care booklet d
TRANSCRIPT
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AnkurChitkara/CAREIndia
D.Nutrition Essentials
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THE PROBLEM:
INDIA CONTINUES TO
HAVE ONE OF THE
HIGHEST PROPORTION
OF CHILDHOOD
MALNUTRITION IN
THE WORLD
Why malnutrition is a matter
of concern
India continues to have one of the
highest proportions of childhood
malnutrition in the world. There arefar more malnourished children in
India than in any other country. Along
with Pakistan and Bangladesh, India
has one of the highest rates of
malnutrition in the world, much higher
than sub-Saharan Africa.
Malnutrition contributes to 60% of the
10 million deaths globally that occur
every year among children less than
five years of age (Figure 1).
Moderately and severely malnourished
children are five to eight times more
likely to die than are adequately
nourished children. The commonest
immediate causes of death in these
children are infections.
Even children with mild malnutrition
(who form the majority of children in a
typical rural Indian community), have
a greater risk of death than children
who are normally nourished.
The total number of child deaths
attributable to mild and moderate
malnutrition is far greater than those
attributable to severe malnutrition
(Figure 2).
Of children that survive, malnutrition
causes long term ill-effects on growth,
health, and mental and educational
development. Malnutrition thus leads
to decrease in productivity over the
entire life of children who survive
malnutrition.
FIGURE 2
Numbers of Children Affected by Malnutrition
Degree of malnutrition
FIGURE 1Causes of Childhood Deaths
Source: EIP/WHO, Caulfield LE, Black RE; 2000
Mild Moderate Severe
Number
ofchildren
Over 80% of malnutrition-linked deaths
are due to mild and moderate forms of
malnutrition not grades 3 and 4
Malaria 8 %
Perinatal
22 %
Others
29 %
Diarrhoea
12 %
Pneumonia
20 %
Measles 5 %
HIV/AIDS 4%
Deaths
associated withundernutrition
60 %
Source: Pelletier et al, Bulletin of the World Health Organisation; 1995
Well nourished child.
AnkurChitkara/CAREIndia
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Malnutrition (Undernutrition,
Inadequate Growth)1
What is malnutrition?
Malnutrition refers to either a
deficiency or an excess of one or moretypes of nutrients absorbed by the
body, and to the effects of this
abnormality. Deficiency, which is the
major public health problem, is
referred to as under-nutrition,
excess is referred to as over-
nutrition.
In the context of children in
developing countries, malnutrition
refers mainly to under-nutrition, andmost often presents as inadequate
growth or anemia, or both.
The immediate reason for inadequate
growth is a deficiency of basic
elements of a diet, made worse by
infections of different kinds, at a very
crucial period in the growth of the
infant and young child. Along with
inadequate growth, the child may have
symptoms and signs of deficiencies in
specific nutrients, such as anemia,
from iron deficiency, and night
blindness, from Vitamin A deficiency.
Even children who are otherwise
growing well can develop specific
nutrient deficiencies. Some of these
specific deficiencies will be discussed
in another section.
How do we recognize inadequate
growth in young childrenAs with other matters, all children are
not equal in growth. Some are shorter,
some taller, some lighter, some heavier
than other children of the same age,
even though they are all equally
healthy. Such differences are inherent
differences between individuals, and
the differences remain even when
children get the best of nutrition and
health care.
Thus, healthy and well-nourished
children of the same age can have a
range of different weights and heights,
all of which are normal. Using
weights and heights of a large number
of such well-nourished children, it is
possible to lay down an average, and
upper and lower limits for the height
and weight of normally growing
children of different ages. A child that
falls outside this limit can then be said
to have inadequate growth.
The set of data that describes how
well-nourished children grow is called
a set of standards or reference
values of growth. It is now well
established that all children, in all
populations, almost everywhere in the
world grow very similarly, provided
they are well nourished. Thus, we can
expect that, given adequate nutrition
and care, Indian children should grow
just as well as the well-nourished
children of any other country.
In the ICDS programmme, growth of
children is monitored using such a set
of reference values derived from the
1 Until recently, it was common to refer to this
condition as Protein-Energy Malnutrition or
PEM. Since much more than energy and protein
deficiency contribute to poor growth, the use
of this term is being replaced by terms like
undernutrition or inadequate growth.
These terms are all equivalently used in this
document, as referring to the same condition.
The term specific nutrient deficiency refers
to the prominent deficiency of one single
nutrient. It is uncommon for children to have
purely a single-nutrient deficiency. For
instance, a child with visible anemia from iron
deficiency would usually have deficiencies of
other nutrients as well, although they may be
difficult to recognize.
weights of a well-nourished Americanpopulation2 :
The growth charts maintained in
every Anganwadi center contain
printed graphs or curves showing
how a well-nourished child should
increase in weight over the first
five years of life (Figure 3, page 5).
Each child enrolled in the
Anganwadi has a separate copy of
the chart for tracking growth.
In the chart, the horizontal axis
shows the age in completed
months, and the vertical axis shows
weight in kilograms. Thus, what is
plotted on the graph is the weight
of the child at each age3 .
2 Since the reference values were compiled by
the Harvard University, these are called
Harvard standards.
3 This is weight-for-age. Similarly one could
have growth charts for height-for-age, or for
weightfor-height. While weight-for-age and
height-for-age charts would say how well the
child is growing compared to well-nourished
children of the same age, the weight-for-height
charts can tell whether a child has put on
enough weight for the height that the child has
already gained. The measurement of body
indices such as weight and height for
determining nutritional status is called
nutritional anthropometry.
Wasted and stunted child.
Source: Nutrition in Children. Developing
Country Concerns. Editors: H.P.S. Sachdev,
Panna Choudhury; 1994.
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How do we determine whether a
child is malnourished at any
point in time
The top curve on the ICDS chart
represents the expected lower limit
of the normal range of growth. Any
child whose weight falls below this
line can be said to weigh less than
expected for her or his age and is
thus considered malnourished.
The expected upper limit for weight-
for-age is not shown on the chart,
because excessive weight is not a
public health problem in areas
covered by ICDS.
The expected average weight-for-
age is also not shown on the ICDS
chart. However, the top curve (the
lower limit of normal) is derived
from the average. It is calculated as
80% of the average. The ICDS growth
chart has three other curves below
this one, corresponding to 70%, 60%
and 50% of the average. Children
Useful facts to rememberwhen assessing the growth of
a child
The weight of a child roughlydoubles by the age of five months,and becomes three times by theage of one year.
An average well-nourished boyis 3.3 kg at birth, doubles hisweight at 5 months, andreaches about 10.0 kg by thefirst birthday.
An average well-nourished girlis 3.1 kg at birth, doubles herweight at 5 months, and
reaches about 9.2 kg at 1 year.
Thus, a child gains about 6 kg inthe first year.
Weight gain in the second year isabout 2.5 kg.
Between 2 and 6 years, weight gain
is steady at about 2 kg per year.
Classification of Malnutrition
The most widely used index for
defining the nutritional status of
children is weight-for age. The Indian
Academy of Pediatrics proposed a
classification of nutritional status,
which is used by the ICDS program:
Category % of
expected
weight-for-
age
Normal > 80
Malnutrition, Grade I 71-80
Malnutrition, Grade II 61-70
Malnutrition, Grade III 51-60
Malnutrition, Grade IV < 50
falling between these curves are
said to be in increasingly severe
grades of malnutrition. (See Box
Classification of Malnutrition and
Figure 3, page 5).
It is important to remember, however,
that all children below the top curve
(i.e., having weight less than 80% of
the average expected for that age)
are malnourished, irrespective of
their grade. In well-nourished
populations, less than 3% of children
fall below this level. As we shall see
below, about half of all Indian
children fall below this level.
In well-nourished populations, girls
are observed to grow more slowly
than boys, and during the pre-school
ages, girls are consistently lighter
than boys of the same age. Thus, the
growth of girls and boys should be
judged by separate standards. Using a
common standard for girls and boys
would naturally overestimate
malnutrition in one and
underestimate malnutrition in the
other, especially when computing
malnutrition figures for populations.
For the individual child, however, the
differences are not large, and for the
sake of convenience, ICDS uses a
common growth chart.
How do we determine whether a
child is growing well over a
period of time
When a series of weights of the samechild are plotted over many months,
it is possible to clearly see a pattern
in the growth of the child. If this
pattern is closely parallel to one of
the printed curves on the chart, the
child is said to have a normal rate of
growth, even though the child may be
underweight.
As can be seen from the curves on the
chart (Figure 3), children grow faster
in the first few months of life, and
then gradually slow down. (See Box
below). This is the normal pattern of
weight gain. The penciled blue line in
Figure 3 show how ideally a child
grows in the first four months of life.
Children who are born with less than
average birth weight sometimes put
on weight faster than normal
children, and climb up several grades.We say the child is catching up to
get back to her or his potential rate
of growth.
However, not all low birth weight
children are able to catch up, and
some of them will continue to have a
body weight less than normal at every
age, even if the growth curve is
parallel to the printed curves.
How to determine malnourishment and a normal rate of growth in a child
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Terms used to describe different levels of malnutrition
Underweight: Where the weight of the child is less than the normal range of weight for that particular age.
Stunting: Where the height of the child is less than the normal range of height for that particular age. Stunting isessentially slowing in skeletal growth and reflects under-nutrition over a long period of time. The child looks short, butnot thin.
Wasting: Where the weight of the child is less than the normal range of weight for that particular height. A wastedchild has lost weight, including fat and muscle and looks very thin. This is recent malnutrition.
Marasmus:Has been commonly used to describe a child who is stunted as well as wasted. This is a severe state ofmalnutrition that has lasted a long time.
Kwashiorkor: Is used to describe any malnourished child (any of the above categories) having edema, or collection offluid under the skin, which appears as a swelling that pits on pressure (usually on the feet and hands and face). Thepresence of edema means the child is seriously ill. This condition is rarely seen today.
What is common to all of the above is that the child is underweight when compared to healthy children of the sameage. This is what we measure with the growth charts in ICDS.
FIGURE 3
Growth Chart for Children 0-5 years (Used in the ICDS Programme)
Source: ICDS Programme, DoWCD, Government of India.
FEBRUARY2003
MARCH
2003
APRIL2003
MAY2003
JUNE2003
JULY2003
AUGUST2003
SEPTEMBER2003
OCTOBER2003
NOVEMBER2003
DECEMBER2003
JANUARY2004
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
16
15
14
13
12
11
10
9
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6
5
4
3
2
1
16
15
14
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12
11
10
9
8
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6
5
4
3
2
1
16
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16
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2
1
Ist Year2nd Year
3rd Year4th Year
5th Year
A G E
Child growthcurve
Normal Grade
Grade I (mild
malnutrition)
Grade II (moderatemalnutrition)
Grade III (severemalnutrition)
Grade IV (severe
malnutrition)
First growthcurve
Second growthcurve
Third growth
curve
Fourth growthcurve
WEIGHT(Kilograms)
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What is the extent of
malnutrition in India?
According to the National Family Health
Survey (NFHS-2) of 1998-99, 47% of
children under the age of three areunderweight, 46% are stunted and 74%
between 6 months and 3 years suffer
from anemia. As can be seen in Figure
4, there has been little change in the
malnutrition status between NFHS-1
(1991-92) and NFHS-2 (1998-99).
Malnutrition is strikingly high in Madhya
Pradesh (55%), Bihar (54%), Orissa (54%)
and Uttar Pradesh (52%).
Malnutrition in the girl child continues
into adulthood, over a third of women
15-49 years are undernourished4 .
Malnutrition is high in both women and
men, but it is more serious in women
because of the intergenerational effect.
Prevalence of anemia among women is
above 50%. About one third of anemic
women are moderately to severely
anemic (having a hemoglobin level of
< 11g/dl).
What causes malnutrition? Whatcan be done to prevent it?
Malnutrition in children does not arise
from one single cause. Its roots go back
into previous generations, and are
embedded in the socio-cultural and
economic contexts of individuals,
families and communities. An
understanding of these causes helps
understand how simple interventions
can be useful in reducing the burden of
malnutrition.
Malnutrition begins with themother before she is pregnant
Malnutrition in children typically begins
with under-nutrition of the mother.
As described in the section on newborn
care, 30-40% of Indian infants are born
with a birth weight below 2.5 kg (i.e.
LBW), and are therefore malnourished
at birth. Not only is their birth-weight
low, but they are also born with
insufficient stores of several nutrients,
like iron and Vitamin A.
About a third of such LBW infants are
small because they were born
prematurely, but the rest are small
because they did not get normal
nourishment while in the womb, and so
did not grow adequately.
Weight gain of the child before birth
depends not just on how well the
mother eats during pregnancy, but also
4 Since growth stops by late adolescence, weight-
for-age to estimate malnutrition in adults does
not hold. Instead, a measure called Body Mass
Index or BMI is used, which is given by (weight in
kg) divided by (square of the height in meters).
This is similar to the weight-for-height measure
used in children.
FIGURE 4The Status of Malnutrition in India
%
malnutritioned
children
60
50
40
30
20
10
0
52
Underweight Stunted Wasted
NFHS-1 (1991-92) NFHS-2 (1998-99)
1619
464747
The NCHS Reference Values
Currently, the WHO recommends the use of a set of reference values compiled by the
National Center for Health Statistics (NCHS), USA, for international use. These reference
values are derived from two studies of American children, one describing growth of
children 0-24 months old and the other of children and adolescents 2-18 years. They
include values for weight-for-age, height-for-age (or length), and weight-for-height (or
length), separately for boys and girls. [By convention, supine (or lying-down) length is
measured until a child is 2 years old; thereafter, standing height is measured.]
The NCHS reference values are published by the WHO as a booklet, Measuring Change in
Nutritional Status. While these values have fewer limitations than the Harvard referencevalues, they still have certain limitations. For instance, they are based on children not
exclusively breastfed for 6 months, and studies have shown that exclusively breastfed
children grow at different rates compared to non-exclusively breastfed children. The
WHO has commissioned a large multi-national study to compile reference values that are
more suitable. Phase 3 (data analysis and the production of the proposed standards)
began in 2002 and plans have been initiated for Phase 4 (development of training
materials, implementation of training programmes and worldwide dissemination of the
new standards).
Source: National Family Health Survey, 1991-92 and 1998-99.
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on how well-nourished she was before
she became pregnant. A woman who
herself grew poorly as a child and
adolescent, may not be able to nourish
her child well even if she eats well
during pregnancy.
The undernourishment may thus have
begun when the mother herself was
born as a LBW infant.
Maternal under-nutrition and
inadequate care during pregnancy
leads to an undernourished baby
Most of the weight gain of the baby in
the womb occurs in the last few
months of pregnancy. Poor diet andheavy physical work with inadequate
rest, particularly during the last few
months of pregnancy can lead to poor
growth of the unborn child.
A well-nourished baby is born with
plenty of nutrients, acquired from the
mother, stored in the body. These
stores last many weeks to months after
birth. When the mother herself is not
well nourished during pregnancy, she is
unable to provide sufficient nutrients
for the body stores of the child. This is
particularly true of iron and Vitamin A.
Inappropriate or inadequate diet inpregnancy could lead to the following
deficiencies
Severe iron deficiency causes anemia
and severe anemia can lead to
maternal death and even perinatal
death.
Folic Acid deficiency in early
pregnancy leads to birth defects (neural
tube defects), and also causes anemia.
FIGURE 5
The Importance of Nutrition Throughout a Womans Life
Birth weight is closely associated with child survival, well-being and
growth, which influences nutrition in adolescence and determines
how well nourished the mother is when she enters pregnancy.
Nutrient stores
built up in
adolescence help
the nutrition of
women during
and between
pregnancies.
Prevention of stunting in
girl children during the
first years can help break
the cycle of malnutrition.
Mothers nutrition before and during pregnancy
influences growth and development of the fetus
and its birth weight; it effects her chances of
survival and delivery.
Adequate nutrition for the
mother should be maintained
during breastfeeding.
Mothers nutrition is important for practicing
child-rearing, care, and household/
economic tasks, and for recovery...
... for future pregnancies.
Source: Adapted from ACC/SCN News 1994.
Improving the nutrition of the
girl child and adolescent is an
investment for the health of
the next generation
Preventing malnutrition in the girl
child under two years of age is
likely to prevent malnutrition in
her children (Figure 5).
Ensuring that adolescents are well
nourished is an effective way of
ensuring that they have adequate
stores of nutrients like iron and
vitamin A when they become
pregnant, and of reducing the
likelihood of giving birth to a baby
with LBW.
Folic acid deficiency in early
pregnancy can cause serious birth
defects of the spine. Since
marriage and childbearing
commonly occur in late
adolescence in many communities
in rural India, it is an appropriate
time to intervene with folic acid
supplements, usually given in
combination with iron.
Avoid early marriage and early
pregnancy.
Improving the nutrition of
adolescent girls is an important
objective of the ICDS programme.
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Inappropriate breastfeeding
deprives an infant of adequate
nutrition and increases chances
of infections
For the first six months of life, breast
milk alone is sufficient to sustain
normal growth and development of
most children. Breast milk is clean,
and protects from infections, both
diarrhoeal disease and respiratory
infections, because it contains immune
substances. Introduction of other
liquids during this age (including
water) can lead to infections, and thus
a risk of malnutrition and even of
death, due to the following reasons:
Other liquids, such as water, tea
or animal milk, and the utensils
(and hands) used for handling
them are difficult to keep clean,
particularly in poor homes, and
can carry infections such as
diarrhoea to the child.
Most liquids other than breast milk
contain inadequate amounts of
nutrients, and fill up the childs
stomach without providing
adequate nutrition. Thus the child
gets less than
what she would
get from breast
milk.
A child given
other food sucksless at the
breast. Reduced
breastfeeding
decreases the
production of
milk in the
mother. Over
time there will
not be enough
breast milk to
sustain growth and other needs ofthe child.
Figure 6 correlates the risk of infants
dying from diarrhoea, with the
benefits of exclusive breastfeeding.
What can be done: Exclusive
breastfeeding (EBF) for 6 months
Initiate immediate breastfeeding
(within about one hour of birth)
This serves as the babys firstimmunization. The infant will
immediately benefit from the
antibodies present in colostrum (the
first milk).
Immediate breastfeeding stimulates
breast milk production.
It takes advantage of the newborns
alert state soon after birth to establish
breastfeeding.
Immediate breastfeeding reduces
uterine bleeding by inducing uterine
contractions and fosters mother-child
bonding.
FIGURE 6Risk of Dying from Diarrhoea in Infants Given
Different Combinations of Feeds
RiskofDeath
2018
16
14
12
10
8
6
4
2
0
1.0
Exclusive
breastfeeding
Feeding Pattern
18.1
5.7
2.5
Breastfeeding
with supplement
Cows milkBreastfeeding
with cows milk
This Brazilian study found that babies given only cows milk had 18 times more chance of
dying than those given exclusive breastfeeding. Those given anything along with
breastfeeding had a lesser chance of dying than those not given any breastfeeding at all,
but this was still much higher than those given exclusive breastfeeding. Thus, even a
little breast milk helps fight diarrhoea, and exclusive breastfeeding is the most beneficial.
Source: Victoria C.G. et al. 1987. Lancet 2:319-22.
Appropriate position for breastfeeding.
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Practice exclusive breastfeeding until
6 months
Breast milk is a complete food and
adequate for the first 6 months. Most
infants will not need anything else, not
even water, since breast milk containsenough water as well.
Breast milk prevents infections,
especially diarrhoea and respiratory
infections.
Exclusive breastfeeding delays the start
of menstruation after delivery, and
helps delay the next pregnancy.
The amount of breast milk produceddepends on the frequency and duration
of feeding.
Inappropriate complementary
feeding leads to under-nutrition
in the infant and young child
Until the age of about 6 months, the
mother is able to produce milk in
amounts that are adequate to meet the
requirements of almost all nutrients.
Most mothers are unable to increase
production of breast milk sufficiently to
meet these needs beyond 6 months.
From around the age of 6 months, the
nutritional needs of the infant increase
substantially, due to a number of
reasons:
Growth continues, and the size of
the body increases. More energy
Nutritional needs of the breastfeeding mother
The nutritional needs of a breastfeeding woman are even greater than during pregnancy.
If a lactating mothers diet is poor, the levels of vitamins and minerals may be reduced in
the breast milk (such as Vitamin A, Vitamin C and B Complex Vitamins), or the mothers
nutritional status may be affected as the mothers reserves are used for compensating
breast milk levels (e.g. iron and calcium).
and nutrients are needed for both
growth and for maintaining a
larger body.
The infant becomes more active,
and activity requires more energy
and nutrients.
The infant becomes more prone to
infections. Fighting infections
requires more energy and nutrients.
Such a child becomes undernourished if
not provided adequate quantity and
quality of complementary foods to
compensate for the deficit.
The point at which a deficit in nutrients
from breast milk alone begins to show
may be a little earlier or later than six
months of age for different infants. This
is commonly seen as a failure to gain
adequate weight, with or without
anemia and Vitamin A deficiency.
According to the National Family Health
Survey (1998-99), the percentage of
infants 6-9 months receiving breast milk
plus complementary food across India is
33.5%; in Rajasthan, Uttar Pradesh and
Bihar the rate is under 20%.
Common reasons why families do not
practice appropriate complementary
feeding vary from place to place, and
include:
different traditional and acquired
beliefs about the age of initiation
to complementary food, and about
what foods are appropriate for
children
lack of awareness that an infant
can actually eat any semi-solid
foods at this age
lack of awareness about what
constitutes appropriate
complementary feeding for the
child
non-availability of a variety of
foods at home needed for
appropriate feeding.
Complementary feeding of children 6-8 months.
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What can be done: Appropriate
complementary feeding for all children
Recently, the WHO has published
Guiding Principles for Complementary
Feeding of the Breastfed Child. The
following recommendations are basedprimarily on these guiding principles.
Initiate complementary foods at 6
completed months (180 days)
The beginning of growth faltering is
sometimes recommended as an
appropriate time for the introduction of
complementary foods. However, the
WHO recommends that at a population
level, it is wise to advise exclusive
breastfeeding until the age of 6 months,particularly when environmental
sanitation is poor, since infections such
as diarrhoea introduced by feeding in
the period before six months may cause
more malnutrition than the malnutrition
prevented by such foods.
This recommendation is based on the
assumption that breastfeeding will be
exclusive, and that the infant is born
with normal birth weight to a normally
nourished mother.
In low birth-weight babies, particularly
when born to poorly nourished mothers,
certain specific nutrient deficiencies
(such as iron deficiency) may occur
before the age of 6 months, despite
exclusive breastfeeding. However, such
infants will benefit more from specific
supplements (such as iron), rather than
from complementary feeding.
Continue frequent, on-demand
breastfeeding until at least 2 years
There are several reasons why
prolonging breastfeeding until the age
of 2 years or more is beneficial for poor
children in developing countries:
A longer duration of breastfeeding
is associated with healthier and
better nourished children, provided
it is accompanied by appropriate
complementary feeding.
Breast milk is a key source of
energy and essential fatty acids
even after complementary foods
are introduced.
Its fat content may be critical for
utilization of carotenoids (a form
of Vitamin A) in predominantly
plant-based diets.
Breast milk can provide a large
proportion of the childs needs of
Vitamin A and several other
nutrients upto 15-18 months of age.
Breast milk continues to provide
protective substances that protect
from common infections.
Give appropriate amounts of
complementary food at different ages
The amount of food to be given to
infants is determined mainly by the
amount of energy that a child needs.
The requirements of other nutrients
need separate attention.
Responsive feeding
It is important to feed infants until they can start feeding themselves adequately. A seven
month old can put things into the mouth, but that does not mean she can feed herself
enough amounts of food regularly. As she gets older, she will be keener to feed herself,
but will need to be supervised until at least the age of about 3 years. During this period,
she will eat best if the care giver is responsive to her needs and moods. The following
principles of responsive feeding are based on studies of feeding behaviour in children:
Feed infants directly and assist older children when they feed themselves, beingsensitive to different ways in which they indicate that they are hungry or satisfied;
Feed slowly and patiently, and encourage children to eat, but do not force them;
If children refuse many foods, experiment with different food combinations, tastes,
textures and methods of encouragement;
Talk to children during feeding, with eye to eye contact;
Minimize distractions during meals if the child loses interest easily.
Complementary feeding of children 9-11 months.
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The WHO recommends that breastfed
infants needs complementary food
equivalent to about 200, 300 and 550
kilocalories daily in the ages 6-8
months, 9-11 months and 12-23 months,
respectively (see Table 2 for details onthe amount of complementary food).
The needs of individual children can
vary, because of several factors:
If an infant is consuming more or
less breast milk than the average,
the amount needed from
complementary foods will differ
accordingly.
Children recovering from illness or
living in cold environments where
energy expenditure is high willrequire more energy than the
average quantities listed above.
Two children of the same age and
size and growing normally, may be
consuming different amounts of
food, showing that there are
individual differences in nutrient
requirements.
In practice, caregivers will not know
the precise amount of breast milk
consumed, nor will they be measuring
the energy content of complementary
foods to be offered. Thus, the amount
of food to be offered should be based on
the principles of responsive feeding (see
Box on Responsive feeding, page 11).
The best guide to whether a child is
getting an adequate amount of food is
the pattern of growth; we can assume
that if a child is growing at expected
rates she is getting enough energy and
key nutrients.
Meal frequency and energy density of
foods required for the growing child
Meals should be given 2-3 times per
day at 6-8 months, and 3-4 times per
day at 9-11 and 12-24 months.
Additional nutritious snacks (such as a
piece of fruit or chapatti) can be
offered 1-2 times per day, as desired.
If the energy density is low, or the
amount of food per meal is low, or the
child is no longer breastfed, more
TABLE 2: The amount of complementary food
The amount of complementary food needed to provide the recommended daily energy intakes depends on the amount of energy the child
is getting from breast milk. Based on studies of breast milk production, we have estimates of the average amount of breast milk produced
by women in developing countries. Using this, and using information about the amount of energy available from different foods, it is
possible to make recommendations on how much of what food to give to a child at different ages. The following table shows an example
of such a recommendation for a common food item, khichdi:
The calculation assumes that the khichdi is cooked to the same consistency of well-cooked rice. If oil or ghee is added to any of these
meals, the amount of khichdi needed to provide the needed energy will be less than shown. Considering that a child has a per meal
stomach capacity of about 250-350 ml, it is not difficult for a child to eat the amount of food recommended. As the child gets older,
snacks (fingerfoods) between meals will supply a significant proportion of energy and other nutrients.
Age group Daily Average Daily Average Energy deficit (needed Amount of khichdi Recommended
(months) Energy Requirements Energy from breast from complementary needed to supply frequency of meals
(Kcal) milk (Kcal) foods) (Kcal) this Energy(ml/day) (per 24 hours)
6-8 615 410 205 200 ml/day 2-3/day
9-11 690 380 310 300 ml/day 3-4/day
12-23 900 350 550 500 ml/day 3-4/day
Complementary feeding of children 12-23 months.
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frequent meals may be required. (See
the two Boxes above).
Consistency of food required at
different stages
As children develop and grow, their
ability to chew and swallow improves.
Infants can eat pureed, mashed and
semi-solid foods beginning at 6 months.
By 8 months most infants can also eat
finger foods (snacks that can be
eaten by children themselves). By 12
months, most children can eat the same
types of foods as consumed by the rest
of the family with some modifications.
For example, the crust of a hard millet
roti can be removed, and the soft inner
portion given to the child.
It is important to avoid foods that may
cause choking (e.g. items that have a
shape and/or consistency that may
cause them to become lodged in the
wind pipe, such as nuts, seeds, grapes,
raw carrots).
Nutrient content of complementary
food
Since most Indian diets are cereal-
based, and cereals do not contain all
nutrients in the same proportion as
human requirements, large amounts
of such foods, and foods from a
variety of sources have to be eaten to
meet these requirements. There is
the danger of children getting foodwhich is deficient in one or another
nutrient.
The following practices should help
ensure that nutrients are adequate:
Adequate energy density: the
cereal, preferably along with a
dal, should be cooked to a
semisolid consistency the
consistency of well-cooked rice,
soft enough for the infant to eateven in the absence of teeth. Oil
orghee added before feeding will
help achieve adequate energy
density. Roti or chapatti may need
to be mashed with dal or milk to
reach this consistency.
Adequate protein: either dal in
sufficiently thick consistency
(liquid, watery dal is inadequate),
or a source of animal protein such
as milk/curd or meat or fish or
egg would provide adequate
protein. Breast milk is an
important source of protein for
the breastfed child.
Adequate micronutrients: a
variety of available red and yellow
vegetables or fruits, mashed, will
provide micronutrients in
vegetarian diets (this will still not
be sufficient to cover for iron and
Vitamin A).
Given the relatively small amounts of
complementary foods that are
consumed at 6-24 months, the nutrient
concentration or density of
complementary foods needs to be
adequately high.
Of all the functions of nutrients, providing energy is one of the most visible. Large
amounts of energy are needed by the body to maintain itself, to grow, to remain
active and to fight infections.
The energy needed for the functioning of the body comes from carbohydrates, fats
and proteins. During digestion, these are broken down into small molecules;proteins into amino acids, carbohydrates into small sugars and fats into fatty acids.
These small molecules are easily absorbed into the blood and transported to all
organs and tissues of the body. In the organs, each individual cell takes up these
molecules from the blood and uses them for either producing energy or for building
larger molecules for other purposes.
Some of the energy is stored in the body, usually as glycogen and fat. A reduction in
stored energy or nutrients below normal levels is the first step to malnutrition.
When a child does not eat enough food, the body first burns up the storage fat, and
when that is exhausted, muscle protein is burnt for producing energy. That is why a
malnourished child loses weight and becomes thin.
Energy:Carbohydrates, fats and proteins, are the only sources of energy
Energy and nutrient density:
Fats increase energy density, water content reduces nutrient andenergy density
Fats are the richest source of energy. Each gram of fat consumed can produce
twice as much energy as a gram of carbohydrate or protein. Hence, a cup of
khichdi to which a spoonful of oil or ghee has been added has a higher energy
density than the same quantity of plain khichdi.
Similarly, khichdi that is cooked to a firm consistency has greater energy and
nutrient density (the amount of nutrients available from a certain amount of food)
than if it is cooked to a more liquid consistency. This is because the latter contains
more water, and water does not provide energy.
For a small infant with a small stomach capacity, it is important to give energy
dense foods. For instance, giving the infant watery dal, without any fat, will fill up
the stomach without giving enough energy. Dal water has very little energy or
nutrients.
Since an infant may eat many different foods in a single day, but has a fixed
stomach capacity, what matters is the average energy density of all the food eaten.
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Safe preparation and storage of
complementary food
The peak incidence of diarrhoeal
disease is between the ages of 6 to 12
months, as the infant starts moving
around and putting things in her mouth.
Adequate hand washing of caregivers
and children before food preparation
and eating is crucial.
Feeding bottles are an important route
of transmission of diarrhoeal disease
and should be avoided totally.
Food should be prepared using clean
utensils, and served immediately or
stored safely. Food stored for more
than 6 hours at room temperature,
will need to be boiled (and cooled)
before feeding it to the child.
Preferably, food should not be stored
for longer than 6 hours.
Fermented foods such as buttermilk or
curds are relatively safer foods,
because most disease causing bacteria
do not survive in fermented foods.
A child should be fed such foods.
A failure to protect infants and
young children from common
infections and their ill-effects
The child is born with a number of
immune substances acquired from the
mother during the last months of
pregnancy, which provide protection
from many infections for several
months after birth. After birth, the
mother continues to protect the infant
in the form of immune substances in
breast milk. These substances protect
from certain respiratory and
gastrointestinal infections.
As the effect of maternally acquired
immunity wears away over the first few
months, the child is at increasing risk
of infection by many microorganisms
Micronutrients
Vitamins
Vitamins are a group of substances of different kinds, required for carrying out many vital functions of the body. Many of them are
involved in the utilization of the major nutrients like proteins, fat and carbohydrates by cells in different organs. Although they are
needed in small amounts, they are essential for the health and well being of the body.
Vitamins are often referred to by their chemical names such as retinol (Vitamin A), carotenoids (a form of Vitamin A present in plant
foods); vitamins of the B complex group: thiamin (Vitamin B1), riboflavin (Vitamin B2), niacin (Vitamin B3), pyridoxine (Vitamin B6),cobalamin (B12), folic acid; ascorbic acid (Vitamin C) and cholecalciferol (Vitamin D).
Small amounts of vitamins are present in all natural foods, in variable concentrations. Processing of food (including cooking) tends
to destroy some of them.
Minerals and trace metals
A variety of minerals are needed for the normal working of the body. Some of these form part of the body structure, but most of
them act as catalysts in cellular functions.
Bones are made up of large amounts of calcium and phosphorus and smaller amounts of other minerals
Iron is a component of hemoglobin, the substance that carries oxygen in the blood.
Iodine is a part of thyroxine, a substance produced by the thyroid gland, which helps regulate the work of all the cells of the body.
Minerals like zinc, molybdenum, selenium, copper, manganese and magnesium are either a structural part or activate a large
number of enzyme systems.
Sodium and potassium are important elements present in fluids within and outside the cells.
Using clean utensils a mother feeds her child.
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that are entirely new to its immune
system. Diarrhoea, respiratory
infections, ear infections, malaria andchildhood diseases like pertussis and
measles are common infections at this
age. Unless prevented or treated
adequately, these infections can lead
to malnutrition or even death.
Infections cause a child to lose
appetite, and eat less, thus becoming
prone to malnutrition. Conversely, a
malnourished child is less able to fight
off infections than a normally
nourished child. Thus a malnourished
child is more prone to infections. It is
this vicious cycle that lies at the rootof childhood malnutrition (Figure 7).
While it is common for a child to lose
appetite during an illness such as
diarrhoea or fever, children usually
regain appetite immediately as the
child begins recovering from an
infection. If fed adequately, most
children will be able to eat more than
normal, to compensate for what they
did not eat during the illness. Such a
The underlying causes of malnutrition
Poverty and food insecurity
Poverty often goes hand in hand with a lack of appropriate water resources, unsafe drinking water, poor sanitation, indoor air pollution,
crowding, poor housing and high exposure to disease vectors. Poverty also affects the familys ability to provide adequate nutrition to the
mother and child in a number of ways:
These families are highly vulnerable to seasonal fluctuations in employment and income.
Restricted incomes force families to compromise on the quality and quantity of foods.
Poverty restricts the time available to the mother for preparing food that is appropriate, and for feeding the child.
Poverty effectively isolates families from access to simple information by keeping the families illiterate and by reducing contact with
health services of good quality.
Poverty and malnutrition most often are seen together, however, malnutrition does not only occur in the poor.
Malnutrition, in turn, reduces productivity and contributes to poverty. Addressing malnutrition now can prevent future poverty.
Gender
In several communities girls are discriminated against from birth. Their lives are marked by poor health care, low educational levels,
heavy household workload, early marriage, early pregnancy, getting an unequal share of food at home, and limited decision-making
power.
Traditional gender roles often prevent men from either taking on the tasks of preparing food and feeding, or taking over other chores
from the mother so that she may be spared for these critical tasks.
Families and communities where women are educated and empowered have better health and nutritional status.
FIGURE 7
The Infection and Under-nutrition Cycle
Source: Adapted from Andrew Tomkins and Fiona Watson, Malnutrition and Infection, Geneva, 1989.
Growth Faltering
Lowering Immunity
Appetite Loss
Nutrient Loss
Inadequate Absorption
of Nutrients
InadequateIntake
Infect ions
child will put on weight rapidly and
regain her pre-illness nutritional
status.
If the child is not given adequate food
in the recovery phase of the illness,such a catch-up may not occur at all.
What can be done?
Continue to provide protective
substances by continuing
breastfeeding.
Hand-washing when preparing food
to minimize chances of diarrhea.
Early action to treat children
having illnesses.
Increase fluid intake during illnessthrough more frequent
breastfeeding, and encourage the
child to eat soft, varied,
appetizing, favorite foods.
After illness, give food more often
than usual and encourage the child
to eat more until the child regains
adequate weight.
Complete and timely immunization
to ensure protection from vaccine
preventable diseases.
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IronIron is an essential part of hemoglobin, the main component of red cells of the blood which transports oxygen to all
parts of the body. Iron is found in many foods. Heme-iron is found only in meat, fish and poultry and is absorbed much
more easily than non-heme iron, which is found primarily in fruits, vegetables, dried beans, nuts and grain products.
The following factors increase iron absorption from non-heme foods:
A good source of Vitamin C (ascorbic acid) such as citrus fruits and guava eaten with non-heme foods.
A heme food eaten with a non-heme food.
The following factors decrease non-heme iron absorption:
Large amounts of tea or coffee consumed with a meal (substances called polyphenols in these drinks reduce
absorption of iron in the body)
Excess consumption of high fiber foods or bran supplements (substances called phytates in such foods reduce
absorption of iron)
High intake of calcium
What is anemia?
Anemia is defined as a condition that results in a lowering of hemoglobin levels below what is considered to be normal
for a specific group (i.e. in preschool children hemoglobin level < 11g/dl, in school children < 12g/dl, in pregnant
women < 11g/dl, in lactating women < 12g/dl.)
What are the causes of iron deficiency/anemia?
Iron deficiency occurs whenever the iron stores in the body do not meet the bodys requirements for iron.
For pregnant and postpartum women extra iron is needed to meet the needs of the growing fetus and to make up
for iron lost due to blood loss during childbirth.
Infants born to women with normal iron stores are born with iron stores that last about six months. Small amounts
of high quality iron comes from breast milk. As babies move to solid foods at 6 months, foods containing high
amounts of iron should be selected to prevent the development of iron deficiency.
Anemia in children can begin when mothers have anemia before or during pregnancy, and the infant is born with
low iron stores.
Children between 6 months and 4 years of age are at risk for developing iron deficiency because of rapid growth
and a lack of sufficient iron in their diets unless iron-fortified foods or a supplement is available.
Adolescents can be prone to anemia because of rapid growth rates, erratic eating habits, and due to heavy
menstrual blood loss.
In a predominantly vegetarian diet, foods are not rich in iron. Also, for a number of reasons, this iron is not well-
absorbed. Hence, vegetarians tend to have more anemia than meat eaters.
In addition, other common cause of anemia include excess of loss of iron from bleeding (menstruation) or
parasites (e.g. hookworm)
What are the consequences of iron deficiency?
During infancy and early childhood a delay in psycho-motor development and cognition
During pregnancy severe anemia leads to increase in maternal and perinatal mortality
In adults a reduced work capacity and productivity
Iron deficiency also causes reduced resistance to infections in all age groups
Prevention of iron deficiency
Each pregnant woman should receive 90-100 tablets of IFA (100 mg of elemental iron) during pregnancy, one tablet a
day. Currently, we do not have a preventive policy for childhood anemia.
Untoward effects of iron given at these doses are known to occur. Blackening of stools is very common, and can be
alarming, but is harmless, and is accepted when properly explained. Other side-effects such as constipation, nausea,
metallic taste are found in usually less than 15% of those who take iron. The side effects are less common in the
presence of iron deficiency (in whom much more iron is absorbed than in non-deficient individuals); and in some
individuals they seem to be less common when iron is consumed after a meal. There is limited absorption of iron
administered along with cereal-based meals. The presence of Vitamin C in the food enhances absorption of iron, and
thus the addition of citrus extracts (such as lemon juice) to meals can help absorption.
Micronutrient Deficiencies
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Yet, there are no universally accepted recommendations on the relationship of iron dosage to meals, especially for
large scale prophylaxis programs. In this situation, it may be best to advice iron to be taken on an empty stomach, and
in those who do experience nausea, to advise taking the tablets with or after meals. The addition of lemon juice to
food can be a universal recommendation, to be practiced whenever possible. The addition of lemon juice would
enhance the absorption of iron from these sources as well.
In general, most diets cannot provide all the iron that a woman needs during pregnancy, and thus iron supplements are
essential during pregnancy. The same applies to the preschool years, when the need for iron is high and most
Indian diets fall short of the amounts needed to fulfill this need.
Treatment of iron deficiency
Ideally, iron is provided daily until anemia is completely corrected, and body stores are restored. Since these are
dificult to determine in the field, there are general recommendations:
Pregnancy (and applicable to any woman with anemia): Two tablets of 100 mg elemental iron (large IFA) a day for 90-
100 days.
Policy for treatment of children who are anemic (
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Diarrhoea and respiratory infections such as pneumonia are more severe in children having Vitamin A deficiency.
Such children also tend to die of these infections more easily than children without Vitamin A deficiency.
Who is at greatest risk?
Children between the ages of 6 months to 6 years, especially the younger ones.
Infant and young children who are not breastfed
Infants and children who do not receive enough breast milk along with complementary feeding
Women, especially during pregnancy and lactation
Vitamin A Supplementation
Prophylactic: As recommended in the National Vitamin A Control Programme/UIP: First dose at 9 months: 100,000 units
single dose. Can be given with Measles vaccine. 2nd-5th doses: 200,000 units every 6 months, starting at 18 months
(the 2nd dose can be given along with the booster of DPT/OPV; at the same time, it is not incorrect to start with the
second dose anytime after 1 year of age, although the stores from the first dose should last for about six months).
The first two doses are only programmatically related to the respective vaccine doses, and have no direct interaction
with the effects of the vaccines, or vice-versa.
Therapeutic: Treatment schedule is to administer 200,000 IU of Vitamin A immediately after diagnosis. This must be
followed by another dose of 200,000 IU 1-4 weeks later. Infants and young children suffering from diarrhoea and
measles or acute respiratory infection must be monitored closely and encouraged to consume Vitamin A rich food.
In case early signs of Vitamin A deficiency are observed, the above treatment schedule must be followed.
All children with xerophthalmia should be given two doses of Vitamin A as stated above. All children suffering from
measles should also be given one dose of Vitamin A, if he/she has not received it during the previous one month.
All cases of severe Protein Energy Malnutrition (based on weight-for-age criteria or clinical nutritional signs) should be
given one additional dose of Vitamin A.
Accidental doubling of a dose is unlikely to cause ill-effects, and the benefits greatly outweigh any potential dangers in
such situations. In addition to saving eyesight, administration of Vitamin A can greatly reduce measles and diarrhoea
mortality.
As part of comprehensive antenatal and postnatal care, women should be screened for night blindness. If pregnant/
lactating women have night blindness, they should be referred to the physician in the nearby Primary Health Centre or
any other health facility for appropriate management. In view of the potential toxic and teratogenic effects of high
doses of Vitamin A, pregnant and lactating women with symptoms of night blindness should be treated with Vitamin A
in dosage not exceeding 10,000 IU per day. They can be given Vitamin A till symptoms of night blindness disappear.
For sustainable elimination of VAD, production and consumption of Vitamin A rich foods must be strongly promoted in
the community, particularly amongst pregnant and lactating women and children.
In case of corneal involvement, treatment with Vitamin A is an emegency proceedure, capable of saving eyesight.
Thus, oral Vitamin A should always be available at every health facility as an emergency drug. In case of doubtful
diagnosis, it is better to first administer one dose of 200,000 doses of Vitamin A and then try to arrive at a diagnosis.
IodineIodine
Iodine is essential for the production of thyroxine (a hormone produced by the thyroid gland), and used for many vital
body functions, such as maintaining body temperature, brain function, growth and reproduction.
What is Iodine deficiency?
Iodine deficiency is the single most significant cause of preventable brain damage and mental retardation. Iodine
deficiency can also cause stillbirths and miscarriages.
Iodine Deficiency Disorders (IDD)
IDD include a range of disorders that affect all stages of human growth and development the fetus, the neonate, the
child, the adolescent and the adult.
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Government programs that
support reduction in
malnutrition
Integrated Child Development
Services (ICDS)The Government of Indias Department
of Women and Child Developments
Integrated Child Development Services
objective is to:
Improve the nutritional and health
status of children below the age of
six years.
Lay the foundation for the proper
psychological, physical and social
development of the child.
Reduce the incidence of mortality,
morbidity, malnutrition and school
dropouts.
Enhance the capability of the
mother to look after the health,
nutritional and developmental
needs of the child, through proper
community education.
Achieve effective coordination of
policy and implementation among
various departments to promote
child development.
The package of services provided to
project paricipants who are children
(0-6 years), and women (15-49 years).
Under this scheme are included:
Nutrition and Health Education
Growth monitoring and promotion
Supplementary nutrition
Immunization
Vitamin A and Iron supplementation
Health checkups and referral
Treatment of minor illnesses
Early childhood care and preschooleducation
Anganwadi
The anganwadi (AW) is literally a
courtyard play centre. It is a childcare
centre, located within the village or the
slum area. It is the focal point for the
delivery of services at the community
level. The anganwadi centre (AWC) is a
meeting ground where women/mothers
groups can come together, with other
frontline workers, to promote
awareness and joint action for child
development and womens
empowerment. All the ICDS services are
provided through the AW in an
integrated manner to enhance their
impact on childcare.
Each AW is run by an anganwadi worker
(AWW), supported by an anganwadi
helper in service delivery, and improves
linkages with the health system
increasing the capacity of communities
and women, especially mothers for
childcare, survival and development.
The population coverage through the
anganwadi worker is approximately
1,000 in rural and urban areas and 700
in tribal areas. Presently, in ICDS,
there are on an average 125-150 AWCs
per project/block. Additional AWCs
have been sanctioned, based on
increased block population. Some ICDSservices, for example, immunization
aim at universal coverage while some
others, for example, supplementary
feeding aim at 40 per cent coverage in
rural/urban projects and 75 per cent
coverage in tribal projects.
Services for children are limited to
young children. This is because the
early years are the most vulnerable
and critical. They contribute to the
unfolding of almost three-fourths of
the total potential for physical, social
and mental development of an adult.
The mother plays a key role in the
overall development of the child,
which is why women between 15 to 45
years have been brought within the
ICDS framework. Any programme that
aims at the holistic development of
the child also includes increased
opportunities for promoting health,
nutritional well-being, care and self-
development of women, and
particularly pregnant and nursing
mothers.
Convergence of services is essential to
address the inter-related needs of
What are the causes of IDD?
IDD occurs when the soil is iodine deficient (usually as a natural phenomenon) resulting in low levels of iodine in
locally grown foods and water supplies. People living in areas with iodine deficient soils are at risk of IDD.
Infants who are not exclusively breastfed are at also at risk of IDD.
In iodine deficient areas lactating women are at high risk of iodine deficiency because the iodine is preferentially
used up for breast milk.
What can be done to prevent IDD?
1. Salt iodization is one of the least expensive, yet effective health and nutrition interventions available.
2. Ensuring that the whole population, particularly women and children, consumes iodized salt can eliminate IDD,
provided that this practice of consuming iodized salt continues for generation after generation.
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children and women, in a
comprehensive and cost-effective
manner. The child-centered approach
of ICDS is based on the rationale that
care, cognitive and psychosocial
development and the childs healthand nutritional well-being, mutually
reinforce each other.
In order to enhance the outreach of
these services, particularly to the
disadvantaged groups and ensure their
better utilization, the anganwadi
worker mobilizes support from the
community. The anganwadi worker
surveys all families in the community
to identify pregnant and nursingmothers, adolescent girls and children
below six years of age from the low-
income families and deprived sections
of the society.
Details of key services are described
below:
Growth Monitoring and Promotion
Growth monitoring and nutrition
surveillance are two important field
activities in ICDS. Both are important
for assessing the impact of health and
nutrition related services.
Children below the age of three years
of age are weighed once a month and
children 3-6 years of age are weighed
quarterly. Fixed day immunization
sessions or days when mothers of
children under two years collect take-
home ration, are opportunities for
growth monitoring and promotion of
younger children. Weight-for-age
growth cards are maintained for all
children. This helps to detect both
growth faltering and also in assessing
nutritional status. This helps keep the
normals in the normal category .
Through discussion and counselling,
growth monitoring also increases the
participation and capacity of mothers
in understanding and improving
childcare and feeding practices. It
helps families understand better thelinkage between dietary intake, health
care, safe drinking water and
environmental sanitation and child
growth. Growth monitoring and
promotion can also be an effective
entry point for primary health care.
The concept of community-based
nutrition surveillance has also been
introduced in ICDS. A community chart
for nutrition status monitoring ismaintained at each anganwadi. This
helps the community in understanding
what the nutrition status of its children
is and to mobilize community support
in promoting and enabling better
breastfeeding, and appropriate
complementary feeding and childcare
practices and in contributing local
resources and improving service
delivery and utilization.
Nutrition and Health Education
Nutrition, Health and Education (NHED)
is a key element of the work of the
anganwadi worker. This has the long
term goal of capacity-building of
women-especially in the age group of
15-45 years so that they can look after
their own health, nutrition and
development needs as well as that of
their children and families. All women
in this age group are expected to be
covered by this component. NHED
comprises basic health, nutrition and
development information related to
childcare and development, infant and
young child feeding practices,
utilization of health services, family
planning and environmental sanitation.
Community education is imparted
through counselling sessions, home
visits and demonstrations.
Anganwadi workers use fixed day
immunization sessions, mother-childprotection days, growth monitoring
days, small group meetings of
mothers/Mahila Mandals, community
and home visits, village contact drives
and other womens groups meetings
(DWCRA, Mahila Samakhya etc.) local
festivals/gatherings for nutrition,
health and developmental education.
Supplementary Feeding
Low-income families and deprivedchildren below the age of six,
pregnant and nursing mothers and
adolescent girls are provided
supplementary feeding support for 300
days in a year. By providing
supplementary feeding, the anganwadi
attempts to bridge the caloric gap
between the national recommended
average intake of children and women
in low income and disadvantaged
communities. This pattern of feeding
aims only at supplementing and not
substituting for family food. It also
provides an important contact
opportunity, with pregnant women and
mothers of infants and young children,
to promote improved behavioral
actions for care of pregnant women
and young children.
Food supplements are provided to
pregnant women and nursing mothers
(up to six months of breastfeeding), to
help meet the increased requirements
during this period. This provides a
crucial opportunity to counsel
pregnant women enabling utilization
of key services i.e. antenatal care;
immunization, iron folic acid
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supplementation; and improved care,
adequate food and rest during
pregnancy.
Special care is also taken to reach
children below the age of two years,and to encourage parents and siblings
to either take ration home or to bring
them to the anganwadi for
supplementary feeding. This provides a
contact opportunity for growth
monitoring of children under two years
of age and nutrition counselling of
mothers, for improved childcare and
development practices.
Early Childhood Care and PreschoolEducation
The early Childhood Care and
Preschool Education (ECCE) component
of the ICDS is the most joyful playway
daily activity, visibly sustained for
three hours a day. It brings and keeps
young children at the anganwadi
centre, an activity that motivates
parents and communities. ECCE, as
envisaged in the ICDS, focuses on total
development of the child upto six
years of age, from the underprivileged
groups. It includes promotion of early
stimulation of the under-threes
through interventions with mothers/
caregivers. Its programme for the
three-to-six-year-old children in the
anganwadi is directed towards
providing and ensuring a natural,
joyful and stimulating environment,
with emphasis on necessary inputs for
optimal growth and development.
Child-centred playway activities,
which build on local culture and
practices, using local support materials
developed by anganwadi workers,
through enrichment training, are
promoted.
The early learning component of the
ICDS is a significant input for providing
a sound foundation for cumulative
lifelong learning and development.
It also contributes to universalization
of primary education, by providing tothe child the necessary preparation for
primary schooling and offering
substitute care to younger siblings,
thus, freeing the older ones, especially
girls, to attend school.
Kishori Shakti Yojana
Kishori Shakti Yojana which was earlier
referred to as the Adolescent Girls
scheme was designed with the aim of
breaking the intergenerational lifecycle of nutritional disadvantage, and
providing a supportive environment for
self-development. This scheme is
implemented through AWCs in both
rural and urban settings. Under the
Scheme, the adolescent girls who are
unmarried and belong to families
below the poverty line and school
drop-outs are selected and attached to
the local AWCs for six-monthly stints of
learning and training activities.
The objectives of this scheme are as
follows:
To improve the nutritional andhealth status of girls in the age
group of 11-18 years;
To provide the required literacy
and numeracy skills through the
non-formal stream of education;
To train and equip the adolescent
girls to improve/upgrade home-
based and vocational skills;
To promote awareness of health,
hygiene, nutrition and family
welfare, home management andchild care; and
To gain a better understanding of
their environment.
The Department of Woman and Child
Development considers that a single
tailor-made scheme for adolescent
girls may not be able to achieve the
objectives of Kishori Shakti Yojana.
Mothers with their children.
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Rationale for administering
large dose of Vitamin A
As Vitamin A is fat soluble, it can
be stored in the liver along with
fat deposits. This means daily
supplements are not necessary.
There should be a basket of
programmatic options available with
the states to selectively intervene for
the development of the adolescent
girls on the basis of their needs and
requirements.
The options are:
Emphasis on IFA supplementation
along with de-worming
interventions and nutrition and
health education including
sanitation and personal hygiene
aspects.
Emphasis on education with
particular attention on school drop-
outs and functional literacy amongilliterate adolescent girls.
Vocational training activities for
their economic empowerment.
Synergy between the Kishori Shakti
Yojana and self-employment schemes
are emphasised.
Reproductive and Child Health
Program (RCH)
Under the Government of Indias
Ministry of Health and Family Welfares
RCH Program are included:
National Nutritional Anemia
Control Program and
National Program for
Prophylaxis Against Blindness in
Children Due to Vitamin A
Deficiency.
National Nutritional Anemia Control
Program
This program aims at decreasing the
prevalence and incidence of anemia in
women in the reproductive age group,
especially pregnant and lactating
women and preschool children. The
program focuses on the following
strategies:
Promotion of regular consumption
of foods rich in iron
Provisions of iron and folate
supplements in the form of tablets
to high risk groups
Identification and treatment of
severely anemic cases.
Recommended doses of Iron and Folic
Acid (IFA) tablets are:
Pregnant women: One big tablet (each
tablet containing 100 mg of elemental
iron and 500 ug folic acid) daily for 100
days. These tablets should be provided
after the first trimester of pregnancy.
Cases of severe anemia are provided
with an additional 100 tablets.
Lactating women: One big tablet daily
for 100 days
Preschool children (1
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Further Reading
1. Dewey K. Guiding Principles for Complementary Feeding of the Breastfed Child. Pan American Health Organization, World Health
Organization; 2002.
2. Ghosh S. The Feeding and Care of Infants and Young Children, 6th Revised Edition, Voluntary Health Association of India, New Delhi; 1992
3. Integrated Child Development Services. Department of Women and Child Development, Ministry of Human Resource Development,
Government of India.
4. National Family Health Survey 1998-99: India. International Institute for Population Sciences (IIPS) and ORC Macro; 2000.
5. Nutrition Essentials. A guide for health managers. BASICS; 1999.
6. Nutrition in Children: Developing Country Concerns; 1994. Editors H. P. S. Sachdev, Panna Choudhury.
7. Nutritive Value of Indian Foods, National Institute of Nutrition, India Council of Medical Research; 1999.
8. Policy on Control of Nutritional Anemia, National Nutritional Anemia Control Programme, Ministry of Health and Family Welfare,
Government of India; 1991.
9. Policy on Management of Vitamin A Deficiency. National Program for Prophylaxis Against Blindness in Children Due to Vitamin A Deficiency.
Ministry of Health and Family Welfare, Government of India; 1991.
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