prevention of childhood malnutrition dr harivansh chopra

Dr. Harivansh ChopraDr. Harivansh Chopra

Dr. Harivansh Chopra, DCH, MD

Professor, Department of Community Medicine, LLRM Medical College, Meerut.

Prevention of Childhood Malnutrition


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.

04/09/23 2observerzparadise.com


Whether this child will grow normally or become malnourished?

? ?



04/09/23 4DR.HARIVANSH CHOPRA


04/09/23 5DR.HARIVANSH CHOPRA


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

05

101520253035404550

Per

cent

age

Stunted Underweight Wasted04/09/23 7observerzparadise.com


Nutritional Status of children below 3 years : NFHS II

35.6

48.6

38.4

49.6

1316.2

0

10

20

30

40

50

Per

cen

tage

Stunted Underweight Wasted

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

10.214.3

19.7

0

10

20

30

40

50

60

Per

cent

age

UNDER WT STUNTED WASTED

HIGHMEDIUMLOW

NFHSII



Nutritional status of under-three children in relation to age

11.9

37.5

58.5 58.4

15.4

30.9

57.5 56.5

9.313.2

21.9

13.2

0

10

20

30

40

50

60

Per

cen

tage

Underweight Stunted Wasted

< 6 months6 - 11 months12 - 23 months24 - 35 months



Percentage of underweight children –Comparison between NFHS I & II

5247

20 18

0

10

20

30

40

50

60

Per

cen

tage

Underweight Severely Underweight

NFHS INFHS II



Nutritional Status of children below 3 years : NFHS III

3846

19

05

101520253035404550

Per

cent

age

Stunted Underweight Wasted04/09/23 12observerzparadise.com


Nutritional Status of children below 3 years : NFHS III

31.1

40.736.4

49

16.919.8

0

10

20

30

40

50

Per

cen

tage

Stunted Underweight Wasted

Urban Rural



Percentage of underweight children –Comparison between NFHS II & III

47 46 46

38

1619

05

101520253035404550

Per

cen

tage

Underweight Stunted Wasted

NFHS IINFHS III



Distribution of 1-5 years children (Gomez classification)

IncomeWeight 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

NNMB04/09/23 15observerzparadise.com


Causes of Malnutrition

1. Inadequate Food Security.

2. Infection.

3. Low weight of adolescent girls.04/09/23 16observerzparadise.com



4. Low Immunization coverage.

5. Maternal Anemia.

6. Low literacy level in female.04/09/23 17observerzparadise.com



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.04/09/23 19observerzparadise.com



13. Lack of Comprehensive Child Health Care Programme.

13. 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 ApproachExclusive Breast Feeding for 6 months.

Infection Prevention/Treatment and Immunization.

Growth Promotion / Monitoring.

Appropriate Weaning Practice. Safe Water

Iron Supplementation.

Nutrition education & Extra-Nutrition inpregnancy & lactation, and illness in child.

No to next pregnancy. 04/09/23 23observerzparadise.com


Weight gain in the first five years of life

88

1st Year 2 - 5 years

Kg.Kg.



Weight gain in the first year of life

44

First 4 months Next 8 months

Kg.Kg.



Weight gain in the next four years of life

2

2

2

2

2nd Year 3rd Year 4th Year 5th Year

Kg.

Kg. Kg.

Kg.



v/s Monitor the Weight

FIRST

SECOND

Weight gain in 1st year of life.

Weight gain in next 4 years of life.



Exclusive Breast Feeding in India – NFHS II

4555

Exclusive Breast Feeding Not Exclusively Breast-fed


Exclusive breast feeding upto 4months


Immunization Coverage

62.2

71.6

51.7

65.1

53.6

62.8

42.2

50.7

35.542

0

10

20

30

40

50

60

70

80

Per

cen

tage

BCG DPT 3doses

OPV 3doses

Measles AllVaccines

NFHS INFHS II



Immunization Coverage

71.6

78.2

55.1 55.3

62.8

78.2

50.7

58.8

42 43.5

0

10

20

30

40

50

60

70

80

Per

cen

tage

BCG DPT 3doses

OPV 3doses

Measles AllVaccines

NFHS IINFHS III



Anemia in Children

31

62

7

Mild Moderate Severe04/09/23 32observerzparadise.com


7479

4 5

0

10

20

30

40

50

60

70

80

90

Any anaemia Severe anaemia

NFHS-2 NFHS-3

Anaemia among Children Age 6-35 MonthsAnaemia among Children Age 6-35 Months

Percent



Iron Supplementation v/sIron Therapy – Cost

30

70

Iron Supplementation Iron Therapy



The BIGWIN ApproachExclusive Breast Feeding for 6 months.

Infection Prevention/Treatment and Immunization.

Growth Promotion / Monitoring.

Appropriate Weaning Practice. Safe Water

Iron Supplementation.

Nutrition education & Extra-Nutrition inpregnancy & lactation, and illness in child.

No to next pregnancy. 04/09/23 35observerzparadise.com


Empowering Women

Poor Perpetually Pregnant female

Powerful Perceptive Problem-solving



Empowering Women

1. Mass Media

2. Government Health System

3. Mahila Mandals04/09/23 37observerzparadise.com


Empowering Women

4. NGOs

5. Link Women

6. Anganwadi04/09/23 38observerzparadise.com


Empowering Women

7. Health Worker

8. School Health

9. BFCI04/09/23 39observerzparadise.com


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 Education3. 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 Education7. 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 Therapy2. 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 Panjiri1. Contents – Bengal gram flour, Wheat flour, Jaggery, Ghee (1 part each).

2. Calories: 500 calorie/100gm.

3. Protein: 9gm/100gm.

+ + +



2. Shakti aahar1. Constituents: Roasted wheat 40gm, Roasted gram 20gm, Roasted

peanuts 10gm, Jaggery 30gm.

2. Calories: 390 calories/100gm.

3. Protein: 11.4gm/100gm.

+ + +



3. Hyderabad Mix1. 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 Kheer1. Constituents: Toned milk 750ml, Sugar 100gm, Sooji 25gm, Oil 5gm

(aqua add 1000ml).

2. Calories: 143 calorie/100gm.


+ + +




3. Small frequent feeds given.

4. Intake gradually increased to 100 Cal/kg/day and 1gm protein/kg/day.




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.




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.



3. Dietary Management – Transfer to Family type diet

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



3. Dietary Management – Transfer to Family type diet

2. Involves nutrition education of parents.

3. Snacks made from peanuts, bengal gram, jaggery, and oil are useful.



Nutritional Rehabilitation1. Majority of children, after discharge from

hospital, again become victim of Malnutrition.

2. To overcome this, Nutritional Rehabilitation is carried out.



Nutritional Rehabilitation

Ambulatory Treatment Rehabilitation in “NutritionRehabilitation Centres”



Ambulatory Treatment1. 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.



Nutritional Rehabilitation 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.



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 NRCs1. 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)

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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.



Triple-A approach

ASSESSMENTof the situation

ANALYSISof the causes of problem

ACTIONbased on the analysis

and available resources

Perceptions & Understanding

Capabilities

Resources

EffectiveDemand



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.



MCQs1. 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.



MCQs2. “Hyderabad Mix”, an energy dense

supplement, used for malnourished children does not contain :

1. Bengal gram.

2. Groundnut.

3. Soyabean.

4. Jaggery.Ans. – 3.



MCQs3. 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. – 2.04/09/23 78observerzparadise.com


MCQs4. NRC is :

1. Nutrition Rehabilitation Centre.

2. Nutrition Rehabilitation Council.

3. Natural Resources Council.

4. Natural Rights of Community.



MCQs5. Giving “timely warning” about food

consumption crisis is an objective of :

1. Disaster Management.

2. Food Census.

3. Nutrition Surveillance.

4. Food & Agriculture Research.



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

Health & Medicine