A strategy to combat malnutrition
Malnutrition is a great crisis not only in undeveloped or developing countries but it has its spread in developed countries also. In spite of several efforts and schemes, India
Due to several reasons, child deaths due to malnutrition could not be reduced significantly in India
As per World Development Indicators by World Bank, in 2009 Infant Mortality Rate of India
Definitions:
Low Birth Weight: At the time of birth a baby weighing less than 2500 Gms. or 2.5 Kg.
Infant Mortality: Death of child before completing first year of age and infant mortality rate can be calculated as No. of children dying under a year of age, divided by No. of live births during that year multiplied by 1000, i.e,
No. of children died under age of one year
Infant Mortality Rate= __________________________________ X 1000 No. of live birth during the same year
Child Mortality: Death of a child between 1st to 5th year of age and child mortality rate can be calculated as;
No. of children died between 1-5 years of age
Child Mortality Rate= _____________________________________ X 1000 0Total No. of children between 1-5 years of age
Neonatal Mortality: Neonatal Mortality can be defined as death of children within 28 days after birth and neonatal mortality rate can be calculated as
No. of children died under 28 days of age
Neonatal Mortality Rate= _________________________________ X 1000 Total No. of live births
Early Neonatal Mortality (ENM): Early Neonatal period is death of a baby within 7 days after birth and ENM Rate can be calculated as
No. of children died under 28 days of age
ENMR = _________________________________ X 1000 Total No. of live births
Perinatal Mortality (PNM): Death of a foetus after 154 days (22 weeks) of gestation with more than 500 gms. weight till 7 days after birth. It includes still birth as well as early neonatal death and the rate can be calculated as sum of the number of fetal deaths of 22 or more weeks gestation plus the number of newborns dying under 7 days of age divided by the sum of the number of resident live births plus the number of resident fetal deaths of 28 or more weeks gestation multiplied by 1,000.
(Number of fetal deaths 22 or more weeks
gestation + Number of newborns died
under 7 days of age)
PNMR = ___________________________________ X 1000 (Number of live births + Number of fetal
deaths of 22 or more weeks gestation)
Malnutrition: Malnutrition can be easily defined as symptoms of unbalanced intake of any one or more than one nutrient. It might be classified as stunting, wasting and under weight. Deficiency of vitamins and minerals does not always associated with signs of reduction in weight or height stunted and must be analysed with other modes like observation, pathological, etc.
- Stunting: Stunted malnutrition refers to low height-for-age, when a child is short for his/her age but not necessarily thin. It is also known as chronic malnutrition, this type of malnutrition has long-term developmental risks.
- Under weight: Under-weight refers to low weight-for-age, when a child can be either thin or short for his/her age. In general weight for age has been taken to assess status of malnutrition among any one.
- Wasting: Wasted malnutrition refers to low weight-for-height where a child is thin for his/her height. It is also known as acute malnutrition, this type of malnutrition carries increased risk of morbidity and mortality. Wasted children have a 5-20 times higher risk of dying from common diseases like diarrhoea or pneumonia than normally nourished children.
Management of Malnutrition at community level:
In combating or to overrule malnutrition, parents and family of every children has the very first responsibility. After parents and family the next responsibility will be of community and after this Government will be accountable for keeping every child healthy.
Till today it is the responsibility of Government to take responsibility of get rid of malnutrition, but after more than 60 years of independence and in lack of proper implementation of various welfare schemes Government, both Central and State, failed to overcome malnutrition among children. In rural and tribal areas and urban slums parents and family are also unable to manage malnutrition due to several reasons, like, ignorance, poverty, illiteracy, natural calamities, cultural values and customs, etc. Thus, cooperation and monitoring by community is now being felt needed in this regard.
“Prevention is better than cure”
To combat for any situation it is better to try to prevent it at the earliest rather than to be perpetuating it within the system and than to cure it. As per the cost analysis also prevention requires low cost and time than cure. As the prevalence of malnutrition is more likely due to ignorance, poverty, illiteracy, natural calamities, cultural values and customs, etc. community should manage to reduce these situations. We have no command over natural calamities like earthquake, flood, snow fall, etc. but we should try to reduce situation of draught. Thus for reducing malnutrition from the community, members of community should work hard to reduce ignorance and illiteracy in their respective area. They should also try to develop healthy culture and customs. On the issue of malnutrition, every member of Panchayati Raj Institution, community as well as parents and family members of the children as well as adolescent girls and pregnant women and lactating mothers should make efforts for:
· Regular growth monitoring of every children and pregnant women must be carried out at AWCs
· Take measures for every child must be enrolled at AWCs and schools and continue their education.
· Swasthya Gram Samiti should effort for making all people aware about health and nutritional needs of the children as well as women and girls.
· Swasthya Gram Samiti should maintain hygiene and sanitation at surroundings of houses and villages.
· Take care of nutritional requirements of adolescent girls, pregnant women and lacing mothers as well as of children. This can be done by;
o Motivate people of the community to cultivate crops having high nutritional values
o Motivate people to develop surrounding waste land in growing vegetable for their daily uses
o Motivate people to use waste water in water harvesting and increase water level of land to overcome situation of draught.
o Encourage people to use high protein foods like Soyabean, groundnut, etc. those are easily available in their local market.
· Early detection of malnutrition
Malnutrition during childhood is mainly due to lack of protein alone or along with lack of energy. Protein with energy deficiency is being observed at the age of weaning i.e., after 6 months or if they could not provided breastfeeding. When the children do not get enough protein giving foods, their bodies become thin and they feel weak. Major causes of this type of malnutrition are “poverty” and “lack of knowledge” where parents are unable to provide enough quantity of food to fulfill child’s need. Where as deficiency of only Protein is being observed at the age of one year or more and it is mostly due to ignorance and improper diet. This type of malnutrition is being faced by those children whose family has sufficient amount of food but due to ignorance it is lacking in protein. Major difference in both of the malnutrition is that in protein deficiency child looks healthy due to oedema and could not be assessed through Mid Upper Arm Circumference (MUAC) while children facing Protein Energy malnutrition are lean and thin, look old and wrinkled. Other signs of malnutrition are:
Ø Dizziness
Ø Chronic fatigue or lack of energy.
Ø Dry, scaly or flaking skin.
Ø A low immune system which cannot fight off infections and illness.
Ø Loss of weight or being underweight.
Ø Slowed reflexes.
Ø Inattentiveness or trouble remembering.
Ø Stinted growth.
Ø Bloated stomach if malnutrition is severe.
Ø Muscle weakness and trembling.
Ø Hair thin, rare and dull
Ø Skin Wrinkles
Ø Apparent rib,
Ø Cry a lot
Ø Very irritable
Ø Increased greedy appetite
Ø Prone to infections, etc.
For measuring malnutrition among children it is essential to follow weight for age matrix. Now a days WHO recommended new type of growth chart which has only three grades i.e., normal, low weight and very low weight. In other words they are called Normal
Growth charts can only reflect protein and protein-energy malnutrition. For detecting other types of malnutrition we have to observe other clinical symptoms as well as pathological diagnosis can be performed accordingly.
For assessing nutritional status of any child it is essential to find out correct age of child i.e., date of birth of the child. Steps for appropriate plotting of growth chart includes:
1. Finding correct age of the child
If the correct date of birth is known to parents the correct status of child could be easily plotted. Thus it is necessary that right date of birth of each and every child living in the community is to be noted at any place either at AWC or at birth register of Panchayat. If the date of birth is not known in case of any child migrate to the village or locality or whose birth is not taken place at this place than probe parents and with the use of local event calendar probable date, month and year of birth of that particular child could be assessed. Month and year of birth of child is to be written in the first box on the horizontal axis of growth chart and all the other boxes should be filled with the subsequent months.
2. Take correct weight of the child
On vertical axis of the growth chart weight of the child in kilograms is to be noted. To take correct weight of a child it is necessary that:
· Child should wear minimum clothes
· Shoes or sandals should be removed.
· Weighing machine should show “0” before putting child over it
· Dial of the machine will be at eye level of reader
· Reader must stand in front of dial not by side.
· Child’s body must not touch any thing like, floor, wall, etc.
· Weight should be recorded in nearest 50 or 100 gms.
Correct weight of the child should be plotted on horizontal across in the column of corresponding month.
3. Draw the Growth Curve.
Draw a line from the previous dot, if any, to the new one to make the child's growth curve and on the basis of direction of growth curve pattern of growth can be understand.
0 0 0 0
Previous Current Previous Current Previous Current
Months Month Months Month Months Month
(Growth increasing) (Growth stunted) (Weight decreased)
Stunted growth and decrease in weight both are serious signs and need immediate action unless the child can fall into tremendous cycle of malnutrition. Increase in weight is although good but it is not sufficient, it is necessary to find out that whether increase in weight is as per standard weight growth or not.
Age | Weight to be increased |
Birth to 6 months | 600-800 gms per month |
6 months to 12 months | 300-400 gms per month |
1 year to 3 years | 150-200 gms per month |
3 year to 6 years | 125-150 gms per month |
In the growth chart once the month and weight was plot then if the plotted dot comes in green zone it means that the child has normal nutritional status. If the plotted dot comes in yellow zone then the child is moderately malnourished and the child needs attention and good nutritious food at AWC as well as at home also. A dot in red zone should be interpreted as severe malnourished and it is danger sign and child must be referred to health institutions.
Assessment of nutritional status of any child by using weight for age is although authentic but it needs weighing scale, growth charts and special skills. Although assessment of nutritional status through MUAC is quite easy and simple and needs only a small tape but can be used for children between age of 12-59 months and in case of protein energy malnutrition where oedema is main symptom all children came under green zone of tape proving themselves as normal.
Steps for taking the MUAC measurement of a child
- Determine the mid-point between the elbow and the shoulder.
- Place the tape measure around the LEFT arm (the arm should be relaxed and hang down the side of the body).
- Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose.
- Read the measurement from the window of the tape or from the tape.
- Record the MUAC to the nearest 0.1 cm or 1mm.
Interpretation of Mid-Upper Arm Circumference MUAC indicators[1]
- MUAC less than 110mm (11.0cm), RED COLOUR, indicates Severe Acute Malnutrition (SAM). The child should be immediately referred for treatment.
- MUAC of between 110mm (11.0cm) and 125mm (12.5cm), orange colour, indicates Moderate Acute Malnutrition (MAM). The child should be immediately referred for supplementation.
- MUAC of between 125mm (12.5cm) and 135mm (13.5cm), yellow colour, indicates that the child is at risk for acute malnutrition and should be counseled and followed-up by regular growth monitoring.
- MUAC over 135mm (13.5cm), green colour, indicates that the child is well nourished.
Advantages of Mid-Upper Arm Circumference (MUAC) screening
- It is simple and cheap. It can be used by service providers at different contact points without greatly increasing their workload and it can be effectively used by community-based people for active case finding.
- It is more sensitive. MUAC is a better indicator of mortality risk associated with malnutrition than Weight-for-Height. It is therefore a better measure to identify children most in need of treatment.
- It is less prone to mistakes. Comparative studies have shown that MUAC is subject to fewer errors than Weight-for-Height (Myatt et al, 2006).
- It increases the link with the beneficiary community. MUAC screening allows service providers from peripheral health units and from the community to refer children with acute malnutrition to therapeutic or supplementary feeding programs. The MUAC colour coding is easy to understand for the child's care-taker.
Malnutrition itself is not much dangerous but due to malnutrition the child is being easily tacked by infections. In India
Not only protein or energy malnutrition is tolling child’s life but Vitamin A, iron and iodine deficiency might also have risk of life. Not only during childhood, during adolescence and pregnancy if woman suffers from iron deficiency then the baby might be under weight or woman has risk of maternal death due to hemorrhage.
Iron Deficiency Anaemia (IDA)
When people do not get enough iron in their diet or iron taken in diet could not be absorbed by body or people have excessive blood loss due to any reason, their blood becomes weak and cannot carry enough oxygen around the body. Iron Deficiency Anaemia affects women and children in particular, as well as adolescents and the elderly. It makes people feel exhausted and slows down learning in children. Signs of anaemia include a pale tongue and inside of the lips, tiredness and breathlessness.
For prevention of anaemia it is necessary to:
- Increase Iron intake through:
- Iron-rich vegetables like dark green vegetables, millet, rice flakes, beans, pulses, nuts, pumpkin seeds, dates, dried fruits, whole grains and wheat germ.
- Fortified foods available in the market or use of sprinkles.
- Eat Iron rich fruits such as water melon, guava, oranges, lemon or other Vitamin-C sources
- Avoid 'Iron Blockers' like tea, coffee and milk for one hour before and one hour after eating an iron-rich meal.
- Take iron tablets as directed by a health worker:
- Pregnant women should take one tablet of iron and folic acid every day for 100 days, if level of hemoglobin doesn’t come to normal range repeat doe of 100 tablets.
- If any adolescent girls have signs and symptoms of anaemia she should also take one tablet per day for 100 days, if symptoms still persists repeat again for 100 days
- Children 6-24 months should take one dose daily for 6-18 months depending upon prevalence of anaemia.
- Prevent Malaria
- Prevent hookworm by taking de-worming tablets twice a year, wear shoes, dispose off faeces properly, wash hands thoroughly before preparing food and eating
Vitamin A deficiency can occur when people do not eat enough foods containing vitamin A or fat. Vitamin A deficiency can cause night blindness and permanent damage to the eyes, blindness and even death. People at risk from vitamin A deficiency are mostly pregnant and breastfeeding mothers and children.
To prevent Vitamin A Deficiency (VAD):
- Increase Vitamin A intake through consumption of yellow / orange fruits and vegetables and fortified foods available in the market.
- Because Vitamin A is fat-soluble ensure intake of fat and oil in adequate quantity. Good sources of these that can be grown at home include sunflower oil, nuts and seeds (ground-nuts, sesame seeds, round-nuts, sunflower seeds, pumpkin seeds), peanut butter and avocado.
- Infants should be exclusively breastfed for the first six months and continue to be breastfed up to twenty-four months.
- Children from 6 to 59 months should get Vitamin A supplementation orally every 6 months (6 months - 1 year: 100,000 IU; >1 year: 200,000 IU).
Iodine is available in soil and due to this reason, crops sown in the land having iodine contains iodine. Thus, if any geographical area, which does not have any iodine in land, crops cultivated in those land are also lack in iodine. In that condition iodized salt is the only source for fulfilling iodine requirement in such particular area. Iodine deficiency can cause growth problems in children as well as hinder brain development. Iodine Deficiency can lead to different grades of goitre and cretinism. Goitre of Grade 2 level can be characterized by a palpable and enlarged thyroid with neck in normal position. Goitre is highest in adolescence, particularly girls.
For prevention of Iodine Deficiency Disorders (IDD):
- Intake of packed iodized salt.
- Store packed iodized salt faraway from heat and from moisture.
- Add salt before serving the food.
Monitoring of malnutrition by the community:
These are the basics of malnutrition and to get rid of malnutrition now it is essential that every human being play active role in process of prevention, treatment and follow up in their respective areas. For effective monitoring and management of malnutrition community involvement has to be motivated. For this purpose every Panchayat of the State has to be considered as a unit. In every Panchayat, Sarpanch, Panch, Swasthya Gram Samiti, AWWs, ASHA, School Teachers, villagers, relatives and family members of children, adolescent girls, pregnant women and lactating mothers must ensure their own roles then and then only malnutrition can be reduced.
Roles and responsibilities of community members:
Sarpanch and Panchayat:
1. List of all children below 6 years, pregnant women, lactating mothers and adolescent girls in every village of Panchayat
2. List of all malnourished both, Moderate and Severe, must also be kept at Panchayat.
3. Identify and mark houses of malnourished children
4. Ensure regular operation of Anganwadi Centre
5. Ensure availability of functional weighing machines and adequate growth charts at Anganwadi Centres
6. Ensure regular growth monitoring of every children.
7. Track growth of malnourished children and provide support family of malnourished children to reach NRC.
8. Proper follow up of children discharged from NRC.
9. Ensure feeding of nutritious diet to malnourished children through proper guidance to parents and caretakers of such children.
10. Ensure availability and distribution of SNP at AWC
11. Ensure accessibility from every village health institutions.
12. Ensure regular visits of ANM in the area.
13. Every pregnant woman should avail proper antenatal care (3ANC+2 TT+100IFA).
14. Ensure every child birth should take place in health institution and receive assistance from skilled health workers.
15. Ensure proper operation PDS, NREGA, NMBS, JSY, etc.
16. Stop migration through arranging works under NREGA or other Govt. and private jobs.
17. Mothers should avail maternity leave, and arrangement of crèches at/near construction sites to ensure breastfeeding of infants.
18. List all families below poverty line and must ensure their food security.
19. Hygiene and sanitation in Panchayat
20. Availability of safe drinking water
21. Ensure education of every child
22. Ensure availability and consumption of iodized salt
23. Should work for adopting healthy behaviour in the area like, early initiation of breastfeeding, colostrums feeding, exclusive breastfeeding, timely initiation of complementary feeding, balanced diet, consumption of mix variety of food (dal+Rice), (dal+wheat+vegetables), (dal+vegetables), use of locally available nutritious foods like soyabean, drumsticks, etc., proper diet during adolescent, pregnancy and lactating, discrimination towards girls child, immunization, etc.
Swasthya Gram Samiti:
1. List of all children below 6 years, pregnant women, lactating mothers and adolescent girls in the village.
2. List of all Moderate and Severe malnourished children.
3. Identify and mark houses of malnourished children
4. Hygiene and sanitation in the village
5. Availability of safe drinking water to every household.
6. Should work for adopting healthy behaviour in the area like, early initiation of breastfeeding, colostrums feeding, exclusive breastfeeding, timely initiation of complementary feeding, balanced diet, consumption of mix variety of food (dal+Rice), (dal+wheat+vegetables), (dal+vegetables), use of locally available nutritious foods like soyabean, drumsticks, etc., proper diet during adolescent, pregnancy and lactating, discrimination towards girls child, immunization, etc.
AWW:
1. List of all children below 6 years, pregnant women, lactating mothers and adolescent girls should be available.
2. List of all malnourished both, Moderate and Severe, must also be kept at AWC.
3. Identify and mark each and every houses of malnourished children
4. Ensure availability and distribution of SNP.
5. SNP must be provided to all the eligible beneficiaries and it should also to be ensure that the beneficiary should take this SNP in recommended quantity regularly.
6. Caretaker of beneficiary should be informed regarding cooking, serving and other do’s and don’ts regarding SNP in case of Take Home Ration.
7. AWWs should visit house of beneficiaries and inquire about consumption of SNP by beneficiaries.
8. Regular operation of Anganwadi Centre
9. Availability of functional weighing machines and adequate growth charts
10. Regular growth monitoring of every children.
11. On the basis of symptoms early diagnosis and referral of malnourished children and pregnant women should be made.
12. Track growth of malnourished children and provide support to family of malnourished children to reach NRC.
13. Proper follow up of children discharged from NRC
14. Proper maintenance of records
15. Ensure regular visits of ANM in the area.
16. Every pregnant woman should avail proper antenatal care (3ANC+2 TT+100IFA).
17. Ensure every child birth in health institution.
18. Ensure education of every child
19. Create awareness among women and girls of the area regarding
§ Institutional Delivery
§ Hygiene during home delivery
§ Early initiation of breastfeeding,
§ Colostrum feeding
§ Exclusive breastfeeding,
§ Timely initiation of complementary feeding,
§ Balanced diet,
§ Consumption of mix variety of food (dal+Rice), (dal+wheat+vegetables), (dal+vegetables), etc.
§ Use of locally available nutritious foods like soyabean, drumsticks, etc.,
§ Proper diet during adolescence, pregnancy and lactation,
§ Consumption of iodized salt
§ Avoid discrimination towards girls child,
§ Complete immunization,
§ Safe drinking water
§ Hand washing and cleanliness
§ Adopt family planning measures for spacing and limiting family,
§ Proper sanitation, etc.
ASHA:
1. List of all children below 6 years, pregnant women, lactating mothers and adolescent girls should be available.
2. List of all malnourished both, Moderate and Severe, must also be kept at AWC.
3. On the basis of symptoms early diagnosis and referral of malnourished children and pregnant women should be made.
4. Track growth of malnourished children and provide support to family of malnourished children to reach NRC.
5. Proper follow up of children discharged from NRC
6. Encourage kangaroo care of low birth weight babies
7. Refer low birth weight babies with complications to health institutions
8. Proper maintenance of records
9. Ensure regular visits of ANM in the area.
10. Every pregnant woman should avail proper antenatal care (3ANC+2 TT+100IFA).
11. Ensure every child birth in health institution.
12. Ensure education of every child
13. Create awareness among women and girls of the area regarding
§ Promote Institutional Delivery
§ Ensure maintenance of hygiene during home delivery
§ Ensure minimum three visits to the house of a newborn in the area.
§ Ensure early initiation of breastfeeding,
§ Colostrum Feeding
§ Exclusive breastfeeding,
§ Timely initiation of complementary feeding,
§ Encourage use of locally available nutritious foods like soyabean, drumsticks, etc.,
§ Proper diet during adolescence, pregnancy and lactation,
§ Avoid discrimination towards girls child,
§ Complete immunization,
§ Safe drinking water
§ Consumption of iodized salt
§ Hand washing and cleanliness
§ Maintenance of sanitation and hygiene inside houses and surroundings of the houses as well as village
§ Adopt family planning measures for spacing and limiting family, etc.
Villagers/neighbours:
1. Must aware of health status of all children below 6 years, pregnant women, lactating mothers and adolescent girls in their nearby houses.
2. On the basis of symptoms early diagnosis and referral of malnourished children and pregnant women should be made.
3. Track growth of malnourished children and provide support to family of malnourished children to reach NRC.
4. Proper follow up of children discharged from NRC
5. Ensure uptake of proper diet and SNP supplied by AWC by all beneficiaries
6. Ensure regular growth monitoring of all children and track growth of malnourished children
7. Support household of pregnant woman by transportation/finance if needed or can be afforded.
8. Ensure every child birth in health institution.
9. Ensure education of every child
10. Must disseminate information gathered from any sources (audio-visual) regarding health and nutrition
11. Create awareness among women and girls of the area regarding
§ Institutional Delivery
§ Hygiene during home delivery
§ Every pregnant woman should avail proper antenatal care (3ANC+2 TT+100IFA).
§ Early initiation of breastfeeding,
§ Colostrum Feeding
§ Exclusive breastfeeding,
§ Timely initiation of complementary feeding,
§ Use of locally available nutritious foods like soyabean, drumsticks, etc.,
§ Proper diet during adolescence, pregnancy and lactation,
§ Avoid discrimination towards girls child,
§ Complete immunization,
§ Safe drinking water
§ Consumption of iodized salt
§ Hand washing and cleanliness
§ Adopt family planning measures for spacing and limiting family, etc.
If each and every person living in the village, Panchayat, District, State and Country understood self responsibility in prevention and reduction of malnutrition then we can have success.
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