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Prevention of Childhood Malnutrition. Dr. Harivansh Chopra DCH, MD Professor Department of Community Medicine, LLRM Medical College, Meerut. harichop@gmail.com. Objectives. To study the magnitude of Protein Energy Malnutrition and causes associated with it. - PowerPoint PPT Presentation
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Dr. Harivansh ChopraDr. Harivansh Chopra
Dr. Harivansh Chopra DCH, MD
Professor Department of Community Medicine, LLRM Medical College, Meerut.
harichop@gmail.com
Prevention of Childhood Malnutrition
04/21/23 1observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Objectives 1. To study the magnitude of Protein Energy
Malnutrition and causes associated with it.
2. To study methods of prevention, treatment, and rehabilitation of PEM.
04/21/23 2observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Whether this child will grow normally or become malnourished?
? ?
04/21/23 3observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Protein Energy Malnutrition
Defined as “chronic pathological condition which arises due to absolute or relative lack of protein and energy in the diet over an extended period of time and is commonly associated with infection albeit infestation in young children”.
04/21/23 4observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Status of children below 3 years : NFHS II
46 47
16
05
101520253035404550
Per
cent
age
Stunted Underweight Wasted04/21/23 5observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Status of children below 3 years : NFHS II
35.6
48.6
38.4
49.6
1316.2
0
10
20
30
40
50
Per
cen
tage
Stunted Underweight Wasted
Urban Rural
04/21/23 6observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional status of under-three children in relation to living index
26.8
46.8
56.9
28.5
45.3
53.7
10.214.3
19.7
0
10
20
30
40
50
60
Per
cent
age
UNDER WT STUNTED WASTED
HIGHMEDIUMLOW
NFHSII
04/21/23 7observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional status of under-three children in relation to age
11.9
37.5
58.5 58.4
15.4
30.9
57.5 56.5
9.313.2
21.9
13.2
0
10
20
30
40
50
60
Per
cen
tage
Underweight Stunted Wasted
< 6 months6 - 11 months12 - 23 months24 - 35 months
04/21/23 8observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Percentage of underweight children –Comparison between NFHS I & II
5247
20 18
0
10
20
30
40
50
60
Per
cen
tage
Underweight Severely Underweight
NFHS INFHS II
04/21/23 9observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Status of children below 3 years : NFHS III
3846
19
05
101520253035404550
Per
cent
age
Stunted Underweight Wasted04/21/23 10observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Status of children below 3 years : NFHS III
31.1
40.736.4
49
16.919.8
0
10
20
30
40
50
Per
cen
tage
Stunted Underweight Wasted
Urban Rural
04/21/23 11observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Percentage of underweight children –Comparison between NFHS II & III
47 46 46
38
1619
05
101520253035404550
Per
cen
tage
Underweight Stunted Wasted
NFHS IINFHS III
04/21/23 12observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Distribution of 1-5 years children (Gomez classification)
IncomeWeight as percentage of normal
≥ 90% 75 – 90% 60 – 75% < 60%
HIG 48.2 40.8 10.5 0.5
MIG 38.8 45.0 15.7 0.5
LIG 20.2 47.6 28.7 3.5
IL 19.4 46.1 31.1 3.4
SLUM 12.7 40.7 38.6 8.0
RURAL 13.0 41.9 37.0 8.1
NNMB04/21/23 13observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Causes of Malnutrition
1. Inadequate Food Security.
2. Infection.
3. Low weight of adolescent girls.04/21/23 14observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Causes of Malnutrition
4. Low Immunization coverage.
5. Maternal Anemia.
6. Low literacy level in female.04/21/23 15observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Causes of Malnutrition
7. Poor sanitary conditions.
8. Low birth weight.
9. Lack of knowledge regarding normal growth of children.
04/21/23 16observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Causes of Malnutrition
10. Poor hygiene.
11. Incorrect child rearing practices.
12. Inaccessible and Inadequate
health services.04/21/23 17observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Causes of Malnutrition
13. Lack of Comprehensive Child Health Care Programme.
14. Lack of political will.
04/21/23 18observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Big problem needs a Big solution.
2. If one wants to Win the battle, the effort has to be intensive and focused.
3. So, it has to be a BIG WIN against MALNUTRITION.
4. BIGWIN approach is to be applied.
04/21/23 19observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Shift Strategy
A shift in strategy is the need of the hour. Infants must be made the focus of attention for mothers as –
• NEITHER a mother would like to deliver a low-birth weight baby;
• NOR any mother would like to have a malnourished child.
04/21/23 20observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
The BIGWIN ApproachExclusive Breast Feeding for 6 months.
Infection Prevention/Treatment and Immunization.
Growth Promotion / Monitoring.
Appropriate Weaning Practice. Safe Water
Iron Supplementation.
Nutrition education & Extra-Nutrition inpregnancy & lactation, and illness in child.
No to next pregnancy. 04/21/23 21observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Weight gain in the first five years of life
88
1st Year 2 - 5 years
Kg.Kg.
04/21/23 22observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Weight gain in the first year of life
44
First 4 months Next 8 months
Kg.Kg.
04/21/23 23observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Weight gain in the next four years of life
2
2
2
2
2nd Year 3rd Year 4th Year 5th Year
Kg.
Kg. Kg.
Kg.
04/21/23 24observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
v/s Monitor the Weight
FIRST
SECOND
Weight gain in 1st year of life.
Weight gain in next 4 years of life.
04/21/23 25observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Exclusive Breast Feeding in India – NFHS II
4555
Exclusive Breast Feeding Not Exclusively Breast-fed
04/21/23 26observerzparadise.com
Exclusive breast feeding upto 4months
Dr. Harivansh ChopraDr. Harivansh Chopra
Immunization Coverage
62.2
71.6
51.7
65.1
53.6
62.8
42.2
50.7
35.542
0
10
20
30
40
50
60
70
80
Per
cen
tage
BCG DPT 3doses
OPV 3doses
Measles AllVaccines
NFHS INFHS II
04/21/23 28observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Immunization Coverage
71.6
78.2
55.1 55.3
62.8
78.2
50.7
58.8
42 43.5
0
10
20
30
40
50
60
70
80
Per
cen
tage
BCG DPT 3doses
OPV 3doses
Measles AllVaccines
NFHS IINFHS III
04/21/23 29observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Anemia in Children
31
62
7
Mild Moderate Severe04/21/23 30observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
7479
4 5
0
10
20
30
40
50
60
70
80
90
Any anaemia Severe anaemia
NFHS-2 NFHS-3
Anaemia among Children Age 6-35 MonthsAnaemia among Children Age 6-35 Months
Percent
04/21/23 31observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Iron Supplementation v/sIron Therapy – Cost
30
70
Iron Supplementation Iron Therapy
04/21/23 32observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Empowering Women
Poor Perpetually Pregnant female
Powerful Perceptive Problem-solving
04/21/23 33observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Empowering Women
1. Mass Media
2. Government Health System
3. Mahila Mandals04/21/23 34observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Empowering Women
4. NGOs
5. Link Women
6. Anganwadi04/21/23 35observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Empowering Women
7. Health Worker
8. School Health
9. BFCI04/21/23 36observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Education
1. Education is a learning process by which a change in behaviour is brought about.
2. For providing nutrition education, one must have sound knowledge of locally available foods.
04/21/23 37observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Education3. The timing of providing education is of
crucial importance.
4. All persons involved in decision making, as well as responsible for cooking must be sensitized.
04/21/23 38observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Education
5. The typical jargon of nutritive value in context of calories and proteins must be avoided.
6. Beneficiaries should be sensitized on protective, body building, and essential foods.
04/21/23 39observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Education7. Vulnerable periods of life, specially
infancy, pregnancy, and lactation must be taken into account.
04/21/23 40observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Therapy
If one is not able to prevent the occurrence of malnutrition, one has to go for treatment of malnutrition. Although prevention is still better than cure.
04/21/23 41observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Principles of Nutrition Therapy
1. Mild to moderate degree of malnutrition can be managed at home.
04/21/23 42observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Principles of Nutrition Therapy2. Only severely malnourished children with
complications need to be hospitalized first.
3. The aim is to provide 1.5 – 2 gms. of protein/ kg per day and 150 – 180 calories/kg/day.
04/21/23 43observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Management of mild to moderate degree of malnutrition
This is usually done with the help of protein and calorie rich diets.
04/21/23 44observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Besan Panjiri1. Contents – Bengal gram flour, Wheat flour, Jaggery, Ghee (1 part each).
2. Calories: 500 calorie/100gm.
3. Protein: 9gm/100gm.
+ + +
04/21/23 45observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
2. Shakti aahar1. Constituents: Roasted wheat 40gm, Roasted gram 20gm, Roasted
peanuts 10gm, Jaggery 30gm.
2. Calories: 390 calories/100gm.
3. Protein: 11.4gm/100gm.
+ + +
04/21/23 46observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
3. Hyderabad Mix1. Constituents: Whole wheat 40gm, Bengal gram 16gm, Groundnuts
10gm, Jaggery 20gm.
2. Calories: 330 calories/86gm.
3. Protein: 11.3gm/86gm.
+ + +
04/21/23 47observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Management of severely malnourished children
1. With complications, they should be hospitalized.
2. Without complications, put straightaway on dietary management.
04/21/23 48observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Dietary Management – Initial Phase
1. Feeding must start gradually.
2. Initially approx. 80 Cal/kg/day and 0.7gm protein/kg/day provided; actual body weight rather than expected body weight counted.
04/21/23 49observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
4. Sooji Kheer1. Constituents: Toned milk 750ml, Sugar 100gm, Sooji 25gm, Oil 5gm
(aqua add 1000ml).
2. Calories: 143 calorie/100gm.
3. Protein: 2.8gm/100gm.
+ + +
04/21/23 50observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Dietary Management – Initial Phase
3. Small frequent feeds given.
4. Intake gradually increased to 100 Cal/kg/day and 1gm protein/kg/day.
04/21/23 51observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Dietary Management – Initial Phase
5. Milk is usually the starting food; for lactose-intolerance, other foods like rice gruel, chicken gruel, soya rice gruel, and cereal pulse gruel are used.
04/21/23 52observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
1. Dietary Management – Initial Phase
6. For enriching milk, generally coconut oil is used.
7. Fluids should be given with cup and spoon; bottle-feeding best avoided.
04/21/23 53observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
2. Dietary management – Phase of High Energy Feeding
1. Caloric intake gradually increased to 150 – 180 Cal/kg/day.
2. Child moved from predominant milk diet to semi solids/solid diet.
3. Protein intake increased to 1.5 – 2gm/kg/day.
04/21/23 54observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
3. Dietary Management – Transfer to Family type diet
1. Child should be taking nutritionally wholesome family-type diet (cereals, pulses, vegetables) before discharge from hospital.
04/21/23 55observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
3. Dietary Management – Transfer to Family type diet
2. Involves nutrition education of parents.
3. Snacks made from peanuts, bengal gram, jaggery, and oil are useful.
04/21/23 56observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Rehabilitation1. Majority of children, after discharge from
hospital, again become victim of Malnutrition.
2. To overcome this, Nutritional Rehabilitation is carried out.
04/21/23 57observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Rehabilitation
Ambulatory Treatment Rehabilitation in “NutritionRehabilitation Centres”
04/21/23 58observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Ambulatory Treatment1. In most cases of malnutrition, education
alone is sufficient to correct situation.
2. Identify the most serious errors in diet eg. distribution of available food in family, inadequate use of vegetables, etc.
3. The problem may need assistance usually as Food Supplements.
04/21/23 59observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Rehabilitation Centres (NRC)
1. Severely malnourished children, after taking treatment from hospital, may be transferred to NRCs.
2. The objective is to teach the mother the various methods of preparing nutritious and tasty foods so that the relapse of malnutrition can be prevented.
04/21/23 60observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Rehabilitation Centres (NRC)
Day care NRCs Residential NRCs
04/21/23 61observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Day care NRCs
1. Similar to crěche or kindergarden.
2. Children spend 6 – 8 hrs daily for 6 days a week in these centres, and take there 3 meals each day.
3. Mothers may attend centre and help preparation of meals, or may attend weekly meeting at centre.
04/21/23 62observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Day care NRCs
4. Food stuffs and utensils used are familiar to the mothers, and available in local market.
5. Adequate medical supervision is essential at the centres.
04/21/23 63observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Residential NRCs1. Larger staff and equipments
than day-care NRCs.
2. Children & their mothers live in these as inpatients.
3. Serves mostly children discharged from hospital after treatment for severe malnutrition.
04/21/23 64observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutrition Supplementation
1. Approach by which both prevention and treatment of malnutrition can be met.
2. Supplementary food supplies 300 Cal/day and 10 – 12 gm protein/day to children, and 500 Cal/day and 25 gm protein/day to mothers for 300 days in an year.
04/21/23 65observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Nutritional Surveillance
1. Surveillance is defined as “Data Collection for Action”.
04/21/23 66observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Objectives of Nutrition Surveillance
1. To aid long term planning in health and development.
2. To provide input for programme management and evaluation.
3. To give timely warning and intervention to prevent short-term food consumption crisis.
04/21/23 67observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Triple-A approach
ASSESSMENTof the situation
ANALYSISof the causes of problem
ACTIONbased on the analysis
and available resources
Perceptions & Understanding
Capabilities
Resources
EffectiveDemand
04/21/23 68observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
Conclusion 1. Malnutrition is a preventable problem.
2. Shift in strategy is the need of the hour.
3. Infants must be made the focus of attention in totality.
4. Application of multiple interventions like BIGWIN will produce the desired result.
04/21/23 69observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
04/21/23 70observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs1. Following is false about weight gain in
first year of life except:
1. Weight gain is 4 kg in 1st year.
2. Weight gain is 4 kg in 1st 4 months.
3. Weight gain is maximum during 6 – 12 months of age.
4. None of the above.Ans. – 2.
04/21/23 71observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs2. “Hyderabad Mix”, an energy dense
supplement, used for malnourished children does not contain :
1. Bengal gram.
2. Groundnut.
3. Soyabean.
4. Jaggery.Ans. – 3.
04/21/23 72observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs2. “Hyderabad Mix”, an energy dense
supplement, used for malnourished children does not contain :
1. Bengal gram.
2. Groundnut.
3. Soyabean.
4. Jaggery.Ans. – 3.
04/21/23 73observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs3. In dietary management of malnutrition,
following is provided to children :
1. 100 Cal/kg and 1gm protein/kg.
2. 180 Cal/kg and 2 gm protein/kg.
3. 300 Calorie and 15 gm protein.
4. 500 Calorie and 25 gm protein.
Ans. – 2.04/21/23 74observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs4. NRC is :
1. Nutrition Rehabilitation Centre.
2. Nutrition Rehabilitation Council.
3. Natural Resources Council.
4. Natural Rights of Community.
Ans. – 1.04/21/23 75observerzparadise.com
Dr. Harivansh ChopraDr. Harivansh Chopra
MCQs5. Giving “timely warning” about food
consumption crisis is an objective of :
1. Disaster Management.
2. Food Census.
3. Nutrition Surveillance.
4. Food & Agriculture Research.
Ans. – 3.04/21/23 76observerzparadise.com
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