Dr. Sharika Nuzhat Assistant Scientist Nutrition and Clinical Services Division, icddr,b

1. DELIVERING FOR NUTRITION IN SOUTH ASIA
Implementation Research in the Context of COVID-19
1 December 2021
Dr. Sharika Nuzhat
Assistant Scientist
Nutrition and Clinical Services Division,
icddr,b
Health and nutritional status of under-five children
in Bangladesh during COVID-19
Impact of COVID-19 on nutritional status and other
morbidities among under-five children including
those born during the pandemic and treated in a
diarrheal disease hospital in Bangladesh

2. The growing global incidence of coronavirus disease 2019 (COVID-19) caused by severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) has led the World Health Organization (WHO)
to acknowledge COVID-19 as a public health emergency
The COVID-19 pandemic is predicted to result in a reduction in health-service coverage of essential
pregnancy and newborn care in 132 low-and-middle-income countries
Childhood malnutrition, including wasting, is expected to increase as a result of sudden decreases
in household incomes, food insecurity and disruption of the healthcare system
Anecdotal observation from Dhaka hospital, icddr,b revealed that, during COVID-19 period, young
infants were unwell compared to young infants admitted to the hospital during pre-COVID-19 period

3. Objective: To address impact of COVID-19 on
morbidity, mortality and nutritional status among
under-5 children admitted to the hospital
Study type: Hospital chart analysis
Study site: The Dhaka Hospital of International
Centre for Diarrhoeal Disease Research,
Bangladesh (icddr,b)
Study period: March 2019 to February 2021

4. Study population
2.47
1.37
1.18
1.14
1.92
3.68
8.35
9.05
14.11
16.85
19.28
20.61
8.3
9.87
8.33
6.86
9.87
8.64
8.22
8.12
7.79
9.81
7.51
6.69
0 5 10 15 20 25
March/2019-2020
April/2019-2020
May/2019-2020
June/2019-2020
July/2019-2020
August/2019-2020
September/2019-2020
October/2019-2020
November/2019-2020
December/2019-2020
January/2020-2021
February/2020-2021
Pre COVID-19 period COVID-19 period
Figure: Percentage of total in patient admission of under-5 children in each months in
Dhaka hospital, icddr,b during pre COVID-19 and COVID-19 period
(March 2019 – February 2021)
Figure: Illustration of the identification of study participants from February 2019 - March 2021

5. Characteristic COVID-19 period
(n=2552)
Pre COVID-19 period
(n=6738)
P value Age- and sex-
adjusted OR
(95% CI)
P value
Age, months; mean ± SD 11.11±8.54 11.59 ± 9.65 0.020
Sex, female 957 (37.50%) 2514 (37.37%) 0.866
Delivery by C-section 887/1815 (48.87%) 1875/4099 (45.74%) 0.026
Immunization as per EPI schedule 1712/1903 (89.96%) 4079/4591 (88.85%) 0.188
Exclusive/partially breastfeeding 1424/2075 (68.63%) 3418/5181 (65.97%) 0.030
Stuntinga 1051/ 2186 (48.08%) 2553/5149 (49.58%) 0.239 0.94 (0.85- 1.04) 0.205
Wastingb 863/1933 (44.65%) 1977/4383 (45.11%) 0.735 1.00 (0.90- 1.11) 0.991
Acute diarrhea (watery/invasive) 2477 (97.06%) 6540 (97.06%) 0.999 1.00 (0.77-1.32) 0.958
Some/severe dehydration 1480/2545 (58.15%) 3499/6657 (52.56%) 0.000 1.26 (1.15-1.38) 0.000
Convulsion (during/after admission) 146 (5.72%) 229 (3.4%) 0.000 1.74 (1.41-2.16) 0.000
Pneumonia 376 (14.73%) 1102 (16.36%) 0.056 0.87 (0.77-0.99) 0.039
Severe pneumonia 217 (8.50%) 700 (10.39%) 0.007 0.79 (0.67-0.93) 0.005
Severe sepsis/septic shock 65 (2.55%) 98 (1.45%) 0.000 1.76 (1.28-2.41) 0.000
Hospital acquired infection 41 (1.61%) 125 (1.86%) 0.420 0.86 (0.60-1.22) 0.399
Death 31 (1.21%) 83 (1.23%) 0.947 0.97 (0.64-1.48) 0.905
Hypernatremiac 213/ 1053 (20.23%) 223/ 1520 (14.67%) 0.000 1.47 (1.20-1.82) 0.000
Hyponatremiad 340/ 1053 (32.29%) 682/ 1520 (44.87%) 0.000 0.59 (0.50-0.70) 0.000
Hyperkalemiae 89/ 1053(8.45%) 139/ 1520 (9.14%) 0.543 0.94 (0.71-1.24) 0.658
Hypokalemiaf 249/ 1053(23.65%) 407/ 1520 (26.78%) 0.073 0.85 (0.71-1.02) 0.089
Raised creatinineg 200/ 577 (34.66%) 318/ 1091 (29.15%) 0.021 1.25 (1.00-1.57) 0.045
a Length- or height-for-age z-score < −2 SD, b Weight-for-length or -height z-score < −2 SD
c Serum sodium ≥ 150 mmol/L., d Serum sodium < 135 mmol/L/, e Serum potassium ˃ 5.5 mmol/L., f Serum potassium < 3.5 mmol/L., g Serum creatinine > 35 μmol/L for < 12 months and > 65 μmol/L for 12–59 months.
Characteristics and age- and sex-adjusted odds ratio of morbidity, mortality, undernutrition among under-5 children
admitted to icddr,b Dhaka hospital during the COVID-19 period compared to the pre COVID-19 period

6. Characteristic COVID-19 period
(n=700)
Pre COVID-19 period
(n=1937)
P value Age- and sex-
adjusted OR
(95% CI)
P value
Age, months; mean ± SD 3.44± 1.48 3.63± 1.49 0.004
Sex, female 288 (41.14%) 741 (38.26%) 0.179
Delivery by C-section 279/554 (50.36%) 600/1224 (49.02%) 0.600
Immunization as per EPI schedule 456/577(79.03%) 1074/1352 (79.44%) 0.839
Exclusive/partially breastfeeding 372/632 (58.86%) 861/1561 (55.16%) 0.113
Stuntinga 386/ 597 (64.66%) 883/1512 (58.40%) 0.000 1.28 (1.05- 1.56) 0.015
Wastingb 237/486 (48.77%) 482/1173 (41.09%) 0.004 1.38 (1.11-1.71) 0.003
Acute diarrhea (watery/invasive) 674 (96.29%) 1869 (96.49%) 0.803 0.93 (0.59-1.48) 0.777
Some/severe dehydration 466/697 (66.86%) 1073/1901 (56.44%) 0.000 1.54 (1.28-1.84) 0.000
Convulsion (during/after admission) 47 (6.71%) 72 (3.72%) 0.001 1.89 (1.29-2.76) 0.001
Pneumonia 151 (21.57%) 409 (21.12%) 0.800 1.04 (0.84-1.28) 0.734
Severe pneumonia 91 (13.00%) 292 (15.07%) 0.182 0.84 (0.65-1.08) 0.177
Severe sepsis/septic shock 30 (4.29%) 44 (2.27%) 0.006 1.85 (1.15-2.98) 0.011
Hospital acquired infection 21 (3.00%) 45 (2.32%) 0.326 1.27 (0.75-2.16) 0.365
Death 20 (2.86%) 33 (1.70%) 0.062 1.66 (0.95-2.92) 0.077
Hypernatremiac 52/ 234 (22.22%) 72/ 389(18.51%) 0.261 1.26 (0.84-1.88) 0.266
Hyponatremiad 87/ 234 (37.18%) 165/ 389 (42.42%) 0.197 0.80 (0.57-1.12) 0.203
Hyperkalemiae 50/ 234 (21.37%) 75/ 389 (19.28%) 0.529 1.14 (0.76-1.71) 0.519
Hypokalemiaf 62/ 234 (26.50%) 94/ 389 (24.16%) 0.515 1.13 (0.78-1.64) 0.513
Raised creatinine g 98/ 169 (57.99%) 144/ 307 (46.91%) 0.021 1.56 (1.07-2.29) 0.021
a Length for-age z-score < −2 SD, b Weight-for-length z-score < −2 SD
c Serum sodium ≥ 150 mmol/L., d Serum sodium < 135 mmol/L/, e Serum potassium ˃ 5.5 mmol/L., f Serum potassium < 3.5 mmol/L., g Serum creatinine > 35 μmol/L for < 12 months and > 65 μmol/L for 12–59 months.
Characteristics and age- and sex-adjusted odds ratio of morbidity, mortality, undernutrition among under 6 months
infants admitted to icddr,b Dhaka hospital during the COVID-19 period compared to the pre COVID-19 period

7. Characteristic All
(N=5662)
COVID-19 period
(n=1195)
Pre COVID-19 period
(n=4467)
P value Age- and sex-
adjusted OR
(95% CI)
P
value
Age, months; mean ± SD 6.29± 2.94 5.59±2.80 6.48 ± 2.95 0.000
Sex, female 2103 (37.14%) 457 (38.24%) 1646 (36.85%) 0.375
Delivery by C-section 1756/3669 (47.86%) 450/895 (50.28%) 1306/2774 (47.08%) 0.096
Immunization as per EPI schedule 3475/4012 (86.62%) 786/923 (85.16%) 2689/3089 (87.05%) 0.138
Exclusive/partially breastfeeding 2920/4509 (64.76%) 674/1008 (66.87%) 2246/3501 (64.15%) 0.112
Stuntinga 2323/4518 (51.42%) 575/ 1044 (55.08%) 1748/3474 (50.32%) 0.007 1.10 (0.96- 1.27) 0.172
Wastingb 1522/ 3694 (41.20%) 400/ 891 (44.89%) 1122/2803 (40.03%) 0.010 1.21 (1.03- 1.41) 0.016
Acute diarrhea (watery/invasive) 5460 (96.43%) 1159 (96.99%) 4301 (96.28%) 0.244 1.24 (0.86-1.79) 0.250
Some/severe dehydration 3033 (54.16%) 740/1191 (62.13%) 2293/4409 (52.01%) 0.000 1.43 (1.26-1.64) 0.000
Convulsion (during/after admission) 219 (3.87%) 70 (5.86%) 149 (3.34%) 0.000 1.74 (1.30-2.34) 0.000
Pneumonia 1097 (19.37%) 225 (18.83%) 872 (19.52%) 0.591 0.92 (0.78-1.08) 0.322
Severe pneumonia 683 (12.06%) 126 (10.54%) 557 (12.47%) 0.070 0.77 (0.62-0.94) 0.013
Severe sepsis/septic shock 110 (1.94%) 32 (2.68%) 78 (1.75%) 0.038 1.37 (0.90-2.09) 0.137
Hospital acquired infection 129 (2.28%) 22 (1.84%) 107 (2.40%) 0.254 0.75 (0.47-1.19) 0.221
Death 82 (1.45%) 20 (1.67%) 62 (1.39%) 0.463 1.12 (0.67-1.86) 0.671
Hypernatremiac 294/ 1419 (20.72%) 110/ 447 (24.61%) 184/ 972 (18.93%) 0.014 1.43 (1.09-1.88) 0.009
Hyponatremiad 499/ 1419 (35.17%) 116/ 447 (25.95%) 383/ 972 (39.40%) 0.000 0.50 (0.39-0.64) 0.000
Hyperkalemiae 175/ 1419 (12.33%) 56/ 447 (12.53%) 119/ 972 (12.24%) 0.879 0.92 (0.65-1.30) 0.632
Hypokalemiaf 349/ 1419 (24.59%) 102/ 447 (22.82%) 247/ 972 (25.41%) 0.292 0.85 (0.65-1.11) 0.236
Raised creatinineg 405/977 (41.45%) 128/ 258 (49.61%) 277/ 719 (38.53%) 0.002 1.38 (1.03-1.86) 0.030
a Length for-age z-score < −2 SD, b Weight-for-length z-score < −2 SD
c Serum sodium ≥ 150 mmol/L., d Serum sodium < 135 mmol/L/, e Serum potassium ˃ 5.5 mmol/L., f Serum potassium < 3.5 mmol/L., g Serum creatinine > 35 μmol/L for < 12 months and > 65 μmol/L for 12–59 months.
Characteristics and age- and sex-adjusted odds ratio of morbidity, mortality, undernutrition among infants born during pandemic
and admitted to icddr,b Dhaka hospital during the COVID-19 period compared to the pre COVID-19 period

8. Under-5 children treated in COVID-19 period were significantly associated with dehydration,
severe sepsis or septic shock, convulsion, hypernatremia, and raised creatinine. Stunting,
wasting and mortality were significantly higher among young infants aged under-6 months.
Malnutrition was significantly higher among infants born during pandemic period than pre-
COVID-19 period
During the pandemic, children presented with more severe illness and poorer nutrition. Efforts
are needed to reduce the adverse effects of the pandemic on the health and well-being of
children
We believe that more effective means of risk assessment, the development of a multisectoral
management task force and appropriate governance for the proper management of the health
sector to ensure basic support for patients, are needed to reduce the adverse effects of the
COVID-19 pandemic on the health and well-being of children, especially that of young infants

9. Thank You