Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh

Abstract

This survey study assesses the health and nutritional status of Rohingya children aged 6 to 59 months in the Kutupalong refugee camp in Bangladesh.

Nearly 700 000 ethnic minority Rohingya people have crossed the border between Myanmar and Bangladesh after violence in Rakhine State, which escalated in August 2017, joining an estimated 200 000 who fled in earlier waves of displacement since the 1990s. The population of 2 preexisting refugee camps and surrounding makeshift settlements have more than doubled with the new influx. Concerns have been raised about the nutritional status of the Rohingya children.

Methods

To assess the health and nutritional status of children aged 6 to 59 months, we conducted a cross-sectional population-representative survey in the Kutupalong refugee camp from October 22 through 28, 2017. Households were randomly selected from a list updated the week preceding data collection. Weight, height, mid–upper arm circumference (MUAC), and presence of bilateral pitting edema were measured using standard procedures. Weight-for-height z score (WHZ) and height-for-age z score (HAZ) were calculated based on 2006 World Health Organization (WHO) growth standards. Two definitions of global acute malnutrition (GAM) and severe acute malnutrition (SAM) were investigated because both can be criteria for admission to treatment programs. GAM was defined as a WHZ less than −2 or MUAC less than 125 mm. SAM was defined as WHZ less than −3 or MUAC less than 115 mm. All acute malnutrition categories additionally included children with edema. Chronic malnutrition was defined as an HAZ less than −2. Anemia screening was conducted by measuring hemoglobin (Hb 301, HemoCue) and classified according to WHO cutoffs. Children aged 6 to 23 months (the target group for fortified food distributions) consuming at least 4 of 7 food groups during the day preceding the survey were classified as receiving minimum dietary diversity. Respondents self-reported registration as refugees with the United Nations High Commissioner for Refugees. Wilson score CIs and results of the Pearson χ² test were used to compare registered and unregistered children. Two-sided tests were considered significant at a P value of less than .05. The US Centers for Disease Control and Prevention determined this study was exempt from human subjects research review because it collected data for programmatic purposes.

Results

Of the 269 children aged 6 to 59 months included, 121 (45.0%) were females, mean age was 31.9 months (SD, 15.3), and 148 (55.0%) were registered refugees. Of the unregistered children, 116 (95.9%) arrived in Bangladesh since August 25, 2017. One family declined participation.

Prevalence of GAM and SAM as assessed by WHZ were 24.3% (95% CI, 19.5% to 29.7%) and 7.5% (95% CI, 4.9% to 11.2%), respectively. The prevalence of acute malnutrition was not significantly different comparing unregistered and registered children (Table). MUAC identified 5.9% (95% CI, 3.7% to 9.4%) of children as having GAM and 0.7% (95% CI, 0.2% to 2.7%) as having SAM. The prevalence of chronic malnutrition was 43.4% (95% CI, 37.6% to 49.4%) and not significantly different between unregistered and registered children (P = .23).

Table. Prevalence of Global Acute Malnutrition, Chronic Malnutrition, Anemia, and Dietary Diversity Among Rohingya Children Aged 6 to 59 Months in the Kutupalong Refugee Camp in Bangladesh, October 2017.

	Overall, % (95% CI)	Unregistered Children, % (95% CI)	Registered Children, % (95% CI)	P Value
Global acute malnutritiona
Weight-for-height z score
Total (<−2 or bilateral pitting edema)	24.3 (19.5-29.7)	27.3 (20.1-35.8)	21.8 (15.9-29.1)	.30
Severe (<−3 or bilateral pitting edema)	7.5 (4.9-11.2)	6.6 (3.4-12.5)	8.2 (4.7-13.7)	.63
Mid–upper arm circumference
Total (<125 mm or bilateral pitting edema)	5.9 (3.7-9.4)	5.8 (2.8-11.5)	6.1 (3.2-11.2)	.92
Severe (<115 mm or bilateral pitting edema)	0.7 (0.2-2.7)	1.7 (0.5-5.8)	0	.12
Chronic malnutrition (height-for-age z score <−2)b	43.4 (37.6-49.4)	47.5 (38.8-56.4)	40.1 (32.6-48.2)	.23
Total anemia (Hb <11.0 g/dL)c	47.9 (42.0-53.9)	52.5 (43.6-61.3)	44.2 (36.4-52.3)	.18
Dietary diversity among children aged 6-23 mod
Minimum dietary diversity (4 of 7 food groups)e	9.8 (5.4-17.1)	4.2 (1.2-14.0)	14.8 (7.7-26.6)	.08
Received fortified blended foods in the past 2 weeks	56.4 (46.7-65.7)	23.4 (13.6-37.2)	85.2 (73.4-92.3)	<.001

Abbreviations: Hb, hemoglobin; MUAC, mid–upper arm circumference.

^aSample sizes: overall, 268; unregistered, 121; registered refugees, 147.

^bSample sizes: overall, 267; unregistered, 120; registered refugees, 147.

^cSample sizes: overall, 265; unregistered, 118; registered refugees, 147.

^dSample sizes: overall, 102; unregistered, 48; registered refugees, 54.

^eConsumption of 4 of 7 food groups ([1] grains, roots, and tubers; [2] legumes and nuts; [3] dairy products; [4] fresh foods; [5] eggs; [6] vitamin A–rich fruits and vegetables; [7] other fruits and vegetables) during the day proceeding the survey.

Prevalence of anemia was 47.9% (95% CI, 42.0% to 53.9%) and not significantly different among unregistered and registered children (52.5% [95% CI, 43.6%-61.3%] for unregistered children vs 44.2% [95% CI, 36.4%-52.3%] for registered children; P = .18). Of children aged 6 to 23 months, 9.8% (95% CI, 5.4% to 17.1%) reported consumption of minimally diverse diets and 56.4% (95% CI, 46.7% to 65.7%) reported receiving fortified foods in the 2 weeks preceding the survey. The proportion of children reporting receipt of fortified foods was significantly higher among registered refugees (23.4% [95% CI, 13.6%-37.2%] for unregistered children vs 85.2% [95% CI, 73.4%-92.3%] for registered children; P < .001) (Table).

Discussion

In this sample of Rohingya children in Kutupalong refugee camp, prevalence of GAM and anemia exceeded the global emergency thresholds of 15% and 40%, respectively, irrespective of their length of stay.

Consistent with previous research from Bangladesh and Myanmar, discordance in the prevalence of acute malnutrition by WHZ and MUAC was found, which suggests a need to revise national treatment protocols to include admission of children with low WHZ in addition to low MUAC. High prevalence of anemia and poor dietary diversity highlight the need to provide more diversified family rations, expand supplemental fortified food distributions, and support continued breastfeeding.

Given the emergency context, this study was designed with a small sample size to provide rapid results, a key limitation. Nutritional outcomes may differ in other camps; however, the similarities in nutritional outcomes comparing registered and unregistered children in this study suggest a need for multisectoral efforts targeting all Rohingya in Bangladesh.

Section Editor: Jody W. Zylke, MD, Deputy Editor.