1.5. SIGNIFICANCE OF THE STUDY ............................................................ 4

CHAPTER 2 ................................................................................................... 5
COMPREHENSIVE LITERATURE REVIEW .................................................. 5
2.2 UNDERSTANDING THE CHARACTERISTICS OF NODDING SYNDROME....... 5
2.3 ETIOLOGY OF NODDING SYNDROME .................................................. 8
2.4 NODDING SYNDROME IN WESTERN EQUATORIA STATE OF SOUTH SUDAN ... 8
2.5 INTERACTION BETWEEN NUTRITION, PHYSICAL AND COGNITIVE
DEVELOPMENT ................................................................................... 10
2.6 EMERGING AND UNMET NEEDS OF NODDING SYNDROME .............. 11
2.6.1 STUDY CONCEPTUAL FRAMEWORK ....................................................................................................... 12

CHAPTER 3 ................................................................................................. 18
PROJECT CONTENT ................................................................................... 18
3.1 STUDY DESIGN ..................................................................................... 18
3.1.1 CASE DEFINITION ....................................................................................................................................... 18
3.1.2 PARTICIPANTS' DESCRIPTION, SOURCE POPULATION AND CATCHMENT AREA .......................................................... 19
3.2 PARTICIPANT INCLUSION CRITERIA .................................................. 19
3.2.1 DEFINITION OF A CASE ................................................................................................................................ 19
3.2.2 DEFINITION OF A CONTROL .......................................................................................................................... 20
3.3 SAMPLING, SAMPLE SIZE AND STATISTICAL POWER ...................... 20
3.3.1 SAMPLING ASPECTS .................................................................................................................................... 21
3.3.2 RECRUITMENT AND ENROLLMENT ................................................................................................................. 21
3.3.3 VARIABLES ............................................................................................................................................... 22
3.3.4 STUDY INSTRUMENT(S) ............................................................................................................................... 22
3.4 DATA HANDLING AND ANALYSIS ....................................................... 22
3.4.1 QUALITATIVE DATA ANALYSIS ...................................................................................................................... 22
3.4.2 QUANTITATIVE DATA ANALYSIS: ................................................................................................................... 23
3.5 DESIGN VALIDITY ................................................................................ 23
3.5.1 INTERNAL VALIDITY .................................................................................................................................... 23
3.5.2 EXTERNAL VALIDITY .................................................................................................................................... 24
3.5.3 RELIABILITY .............................................................................................................................................. 24
3.6 ETHICAL CONSIDERATION ................................................................. 25
3.6.1 ETHICAL CLEARANCE AND REVIEW BOARD APPROVAL ....................................................................................... 25
3.6.2 CONFIDENTIALITY ...................................................................................................................................... 26
3.6.3 THE CONSENT PROCESS............................................................................................................................... 26
3.7 ACTIVITIES TIMELINE ........................................................................ 26
3.8 SCOPE AND LIMITATIONS OF THE STUDY .......................................... 27
3.8.1 CONCEPTUAL AND TIME SCOPE ..................................................................................................................... 27
3.8.2 LIMITATIONS OF THE STUDY: ........................................................................................................................ 28
3.9 RESULTS ............................................................................................. 29
3.9.1 MEASUREMENTS .............................................................................................................................. 29
3.9.1 TYPE OF SOURCE POPULATION OF NODDING SYNDROME CASES ................................................................. 30
3.9.2 LOCATION OF NODDING SYNDROME CASES (N=38) ................................................................................. 30
3.9.3 ANTHROPOMETRY ............................................................................................................................ 31
3.9.3.1 Sex of participants ....................................................................................................................... 31
3.9.3.2 Stunting: Height for Age (HFA) index Analysis ............................................................................. 34
3.9.3.3 Comparison of Nodding Syndrome cases and controls by Height-For-Age (HFA) z-scores ......... 35
3.9.3.4 Matched analysis of Severe Stunting (height-for-age z-score and their controls. ....................................................................................................................... 37
3.9.4 WASTING: BODY-MASS-INDEX FOR AGE (BMI-FOR AGE) ANALYSIS ........................................................... 38
3.9.4.1 Unmatched Comparison of Wasting (BMI-for-Age z-scores) of Nodding Syndrome cases and
their controls ............................................................................................................................... 39

3.9.4.2 Matched analysis of Nodding Syndrome cases and their paired controls for severe wasting
(BMI-for-age z-score
3.9.5 CORRELATION BETWEEN DURATION OF NODDING SYNDROME, STUNTING AND WASTING .............................. 41
3.9.5.1 Wasting in Case-Control cases (BMI-for-Age z-scores) and duration of Nodding Syndrome ...... 41
3.9.5.2 Stunting (height-for-age z-scores) and duration of Nodding Syndrome ...................................... 42
3.9.5.3 Combined (Nodding Syndrome cases) Analysis of the relationship between Stunting (Height-

For-Age z-scores) and durtaion of Nodding Syndrome (n=50)..................................................... 43
3.9.5.4 Analysis of the relationship between Stunting (Height-For-Age z-scores) and Age of Nodding
Syndrome (n=50) ......................................................................................................................... 44

3.10 HISTORY OF CHILD GOING HUNGRY ........................................... 45
CHAPTER 4 ................................................................................................ 49
DISCUSSION, RECOMMENDATIONS AND CONCLUSION ........................ 49
4.0 INTRODUCTION.................................................................................. 49
4.1 DISCUSSION ....................................................................................... 49
4.1.1 ANTHROPOMETRIC INFORMATION ....................................................................................................... 49
4.1.1.1 Gender of Participants (Male and Female) .................................................................................. 50
4.1.1.2 Stunting: (Height-for-Age) index ................................................................................................. 51
4.1.1.3 Wasting: BMI-for-Age index ........................................................................................................ 53
4.1.2 RELATIONSHIP BETWEEN STUNTING, WASTING AND DURATION OF NODDING SYNDROME ............................... 54
4.1.3 HISTORY OF GOING HUNGRY .............................................................................................................. 55
4.2 LIMITATIONS OF THE STUDY ............................................................. 56
4.3 RECOMMENDATIONS .......................................................................... 57
4.3.1 IMMEDIATE AND INTERMEDIATE RECOMMENDATIONS ............................................................................. 59
4.3.2 RECOMMENDATIONS TO ADDRESS UNDERLYING FACTORS ......................................................................... 60
4.4 FURTHER RESEARCH ........................................................................ 63
4.5 CONCLUSION ...................................................................................... 64


LIST OF APPENDIXES
Appendix A: Map of South Sudan by counties and States ..................................... 65
Appendix B: Spatial location of South Sudan ..................................................... 65
Appendix C: Map of Western Equatoria State ................................................... 66
Appendix D: Consent form ............................................................................. 67
Appendix E: Study questionnaire .................................................................... 72
Appendix F: Letter of authorization to use data ................................................. 82
LIST OF TABLES
TABLE 01: DISTRITION OF NS CASES AND CONTROLS BY LOCATION ...................................... 30
TABLE 02: MEAN DURATION OF NS BETWEEN MALE AND FEMALE CASES ........................... 34
TABLE 03: COMPARISON OF HFA Z-SCORES OF NS CASES AND CONTROLS .......................... 36
TABLE 04:
MATCHED ANALYSIS OF HFA Z-SCORES OF NS CASES AND CONTROLS ................ 37
TABLE 05: COMPARE BMI-FOR-AGE Z-SCORES OF NS CASES AND CONTROLS ..................... 39
TABLE 06: MATCHED COMPARISON OF BMI-FOR-AGE Z-SCORES ........................................ 40
TABLE 07: COMPARISON OF HOSTORY OF GOING HUNGRY .................................................. 46
TABLE 08: STRATIFIED ANALYSIS OF HISTORY OF GOING HUNGRY BY SEX ............................ 47
LIST OF FIGURES
FIGURE 01: Distribution of NS cases by location ................................................ 31
FIGURE 02: Frequency distribution of the age of NS cases and their controls .......... 32
FIGURE 03: Percentile distribution of the age of NS cases and controls .................. 33
FIGURE 04: Frequency distribution of age at onset of NS cases ............................ 34
FIGURE 05: Frequency distribution of HFA z-scores of NS cases and controls ......... 35
FIGURE 06: Median HFA z-scores of NS cases and their controls ......................... 36
FIGURE 07: Frequency distribution of BMI-for-age z-scores of NS cases and controls...... 38
FIGURE 08: Scatter plot of NS duration and BMI-for-age z-scores (n=38) ............. 42
FIGURE 09: Scatter plot of NS duration and HFA z-scores (n=38) ........................ 43
FIGURE 10: Scatter plot of NS duration and HFA (n=50) .................................... 44
FIGURE 11: Scatter plot of Age of NS cases and HFA z-scores (n=50) ..................... 45

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