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Al-Azhar University of Gaza College of Pharmacy Master Programme of Clinical Nutrition

Research Proposal Assessment of Nutrition Status of Palestinian Children with Rickets Under Three Years Old in Gaza City

Submitted by: Rula F. Abu Zuaiter

Supervisors Dr. Jehad H. Elhissi Ass. Prof. of Public Health Health Consultant Dr. Mazen El Sakka Ass. Prof. of Pharmacognosy Al-Azhar University

2009

Assessment of Nutrition Status of Palestinian Children with Rickets Under Three Years in Gaza City
Introduction
Nutrition assessment is the evaluation of an individual's nutritional status based on the interpretation of clinical information obtained from the medical history, diet history, review of systems, physical examinations, and laboratory data. The purpose of the nutrition assessment is to evaluate an individual's dietary intake and nutritional status accurately; to determine if medical nutrition therapy or counseling, or both, is needed to monitor changes in nutritional status and evaluate the effects of nutritional interventions (Hark &Morrison, 2003). Nutritional rickets is a disorder of growing children due to defective mineralization of newly formed bone matrix because of vitamin D deficiency. Vitamin D is made available to the body by photosynthesis in the skin (endogenous vitamin D from ultra violet ray exposure) and from dietary intake (exogenous vitamin D from dietary or specific supplementation) (Holic, 1994; Phyllis, 2001). Without vitamin D supplementation for the baby, lack of sunlight exposure (Crocombe et al. 2004) inappropriate dietary intake and poor housing would contribute to the development of rickets (Rajakumare, 2003). Nutritional rickets remains a public health problem in many countries, despite dramatic declines in the prevalence of the condition in many developed countries since the discoveries of vitamin D and the role of ultraviolet light in prevention. The disease continues to be problematic among infants in many communities, especially among infants who are exclusively breast-fed, infants and children of dark skinned immigrants living in temperate climates, infants and their mothers in the Middle East (The American Journal of Clinical Nutrition, 2004). Vitamin D deficiency remains the major cause of rickets among young infants in most countries, because breast milk is low in vitamin D and its metabolites and social and religious customs and/or climatic conditions often prevent adequate ultraviolet light exposure (The American Journal of Clinical Nutrition, 2004).

The role of low dietary calcium intakes in exacerbating the development of vitamin D deficiency rickets has been known for many years (Sly, et al. 1984). Several pathogenetic mechanisms have been proposed, including lack of sunlight exposure, increased skin pigmentation, lack of dietary vitamin D intake, genetic predisposition, low-calcium diets, and high phytate contents in the diet (Clements, 1989).

Goal To understand the nutritional status and its role in increasing rickets in Palestinian children under three years old in Gaza city. Objectives
1- To identify the nutritional determinants contributing to the development of

nutritional rickets in children less than three years old. 2- To identify the role of the socioeconomic factors in development of nutritional rickets. 3-To raise recommendations for policy makers to regulate a public health policy to increase surveillance and limiting the growth of the disease. Problem statement Locally, according to the Palestinian Ministry of Health records rickets is common and a steady trickle of new cases is still recorded (MOH, 2004). The prevalence of clinical rickets among Palestinian children in Gaza Strip aged between 6-36 months is 4.1 percent (WHO, 2004). According to Ministry of Health annual reports there were 308, 444, and 325 new reported cases of rickets during 2002, 2003 and 2004 in Gaza Strip. It seems, therefore, that nutritional rickets is not returning, but has always continued to be with us. It is increasing in frequency again, partly because it is being recognized in its different manifestations but mainly because vitamin D and calcium supplementation is no longer regarded as essential for at risk individuals. Unfortunately, this is not diminishing in a sunshine countries so the time has come to mount a national campaign to promote awareness of the risks of nutritional rickets, particularly among susceptible populations (Arch Dis Child, 2004). Justification A little information is available about nutritional rickets and the risk factors associated with it in Gaza Strip.

The peak age at which rickets is most prevalent is 3-18month (Salimpour, 1975 ; Molla, et al. 2000). Rickets causes softening of the bones, which can be cured by treatment. However, until treated, the bones are more prone to fractures. If is untreated for a long time, there is a possibility that bone deformities and contracted pelvis problems that might need surgery (Holick, 2004). The risk of getting osteoporosis (bone thinning and fractures in old age) may be increased. This is because vitamin D is thought to help in preventing some conditions such as diabetes, heart disease and cancer. If severe, low calcium can lead to muscle spasms (cramps), seizures or breathing difficulties (Elidrissy, et al. 1984; Al Jurayyan, et al. 2002).

Methodology
Study Design A cross sectional descriptive study that will be conducted on children with rickets to assess their nutritional status. Study Setting The study will be conducted at the UNRWA clinics, Ard Al Ensan and Al Shatea clinic these are the main centers at which patients are currently available in Gaza city. Study Period The proposed study will be conducted from April 2009 to November 2009. Population and Sampling The target population are rickitic children will be recruited according to the inclusion criteria in the study after getting their parent or the caregiver consent. The sample of the study will be 100 child from the target population and according to the inclusion criteria. Eligibility Criteria Inclusion Criteria
1. Children diagnosed with nutritional rickets. 2. Children three years old and less.

Exclusion Criteria 1. Children with rickets of non nutritional origin


2. Children older than three years old. 3. Children with fat malabsorption. 4. Children with liver disease.

5. Children with renal insufficiency. Ethical Consideration

1. Approval of Dean of postgraduate studies & research affairs.


2. Approval letters from Dean of college of pharmacy to director general of

concerned hospital or clinic.


3. Consent of the parent or caregiver of the patient.

Data Collection 1. Health Records The medical record file for the child will be reviewed regarding medical and personal history as age, gender, date of birth, month of presentation to hospital, place of birth, gestational age, occupation. 2. Interview Questionnaire A questionnaire will be used to collect the following data from each participant: date of birth, gender, birth weight, child and maternal diet, sun exposure, educational background of the parents, social-economical factors, type of accommodation, family size and home environment. 3. Anthropometric Measurements a. Height. b. Weight c. Body mass index.
d. Head circumference.

4. Clinical Examination The patient will be examined by the physicians for signs & symptoms of rickets Clinical examination will be conducted for vital signs, pulse, respiration, generalized polygonal scales, bilateral ectropion, enlargement of the costochondral junctions, wrists, ankles, and hyperkeratosis of the palms and soles, radiographs of the wrists and knees confirm active rickets. 5. Biochemical Measurements a- Calcium & phosphorus serum levels. b- Alkaline phosphatase (ALP). c- 25(OH)vitamin D.
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d- Hemoglobin 6. Dietary History Food frequency questionnaire will be conducted about the child and his mother. Data Analysis 1. Define variables. 2. Data entry. 3. Data cleaning.
4. Data analysis using SPSS (V.15) analysis package. 5. Significant tests will be used, including chi square test for measuring difference

between discrete variables. Time Schedule


Activity Development of proposal Ethical consideration Design of questionaire Pilot study Data collection Data entry and analysis Research writing Dissemination of findings
April 2009 May 2009 June 2009 July 2009 Aug 2009 Sep 2009 Oct 2009 Nov. 2009

The Budget No. .1 .2 .3 .4 .1 .2 .3 .1 .2 Description of activities . Employees Data collector Lab. technician Statistician Nurse Sub Total . Supply Weight scale Calipers Blood analysis Sub Total . Overhead Transportation Stationary Sub Total Total + + 200 300 200 200 900 100 100 1600 1800 50 200 250 2950 Estimated cost (USD)

References

Acchiardo SR, Moore LW, Latour PA. (1983). Malnutrition as the main factor in morbidity and mortality of hemodialysis patients. Kidney International suppl (16):S199-S203. Al Jurayyan NA, El Desouki ME, Al Herbish AS, Al Mazyad AS, Al Qhtani MM. (2002) Nutritional rickets and osteomalacia in school children and adolescents. Saudi Med J; 23 : 182. Arch Dis Child 2004;89:699701. doi: 10.1136/adc.2003.036780 Correspondence to: Dr J Allgrove, Newham General Hospital, Glen Road, Plaistow, London. Clements MR. (1989). The problem of rickets in UK Asians. J Hum Nutr Diet;2:10516. Crocombe S, Mughal MZ and Berry JL. Symptomatic, (2004). Vitamin D deficiency among non-caucasian adolescents living in the United Kingdom. Archives of diseases in childhood; 89: 197-199. Dawodu A, Agarwal M, Hossain M, Kochiyil J, Zayed R. (2003). Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer: a justification for vitamin D supplementation of breast-feeding infants. J Pediatr; 142 : 16973.) E13 8RU, UK; jeremy.allgrove@newhamhealth. nhs.uk Elidrissy ATH, Sedrani SH, Lawson DEM. (1984).Vitamin D deficiency in mothers of rachitic infants. Calcif Tissue Int; 36 : 266-8. Holic, M.F. (1994). Mineral and vitamin D adequacy in infant fed milk or formula between 6 and 12 months of age jornal of pediatrics, Aug117(2pt2): S 134-142. Holick MF. (2004). Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease, and osteoporosis. Am J Clin Nutr; 79 : 362-71. Molla AM, Badawi MH, Al-Yaish S, Sharma P, el-Salam RS, Molla AM.( 2000). Risk factors for nutritional rickets in children in Kuwait. Pediatr Int;42:2804. Phyllis A Balch, 2001. Prescription for Nutritional Healing: The A-To-Z Guid to Supplements. 3ed. Page 45. AVERY, Newyork. Rajakumar M, (2003). Vitamin D, Cod-Liver Oil, Sunlight, and Rickets: Ahistorical Perspective. Pediatrics; 112(2):el32-el35. Salimpour R. (1975). Rickets in Tehran. Arch Dis Child;50:63 6. Sly MR, van der Walt WH, Du Bruyn D, Pettifor JM, Marie PJ. (1984). Exacerbation of rickets and osteomalacia by maize: a study of bone histomorphometryand composition in young baboons. Calcif Tissue Int;36:370 9.

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