E-ISSN 1858-8360 | ISSN 0256-4408
 

Original Article 


SUDANESE JOURNAL OF PAEDIATRICS

2020; Vol 20, Issue No. 2

ORIGINAL ARTICLE

Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan

Arwa S. A. Mohammedahmed (1,2), Abubaker Emadeldin Adlan Koko (1), Ali M. E. Arabi (3), Mohamed A. Ibrahim (4)

(1) Faculty of Medicine, University of Khartoum, Khartoum, Sudan

(2) Pediatrics and Child Health Specialty Council, Sudan Medical Specialization Board, Khartoum, Sudan

(3) Department of Paediatrics and Child Health, Faculty of Medicine, University of Khartoum, Khartoum, Sudan

(4) Mental Health Service, Hamad Medical Corporation, Doha, Qatar

Correspondence to:

Abubaker Emadeldin Adlan Koko

Faculty of Medicine, University of Khartoum, Khartoum, Sudan.

Email: bakri.imad.adlan [at] gmail.com

Received: 19 May 2020 | Accepted: 24 June 2020

How to cite this article:

Mohammedahmed ASA, Koko AEA, Arabi AME, Ibrahim MA. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Pediatrics Teaching Hospital, Sudan. Sudan J Paediatr. 2020;20(2):111–121.

https://doi.org//10.24911/SJP.106-1590606922


ABSTRACT

Malnutrition remains one of the main disabling issues in child health, especially in developing countries. Maternal depression by its related disabilities has been linked with children undernutrition in the studies abroad. Unfortunately, not much is known regarding this issue in Sudan, so this study aims to examine the association between maternal depression and severe acute malnutrition (SAM) in children under 5 years of age. A matched case-control study was conducted in Omdurman Paediatrics Teaching Hospital. Children admitted with SAM were assigned as cases, whereas controls were age- and sex-matched children with normal weight and height admitted in the same hospital. Mothers of both cases and controls were assessed for depression utilising the Patient Health Questionnaire-9 tool. The prevalence of depression among mothers of malnourished children was high (41.5%) compared to the mothers of controls (19.1%). In multivariate logistic regression analyses, the adjusted odds ratio (AOR) of maternal depression were markedly higher in cases than in controls (AOR = 3.09, p = 0.002), as was the odds of below 1-year breastfeeding weaning (AOR = 18.60, p = 0.006) and mother illiteracy (AOR = 2.42 p = 0.031). Furthermore, the analysis found a significant negative association between the occurrence of malnutrition and exclusive breastfeeding (AOR = 0.43, p = 0.015). Maternal depression carries a significant burden in the mothers of children hospitalised with SAM. We strongly recommend routine screening and treatment for depression in childbearing age mothers in the available relative maternal and child health clinics.


KEYWORDS

Severe acute malnutrition; Children under 5 years; Maternal depression; Sudan.


INTRODUCTION

Child malnutrition is a very common health and social care problem globally despite being a treatable condition. Malnutrition with its wide range of illnesses kills, retards, cripples, blinds and impairs human developments on truly massive scale worldwide [1]. The repercussions of malnutrition in terms of developmental, economic, social and medical consequences are serious and long lasting for individuals, their families, communities and countries [2].

The World Health Organisation (WHO) estimates that wasting, severe wasting and stunting affect 52, 17 and 155 million children under 5 years of age, respectively, whereas 41 million are overweight or obese. Around 45% of deaths among children under 5 years of age are linked to undernutrition worldwide. These mostly occur in low- and middle-income countries (LMICs) [3].

Predisposing factors for malnutrition include a myriad of proximate and distal factors. Proximate factors include age, sex, inadequate nutritional intake, unsatisfactory feeding practices and infections, whereas distal factors comprise an array of economic, sociocultural, political, environmental and climatic factors that affect household food security, personal security and access to economic opportunities, health care and education [2,4]. In addition, there is strong evidence that depression in the postnatal period and low maternal intelligence are also associated with malnutrition in children [57].

The 1st year after a woman gives birth to an infant is a particularly high-risk time for the occurrence of depression, and it is also a very critical period in the infant’s physical and psychological development. Depressive symptoms not only complicate maternal health during and after pregnancy but also predict low birth weight, preterm birth, decreased breastfeeding rates, compromise mother-child attachment and importantly cause functional impairment at a time when the mother is performing tasks vital to her infant’s physical growth, nutrition and development [8,9].

Postpartum depression (PPD) prevalence estimates vary from 15% to 57% across nations. In general, depression is considered as a leading cause of disease-related disability among reproductive aged women globally [10it is known that genetics play an important role in the genesis of this disorder. This paper reviews epidemiological evidence supporting the role of genetics in postpartum depression (PPD]. In the Sub-Saharan African setting, the estimates of maternal depression range from 6% to 30%. Approximately, 20% of women experience clinically relevant depressive symptoms during pregnancy, in over 40% of them, the symptoms continue postpartum and 80% of women with PPD have subsequent depressive episodes [8].

Several studies have pointed out the possible link between child malnutrition and maternal depression in LMICs, but most of these studies were conducted in the South Asian setting [1113]. Still, maternal mental health is still a largely neglected component in mother and child health programs in developing countries such as Sudan despite available evidence of estimated reduction in impaired child growth up to 30% in response to the reduction of the prevalence of maternal depression [5].

In Sudan, a study by Khalifa et al. [14] reported that the factors associated with post-natal depression are comparable to factors from other developing countries. However, there is scant evidence of the contribution of maternal depression to child nutritional outcomes. Hence, this study attempts to assess maternal depression as risk factor for severe acute malnutrition (SAM) in children under 5 years of age at Omdurman Paediatrics Teaching Hospital, Khartoum State, Sudan.


MATERIALS AND METHODS

Study setting

This study was a matched, comparative case-control hospital-based study. It was conducted in Omdurman Paediatric Teaching Hospital, which is considered to be one of the biggest public teaching hospitals in Sudan. It was established in 1986 with a total area of 7,200 m2 and consists of two floors, with around 300 bed capacity, emergency department, 10 general paediatric units, two malnutrition wards (around 18-bed capacity) with nutrition support program, neonatal intensive care unit, paediatric intensive care unit, dialysis unit, asthma clinic, diabetes clinic, endocrine clinic and tuberculosis referral clinic. The data were collected during the period from August to November 2019.

Study population

Cases were defined as children aged 6-59 months, admitted to Omdurman Paediatric Teaching Hospital with SAM (according to the WHO standards), whereas controls were age- and sex-matched, well-nourished children admitted to the same hospital with other ailments. Severely ill children with comorbidities, those who were preterm and those who suffered from intrauterine growth restriction were excluded from the study. In addition, children whose mothers were not the primary care giver of the child and mothers with a known diagnosis of depression or mental health problems were also excluded.

Study sample

Sample size was calculated using Epi Info StatCalc version 7.2.2.6, taking into consideration a power of 80%, confidence interval (CI) level of 95% and assumed prevalence of exposure among controls of 3.8% [14]. The sample size of each of the case and control groups equated to 89, yielding a total of 178 subjects. All cases admitted with SAM during the study period who met the inclusion criteria were approached sequentially to participate in the study until the sample size was complete. Controls were also sequentially selected from general paediatric wards of Omdurman Paediatric Teaching Hospital after matching for age and sex of selected cases.

Data collection tools

The data were collected by the first author (ASAM) using a structured close-ended questionnaire, which included demographic data for the mother and child, assessment for the risk factors of SAM and maternal depression screening using the Patient Health Questionnaire-9 (PHQ-9) [15,16].

Child anthropometry

Children’s weight, height and mid-upper arm circumference (MUAC) were taken by following the standard anthropometric procedures for newly admitted children, whereas retrieved from files for those who had been admitted for long time and established nutritional support. Children’s age was determined by maternal report which then approximated to the previous or later month with a cutoff point less or more than 15 days, respectively. Children were classified as malnourished if their weight for height was below −3z score of the median WHO growth standards or MUAC less than 115 mm or by the presence of nutritional oedema as an independent criterion [17]. Control children were included if their weight for age and height for age were between 25th and 75th centiles in Centres for Disease Control and Prevention charts.

Maternal depression

Maternal depression was assessed using the PHQ-9 screening tool which is a multipurpose instrument used for screening, diagnosing, monitoring and measuring the severity of depression with available validated Arabic version [16]. It is a self-administered depression scale with nine items enquiring about the past 2 weeks with response options ranging from ‘not at all’ to ‘nearly every day’. The items reflect the nine criteria, on which the diagnosis of DSM-V major depressive disorder is based. The PHQ-9 was also used to grade the severity of depressive symptoms as none (score of 0–4), mild (5–9), moderate (10–14) or moderately severe/severe (11–27), as recommended by the scale developers [15,1820].

Data management and analysis

The data were entered, cleaned and analysed using the Statistical Package for the Social Sciences version 25. The descriptive statistics were applied in terms of frequency tables with percentages, means and standard deviations for numerical data. The differences between groups regarding categorical variables were assessed using the Chi-square tests; the independent t-tests were done for quantitative variables, whereas odds ratios (OR) and 95% CI were determined for categorical variables using logistic regression analysis with the dependent variable being case/control status and the independent variables being mother’s depression at the time of admission, age, marital status, education attained, occupation, vaccination and breast feeding practice. Variables which demonstrated an association with the outcome variable (SAM) after bivariable logistic regression analysis were inserted into a multiple logistic regression model to estimate the adjusted OR (AOR) of association between maternal depression and SAM in children and other significant risk factors. A p-value ≤0.05 was considered to be significant for all purposes.


RESULTS

The study included 178 participants (89 cases and 89 controls), with male:female ratio of 1.2:1. The mean age of children was 14 ± 6.1 months, and the most reported age range was 6-12 months (48.3%). Mothers’ age ranged from 15 to 40 years, with 20-29 years being the most common age range (54%), and a mean age of 27.3 ± 6 years. Most of the mothers (98.3%) were married, and about one-quarter (24.7%) did not receive any formal education (31.5% in cases and 18% in controls). The majority of mothers (84%) were unemployed, whereas only 13.8% of those who were employed had professional jobs. Most of the mothers (84.2%) were residing in Khartoum State, whereas Kordofan states were the most commonly reported states of origin (35.6%). There were no statistically significant differences between mothers of cases and controls with regard to demographic characteristics (age, marital status, education, employment, residence and origin) (Table 1).

Nearly similar percentages (69.7% and 73%) of children in the case and control groups were fully vaccinated, respectively (p = 0.264). In addition, 48.3% of cases were exclusively breastfed compared to 69.7% of controls (p = 0.004), whereas exclusive breastfeeding duration did not differ significantly between the two groups (p = 0.859). Moreover, the study found that the proportion of mothers who stopped breastfeeding below 1 year among the case groups (16.8%) was significantly higher compared with the control group (1.1%) (p-value = 0.000), with the most common reason for discontinuing being mother’s new pregnancy in the case group (44.6%) and child’s illness (30.8%) in the control group. There was no significant difference between the proportion children, for whom solid food was introduced before 6 months in the case (55%) and control (44%) groups (p = 0.27) (Table 2).

The overall prevalence of depression was significantly higher among the mothers of cases than controls (41.5% vs. 19.1%, p = 0.001), with 38% displaying severe or moderately severe depression in the case group compared to 17.7% in the control group. Moreover, the mean score of depression among mothers in the case group (4.47 ± 0.48) was significantly higher than those in the control group (2.46 ± 0.33) (p = 0.001). In addition, the predictors of maternal depression were mother’s origin from Kordofan states (OR = 2.18; 95% CI: 1.13-4.21, p = 0.02) and mother’s employment (OR = 3.1; 95% CI: 1.58-8.15, p = 0.002), whereas other factors such as child’s gender, mother’s age, educational level or feeding practices were not associated with maternal depression in this study.

Bivariate logistic regression analysis for the risk factors of malnutrition revealed that early weaning before 1 year (OR = 22.5; 95% CI: 2.86-176.8, p = 0.003), mother’s illiteracy (OR = 5.28; 95% CI: 1.40-19.92, p = 0.014) and maternal depression (OR = 3.014; 95% CI: 1.53-5.95, p = 0.001) increased the odds of developing child malnutrition, whereas exclusive breastfeeding decreased the odds by 0.41 (95% CI: 0.22-0.75, p = 0.004) (Tables 3 and 4). These factors were still significant in a multivariate logistic regression analysis that confirmed the association between child malnutrition and early weaning (AOR = 18.6; 95% CI: 2.30-150.21), mother’s illiteracy (AOR = 2.42; 95% CI: 1.08-5.42) and maternal depression (AOR = 3.09; 95% CI: 1.49-6.38) and the negative association with exclusive breast feeding (AOR = 0.43; 95% CI: 0.22-0.85, Table 5).

Table 1. Distribution of the study participants according to mothers’ demographic characteristics.

Mothers’ demographic data Study group Total (%)
(n = 178)
x2 (p-value)
Cases (n = 89) Controls (n = 89)
Mothers’ age (years)
<20 9 (10.1%) 7 (8%) 16 (9%) 0.357 (0.949)
20-29 48 (54%) 51 (57.3%) 99 (55.6%)
30-39 31 (34.8%) 30 (33.7%) 61 (34.2%)
>39 1 (1.1%) 1 (1.1%) 2 (1.2%)
Marital status
Married 86 (96.7%) 89 (100%) 175 (98.3%) 3.1 (0.217)
Divorced 1 (1.1%) 0 (0%) 1 (0.6%)
Widowed 2 (2.2%) 0 (0%) 2 (1.1%)
Education
Illiterate 25 (28%) 13 (14.6%) 38 (21.3%) 8.1 (0.087)
Khalwa 3 (3.5%) 3 (3.4%) 6 (3.4%)
Primary school 43 (48.3%) 42 (47.2%) 85 (47.8%)
Secondary school 14 (15.7%) 20 (22.5%) 34 (19.1%)
University or above 4 (4.5%) 11 (12.3%) 15 (8.4%)
Employment
Yes 15 (16.8%) 14 (15.7%) 29 (16%) 0.04 (0.839)
No 74 (83.2%) 75 (84.3%) 149 (84%)
Job
Professional 1 (6.7%) 3 (21.4%) 4 (13.8%) 1.3 (0.249)
Non professional 14 (93.3%) 11 (78.6%) 25 (86.2%)

x2 = Chi-square statistics.


DISCUSSION

This study highlights the possible association between maternal depression and SAM. It also supports the association between SAM and early breastfeeding weaning, mother illiteracy and non-exclusive breastfeeding practice.

The evidence provided by this study shows that children of depressed mothers have a 3-fold increased odds for having SAM compared to children of non-depressed mothers. This conforms with the findings of other studies conducted in LMICs such as Pakistan, Bangladesh, India, Kenya and Nigeria [7,18,2123]. These results also indicate the gravity of maternal depression, as it does not only reduce maternal interest in the child but also impair a woman’s ability to cope with the responsibilities of being a mother. Moreover, the presence of this association in LMICs carries a worse outcome due to more adverse environmental and socioeconomic circumstances that compromise the ability of mothers to provide a healthful diet and implement good parental practice during the child’s crucial time of growth [8,18,2325].

Table 2. Distribution of the study participants according to child’s characteristics and risk factors for SAM.

Variables Study group Total (%)
N = 178
x2 (p-value)
Cases (n = 89) Controls (n = 89)
Exclusive breast feeding
Yes 43 (48.3%) 62 (69.7%) 105 (59%) 8.4 (0.004)*
No 46 (51.3%) 27 (30.3%) 73 (41%)
Duration of exclusive breast feeding (months)
<4 4 (9.3%) 7 (11.3%) 11 (10.5%) 0.76 (0.859)
4-6 35 (81.3%) 47 (75.8%) 82 (78.1%)
7-10 3 (7%) 7 (11.3%) 10 (9.5%)
Doesn’t remember duration 1 (2.4%) 1 (1.6%) 2 (1.9%)
Stopped breast feeding
Less than 1 year 15 (16.8%) 1 (1.1%) 16 (9%) 17.3 (0.000)*
≤1 year-2 years 32 (36%) 25 (28%) 57 (32%)
Not yet 42 (47.2%) 63 (70.9%) 105 (59%)
Reason for stopping breast feeding
Completed 2 years 2 (4.2%) 4 (15.4%) 6 (8.2%) 6.5 (0.258)
Child’s illness 11 (23.4%) 8 (30.8%) 19 (26%)
Child’s refusal 2 (4.2%) 1 (4 %) 3 (4.2%)
Mother’s illness 5 (10.6%) 1 (3.8%) 6 (8.2%)
Mother’s desire 5 (10.6%) 5 (19.2%) 10 (13.6%)
Mother’s pregnancy 21 (44.6%) 5 (19.2%) 26 (35.6%)
Others 1 (2.1%) 2 (7.6%) 3 (4.2%)
Weaning time
Less than 6 months 49 (55%) 39 (44%) 88 (49.4%) 3.9 (0.270)
6 months 26 (29.2%) 36 (40.4%) 62 (34.8%)
6-13 months 10 (11.3%) 12 (13.4%) 22 (12.5%)
Does not remember 1 (1.1%) 1 (1.1%) 1 (1.1%)
Not yet 3 (3.4%) 1 (1.1%) 4 (2.2%)

*Significant values; x2 = Chi-square statistics.

The study revealed an overall prevalence of maternal depression of 30.3%, with almost two-thirds of them being mothers of malnourished children, compared to 17% reported by a recent cross-sectional study in Sudan [26]. While general estimates of PPD prevalence in Africa ranged from 6.1% to 30.6% [18], these estimates highlight the need for a potent maternal healthcare system and more extensive research work that will reflect on both mother’s and child’s welfare [26].

Maternal depression was significantly associated with mother’s origin from Kordofan states, which are peripheral states of the west and south of Sudan. This is inconsistent with evidence reported in India, as PPD was more prevalent in urban than rural areas [6]. The finding may be due to scarce or lacking specialised mental health care in peripheral healthcare facilities, cultural, behavioural or even psychosocial stressor variables that predispose to the depression of mothers in these states.

Table 3. The ORs of maternal factors associated with SAM obtained from bivariate logistic regression analysis.

Variables OR (95% CI) p-value
Depression in the mother
Depression 3.01 (1.53-5.93) 0.001*
Severity of depression
Mild (5-9) 0.54 (0.05-5.79) 0.617
Moderate (10-14) 1.83 (0.12-27.79) 0.662
Moderately severe (15-19) (a)
Education
Illiterate 5.28 (1.40-19.92) 0.014*
Khalwa 2.75 (0.38-19.67) 0.315
Primary school 2.81 (0.83-9.54 ) 0.097
Secondary school 0.51 (1.06-7.29 ) 0.335
University or above (a)
Employment
Yes 1.09 (0.49-2.40 ) 0.839
Job
Professional 0.143 (0.01-1.66) 0.121
Non-professional (a)

CI, confidence interval; OR, odds ratio.

(a) = Reference category; *Significant values.

Maternal depression was also significantly associated with mother’s employment although unemployment was considered as a risk factor for maternal depression in many studies across Asian countries [11]. Women employment in LMICs and its associated stress can reflect the financial difficulties in the families, and poor socio-economic factors increase the susceptibility to perinatal depression [6,11].

Socioeconomic deprivation variables such as a low educational level and feeding practices were not associated with maternal depression in this study. This is in contrast to the existing evidence, which states that high maternal education and exclusive breastfeeding serve as the protective factors for maternal depression in LMICs and Sudan [3,6,14,23].

The present study highlighted the association between SAM and early cessation of breastfeeding in the first year, which further solidifies the evidence of contribution of the early cessation of breastfeeding to malnutrition in India, Bangladesh and across many African countries [4,2729]. However, prolonged breastfeeding without complementary food was reported to be a contributor to undernutrition in Ghana and Nigeria [30,31].

Moreover, maternal illiteracy was found to be a significant contributor to the development of SAM, which is in line with the findings of previous studies in Bangladesh, Pakistan, Afghanistan and Benin [3235]. Mothers with low education tend to live in rural areas with more limited nutritional knowledge and health access [36]. In addition, education empowers women financially and influence their capacity to make decisions concerning children’s nutrition and access to health services [3]. Educated women are able to make better health choices for their children as well as having more knowledge about good child nutrition and feeding practices [8,37].

Table 4. The ORs of child risk factors associated with SAM obtained from bivariate logistic regression analysis.

Variables OR (95% CI) p-value
Vaccination
Fully vaccinated 1.91 (0.54-6.65 ) 0.311
Partially vaccinated 2.87 (0.74-11.19 ) 0.128
Not vaccinated (a)
Exclusive Breast feeding
Yes 0.41 (0.22-0.75 ) 0.004*
Duration of exclusive breast feeding
<4 1.33 ( 0.21-8.28) 0.758
4-6 1.73 (0.41-7.20 ) 0.446
7-10 (a)
Stopped breast feeding
Less than 1 year 22.5 (2.86-176.8) 0.003*
1-2 year 1.92 (0.91-3.68) 0.061
Not yet (a)
Reason for stopping breast feeding
Completed 2 years 1.33 (0.06-26.6) 0.851
Child illness 2.75 (0.21-35.8) 0.44
Child refusal 4.00 (0.134-119.23) 0.423
Mother illness 10.00 (0.39-250.4) 0.161
Mother desire 2.00 (0.13-29.81) 0.615
Mother pregnancy 8.40 (0.63-112.1) 0.107
Other (a)
Weaning time
Less than 6 months 1.63 (0.64-4.12) 0.299
6 months 0.93 (0.35-3.36) 0.898
6-13 months (a)

CI, confidence interval; OR, odds ratio.

(a) = Reference category; *Significant values.

Table 5. The AOR of factors associated with SAM obtained from multivariate logistic regression analysis.

Factors AOR 95% CI p-value
Maternal depression 3.09 1.49-6.38 0.002*
Exclusive breast feeding 0.43 0.22-0.85 0.015*
Stopped breast feeding <1 year 18.60 2.30-150.21 0.006*
Mother illiteracy 2.42 1.08-5.42 0.031*

AOR, adjusted odds ratio; CI, confidence interval.

*Significant values.

Limitations

This was hospital-based study, making it difficult to generalise the results to the general population. Moreover, a hospital setting may have influenced the results due to maternal distress associated with the child’s sickness. Hence, a community-based survey is recommended to further solidify the evidence. In addition, the study was of cross-sectional design, which makes it difficult to scrutinise the cause-effect relationship between maternal depression and SAM. Finally, PHQ-9 is not a validated tool for maternal depression screening in Sudan yet despite being considered the gold standard screening tool in many countries, and this may be inflicting some resultant bias.


CONCLUSIONS

This study provides a significant association between maternal depression and adverse nutritional outcome, namely SAM in under 5-year-old children. It also provides an association between SAM and maternal illiteracy, as well as poor feeding practice in the form of nonexclusive breast feeding and early breast feeding weaning at age less than 1 year. Moreover, it shows that maternal depression is of considerable burden among Sudanese women at childbearing age. Hence, instant measures need to be instituted to mitigate its influence on maternal and child’s welfare. These measures may include the formation of self-help and support groups for the mothers of children with SAM admitted to hospitals, incorporation of maternal health care into mother and childcare programs, as well as early screening for depression at community level, postpartum visits and immunisation visits.


ACKNOWLEDGEMENTS

The authors would like to sincerely thank all the participants in this study.


CONFLICT OF INTEREST

The authors declare that there is no conflict of interest regarding the publication of this article.


FUNDING

None.


ETHICAL APPROVAL

Ethical approval was obtained from the Ethics Committee of Sudan Medical Specialisation Board, whereas permission was obtained from the administrative authority of Omdurman Paediatric Teaching Hospital. Informed written consent was obtained from the mothers. Participants were informed that study data will be used for research purposes only while maintaining confidentiality, and they have the right to withdraw from the study at any stage without any detriment to their child’s care.


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How to Cite this Article
Pubmed Style

Mohammedahmed ASA, Koko AEA, Arabi AME, Ibrahim MA. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudan J Paed. 2020; 20(2): 111-121. doi:10.24911/SJP.106-1590606922


Web Style

Mohammedahmed ASA, Koko AEA, Arabi AME, Ibrahim MA. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. http://www.sudanjp.com/?mno=110534 [Access: October 29, 2020]. doi:10.24911/SJP.106-1590606922


AMA (American Medical Association) Style

Mohammedahmed ASA, Koko AEA, Arabi AME, Ibrahim MA. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudan J Paed. 2020; 20(2): 111-121. doi:10.24911/SJP.106-1590606922



Vancouver/ICMJE Style

Mohammedahmed ASA, Koko AEA, Arabi AME, Ibrahim MA. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudan J Paed. (2020), [cited October 29, 2020]; 20(2): 111-121. doi:10.24911/SJP.106-1590606922



Harvard Style

Mohammedahmed, A. S. A., Koko, . A. E. A., Arabi, . A. M. E. & Ibrahim, . M. A. (2020) Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudan J Paed, 20 (2), 111-121. doi:10.24911/SJP.106-1590606922



Turabian Style

Mohammedahmed, Arwa S. A., Abubaker Emadeldin Adlan Koko, Ali M. E. Arabi, and Mohamed A. Ibrahim. 2020. Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudanese Journal of Paediatrics, 20 (2), 111-121. doi:10.24911/SJP.106-1590606922



Chicago Style

Mohammedahmed, Arwa S. A., Abubaker Emadeldin Adlan Koko, Ali M. E. Arabi, and Mohamed A. Ibrahim. "Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan." Sudanese Journal of Paediatrics 20 (2020), 111-121. doi:10.24911/SJP.106-1590606922



MLA (The Modern Language Association) Style

Mohammedahmed, Arwa S. A., Abubaker Emadeldin Adlan Koko, Ali M. E. Arabi, and Mohamed A. Ibrahim. "Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan." Sudanese Journal of Paediatrics 20.2 (2020), 111-121. Print. doi:10.24911/SJP.106-1590606922



APA (American Psychological Association) Style

Mohammedahmed, A. S. A., Koko, . A. E. A., Arabi, . A. M. E. & Ibrahim, . M. A. (2020) Maternal depression, a hidden predictor for severe acute malnutrition in children aged 6-59 months: a case-control study at Omdurman Paediatrics Teaching Hospital, Sudan. Sudanese Journal of Paediatrics, 20 (2), 111-121. doi:10.24911/SJP.106-1590606922





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