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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 112-119

Impact of morbidity among under-five children: A meta-analysis

1 Narayana Health Corporate Social Responsibility (CSR), Kalaburagi, India
2 Department of Pediatrics, Jawaharlal Nehru Medical College, Belagavi, India
3 Department of Community Medicine, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Date of Submission22-Oct-2021
Date of Acceptance22-Feb-2022
Date of Web Publication23-Mar-2022

Correspondence Address:
Dr. Vijayashree Shivprasad Mathad
Narayana Health Corporate Social Responsibility (CSR), Kalaburagi 585102, Karnataka.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mgmj.mgmj_81_21

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The burden of morbidity and mortality among infants is the highest in developing countries. The future economic growth of a country depends upon the well-being of the infants of today; hence, infants need the utmost attention of society through organized medical care and social activities. Feeding infants and young children properly are essential for their growth, development, nutritional status, health, and survival. Improper feeding practices may lead to irreversible outcomes like malnutrition, infectious diseases, attention deficit, memory failure, lower IQ, and lifelong poor cognitive and behavioral development. This review was taken to assess the cause, prevalence, and impact of various morbidities during infancies. The literature search covered both conceptual and specific literature. The specific literature search was on the assessment of morbidities among infants. Morbidities were further classified into diarrhea, acute respiratory infections (ARIs), and fever. Factors affecting each morbidity during the first year of life were classified as International and Indian studies. The studies were further categorized based on methodology as cross-sectional, prospective studies, systematic reviews, and meta-analysis. We conclude that the incidence of morbidities specifically ARIs, diarrhea, and fever have a debilitating effect on the growth and development of infants. Further research is required to assess the impact of morbidity on growth and development in children.

Keywords: Acute respiratory infections, development, growth, infants, meta-analysis, morbidity

How to cite this article:
Mathad VS, Mahanshetti NS, Naik VA. Impact of morbidity among under-five children: A meta-analysis. MGM J Med Sci 2022;9:112-9

How to cite this URL:
Mathad VS, Mahanshetti NS, Naik VA. Impact of morbidity among under-five children: A meta-analysis. MGM J Med Sci [serial online] 2022 [cited 2022 May 17];9:112-9. Available from: http://www.mgmjms.com/text.asp?2022/9/1/112/340595

  Introduction Top

The word morbidity is derived from the Latin word “Morbidus” and was first used in 1656, which means diseased. It is defined as “the departure from physical, psychological wellbeing resulting from disease, illness or sickness, especially where the affected individual is aware of his or her condition.” According to the World Health Organization (WHO), morbidity is measured in terms of the number of persons ill, Persons experiencing these illnesses, and duration of illness. Medical Dictionary defines “morbidity” as a disease condition or state or the incidence and prevalence of diseases in a community.[1],[2] The literature is presented in the following sections [Figure 1].
Figure 1: Flow of literature

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  Morbidities during infancy Top

Acute respiratory infections (ARIs) are the major cause of morbidity among infants. Pneumonia is the single most important cause of morbidity and mortality among infants globally. ARI forms sixty percent of the pediatric outpatients department (OPD) and constitutes thirty percent of all hospital admissions. Morbidity is defined as the presence of diagnosed conditions and by utilization of health services[2] [Figure 2].
Figure 2: Diagram showing leading causes morbidity and mortality among infants

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  Etiology and risk factors for morbidity Top

The determinants of childhood morbidity and survival were categorized into various groups of studies as follows: education of mothers, malnutrition, birth spacing, and family income [Table 1]. Diarrheal illness, enteric infections, and malnutrition among infants are correlated factors. Diarrheal diseases decrease the appetite and lead to malnutrition.[3] Diarrhea is the major cause of mortality among under-five children globally. One in six under-five children dies due to diarrhea, and about 2.3 million deaths per year in India are attributed to it[4] [Figure 3].
Table 1: Determinants of childhood morbidity

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Figure 3: Contributing factors of diarrheal diseases among infants

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The etiological factors of ARI are classified as bacterial and viral. Causes of acute fever are respiratory infections, gastroenteritis, otitis media, pneumonia, and urinary tract infections. Chronic causes of fever include hepatitis, tuberculosis, abdominal abscesses, osteomyelitis, endocarditis, etc. Warning signs of fever among infants less than 2 months include petechie, purpura, neck stiffness, difficulty in breathing, lethargy, and confusion.

  Underlying causes of morbidities Top

The risk factors for morbidities as per international studies are mothers’ literacy. Infants of literate mothers had fewer incidences of morbidity as compared to those of illiterate mothers. Infants delivered after a gestational age of 37 weeks showed less incidence of morbidity as compared to those delivered before 37 weeks of gestation. The age of the mother also had a significant impact on the number of episodes of morbidity. The higher the age of the mother, the lesser is the frequency of morbidities.[5],[6] Morbidities among mothers also had a significant impact on the infants. Mothers with maternal asthma and poor psychological health showed a higher incidence of morbidities. Multiparous mothers had a significantly higher incidence of morbidities compared to primiparous. Socioeconomic, psychological, and cultural factors influencing morbidity among infants showed that low socioeconomic status was significantly associated with an increased frequency of morbidities among infants. Feeding practices adversely affect morbidities among infants. Proper feeding practices involve the initiation of breastfeeding within 30 minutes of delivery, exclusive breastfeeding for 6 months, and continued feeding for 2 years. Inadequate immunization and improper sanitation lead to an increased frequency of morbidity among infants.[7],[8],[9] Biological factors affecting morbidities among infants are as follows: globally, males showed a higher incidence of morbidities, whereas in India female children had a higher incidence of morbidities. Immunization with measles had a protective effect on the incidence of morbidities. Increased birth order and decreased spacing harmed morbidities. Low birth weight of less than 2500 g had a significant impact on the incidence of morbidities. Maternal anxiety and depression had a significant impact on the incidence of morbidities. Instillation of oil into eyes, ears, and nose leads to increased morbidities among infants.[10],[11]

  Health consequences of morbidity and their significance Top

Reduced appetite is the direct health consequence of morbidity. Underweight is significantly associated with ARI, whereas stunting is a long-term effect of morbidity manifested during the second 6 months of life. Diarrhea is significantly associated with being underweight, and ARI has a chronic impact on stunting among children.[12],[13],[14],[15],[16],[17]

  Prevention of morbidities Top

The following factors contribute to preventing or reducing the incidence of morbidities: (1) complete immunization, (2) proper sanitation and provision of safe drinking water, (3) exclusive breastfeeding for 6 months, (4) timely treatment of morbidities, (5) educating and treating mothers on care for the sick child, and (6) early initiation of breastfeeding.[18],[19],[20],[21],[22]

  Global studies on morbidities Top

Numerous longitudinal studies on infants in Indonesia, Kenya, and Mexican villages on the incidence of morbidity and its impact on growth among infants show that a high incidence of morbidities like ARI, diarrhea, and skin infections was associated with growth impairment. Morbidities also hurt the nutritional status of infants leading to malnutrition as assessed by the presence of stunting and underweight among them. The incidence of these diseases is the highest during the first 6 months of infancy.[23],[24]

In a follow-up study to assess the incidence of morbidity among infants in Bangladesh where children were followed up for 6 months after recovering from severe acute malnutrition, the common morbidities were significantly high among SAM (severe acute malnutrition) as compared to normal infants.[9],[25]

A case-control study in Bangladesh to determine the long-term effect of breastfeeding on Vitamin A deficiency among children aged 6 months to 3 years was improper breastfeeding, nonimmunization with measles vaccination, illiteracy, and low socioeconomic status.[10],[26] Many systematic studies show the impact of cultural practices on morbidities among infants. Cultural taboos restrict from adopting modern medical treatment for illnesses. Breastfeeding despite a proven positive impact on infant health is not practiced universally due to cultural beliefs and customs.[27],[28]

In a cohort study at São Paulo, the information was extracted from more than two lakh records to study the determinants of early infant morbidities. Multivariate logistic regression was used to assess the effect of factors determining infant morbidity. The determinants of infant morbidities were distal determinants which include race, mother’s literacy, and community factors. The parity and age of the mother were less proximate determinants. More proximate determinants were gestational age, birth weight, and several prenatal visits.[29]

A prospective cohort study done in southern Brazil during 2006–2008 found a positive association between postnatal abuse against women with the risk of infant diarrhea and respiratory infections. Poisson regression with robust variance was used to estimate crude and relative risk at 95% confidence interval (CI). About 35% of the mothers who were exposed to abuse during the pre-and postnatal period showed an increased incidence of diarrhea (relative risk [RR] = 2.41, 95% CI = 1.27, 4.57) and respiratory infection (RR = 1.82, 95% CI = 1.23, 2.71) among infants.[28]

A cross-sectional hospital-based study to assess the causes and risk factors associated with infant morbidities had categorized as follows: Male gender showed a higher incidence of morbidity compared to the female. Incidence of morbidity increased with birth order and with decreased spacing. Factors that decrease the incidence of morbidities were feeding of colostrums, proper feeding practices, immunization, and full-term gestational age.[30],[31],[32] In a study carried out to study the relationship between breastfeeding and infant illness, the determinants of infant illness were exclusive breastfeeding for the first 6 months which had a protective effect on illness compared to less breastfed infants.[33],[34]

The cross-sectional study carried out in China and Uganda also revealed a positive association between postnatal abuse on diarrhea (odds ratio [OR] = 1.65) and respiratory infections (OR = 1.37) among infants. A 1-year longitudinal study on the impact of maternal abuse on morbidity also showed a positive association between diarrhea (RR = 1.20) and respiratory infections (RR = 1.31).[11],[35]

  National research on morbidities Top

A community-based cohort study was carried out in southern India showed low socioeconomic status was associated with an increased incidence of morbidity. Primiparous children exhibited better growth compared to multiparous children.[36] The predictors of morbidity among infants as per the longitudinal study carried out at Guntur were poor feeding practices such as exclusive breastfeeding, mothers’ education, and socioeconomic status. Morbidity was high during the second 6 months of infancy compared to the first 6 months.[19] The determinants of increased incidence of diseases were poor feeding practices, low socioeconomic status, and improper sanitation.[37],[38]

Longitudinal studies conducted in Delhi and south India among infants revealed that the incidence of illness during the first year of life was 4.27%. The morbidity rate was low during the first 6 months compared to the next 6 months. There was a positive correlation among socioeconomic status, literacy rate, and sex.[39],[40] In a case-control study done among infants of Dhaka, to study the association between Vitamin A deficiencies and feeding practices, breastfed infants had a 74% reduced risk of Vitamin A deficiency. Various studies conducted to assess the effect of feeding practices on morbidity among infants revealed a higher incidence of morbidity among partially breastfed and bottle-fed infants and a high risk of complications was attributed to ARI and diarrhea.[40],[41],[42] A follow-up community-based study done among LBW babies of Kolkata, focused to study morbidity patterns, revealed an increase in the episodes of morbidities and hospitalization rate among LBWs.[43]

A prospective observational study carried out in Dandee to assess the effect of breastfeeding among infants showed that proper breastfeeding habits had a positive effect on controlling gastrointestinal diseases, whereas they didn’t have much evidence of a reduction in eczema, nappy rash, skin, eye, ear, and respiratory tract infections.[44],[45] The important strategies for control of diarrheal diseases among infants are proper infant feeding practices and environmental sanitation. Good breastfeeding practices eliminate exposure to food and water-borne infections and increase immunity and resistance to infections and proper environmental sanitation reduces exposure to fecal matter which eliminates enteric pathogens. A cross-sectional study to assess infant feeding and rearing practices among rural and urban infants of Jammu showed various faulty feeding practices which included delayed initiation of breastfeeding, administration of prelacteal feeds, and early weaning practices. All these factors contributed to an increased incidence of diarrhea and vomiting.[46]

  Literature on impact of morbidity Top

A longitudinal study on maternal and child health in urban slums of Africa revealed a synergistic effect of morbidity and malnutrition among infants.[42] The effect of morbidity on malnutrition showed the collective effect of deprived nutritional status and morbidities. Malnourished children are prone to infections like diarrhea, malaria, and fever. Morbidities further reduce the appetite leading to malnutrition. This further leads to deprivation of growth and development leading to death. The bivariate analysis reveals a positive effect of malnutrition on diarrhea.[47]

In a longitudinal prospective study carried out in Indonesia, the information on infant morbidity was assessed every week and anthropometry on monthly basis. The most prevalent morbidity was ARI (47%) followed by fever (14%) and diarrhea (13%). The duration of these diseases was 14 ± 9 days for ARI, 6 ± 4 days for fever, and 7 ± 11 days for diarrhea. There was no statistical association between morbidity and growth during the first 6 months, whereas ARI was significantly associated with weight loss during the second half phase of infancy. The length was not statistically associated with any phase of infancy.[48]

Various studies conducted to assess the effect of morbidity from infectious diseases and physical growth of infants revealed a positive association between morbidities and decreased average weight and length for age during infancy. Malnutrition was considerably higher among bottle-fed children than among breastfed children. In a longitudinal prospective study carried out to assess the impact of morbidity on malnutrition among children less than 2 years of age, morbidities were recorded every week and anthropometry on monthly basis. A total of 3932 episodes were recorded during the study period. Respiratory and gastrointestinal diseases were the most commonly noted diseases. The incidence of morbidity was 12.5 illness/child-year. Stunting was seen among one-third of the children and two-thirds exhibited at least one episode of growth failure.[49],[50],[51],[52],[53] In a longitudinal study conducted in 1973 among 500 infants attending the well-baby clinic, an increase was noticed in the average weight of the baby of 6 months among exclusively breastfed, and a positive association was found between artificially fed infants and diarrhea and severe malnutrition[41] [Table 2].
Table 2: : Longitudinal studies showing morbidities among children[50],[51],[52],[53],[54],[55],[56]

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A longitudinal study among infants in New York to assess the effect of exclusive breastfeeding on morbidities revealed a statistically significant increase in the incidence of morbidities among infants with limited breastfeeds (<4½ months) and bottle feeds.[12]

Prospective studies carried out globally and in India showed the prevalence of diarrhea to be high among non-breastfed infants. Multiple episodes of otitis media were significantly associated with bottle feeding. A longitudinal study at the urban pediatric center, Puducherry to study feeding patterns and growth parameters showed a proper gain in weight among infants up to 7 months of age who were exclusively breastfed[54],[55],[56],[57] [Table 3].
Table 3: Determinants of morbidity

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The developmental milestones among infants were assessed using Trivandrum Development screening chart.[58] In a prospective follow-up study carried out in a hospital and community in Thiruvananthapuram children were subjected to stimulation package and nutritional management. The study revealed stimulation package to be more effective than nutritional management in influencing the positive effect on growth and development. There was also a positive correlation between environmental parameters, anthropometric scores, and IQ level.[59],[60] A study conducted among under-five children in Thiruvananthapuram to assess the prevalence of developmental delay, deformity, and disability revealed that a total of 2.48% of children with developmental delay, deformity and disability and up to 2 years of developmental delay were found to constitute 2.31%.[61],[62]

  Conclusion Top

Diarrheal illness, enteric infections, and malnutrition among infants are correlated factors. Growth flattering and malnutrition among infants increases the severity and frequency of diarrheal diseases. Diarrheal diseases decrease the appetite leading to malnutrition. One in six under-five children dies due to Diarrhea. Literature globally reveals the negative impact of morbidity on growth and development among infants and under-five children. More longitudinal studies are required to assess the impact of morbidity on the growth and development of under-five children.

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  [Table 1], [Table 2], [Table 3]


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