General information on child nutrition
OBJECTIVES
SKILL DEVELOPMENT FOR
WEIGHING PREGNANT WOMEN AND PRESCHOOL
CHILDREN
DETECTION OF UNDERNUTRITION AND GROWTH
FALTERING IN CHILDREN
NUTRITION AND HEALTH EDUCATION FOR
PREVENTION AND MANAGEMENT OF UNDERNUTRITION
IN CHILDREN
Why focus on under-nutrition in early
childhood?
Under-nutrition in early childhood will
adversely affect their growth, development and
health status during childhood and adolescence
influence their nutrition and health status
through out their life span
may render them more susceptible to overnutrition and non communicable disease risk in
adult life
100
Trends in prevalence (%) of
undernutrition in children
60
80
Trends in prevalence (%) of
severe undernutrition in
children
%
50
60
%
40
30
40
20
20
10
0
75- 88- 96- 00- 0479 90 97 01 05
NNMB
Underw eight
92- 98- 0593 99 06
0
7579
8890
NFHS
Stunting
Wasting
9697
0001
0405
NNMB
Underw eight
9293
9899
NFHS
Stunting
Wasting
Over years there has been a decline in severe and
moderate under nutrition (weight-for-age and heightfor-age) but not in wasting (weight-for-height).
Over the last 15 years there has been a decline in
stunting and underweight.
In the last five years there had been no decline in
underweight rates (NFHS2-NFHS3), stunting rates had
shown substantial decline and wasting rates have
shown an increase.
Prevalence of undernutrition
% prevalence
NFHS1
NFHS 2
NFHS3
60
50
40
30
20
10
0
INDIA
West
Bengal
Orissa
Delhi
Manipur
Punjab
Kerala
Jammu &
Kashmir
Under-nutrition rates in Delhi has not shown any reduction
in the last two decades.
Several small and medium sized states have lower
undernutrition rates than Delhi
Beginning of under-nutrition: in utero
Nutritional status during infancy
Nutritional status in early childhood
Detection of undernutrition
Under-nutrition begins in utero
Undernutrition in infancy
WHO <-2SD
%prevalene
50
40
30
20
10
0
at birth
0to2
3to 5
6to 8
9to11
age in m onths
One third of Indian infants weigh below 2.5kg at
birth.
Prevalence of preterm births is about 12%.
Majority of LBW babies are mature but had poor
intrauterine growth.
Birth weight and maternal nutrition
3100
3000
2900
2800
2700
2600
2500
2400
2300
2200
Source: Tenth Five Year Plan 2002
60
50
40
30
20
10
0
< 16
16-17
17-18.5
18.5-20
20-25
> 25
BMI (Kg/m2)
Mean Birth Weight (g)
Prevalence of LBW (%)
Low maternal pre-pregnancy weight & low weight
gain in pregnancy result in lower birth weight.
Increased food intake (?Food grain supplements to
underweight women) and reduction in work load can
improve pregnancy weight gain & birth weight.
Prevalence of Anaem ia (%){DLHS 2003}
Anaemia begins in
childhood, worsens
during adolescence
in girls and gets
aggravated
in
pregnancy.
Percentage
100%
80%
60%
40%
20%
0%
preschool
children
adolescent girls
pregnant w omen
Group
moderate
mild
Anaemic women
deliver infants with
lower birth weight.
Effective treatment
of
anaemia
improves
birth
weight.
no anaemia
Maternal Hb and Birth w eight (g)
Birthweight(G)
severe
3000
2900
2800
2700
2600
2500
2400
<8.0
8.0 – 11.0
H b ( g/ dl )
>11.0
Antenatal care for improving birth weight
Weigh all pregnant women
Provide advise regarding diet and physical activity
based on their nutritional status,
Identify those weighing < 45 kg; NE to increase
dietary intake and/or reduce physical activity. If
needed provide monthly food grain supplements so
that they can consistently improve food intake
throughout pregnancy,
Provide universal adequate antenatal care,
Identify and treat anaemic women appropriately
Detect and treat antenatal problems,
All these can be effectively implemented through
convergence between ICDS & NRHM.
This opportunity should be fully utilised.
Nutritional status during infancy
Prevalence of undernutrition in infancy (WHO 2006 <-2SD)
DLHS 2002-04
% under nourished
50
40
30
20
10
0
0to2
3to 5
6to 8
9to11
Age (m onths )
Most women exclusively breast feed in the first three
months. Exclusive breast feeding provides adequate
nutrients, prevents infection and promotes normal
growth.
As a result prevalence of under-weight in first three
months is 30% (same as low birth weight
prevalence).
Prevalence of undernutrition in infancy ( WHO 2006<-2SD)
% under nourished
50
40
30
20
10
0
0to2
3to 5
6to 8
9to11
Age(m onths )
After 3 months underweight rate rises – due to
early introduction of milk supplements and higher
morbidity rates due to infections,
Between 6 and 11 months underweight rate further
rises to 45% - partly due to inadequate
complementary feeding and partly due to increase in
morbidity due to infections.
Birth weight and growth during infancy
Birth weight is a major determinant of growth in
infancy and childhood. Infants whose birth weight
was low, have a lower growth trajectory.
Nutritional status in early childhood
Undernutrition in childhood
%prevalence
<-2SD WHO
60
50
40
30
20
10
0
0 to5
6to11
12to 17
18to23
24 to
35
36 to-59
age (mth)
Progressive increase in the underweight rates in 12 to 24
months of age is attributable to decreasing breast milk intake
and inadequate intake of family food,
Nutrition education that children in 12- 23 month age group
should continue to be breast fed and given modified family
food 4-5 times a day, will go a long way in reducing the undernutrition in this age group.
Mean Energy Consumption - NNMB 2000
Age groups
Males
Kcals
Females
RDA % RDA Kcals RDA % RDA
Pre-school
889
1357
65.5
897
1351
66.4
School Age
1464
1929
75.9
1409
1876
75.1
Adolescents
Adults
2065
2226
2441
2425
84.6
91.8
1670
1923
1823
1874
91.6
102.6
The gap between RDA and the actual energy intake
is greatest in preschool children and lowest in
adults.
Lack of knowledge and poor child feeding/ caring
practices rather than poverty appear to be the major
factors for low energy intake in children.
Dietary Intake
Adult Male
Adult Female
Preschool Children
+++
Adequate
Adequate
Adequate
++-
Adequate
Adequate
Inadequate
---
Inadequate
Inadequate
Inadequate
Over years there has been an increase in the
number of households where adults are getting
adequate food but children are not. There is an
urgent need to focus on nutrition and health
education on child feeding & caring practices to
improve dietary intake in preschool child.
Prevention of under nutrition in 0–60 months
Nutrition education is the critical intervention
Exclusive breast feeding for first six months,
Appropriate adequate complementary feeding 3-5
times a day from six months of age,
Continued breast feeding and feeding family food
4-5 times a day upto 24 months,
Feeding 2-5 year old children 4-6 times a day from
family food consisting of cereals, pulses and
vegetables.
Advise regarding timely immunisation, measures
to prevent infections, care during illness and
convalescence.
Detection of undernutrition
DETECTION OF UNDER NUTRITION
At least once in three months all children should
be weighed (provision for functional balances).
All AWW should be trained in
checking the accuracy of the balance,
correctly weighing the children,
plotting the weight in the child’s card (cards
should be made available for every child), and
assessing child’s nutritional status
informing the mother about the child’s
nutritional status, and
providing her appropriate advise on feeding
and care, based on the age, feeding practices
and nutritional status of the child.
Assessment of nutritional status
Weight-for-age is most widely used index for
assessment of nutritional status in children in all
settings – hospitals to anganwadi.
In India, three standards for weight for age are being
used for assessing & reporting under-nutrition
IAP standards
programme,
–
currently
used
in
ICDS
WHO/NCHS standards: Used in NNMB, NFHS
and DLHS,
WHO (2006) used in NFHS-3 and DLHS – 2.
Prevalence of moderate and severe undernutrition in
DLHS using WHO (2006), NCHS and IAP norms
70
60
%
50
40
30
20
10
0
0-2
WHO
3-5
NCHS
6-8
IAP
9-11
12-14 15-17 18-20 21-23 24-35 36-60
Age in months
Prevalence of under-nutrition 0-12 and 13-60 months
%
(All India – DLHS 2 - NIHFW)
60
50
40
30
20
10
0
WHO 2006
NCHS
<1yr
IAP
WHO 2006
NCHS
>13 mths
IAP
There are substantial differences in prevalence of
under-nutrition as assessed by the three standards
These vary with age of the child.
Use of multiple standards in different reporting
systems has created a lot of confusion.
Government of India has decided to hence forth
use the WHO 2006 standards in ICDS as well as
health care settings .
NORMAL
MODERATE
UNDERNUTRITION
SEVERE
UNDERNUTRITION
To sum up
Low birth-weight rate in India is 30% could be
reduced through better antenatal care
Prevalence of under-weight in first three months is
30%- exclusive breast-feeding prevents deterioration
in nutritional status.
After 3 months underweight rate rises – due to
introduction of milk supplements & infections.
Between 6 and 11 months underweight rate further
rises to 45% - due to inadequate complementary
feeding & infections.
Poor infant feeding and caring practices are major
determinants of underweight in infancy; nutrition
education and health care can prevent the rise in
under-nutrition rates.
Progressive increase in the underweight rates in
12 to 24 months of age – mainly attributable to
inadequate intake of family food due to poor child
feeding practices. Nutrition education to correct
these faulty habits is the critical intervention
needed.
Further rise in under-nutrition rates is mainly
due to poor intra-family distribution of food;
nutrition education to parents that children have
small stomach capacity and have to be fed 5-6
times a day to fully get adequate food intake will
improve dietary intake and nutritional status .