Under nutrition in young children - India

UNDERNUTRITION IN YOUNG CHILDREN

Dr Soni RaniPGT-1ST Year

Department Of Community MedicineKatihar Medical College, Katihar

Presentation Outline

1. Introduction

2. Problem statement ( World/ India)

3. Causes of Under nutrition.

4. Prevention of Under nutrition.

5. Summary

2.1by 2030 end hunger and ensure access by all people, in particular the poor and people in vulnerable situations including infants, to safe, nutritious and sufficient food all year round2.2by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons2.3by 2030 double the agricultural productivity and the incomes of small-scale food producers, particularly women, indigenous peoples, family farmers, pastoralists and fishers, including through secure and equal access to land, other productive resources and inputs, knowledge, financial services, markets, and opportunities for value addition and non-farm employment

SDG- 2End hunger, achieve food security and improved nutrition and promote sustainable agriculture

Introduction

• Preschool children are most vulnerable to the effect of under nutrition because of rapid growth.

• In SEAR the problem of under nutrition is widespread and ranging from 30 to 63% in form of stunting.

Introduction

• The cost of under nutrition in terms of development and productivity are enormous.

• The number of people suffering from food insecurity and hunger is growing- even though food production has doubled In last 40 years.

• Under nutrition by far the most important single cause of illness and death globally, accounting for 12% of all deaths and 16% of DALYs lost.

Malnutrition in young Children, India/World

47 48.3 47.5 47.2

37.8

25.8

17.6

10.67.8

1.6 0

World development indicators-2006, NFHS-3

Problem statement- World

• Low birth weight is associated with more than half of all deaths among young children , accounting for more than 6 millions deaths a year.

• Every day 799 millions people in developing countries , about 18% of world population goes hungry.

• In SEAR one person in four goes hungry, is as high as one in three.

• Around 175 million children under five are estimated to be under weight.

• A third of preschool children are stunted, 16% of newborn babies weighs less than 2.5 kg and about 243 million adults are severely malnourished.


• Two billion women and children are anemic , 250 million children suffer from vitamin – A deficiency .

• Two billion people are at risk from Iodine deficiency.


India and Under nutrition

• India is home to over 65 million under five children who have protein energy malnutrition.

• The prevalence of underweight children in India is among the highest in the world, and is nearly double that of Sub- saharan Africa.

NFHS Stunted Wasted Under Weight

NFHS-3 (2005-06)

Total 38.4 19.1 45.9

Urban 31.1 16.9 36.4

Rural 40.7 19.8 49.0

NFHS-2 (1998-99) NA NA 46.7

NFHS-1 (1992-93) NA NA 51.5

UNDERNUTRITION- INDIA

Trends in prevalence according to NNMB

78.6

18.1

77.5

65.1

19.9

68.663

16.7

63.6

Stunted wasted underweight

NNMB(1975-1979)

NNMB(1988-1990)

NNMB(1994)

Stunted WastedUnder Weight

Bihar

NFHS-4 (2015-16)

Total 48.3 20.8 43.9

Urban 39.8 21.3 37.5

Rural 49.3 20.8 44.6

NFHS-3 (2005-06)

Total 42.3 27.7 58.4

Urban 31.9 28.8 51.5

Rural 43.7 27.5 59.3

UNDERNUTRITION- BIHAR

Prevalence of Under-nutrition in children (0-5 Years)

55 54 54 52 51

37

27

DATA SOURCE- NFHS-3

Micro nutrient deficiency( anaemia) India

• The prevalence of anemia among pregnant woman in India is 57.8%. (NFHS-3).

• 69.5% of 6-59 months of children are suffering from iron deficiency anaemia.

Mild Moderate Severe

26.3

40.2

2.9

Micro nutrient deficiency- India

62.00%

35%

70%65% 65%

DATA SOURCE- NFHS-3

Micro nutrient deficiency(Anaemia)-Bihar

NFHS-4 (6-59 months) NFHS-3 (6-35 Months)

Urban Rural Total

75.8

89.087.4

Urban Rural Total

58.8

64.063.5

Micro nutrient deficiency(Anaemia)-Bihar

• In Bihar 78% of 6-59 months of children have some anaemia.

Mild Moderate severe

29.60%

46.80%

1.60%

DATA SOURCE- NFHS-3

Nutritional Status Of Pregnant Women and Children- India

58.861.7

58.7

22.2

6458

60.5

31.8

63.558.3 60.3

30.4

CHILDREN( 6-35) ANAEMIC PREGNANT WOMEN EVER MARRIED WOMEN(15-49)

BMI BELOW NORMAL

URBAN RURAL TOTAL

DATA SOURCE- NFHS-3

Nutritional Status Of Pregnant Women and Children-Bihar

DATA SOURCE- NFHS-3

75.8

66.4 68.8

25.1

89

59.468.2

45.9

87.6

60.268.3

43

CHILDREN( 6-35)ANAEMIC

PREGNANT WOMEN EVER MARRIEDWOMEN( 15-49)

BMI BELOWNORMAL

URBAN RURAL TOTAL

58.861.7

58.7

22.2

6458 60.5

31.8

63.558.3 60.3

30.4

CHILDREN( 6-35)ANAEMIC

PREGNANT WOMEN EVER MARRIEDWOMEN( 15-49)

BMI BELOWNORMAL

URBAN RURAL TOTAL

DATA SOURCE- NFHS-4

Nutritional Status Of Pregnant Women and Children-Bihar

Prevalence Of Severe PEM( NFHS-2)

Prevalence % States

≤5 Kerela, Goa, Sikkim

6 to 9J/K, Punjab, AP, manipur, Nagaland

10 to 18

Delhi, haryana, HP, WB , Assam, Meghalaya, Andhra Pradesh, Karnatka, Tamilnadu

>20Rajasthan, Bihar, Odisha, MP,UP

Measuring child Nutrition

• Anthropometric Measurements are mainstay of assessment of PEM/ Undernutrition/ Overnutrition. These are-

1. Weight for age

2. Height for age

3. Weight for height

Measuring child Nutrition

4. MUAC( Mid upper arm circumference)

5. Underweight

6. Stunting

7. Wasting

Causes Of Under nutrition

1. Early marriage and teenage Pregnancy

2. Low Birth weight

3. Infant feeding Practices

4. Infections and Environment

Causes Of Under nutrition

5. Birth Interval

6. Maternal education

7. Food security

8. Intra household food security

1. Early marriage and teenage Pregnancy

• The majority (53.4%) of rural women in India were married before they turned 18 years (NFHS-3).

• According to DLHS-3( 2007-08) 43.7% of girl’s marry before 18 years in Katihar District.

• In urban areas of India, the women marries before 18 years id 30%.

Teenage Pregnancy In India( 2005-06)

14.5

4.6

19.1

6.3

2.4

8.7

Have had a live birth Pregnant women with firstchild

have begun child bearing

Rural Urban

DATA SOURCE- NFHS-4

2. Low Birth Weight

• In India, nearly 22% (NFHS-2) of newborns have LBW.

• Males have less frequency of LBW than females.

• The North-east zone has the lowest prevalence of LBW while the north zone has the highest.

• Mother's education, access to TV and nuclear family, and intake of iron tablets are the most important socio-economic influences on the determination of birth weight in India.

3. Infant Feeding Practices

• In India only 23.4% (NFHS-3) of newborn babies are put on breast feeding within one hour of Birth.

• Only 37% of mothers initiated breastfeeding within one day.

• According to IRMS, in Bihar about 29% of mother started breast feeding within in 24 hours.

28.9

40.3

21.5

48.3

23.4

46.3

CHILDREN BREASTFED WITHIH ONEHOUR OF BIRTH

CHILDRN EXCLSIVELY BREASTFED

URBAN RURAL TOTAL

Infant Feeding Practices- India

DATA SOURCE- NFHS-3

Infant Feeding Practices- Bihar

6

31.6

44.2

3.8

27.3

58.3

4

27.9

57.3

Children under age 3 yearsbreastfed within one hour

of birth(%)

Children under age 6months exclusively

breastfed(%)

Children age 6-8 monthsreceiving solid or semi-solid

food and breastmilk %

Urban Rural Total

DATA SOURCE- NFHS-3

Infant Feeding Practices- Bihar

41.846.8

41.2

34.2

54.2

29.534.9

53.5

30.7

Children under age 3 yearsbreastfed within one hour

of birth(%)

Children under age 6months exclusively

breastfed(%)

Children age 6-8 monthsreceiving solid or semi-solid

food and breastmilk %

Urban Rural Total

DATA SOURCE- NFHS-4

Complementary feeding practices-India

• Protein Energy Malnutrition ( PEM) is much more common in age group of 6-24 months.

• The obvious reason is delay in the weaning-complementary feeding in young children 9 month or beyond.

• Only 55.8% of breast fed children aged 6-9 months received solid – semisolid food.

DATA SOURCE- NFHS-3

Complementary feeding practices-Bihar

8.4

11

8.8

7.1

9

7.47.3

9.2

7.5

Breastfeeding children age6-23 months receiving an

adequate diet

Non-breastfeeding childrenage 6-23 months receiving

an adequate diet

Total children age 6-23months receiving an

adequate diet

Urban Rural Total

4. Birth Interval And Under- Nutrition

• Studies shows that prevalence of Under-Nutrition was higher when interval between two births were less that 2 years.

• Young children in family with four or ore siblings were nutritionally the most disadvantaged as observed in several studies.

• Deprivation of maternal care is also found in large family.

• Female infants receive less attention than male, especially where there is already several female children.

5. Maternal Education and Under-Nutrition

50.3

4.8

15.1

46.9

0.4

12.9

42.9

3.7

11.8

41.7

2.47.3

22.9

2.16.7

Stunted Wasted LBW

No education Junior primary Senior Primary

Junior Secondary senior Secondary

The Impact of Maternal Education on Child Nutrition: Evidence fromMalawi, Tanzania, and Zimbabwe- Demographic and Health Survey 2013

6. Food Security

1950-51 1965 2008 2015-16

50.82

89

230

253.6Food Production in India (MT)

• Spite of sufficient buffer stock, there is 26% of population is still living below poverty line .

• Most ST and 40% of SC casual workers are poor, the landless casual workers being the poorest.

• Other Reasons are unfair/unequal distribution of food, land wealth, less purchasing power and Unemployment.

6. Food Security

• Though food production has been increase through Green/white/ yellow revolutions, the level of chronic food security in India is still high.

• The increase in population size, low literacy level, recurrent drought conditions, increasing unemployment , and decreasing household food security status contributing to the dilution of effect of development.

6. Food Security

7. Intra household Food security

• Food Security defined as physical, economic and social access to balanced diet, safe drinking water, environmental hygiene, and Primary Health Care (M S Swaminathan) .

• Household food security means “ the access of all people to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.


• Household food security has four basic components, availability, accessibility, utilization and stabilization.

• Unequal distribution of food between Male, Female and children in family .

• The reasons are lower status of women in family, ignorance about child feeding, low literacy, lack of awareness and poverty.

• 60% of farmers on an average own 0.4 hectare while 20% holds 1.4 hectare.

• Such a meager land holding by large majority of farmers is neither viable nor sustainable.

• The average land holding per head among rural farmers in developing countries declined from3.6 hectares in 1972 to 0.26 hectares in 1992 and continue to fall.


• The current wave of globalization and linearization contribute to increase inequalities with in both developing and developed countries.

• The organization for economic cooperation and development ( OECD) controlled 90% of global seed market.

• From1970to1996 OECD share of the volume of world cereal export rose from 73 to 82%, making US major exporter of commercial crops.


Prevention and control of under nutrition

1. Feeding practices of infant and young children

2. Immunization

3. Control of infection

4. female literacy

5. Population control and stabilization

6. School health programmes


7. Supplementary feeding programmes through ICDS.

8. Growth monitoring and promotion .

9. Food production and distribution.

10.Public distribution system( PDS)/Annapurna Yojana

11.Employment guarantee act and scheme.

12.Fight against hidden hunger.

1. Feeding practices of infant and young children- EBF

• Initiation of breastfeeding within the first hour of life

• Exclusive breastfeeding – that is the infant only receives breast milk without any additional food or drink, not even water

• Breastfeeding on demand – that is as often as the child wants, day and night

• exclusive breastfeeding for 6 months is the optimal way of feeding infants.

• Thereafter infants should receive complementary foods with continued breastfeeding up to 2 years of age or beyond.

Feeding Practices- Complementary feeding

• The adequacy of complementary feeding (adequacy in short for timely, adequate, safe and appropriate) not only depends on the availability of a variety of foods in the household, but also on the feeding practices of caregivers.

• Feeding young infants requires active care and stimulation, where the caregiver is responsive to the child clues for hunger and also encourages the child to eat.

• This is also referred to as active or responsive feeding.

Feeding Practices- Complementary feeding

• WHO recommends that infants start receiving complementary foods at 6 months of age in addition to breast milk, initially 2-3 times a day between 6-8 months,

• increasing to 3-4 times daily between 9-11 months and

• 12-24 months with additional nutritious snacks offered 1-2 times per day, as desired.

National Guidelines on infant and Young child feeding

1. Early initiation of breast feeding within half an hour of birth .

2. Feeding Of Colostrums.

3. Exclusive breastfeeding for first six months.

4. Introduction of complementary feeding after six months.

5. Staple cereal of the family should be used to make the first food for infant.


6. Encourage foods which are routinely cooked in family.

7. Energy density of infant food should be increased by adding tea spoonful of oil or ghee in every feed or by adding sugar and jaggery.

8. Infant and young children should fed 5-6 times a day.


9. Continue breast feeding up to age of two years or beyond.

10.Appropriate feeding during or after illness.

11.Growth monitoring and promotion.

12. Feeding in difficult circumstances.


13.HIV and Breast feeding-WHO recommends that all mothers, regardless of their HIV status, practise exclusive breastfeeding – which means no other liquids or food are given – in the first six months.

• After six months, the baby should start on complementary foods.

• Mothers who are not infected with HIV should breastfeed until the infant is two years or older.

2. Immunization

• Children should be given all recommended vaccine according to Immunization schedule (UIP).

• Vitamin A should be given with first dose of Measles vaccine.

3. Control Of Infection

• Washing of hands, clean food, use of safe drinking water, safe disposal of human excreta prevent diarrheal diseases, worm infestations.

• Home available foods, ORS, Zinc and breastfeeding , if child develops diarrhea.

• Increase frequency of feeding after diarrhea helps catch-up growth in young children.

• Deworming is also essential.

Nutrition of adolescents, pregnant women and lactating mothers

• Nutrition education

• Supplementation of IFA tablets to adolescents.

• Right age of marriage and adequate nutrition of pregnant women/ supplementation of IFA

• Adequate nutrition of lactating women ensure adequate breast milk, essential for child survival, growth and development.

4. Female literacy

• Female literacy is first determinant of child under nutrition .

• it is inter-linked with various factors like nutrition, maternal health, anaemia control, spacing of pregnancies and antenatal care., hygiene and sanitation, immunization and accessing health services.

Women literacy Rate improved

8.86

15.35

21.97

29.76

39.29

54.16

65.46

0

10

20

30

40

50

60

70

1951 1961 1971 1981 1991 2001 2011

FEMALE LITERACY RATE

Female literacy

• The bold decision to declare “ education as the fundamental right” in April 2010 ensure the free and compulsory education to fulfill the constitutional commitment of “education for all”.

• Effort is being made to reach the unreached women and children through “ sarva shikshaAbhiyan( SSA) launched in 2001.

5. Population control and stabilization

• India was the first country in the world to have launched a National Programme for Family Planning in 1952.

• currently being repositioned to not only achieve population stabilization goals but also promote reproductive health and reduce maternal, infant & child mortality and morbidity.

• NPP (2000) agenda was to bring down birth rate to 2.1 by 2010.

6. School Health programme

• School Health program is a program for school health service under National Rural Health Mission, cover 12,88,750 Government and private aided schools covering around 22 Crore students all over India.

Components of School Health Program

1. Screening, health care and referral

• Screening of general health, assessment of Anaemia/Nutritional status, visual acuity, hearing problems, dental check up, common skin conditions, Heart defects, physical disabilities, learning disorders, behavior problems, etc.

• Basic medicine kit will be provided to take care of common ailments prevalent among young school going children.

• Referral Cards for priority services at District / Sub-District hospitals


2. Immunisation:

• As per national schedule

• Fixed day activity

• Coupled with education about the issue

3. Micronutrient (Vitamin A & IFA) management:

• Weekly supervised distribution of Iron-Folatetablets coupled with education about the issue

• Administration of Vitamin-A in needy cases.


4. De-worming

• As per national guidelines

• Biannually supervised schedule

• Prior IEC

• Siblings of students also to be covered


5. Health Promoting Schools• Counseling services• Regular practice of Yoga, Physical education,

health education• Peer leaders as health educators.• Adolescent health education-existing in few

places• Linkages with the out of school children• Health clubs, Health cabinets• First Aid room/corners or clinics.


6. Capacity building

7. Monitoring & Evaluation

8. Mid Day Meal

Mid day Meal Scheme/Programme

The objectives of the mid day meal scheme are:1. Improving the nutritional status of children in

classes I – VIII in Government, Local Body and Government aided schools, and EGS and AIE centres

2. Encouraging poor children, belonging to disadvantaged sections, to attend school more regularly and help them concentrate on classroom activities.

3. Providing nutritional support to children of primary stage in drought-affected areas

7. Supplementary Feeding Programme through ICDS

• The Supplementary Nutrition is one of the six services provided under the Integrated Child Development Services (ICDS) Scheme which is primarily designed to bridge the gap between the Recommended Dietary Allowance (FDA) and the Average Daily Intake (ADI).

• Supplementary Nutrition is given to the children (6 months – 6 years) and pregnant and lactating mothers under the ICDS Scheme.

Revised feeding and cost norms

World Food Program (WFP)

• The world Largest food aid organization working with goal “ a world in which every man, woman and child has access at all times to the food needed for an active an healthy life”

• In India under a new country strategic plan 2015-18, WFP supporting the GOI under national food security act ( NFSA), including ICDS Scheme/MDM Programme/TDPS.

Management of children with SAM

• Severe acute malnutrition (SAM) can be categorized into:

1. SAM with medical complication.

2. SAM without medical complication.

• Nutrition rehabilitation centers( NRC) has been established for SAM at district level.

• Community based programme should be in place.


8. Growth monitoring and promotion .

children below the age of three year weighed

once in month and 3-6 years, once in three

month.

9. Food production and distribution.

Graduating from “ food security” to “ household food security” to “Nutrition and health security” of all.

10. Public distribution system evolution

1. Public distribution System ( 1960)2. Revamped Public Distribution System (RPDS)

was launched in June 1992 in 1775 blocks throughout the country.

3. Targeted Public Distribution System (TPDS) was introduced with effect from June 1997.

4. Antyodaya Anna Yojana” (AAY) was launched in December, 2000 for one crore poorest of the poor families.

5. Food security bill ( 2013)

Annapurna Scheme

• To providing food security to meet the requirement of those senior citizens who though eligible have remained uncovered under the National Old Age Pension Scheme.

• The target group receives 10 kgs of food grains per month free of cost.

• Gol has fixed a numerical ceiling of 64,800 beneficiaries under the scheme for the entire State.

• Target Group:Senior citizens of 60 years and above, who are eligible for all old age pension schemes, but not covered under the same.

•The Mahatma gandhi National

Rural Employment Guarantee

Act (MNREGA) is an Indian job

guarantee scheme, enacted by

legislation on August 25, 2005.

•The scheme provides a legal

guarantee for one hundred days

of employment in every

financial year to adult members

of any rural household willing to

do public work-related unskilled

manual work at the statutory

minimum wage of 120 (US$2.43)

per day in 2009 prices.

11. Mahatma Gandhi national rural employment gurantee act and scheme

DID

YO

U K

NO

W ?

What are the Unique Features of NREGA?

•Time bound employment guarantee and wage payment within 15 daysIncentive-disincentive structure to the State Governments for providing employment as 90 per cent of the cost for employment provided is borne by the Centre •payment of unemployment allowance at their own cost and emphasis on labour intensive works prohibiting the use of contractors and machinery.•The Act mandates a 33 per-cent participation for women.

WORKING GROUPS IN PER-CENT

4036

26

62

0

10

20

30

40

50

60

70

women SC ST SC/ST

12. Fight against Hidden Hunger( Micronutrient deficiency)

• Should focus on food based approach rather than food fortification.

• Micronutrient supplementation programme of Vit-A and IFA should be focused and targeted to 1-3 years children.

• Universal Iodized salt consumption should be strived.

Summary

• Integrated health, nutrition, educational approach.

• Convergence of ICDS/self help groups/ village panchayat at village level.

• EBF/supplementary feeding

• Eating clean/immunization/response to infections.

• Supporting mothers and building their capacities at household level.

BYE !THANKS!

Health & Medicine

Under nutrition in young children - India