Introduction

Childhood malnutrition is a major public health problem in India. It is one of the biggest contributor to under-five mortality due to increased susceptibility to infections and slow recovery from illness.1 Children are in the process of growth and development, therefore are more prone to develop nutritional deficiencies.

As per WHO2 malnutrition is a cellular imbalance between supply of nutrients and energy and body demand for them to ensure growth maintenance and specific functions. In 2019, globally one hundred fourty four million under five children were stunted and 47 million were wasted.3

Severe Acute Malnutrition is the most severe and visible form of undernutrition. In 2017, globally around 50 million under 5 children were acutely malnourished.4 As nutrients are required for maintenance of ocular health therefore ocular involvement in malnourished children is quite common and more serious during early childhood. It has varied presentation ranging from asymptomatic cases to permanent blindness, thus is an important cause of preventable blindness and is to be taken care of. Deficiencies of retinol, folate, and minerals like iron, magnesium and potassium are usually seen in SAM. Among these, deficiency of retinol is most important as it may lead to keratomalacia and permanent blindness. It has been estimated that approximately 250,000 to 500,000 malnourished children go blind each year from a deficiency of vitamin A.5

Prevention of xerophthalmia is of utmost importance in preventing early childhood blindness. Vitamin A deficiency is one of the most important cause of preventable blindness in children. It has been a nutritional problem of public health significance in India. Besides vitamin A deficiency, which has major ocular features, other vitamin deficiencies also effect the eye.6 By looking at these facts, there is a need of this study to know the nature, magnitude and severity of ocular morbidity in SAM and to assess its institutional prevalence, also to detect the associated risk factors with nutritional deficiencies in younger vulnerable group of children with the hope, that it would provide useful information regarding magnitude of the problem and would lead to a better understanding of related factors, enabling us to tackle it more effectively and help us to improve parameters of nutrition, by increasing awareness, education and information regarding nutrition and vaccination.

Aims of this study were

Materials and Methods

This hospital based observational study was carried out at tertiary care centre in Department of Ophthalmology in collaboration with Department of Pediatrics, during the study period of 2 years i.e. from 1^st November 2018 to 30^th September 2020. Children were diagnosed to be SAM by Pediatricians according to criteria defined by WHO and UNICEF as any of the following

All children in age group of 6 months to 5 years, either admitted in pediatric ward or attending ophthalmic OPD and whose parents were willing to participate in the study were included. Children less than 6months and more than 5 years were excluded.

Before commencing the study, Ethics committee approval was obtained. Written consent was obtained from all the parents/care givers.

Socio-demographic profile of the cases were recorded such as age, sex, socio economic status etc. Detailed history including regarding birth history (birth order, birth weight, mode of delivery, any birth complications, history of Exclusive Breast Feed), present ocular, medical and surgical history of child, history of vitamin A intake, treatment history. Immunization status was recorded based on immunization cards and verbal record from mothers.

The chief ocular and other complaints with their duration were noted. The history of presenting illness was enquired in detail including the mode of onset of symptoms with duration from mother/care taker. A detailed history of diet and dietary habits of each patient was noted. A past history of general and ocular illness was noted to know whether the patient was chronically ill and/ or suffered from any eye disease of significance.

Detailed family history including parents occupation, family per capita income, parents educational status, number of siblings and any similar complaint in any of them was noted.

All the patients were subjected to detailed general and physical examination and height, weight, skin/hair changes, pitting edema over extremities of every child was noted. Anthropometric measurements were taken using standard technique and instruments. All the systems were examined with emphasis on GIT and respiratory tract. The cases were subjected to through ocular examination. Recording of visual acuity in severely comorbid infants and younger age group children was not possible. Wherever possible, visual acuity measurement was done, i.e. for children under 2 years, Binocular Fixation Method and 2-3 years the preferential gaze method (Teller visual acuity cards at 55 cm) was used, making the correlation with the Snellen chart. And for children aged 3 to 5 years visual acuity was measured using the table of figures and Snellen at 6 meters. Ocular adnexa as well as anterior segment of the eye, including conjunctiva, sclera, cornea, anterior chamber, pupil and lens were examined in a good diffuse light using a pen torch and a binocular hand held loupe. Signs of protein-energy malnutrition (lid oedema, chemosis, external infections) and vitamin-A deficiencies (conjunctival and corneal xerosis, Bitot's spots, corneal scars or xerophthalmia) were looked.

The cornea was examined using the hand held binocular loupe; and stained with fluorescein after application of topical anaesthesia, if the normal luster of the cornea was lost. Full mydriasis was obtained for every patient using 1% Tropicamide eye drops and the posterior segment was examined using direct and indirect ophthalmoscope using lid speculum. Particular attention was offered for optic atrophy, optic neuritis, xerophthalmic fundus, macular pigmentation and retinal haemorrahges. Further, investigations such as CBC, LFT, RFT, serum proteins and serum electrolytes were done.

Results

A total of 100 severe acute malnourished children belonging to age range of 6 months to 5 years (60 months) were enrolled and screened for presence of ocular manifestation.

Table 1 reveal sociodemographic details of the children diagnosed as SAM. Slight female preponderance for severe acute malnutrition was observed with male:female ratio of 1:1.1. Majority of children belonged to 6 months to 12 months of age group (58%). Majority of children diagnosed as SAM had low birth weight i.e. <2.5 kg (43%). About 73% children were fully immunized and history of exclusive breast feeding was absent in majority i.e. 68% cases.

Among children with severe acute malnutrition, most common comorbidity was anemia (78%).

Figure 1

Ocular involvement in cases

In present study, prevalence of ocular involvement in severe acute malnourished children was 72%.

Out of 72 cases with ocular involvement, bilateral involvement was observed in 68 (94.4%) cases whereas unilateral involvement was observed in 2 (2.8%) cases. However in 2 (2.8%) cases both unilateral as well as bilateral involvement was noted due to multiple manifestations. Conjunctival pallor was most common ocular manifestation in 48 (70.6%) cases in cases with bilateral involvement.

Anterior segment findings were observed in 179 eyes, most common was conjunctival pallor (71.5% eyes). Posterior segment findings were observed in 19 eyes, and retinal hemorrhages was most common (36.8%). Vitamin A deficiency signs were observed in 17 eyes (8.5%). Of them, conjunctival xerosis was most common finding observed in 10 (58.9%) eyes.

Higher birth order and number of sibling was significantly associated with higher incidence of ocular manifestations (p<0.05). However, other variables showed no significant association between other variables and ocular manifestations (p>0.05).

Discussion

Severe Acute Malnutrition is one of the important cause of under 5 morbidity in our country, since severe ocular involvement is associated with SAM, therefore an institutional based observational study was undertaken to study the ocular manifestations in SAM and its correlation with risk factors associated with ocular manifestations.

Our study population included 100 cases of SAM. There was slight female preponderance observed with male:female ratio of 1:1.1. Majority of children belonged to 6 months to 12 months of age group (58%) whereas only 4% children belonged to age group 37 to 48 months. Majority of them had low birth weight i.e. <2.5 kg (43%). While it was within normal range (2.5 to 3 kg) in 31% children and it was not known in 19% cases. About 73% children were fully immunized whereas 19% and 8% children were partially immunized and not immunized respectively.

Similar findings were observed by Ahmed et al,7 male to female ratio was found to be evenly distributed, males (48%) and females (52%). This is because younger children are rapidly growing with high energy requirements and are prone to recurrent infections, therefore are at increased risk of SAM. About 40% were fully immunized, (50.67%) were partially and (9.39%) were not immunized at all.7 This suggest that there is better utilization of immunization service in our country as suggested by our study.

As per recommendations from World Health Assembly Resolution. Infant and young child nutrition in 2001, infants should be EBF for the first 6 months of life to achieve optimal growth, development and health. Thereafter to meet their evolving nutritional requirements, they should receive nutritionally adequate and safe complementary foods. The effect of diet, early weaning increases the risk for infections and thus increases the risk of SAM. Majority of cases(68%) were not given exclusive breast feeding until six months as they were started with complementary diet too early, also due to cultural and social reasons, children are more likely to be subjected to inadequate feeding practices and low nutritive foods.

Prevalence of ocular involvement noted was 72%. Singh et al8 documented 16.6% prevalence of ocular manifestations in malnourished children attending anganwadi centers. In present study, prevalence was very high compared to reference study. This could be due to the fact that our study included only children with SAM, having severe comorbidities whereas their study included total malnourished children, both acute and chronic.

Out of 72 cases with ocular involvement, bilateral involvement was observed in 68 (94.4%) cases whereas unilateral involvement was observed in 2 (2.8%) cases. Overall, conjunctival pallor was most common ocular manifestation. Blepharitis was observed in 7(10.29%) cases, and conjunctivitis in 3(4.41%) cases with bilateral involvement. These infections may be due to the secondary immunodeficiency caused by malnutrition leading to predisposition to external infections and also bad hygiene.

Ahmed et al7 also documented conjunctival palor as the most common ocular manifestation observed in (96%), this suggest that almost all children were anaemic and conjunctivitis was found in (46.67%) cases, wheras Blepharitis was not found in any patient.

Anterior segment findings were observed in 179 eyes out of 200 eyes. Of them, conjunctival pallor was the most common finding observed in 128 (71.5%) eyes. This was followed by lid edema and discharge in 14 (7.8%) eyes each. Posterior segment findings were observed in 19 eyes. Most common posterior segment finding observed in children with severe acute malnutrition was retinal hemorrhages followed by disc edema in 36.8% and 31.6% eyes respectively. Vitamin A deficiency signs were observed in 17 eyes (8.5%). Of them, conjunctival xerosis was the most common finding observed in 10 (58.9%) eyes. Apart from this, corneal xerosis, keratomalacia, and corneal perforation were documented in 2 (11.8%) eyes each. No case presented with Bitot spots were reported.

Similar findings were noted by Ahmed et al7 in which discharge (28%) and lid oedema was found in (46.67%) cases. Corneal opacity and subconjunctival haemorrhage in 1.33% cases. Retinal haemorrhages were also the most common posterior segment finding detected in (4%) cases.

Anandakumar et al9 documented conjunctival xerosis in 36% cases of SAM. However, Bitot spots were seen in 24% of cases. Corneal scar was seen in one case. Night blindness was not noted in any children.9 Ferdousi et al10 in their study observed signs of vitamin A deficiency in 10% cases. Of them, xerosis was present in 4 cases and corneal ulcer in 1 case. No case presented with Bitot spots, this is similar with our study.10 Since in our study xeropthalmia was present in 5% cases when comparing with above studies, we notice that there is a reduction in vitamin-A deficiency signs this could be attributed to better utilization of the national policy of giving vitamin-A supplementation.

While observing the risk factors associated with ocular involvement in severe acute malnutrition it, was found that among gender, age, birth weight, birth order, immunization status, exclusive breast feeding, no of siblings, residence, mother education, mother occupation and socioeconomic status, only birth order and no of siblings were significantly associated. This could be due to reason that general condition of mother also deteriorates after multiple pregnancies and also because of increase in number of children, mother is unable to give them attention properly.

However, Ahmed et al7 found Dacrocystitis as the only ocular finding which was statistically significant related to immunization status. There is a lack of evidence in literature studying the risk factors associated with ocular involvement in severe acute malnutrition, only some of the studies are done that too on total malnourished children, therefore we can't compare our study with other studies. Limitation of our study being a single center hospital-based study, the results cannot be extrapolated to study the prevalence of Ocular manifestations in the general population.

Conclusion

The prevalence of ocular manifestations of severe malnutrition are noticable and under 5 children forms an important target group and must be screened adequately for early detection of ocular findings and prevention of VAD. Also, every child should be immunized, given prophylaxis for vitamin A and promotion of EBF should be encouraged.Training should be given to health workers at the primary health care level and health centers on counseling mothers on feeding, growth monitoring, the preventable eye blinding diseases and hygiene during the vaccination sessions and early referral of children with eye signs to hospitals. Thus preventing adverse impact on childhood morbidity and mortality. Also education of couple regarding proper nutrition of mother and child should be encouraged and couples should be insisted to have not more than two children.

Strength of the study

Limitations of Study

Opportunity Laid by the Study

Source of Funding

None   

Conflict of Interest

None.