Prevention of childhood malnutrition dr harivansh chopra

Prevention of Childhood
Malnutrition
Dr. Harivansh Chopra,
DCH, MD
Professor,
Department of Community Medicine,
LLRM Medical College, Meerut.
DDrr.. HHaarriivvaannsshh CChhoopprraa

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.
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? ?
Whether this child will grow normally
or become malnourished?

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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”.

Nutritional Status of children
below 3 years : NFHS II
46 47
16
50
45
40
35
30
25
20
15
0 510
Percentage
Stunted Underweight Wasted

Nutritional Status of children
below 3 years : NFHS II
Percentage Stunted Underweight Wasted
35.6
48.6
38.4
49.6
13
16.2
50
40
30
20
10
0
Urban Rural

Nutritional status of under-three
children in relation to living index
26.8
46.8
56.9
28.5
45.3
53.7
10.2
HIGH
MEDIUM
LOW
14.3
19.7
60
50
40
30
20
10
0
Percentage
UNDER WT STUNTED WASTED
NFHSII

Nutritional status of under-three
children in relation to age
Percentage Underweight Stunted Wasted
30.9
37.5
11.9
58.5 58.4
15.4
57.5 56.5
9.3
13.2
21.9
13.2
60
50
40
30
20
10
0
< 6 months
6 - 11 months
12 - 23 months
24 - 35 months

Percentage of underweight children –
Comparison between NFHS I & II
52
47
NFHS I
NFHS II
20 18
60
50
40
30
20
10
0
Percentage
Underweight Severely Underweight

Nutritional Status of children below
3 years : NFHS III
38
46
19
50
45
40
35
30
25
20
15
0 510
Percentage
Stunted Underweight Wasted

Nutritional Status of children below
3 years : NFHS III
Percentage Stunted Underweight Wasted
31.1
40.7
36.4
49
16.9
19.8
50
40
30
20
10
0
Urban Rural

Percentage of underweight children –
Comparison between NFHS II & III
47 46 46
38
16
NFHS II
NFHS III
19
50
45
40
35
30
25
20
15
10
5
0
Percentage
Underweight Stunted Wasted

Distribution of 1-5 years children
(Gomez classification)
Income
Weight 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
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Causes of Malnutrition
1. Inadequate Food Security.
2. Infection.
3. Low weight of adolescent girls.

4. Low Immunization coverage.
5. Maternal Anemia.
6. Low literacy level in female.

7. Poor sanitary conditions.
8. Low birth weight.
9. Lack of knowledge regarding
normal growth of children.

10. Poor hygiene.
11. Incorrect child rearing practices.
12. Inaccessible and Inadequate
health services.

13. Lack of Comprehensive Child
Health Care Programme.
1. Lack of political will.

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.

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.

The BIGWIN Approach
Exclusive Breast Feeding for 6 months.
Infection Prevention/Treatment and Immunization.
Growth Promotion / Monitoring.
Appropriate Weaning Practice. Safe Water
Iron Supplementation.
Nutrition education & Extra-Nutrition in
pregnancy & lactation, and illness in child.
No to next pregnancy.

Weight gain in the first
five years of life
1st Year 2 - 5 years
8
8
Kg.
Kg.

Weight gain in the first year of life
First 4 months Next 8 months
4
4
Kg.
Kg.

Weight gain in the next
four years of life
2nd Year 3rd Year 4th Year 5th Year
2
2
2
2
Kg.
Kg. Kg.
Kg.

v/s
Monitor the Weight
FI
RS
T
S
E
C
OND
Weight gain in 1st year of life.
Weight gain in next 4 years of life.

Exclusive Breast Feeding in India –
NFHS II
Exclusive Breast Feeding Not Exclusively Breast-fed
45
55

Exclusive breast feeding upto
4months

Immunization Coverage
Percentage BCG DPT 3
62.2
71.6
51.7
65.1
53.6
62.8
42.2
50.7
NFHS I
NFHS II
35.5
42
80
70
60
50
40
30
20
10
0
doses
OPV 3
doses
Measles All
Vaccines

Immunization Coverage
71.6
78.2
55.1 55.3
62.8
78.2
50.7
58.8
NFHS II
NFHS III
42 43.5
80
70
60
50
40
30
20
10
0
Percentage
BCG DPT 3
doses
OPV 3
doses
Measles All
Vaccines

Anemia in Children
31
62
7
Mild Moderate Severe

AAnnaaeemmiiaa aammoonngg CChhiillddrreenn AAggee 66--3355 MMoonntthhss
74
79
4 5
90
80
70
60
50
40
30
20
10
0
Any anaemia Severe anaemia
NFHS-2 NFHS-3
Percent

Iron Supplementation v/s
Iron Therapy – Cost
Iron Supplementation Iron Therapy
30
70

The BIGWIN Approach
Exclusive Breast Feeding for 6 months.
Infection Prevention/Treatment and Immunization.
Growth Promotion / Monitoring.
Appropriate Weaning Practice. Safe Water
Iron Supplementation.
Nutrition education & Extra-Nutrition in
pregnancy & lactation, and illness in child.
No to next pregnancy.

Empowering Women
Poor Perpetually Pregnant female
Powerful Perceptive Problem-solving

Empowering Women
1. Mass Media
2. Government Health System
3. Mahila Mandals

Empowering Women
4. NGOs
5. Link Women
6. Anganwadi

Empowering Women
7. Health Worker
8. School Health
9. BFCI

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.

Nutrition Education
3. 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.

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.

Nutrition Education
7. Vulnerable periods of life, specially
infancy, pregnancy, and lactation must be
taken into account.

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.

Principles of Nutrition Therapy
1. Mild to moderate
degree of
malnutrition can
be managed at
home.

Principles of Nutrition Therapy
2. 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.

Management of mild to moderate
degree of malnutrition
This is usually done
with the help of
protein and calorie
rich diets.

1. Besan Panjiri
1. Contents – Bengal gram flour, Wheat flour, Jaggery, Ghee (1 part each).
+ + +
2. Calories: 500 calorie/100gm.
3. Protein: 9gm/100gm.

2. Shakti aahar
1. Constituents: Roasted wheat 40gm, Roasted gram 20gm, Roasted
peanuts 10gm, Jaggery 30gm.
+ + +
2. Calories: 390 calories/100gm.
3. Protein: 11.4gm/100gm.

3. Hyderabad Mix
1. Constituents: Whole wheat 40gm, Bengal gram 16gm, Groundnuts
10gm, Jaggery 20gm.
+ + +
2. Calories: 330 calories/86gm.

Management of severely
malnourished children
1. With complications,
they should be
hospitalized.
2. Without complications,
put straightaway on
dietary management.

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.

4. Sooji Kheer
1. Constituents: Toned milk 750ml, Sugar 100gm, Sooji 25gm, Oil 5gm
+ + +
(aqua add 1000ml).
2. Calories: 143 calorie/100gm.

Initial Phase
3. Small frequent feeds
given.
4. Intake gradually
increased to 100
Cal/kg/day and 1gm
protein/kg/day.

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.

Initial Phase
6. For enriching milk,
generally coconut oil is
used.
7. Fluids should be given
with cup and spoon;
bottle-feeding best
avoided.

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.

Transfer to Family type diet
1. Child should be taking
nutritionally wholesome
family-type diet (cereals,
pulses, vegetables) before
discharge from hospital.

Transfer to Family type diet
2. Involves nutrition
education of parents.
3. Snacks made from
peanuts, bengal
gram, jaggery, and
oil are useful.

Nutritional Rehabilitation
1. Majority of children, after discharge from
hospital, again become victim of
Malnutrition.
2. To overcome this, Nutritional
Rehabilitation is carried out.

Ambulatory Treatment Rehabilitation in “Nutrition
Rehabilitation Centres”

Ambulatory Treatment
1. 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.

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. 08/29/14 observerzparadise.com 63

Nutritional Rehabilitation Centres
(NRC)
Day care NRCs Residential NRCs

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.

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.

Residential NRCs
1. 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.

Nutrition Supplementation
1. Approach by which both prevention and treatment
of malnutrition can be met.
2. Supplementary food supplies 500 Cal/day and 12 –
15 gm(rs 4) protein/day to children,
3. Severely malnourshied 800 cal/day and 20-25gm
Proteins/day (rs 6)
1. .

Nutrition Supplementation
Pregnant and lactating mothers
600 Cal/day and 18-20 gm
protein/day(rs 5) to mothers
for 300 days in an year

Nutritional Surveillance
1. Surveillance is
defined as “Data
Collection for
Action”.

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. 08/29/14 observerzparadise.com 71

Triple-A approach
ASSESSMENT
of the situation
ACTION
based on the analysis
and available resources
ANALYSIS
of the causes of problem
Perceptions &
Understanding
Resources
Capabilities
Effective
Demand

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.

MCQs
1. 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.

MCQs
2. “Hyderabad Mix”, an energy dense
supplement, used for malnourished
children does not contain :
1. Bengal gram.
2. Groundnut.
3. Soyabean.
4. Jaggery.
Ans. – 3.

MCQs
3. 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.

MCQs
4. NRC is :
1. Nutrition Rehabilitation Centre.
2. Nutrition Rehabilitation Council.
3. Natural Resources Council.
4. Natural Rights of Community.
Ans. – 1.

MCQs
5. 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.

THERAPEUTIC FOOD
The therapy used in this phase is F-75,
a milk-based liquid food containing
modest amounts of energy and protein
(75 kcal/100 mL and 0.9 g protein/100
mL)
and the administration of parenteral
antibiotics.

THERAPEUTIC FOOD
When an improvement in the child’s
appetite and clinical condition is observed,
the child is then entered into phase two of
the treatment. This phase uses F-100 for
feeding the child. F-100 is a “specially
formulated, high-energy, high-protein
(100 kcal/100 mL, 2.9 g protein/100 mL)
milk-based liquid food”.

Prevention of childhood malnutrition dr harivansh chopra

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