UTPAL GANGULY

UNDERSTANDING MALNUTRTION IN CHILDREN

POOR NUTRTION; THE SILENT ENEMY

Poor nutrition in the first 1,000 days of children’s lives can have irreversible consequences. It means they are -

• forever, stunted.

• susceptible to sickness

• more likely to become overweight when they enter adulthood.

• and more prone to non-communicable disease.

• About one third of under-five mortality is attributable to under-nutrition.

Under-nutrition contributes to child mortality and morbidity

• Stunting and other forms of under-nutrition are clearly a major contributing factor to child mortality, disease and disability.

• For example, a severely stunted child faces a four times higher risk of dying, and a severely wasted child is at a nine times higher risk.

• Specific nutritional deficiencies such as vitamin A, iron or zinc deficiency also increase risk of death.

• Under-nutrition can cause various diseases such as blindness due to vitamin A deficiency and neural tube defects due to folic acid deficiency

What are the first 1000 days?

• From a life-cycle perspective, the most crucial time to meet a child’s nutritional requirements is in the 1,000 days including the period of pregnancy and ending with the child’s second birthday.

What is stunting, wasting and underweight?

• Stunting (inadequate length/height for age) captures early chronic exposure to under-nutrition;

• wasting (inadequate weight for height) captures acute under-nutrition;

• underweight (inadequate weight for age) is a composite indicator that includes elements of stunting and wasting

Mid upper arm circumference (MUAC)

• The circumference of the child’s upper arm half way between their shoulder and elbow provides an indication of acute malnutrition independent of the child's age. If the child’s arm is less than 11.5cm in circumference, she is severely malnourished; if the child’s arm is between 11.5 and 12.5cm in circumference, she is moderately malnourished. These values are appropriate for children from 6 months to 60 months.

Understanding standard deviation

Weight-for-Length Reference Card (below 87 cm)

Weight for length reference table page 7 annex 1

• When assessing weight-for-height, infants and children under 24 months of age should have their lengths measured lying down (supine).

• Children over 24 months of age should have their heights measured while standing.

• For simplicity, however, infants and children under 87 cm can be measured lying down (or supine) and those above 87 cm standing.

• A z-score is the number of standard deviations (SD) below or above the reference median value.

What is stunting?

• Stunting reflects chronic under-nutrition during the most critical periods of growth and development in early life.

• It is defined as the percentage of children aged 0 to 59 months whose height for age is below minus two standard deviations (moderate and severe stunting) and minus three standard deviations (severe stunting) from the median of the WHO Child Growth Standards.

What is under weight?

• Underweight is a composite form of under-nutrition that includes elements of stunting and wasting. It is defined as the percentage of children aged 0 to 59 months whose weight for age is below minus two standard deviations (moderate and severe underweight) and minus three standard deviations (severe underweight) from the median of the WHO Child Growth Standards.

What is wasting?

• Wasting reflects acute under-nutrition.

• It is defined as the percentage of children aged 0 to 59 months whose weight for height is below minus two standard deviations (moderate and severe wasting) and minus three standard deviations (severe wasting) from the median of the WHO Child Growth Standards.

DIAGNOSTIC CRITERIA FOR SAM IN CHILDREN AGED 6–60 MONTHS

• Indicator Measure Cut-off

• Severe wasting Weight-for-height < -3 SD

• Severe wasting MUAC < 115 mm

• Bilateral oedema Clinical sign (may not be considered)

Overweight???

• Overweight is defined as the percentage of children aged 0 to 59 months whose weight for height is above two standard deviations (overweight and obese) or above three standard deviations (obese) from the median of the WHO Child Growth Standards.

Low birth weight??

• Low birth weight is defined as a weight of less than 2,500 grams at birth.

Understanding under nutrition changing focus…

• In tackling child under-nutrition, there has been a shift from efforts to reduce underweight prevalence (inadequate weight for age) to prevention of stunting (inadequate length/height for age).

• There is better understanding of the crucial importance of nutrition during the critical 1,000-day period covering pregnancy and the first two years of the child’s life, and of the fact that stunting reflects deficiencies during this period.

• The World Health Assembly has adopted a new target of reducing the number of stunted children under the age of 5 by 40 per cent by 2025.

How big is the problem?

• Stunting

• Globally, about one in four children under 5 years old are stunted (26 per cent in 2011). An estimated 80 per cent of the world’s 165 million stunted children live in just 14 countries.

• Sub-Saharan Africa and South Asia are home to three fourths of the world’s stunted children. In sub-Saharan Africa, 40 per cent of children under 5 years of age are stunted; in South Asia, 39 per cent are stunted.

• 80% of the worlds stunted children live in 14 countries (Figure 5 page 9 unicef report)

• Underweight

• Globally in 2011, an estimated 101 million children under 5 years of age were underweight, or approximately 16 per cent of children under 5.

• As per Hungama report 2011, 42 per cent of children under five are underweight and 59 percent are stunted. Of the children suffering from stunting, about half are severely stunted.

Wasting: Burden estimates in the 10 most affected countries

• Figure 12 page 13 unicefreportNutrition_Report_final_lo_res_8_April.pdf

• Low birth weight

• The World Health Assembly has set a new target to reduce low birthweight by 30 per cent between 2010 and 2025. In 2011, more than 20 million infants, an estimated 15 per cent globally, were born with low birth weight. India alone accounts for one third of the global burden. South Asia has by far the greatest regional incidence of low birth weight, with one in four newborns weighing less than 2,500 grams at birth (Figure 17).

• Overweight

• Rates of overweight continue to rise across all regions. Overweight was once associated mainly with high-income countries, but in 2011, 69 per cent of the global burden of overweight children under 5 years old were in low- and middle-income countries. However, the prevalence of overweight remains higher in high-income countries (8 per cent) than in low-income countries (4 per cent).

• Globally, an estimated 43 million children under 5 years of age are overweight, or 7 per cent of children under 5 years old.

Global focus on nutrition….• Recognizing that investing in nutrition is a key way to advance global

welfare, the G8 has put this high on its agenda. The global nutrition community is uniting around the Scaling Up Nutrition movement.

• The United Nations Secretary-General has included elimination of stunting as a goal in his Zero Hunger Challenge to the world.

• The 2013 World Economic Forum highlighted food and nutrition security as a global priority.

• And a panel of top economists from the most recent Copenhagen Consensus selected stunting reduction as a top investment priority.

• The World Health Assembly has set the goal of achieving a 40 per cent reduction in the number of stunted children

• The global nutrition community is uniting around the Scaling Up Nutrition (SUN) movement, which supports nationally driven processes for the reduction of stunting and other forms of malnutrition.

Nutrition-specific interventions

• Promoting optimal nutrition practices, meeting micronutrient requirements and preventing and treating severe acute malnutrition are key goals for nutrition programming

• Maternal nutrition and prevention of low birth weight

• Infant and young child feeding (IYCF) Breastfeeding, with early initiation (within one hour of birth) and continued exclusive breastfeeding for the first six months followed by continued breastfeeding up to 2 years

Nutrition-specific interventions

• Safe, timely, adequate and appropriate complementary feeding from 6 months onwards

• Prevention and treatment of micronutrient deficiencies

• Prevention and treatment of severe acute malnutrition

• Promotion of good sanitation practices and access to clean drinking water

• Promotion of healthy practices and appropriate use of health services

Nutrition-specific interventions

• Key proven practices, services and policy interventions for the prevention and treatment of stunting and other forms of undernutrition throughout the life cycle

• Figure 18 page 18 Unicef report

Nutrition-specific interventions

• Anganwadi centers are charged with regularly measuring the weight of children to determine if they are underweight. The age and weight are plotted on the WHO charts. Children are severely underweight if their age and weight put them below the line marked “-3”; they are moderately underweight if their age and weight put them between the line marked “-2” and the line marked “-3”

Conceptual framework

• Unicef 1990 Page 4 figure 1

Key findings of the Hungama report 2011

• Household socio-economic status has a significant effect on children’s nutrition status: The prevalence of malnutrition is significantly higher among children from low-income families, although rates of child malnutrition are significant among middle and high income families.

• Children from households identifying as Muslim or belonging to Scheduled Castes or Schedule Tribes generally have worse nutrition.

• Girls’ nutrition advantage over boys fades away with time: Girls seem to have a nutrition advantage over boys in the first months of life; however this advantage seems to be reversed over time a s girls and boys grow older, potentially indicating feeding and care neglect vis-à-vis girls in infancy and early childhood;

• Mothers’ education level determines children’s nutrition: In the 100 Focus Districts,

• 66 per cent mothers did not attend school;

• rates of child underweight and stunting are significantly higher among m others with low levels of education;

• the prevalence of child underweight among mothers who cannot read is 45 percent while that among mothers with 10 or more years of education is 27 percent.

• T he corresponding figures f or child stunting are 63 and 43 per cent respectively.

• Giving colostrum to the newborn and exclusive breastfeeding for first 6 months of a child’s life are not commonly practised:

• In the 100 Focus Districts 5 1 per cent mothers did not give colostrum to the newborn soon after birth and 58 per cent mothers fed water to their infants before 6 months.

• Hand washing with soap is not a common practice:

• In the 100 Focus Districts 11 per cent mothers said they used soap to wash hands before a meal and 1 9 per cent do so after a visit to the toilet;

• Anganwadi Centres are widespread but not always efficient:

• There is a n Anganwadi centre in 9 6 per cent o f the villages in t he 1 00

• Focus Districts, 61 per cent o f them in pucca buildings;

• the Anganwadi service accessed by the largest p roportion of m others (86 p er c ent) i simmunization;

• 61 per cent of Anganwadi Centreshad dried rations available and

• 5 0 p er c ent provided f ood on the day of s urvey;

• only 19 p ercent of the mothers reported that the AnganwadiCentre provides nutrition counseling to parents.

Complex problems …simple solutions…

• Most of the solutions to the complex problems of under nutrition in India are simple

Why are they not simply practiced?