Under nutrition under 5 years of age

1. UNDERNUTRITION IN
YOUNG CHILDREN
Dr Soni Rani
PGT-1ST Year
Department Of Community Medicine
Katihar Medical College, Katihar

2. Presentation Outline
1. Introduction
2. Problem statement ( World/ India)
3. Causes of Under nutrition.
4. Prevention of Under nutrition.
5. Summary

3. 2.1
by 2030 end hunger and ensure access by all people, in particular the poor and
people in vulnerable situations including infants, to safe, nutritious and
sufficient food all year round
2.2
by 2030 end all forms of malnutrition, including achieving by 2025 the
internationally agreed targets on stunting and wasting in children under five
years of age, and address the nutritional needs of adolescent girls, pregnant
and lactating women, and older persons
2.3
by 2030 double the agricultural productivity and the incomes of small-scale
food producers, particularly women, indigenous peoples, family farmers,
pastoralists and fishers, including through secure and equal access to land,
other productive resources and inputs, knowledge, financial services, markets,
and opportunities for value addition and non-farm employment
SDG- 2
End hunger, achieve food security and improved nutrition
and promote sustainable agriculture

4. Introduction
• Preschool children are most vulnerable to the
effect of under nutrition because of rapid
growth.
• In SEAR the problem of under nutrition is
widespread and ranging from 30 to 63% in
form of stunting.

5. Introduction
• The cost of under nutrition in terms of
development and productivity are enormous.
• The number of people suffering from food
insecurity and hunger is growing- even though
food production has doubled In last 40 years.
• Under nutrition by far the most important
single cause of illness and death globally,
accounting for 12% of all deaths and 16% of
DALYs lost.

6. Malnutrition in young Children,
India/World
47 48.3 47.5 47.2
37.8
25.8
17.6
10.6
7.8
1.6 0
World development indicators-2006, NFHS-3

7. Problem statement- World
• Low birth weight is associated with more than
half of all deaths among young children ,
accounting for more than 6 millions deaths a
year.
• Every day 799 millions people in developing
countries , about 18% of world population
goes hungry.

8. • In SEAR one person in four goes hungry, is as
high as one in three.
• Around 175 million children under five are
estimated to be under weight.
• A third of preschool children are stunted, 16%
of newborn babies weighs less than 2.5 kg and
about 243 million adults are severely
malnourished.
Problem statement- World

9. • Two billion women and children are anemic ,
250 million children suffer from vitamin – A
deficiency .
• Two billion people are at risk from Iodine
deficiency.
Problem statement- World

10. India and Under nutrition
• India is home to over 65 million under five
children who have protein energy
malnutrition.
• The prevalence of underweight children in
India is among the highest in the world, and is
nearly double that of Sub- saharan Africa.

11. NFHS Stunted Wasted Under Weight
NFHS-3 (2005-06)
Total 38.4 19.1 45.9
Urban 31.1 16.9 36.4
Rural 40.7 19.8 49.0
NFHS-2 (1998-99) NA NA 46.7
NFHS-1 (1992-93) NA NA 51.5
UNDERNUTRITION- INDIA

12. Trends in prevalence according to
NNMB
78.6
18.1
77.5
65.1
19.9
68.6
63
16.7
63.6
Stunted wasted underweight
NNMB
(1975-1979)
NNMB
(1988-1990)
NNMB
(1994)

13. Stunted Wasted
Under
Weight
Bihar
NFHS-4 (2015-16)
Total 48.3 20.8 43.9
Urban 39.8 21.3 37.5
Rural 49.3 20.8 44.6
NFHS-3 (2005-06)
Total 42.3 27.7 58.4
Urban 31.9 28.8 51.5
Rural 43.7 27.5 59.3
UNDERNUTRITION- BIHAR

14. Prevalence of Under-nutrition in
children (0-5 Years)
55 54 54 52 51
37
27
DATA SOURCE- NFHS-3

15. Micro nutrient deficiency( anaemia)
India
• The prevalence of anemia among pregnant
woman in India is 57.8%. (NFHS-3).
• 69.5% of 6-59 months of children are suffering
from iron deficiency anaemia.
Mild Moderate Severe
26.3
40.2
2.9

16. Micro nutrient deficiency- India
62.00%
35%
70%
65% 65%
DATA SOURCE- NFHS-3

17. Micro nutrient deficiency(Anaemia)-
Bihar
NFHS-4 (6-59 months) NFHS-3 (6-35 Months)
Urban Rural Total
75.8
89.0
87.4
Urban Rural Total
58.8
64.0
63.5

18. Micro nutrient deficiency(Anaemia)-
Bihar
• In Bihar 78% of 6-59 months of children have
some anaemia.
Mild Moderate severe
29.60%
46.80%
1.60%
DATA SOURCE- NFHS-3

19. Nutritional Status Of Pregnant Women and
Children- India
58.8
61.7
58.7
22.2
64
58
60.5
31.8
63.5
58.3 60.3
30.4
CHILDREN( 6-35) ANAEMIC PREGNANT WOMEN EVER MARRIED WOMEN(
15-49)
BMI BELOW NORMAL
URBAN RURAL TOTAL
DATA SOURCE- NFHS-3

20. Nutritional Status Of Pregnant Women and
Children-Bihar
DATA SOURCE- NFHS-3
75.8
66.4 68.8
25.1
89
59.4
68.2
45.9
87.6
60.2
68.3
43
CHILDREN( 6-35)
ANAEMIC
PREGNANT WOMEN EVER MARRIED
WOMEN( 15-49)
BMI BELOW
NORMAL
URBAN RURAL TOTAL

21. 58.8
61.7
58.7
22.2
64
58 60.5
31.8
63.5
58.3 60.3
30.4
CHILDREN( 6-35)
ANAEMIC
PREGNANT WOMEN EVER MARRIED
WOMEN( 15-49)
BMI BELOW
NORMAL
URBAN RURAL TOTAL
DATA SOURCE- NFHS-4
Nutritional Status Of Pregnant Women
and Children-Bihar

22. Prevalence Of Severe PEM( NFHS-2)
Prevalence % States
≤5 Kerela, Goa, Sikkim
6 to 9
J/K, Punjab, AP, manipur,
Nagaland
10 to 18
Delhi, haryana, HP, WB ,
Assam, Meghalaya, Andhra
Pradesh, Karnatka,
Tamilnadu
>20
Rajasthan, Bihar, Odisha,
MP,UP

23. Measuring child Nutrition
• Anthropometric Measurements are mainstay
of assessment of PEM/ Undernutrition/
Overnutrition. These are-
1. Weight for age
2. Height for age
3. Weight for height

24. Measuring child Nutrition
4. MUAC( Mid upper arm circumference)
5. Underweight
6. Stunting
7. Wasting

25. Causes Of Under nutrition
1. Early marriage and teenage Pregnancy
2. Low Birth weight
3. Infant feeding Practices
4. Infections and Environment

26. Causes Of Under nutrition
5. Birth Interval
6. Maternal education
7. Food security
8. Intra household food security

27. 1. Early marriage and teenage Pregnancy
• The majority (53.4%) of rural women in India
were married before they turned 18 years
(NFHS-3).
• According to DLHS-3( 2007-08) 43.7% of girl’s
marry before 18 years in Katihar District.
• In urban areas of India, the women marries
before 18 years id 30%.

28. Teenage Pregnancy In India( 2005-06)
14.5
4.6
19.1
6.3
2.4
8.7
Have had a live birth Pregnant women with first
child
have begun child bearing
Rural Urban
DATA SOURCE- NFHS-4

29. 2. Low Birth Weight
• In India, nearly 22% (NFHS-2) of newborns have
LBW.
• Males have less frequency of LBW than females.
• The North-east zone has the lowest prevalence of
LBW while the north zone has the highest.
• Mother's education, access to TV and nuclear
family, and intake of iron tablets are the most
important socio-economic influences on the
determination of birth weight in India.

30. 3. Infant Feeding Practices
• In India only 23.4% (NFHS-3) of newborn
babies are put on breast feeding within one
hour of Birth.
• Only 37% of mothers initiated breastfeeding
within one day.
• According to IRMS, in Bihar about 29% of
mother started breast feeding within in 24
hours.

31. 28.9
40.3
21.5
48.3
23.4
46.3
CHILDREN BREASTFED WITHIH ONE
HOUR OF BIRTH
CHILDRN EXCLSIVELY BREASTFED
URBAN RURAL TOTAL
Infant Feeding Practices- India
DATA SOURCE- NFHS-3

32. Infant Feeding Practices- Bihar
6
31.6
44.2
3.8
27.3
58.3
4
27.9
57.3
Children under age 3 years
breastfed within one hour
of birth(%)
Children under age 6
months exclusively
breastfed(%)
Children age 6-8 months
receiving solid or semi-solid
food and breastmilk %
Urban Rural Total
DATA SOURCE- NFHS-3

33. Infant Feeding Practices- Bihar
41.8
46.8
41.2
34.2
54.2
29.5
34.9
53.5
30.7
Children under age 3 years
breastfed within one hour
of birth(%)
Children under age 6
months exclusively
breastfed(%)
Children age 6-8 months
receiving solid or semi-solid
food and breastmilk %
Urban Rural Total
DATA SOURCE- NFHS-4

34. Complementary feeding practices-
India
• Protein Energy Malnutrition ( PEM) is much
more common in age group of 6-24 months.
• The obvious reason is delay in the weaning-
complementary feeding in young children 9
month or beyond.
• Only 55.8% of breast fed children aged 6-9
months received solid – semisolid food.
DATA SOURCE- NFHS-3

35. Complementary feeding practices-
Bihar
8.4
11
8.8
7.1
9
7.47.3
9.2
7.5
Breastfeeding children age
6-23 months receiving an
adequate diet
Non-breastfeeding children
age 6-23 months receiving
an adequate diet
Total children age 6-23
months receiving an
adequate diet
Urban Rural Total

36. 4. Birth Interval And Under- Nutrition
• Studies shows that prevalence of Under-
Nutrition was higher when interval between two
births were less that 2 years.
• Young children in family with four or ore siblings
were nutritionally the most disadvantaged as
observed in several studies.
• Deprivation of maternal care is also found in large
family.
• Female infants receive less attention than male,
especially where there is already several female
children.

37. 5. Maternal Education and Under-
Nutrition
50.3
4.8
15.1
46.9
0.4
12.9
42.9
3.7
11.8
41.7
2.4
7.3
22.9
2.1
6.7
Stunted Wasted LBW
No education Junior primary Senior Primary
Junior Secondary senior Secondary
The Impact of Maternal Education on Child Nutrition: Evidence from
Malawi, Tanzania, and Zimbabwe- Demographic and Health Survey 2013

38. 6. Food Security
1950-51 1965 2008 2015-16
50.82
89
230
253.6
Food Production in India (MT)

39. • Spite of sufficient buffer stock, there is 26% of
population is still living below poverty line .
• Most ST and 40% of SC casual workers are
poor, the landless casual workers being the
poorest.
• Other Reasons are unfair/unequal distribution
of food, land wealth, less purchasing power
and Unemployment.
6. Food Security

40. • Though food production has been increase
through Green/white/ yellow revolutions, the
level of chronic food security in India is still
high.
• The increase in population size, low literacy
level, recurrent drought conditions, increasing
unemployment , and decreasing household
food security status contributing to the
dilution of effect of development.
6. Food Security

41. 7. Intra household Food security
• Food Security defined as physical, economic
and social access to balanced diet, safe
drinking water, environmental hygiene, and
Primary Health Care (M S Swaminathan) .
• Household food security means “ the access of
all people to sufficient, safe and nutritious
food to meet their dietary needs and food
preferences for an active and healthy life.

42. 7. Intra household Food security
• Household food security has four basic
components, availability, accessibility,
utilization and stabilization.
• Unequal distribution of food between Male,
Female and children in family .
• The reasons are lower status of women in
family, ignorance about child feeding, low
literacy, lack of awareness and poverty.

43. • 60% of farmers on an average own 0.4 hectare
while 20% holds 1.4 hectare.
• Such a meager land holding by large majority
of farmers is neither viable nor sustainable.
• The average land holding per head among
rural farmers in developing countries declined
from3.6 hectares in 1972 to 0.26 hectares in
1992 and continue to fall.
7. Intra household Food security

44. • The current wave of globalization and
linearization contribute to increase inequalities
with in both developing and developed countries.
• The organization for economic cooperation and
development ( OECD) controlled 90% of global
seed market.
• From1970to1996 OECD share of the volume of
world cereal export rose from 73 to 82%, making
US major exporter of commercial crops.
7. Intra household Food security

45. Prevention and control of under
nutrition
1. Feeding practices of infant and young
children
2. Immunization
3. Control of infection
4. female literacy
5. Population control and stabilization
6. School health programmes

46. Prevention and control of under
nutrition
7. Supplementary feeding programmes through
ICDS.
8. Growth monitoring and promotion .
9. Food production and distribution.
10.Public distribution system( PDS)/Annapurna
Yojana
11.Employment guarantee act and scheme.
12.Fight against hidden hunger.

47. 1. Feeding practices of infant and
young children- EBF
• Initiation of breastfeeding within the first hour of life
• Exclusive breastfeeding – that is the infant only
receives breast milk without any additional food or
drink, not even water
• Breastfeeding on demand – that is as often as the child
wants, day and night
• exclusive breastfeeding for 6 months is the optimal
way of feeding infants.
• Thereafter infants should receive complementary foods
with continued breastfeeding up to 2 years of age or
beyond.

48. Feeding Practices- Complementary
feeding
• The adequacy of complementary feeding
(adequacy in short for timely, adequate, safe and
appropriate) not only depends on the availability
of a variety of foods in the household, but also on
the feeding practices of caregivers.
• Feeding young infants requires active care and
stimulation, where the caregiver is responsive to
the child clues for hunger and also encourages
the child to eat.
• This is also referred to as active or responsive
feeding.

49. Feeding Practices- Complementary
feeding
• WHO recommends that infants start receiving
complementary foods at 6 months of age in
addition to breast milk, initially 2-3 times a
day between 6-8 months,
• increasing to 3-4 times daily between 9-11
months and
• 12-24 months with additional nutritious
snacks offered 1-2 times per day, as desired.

50. National Guidelines on infant and
Young child feeding
1. Early initiation of breast feeding within half
an hour of birth .
2. Feeding Of Colostrums.
3. Exclusive breastfeeding for first six months.
4. Introduction of complementary feeding after
six months.
5. Staple cereal of the family should be used to
make the first food for infant.

51. National Guidelines on infant and
Young child feeding
6. Encourage foods which are routinely cooked
in family.
7. Energy density of infant food should be
increased by adding tea spoonful of oil or
ghee in every feed or by adding sugar and
jaggery.
8. Infant and young children should fed 5-6
times a day.

52. National Guidelines on infant and
Young child feeding
9. Continue breast feeding up to age of two
years or beyond.
10.Appropriate feeding during or after illness.
11.Growth monitoring and promotion.
12. Feeding in difficult circumstances.

53. National Guidelines on infant and
Young child feeding
13.HIV and Breast feeding-WHO recommends that
all mothers, regardless of their HIV status,
practise exclusive breastfeeding – which means
no other liquids or food are given – in the first
six months.
• After six months, the baby should start on
complementary foods.
• Mothers who are not infected with HIV should
breastfeed until the infant is two years or older.

54. 2. Immunization
• Children should be given all recommended
vaccine according to Immunization schedule
(UIP).
• Vitamin A should be given with first dose of
Measles vaccine.

55. 3. Control Of Infection
• Washing of hands, clean food, use of safe
drinking water, safe disposal of human excreta
prevent diarrheal diseases, worm infestations.
• Home available foods, ORS, Zinc and
breastfeeding , if child develops diarrhea.
• Increase frequency of feeding after diarrhea
helps catch-up growth in young children.
• Deworming is also essential.

56. Nutrition of adolescents, pregnant
women and lactating mothers
• Nutrition education
• Supplementation of IFA tablets to adolescents.
• Right age of marriage and adequate nutrition
of pregnant women/ supplementation of IFA
• Adequate nutrition of lactating women ensure
adequate breast milk, essential for child
survival, growth and development.

57. 4. Female literacy
• Female literacy is first determinant of child
under nutrition .
• it is inter-linked with various factors like
nutrition, maternal health, anaemia control,
spacing of pregnancies and antenatal care.,
hygiene and sanitation, immunization and
accessing health services.

58. Women literacy Rate improved
8.86
15.35
21.97
29.76
39.29
54.16
65.46
0
10
20
30
40
50
60
70
1951 1961 1971 1981 1991 2001 2011
FEMALE LITERACY RATE

59. Female literacy
• The bold decision to declare “ education as
the fundamental right” in April 2010 ensure
the free and compulsory education to fulfill
the constitutional commitment of “education
for all”.
• Effort is being made to reach the unreached
women and children through “ sarva shiksha
Abhiyan( SSA) launched in 2001.

60. 5. Population control and stabilization
• India was the first country in the world to have
launched a National Programme for Family
Planning in 1952.
• currently being repositioned to not only
achieve population stabilization goals but also
promote reproductive health and
reduce maternal, infant & child mortality and
morbidity.
• NPP (2000) agenda was to bring down birth rate
to 2.1 by 2010.

61. 6. School Health programme
• School Health program is a program for school
health service under National Rural Health
Mission, cover 12,88,750 Government and
private aided schools covering around 22
Crore students all over India.

62. Components of School Health Program
1. Screening, health care and referral
• Screening of general health, assessment of
Anaemia/Nutritional status, visual acuity, hearing
problems, dental check up, common skin conditions,
Heart defects, physical disabilities, learning disorders,
behavior problems, etc.
• Basic medicine kit will be provided to take care of
common ailments prevalent among young school going
children.
• Referral Cards for priority services at District / Sub-
District hospitals

63. Components of School Health Program
2. Immunisation:
• As per national schedule
• Fixed day activity
• Coupled with education about the issue
3. Micronutrient (Vitamin A & IFA) management:
• Weekly supervised distribution of Iron-Folate
tablets coupled with education about the issue
• Administration of Vitamin-A in needy cases.

64. Components of School Health Program
4. De-worming
• As per national guidelines
• Biannually supervised schedule
• Prior IEC
• Siblings of students also to be covered

65. Components of School Health Program
5. Health Promoting Schools
• Counseling services
• Regular practice of Yoga, Physical education,
health education
• Peer leaders as health educators.
• Adolescent health education-existing in few
places
• Linkages with the out of school children
• Health clubs, Health cabinets
• First Aid room/corners or clinics.

66. Components of School Health Program
6. Capacity building
7. Monitoring & Evaluation
8. Mid Day Meal

67. Mid day Meal Scheme/Programme
The objectives of the mid day meal scheme are:
1. Improving the nutritional status of children in
classes I – VIII in Government, Local Body and
Government aided schools, and EGS and AIE
centres
2. Encouraging poor children, belonging to
disadvantaged sections, to attend school more
regularly and help them concentrate on
classroom activities.
3. Providing nutritional support to children of
primary stage in drought-affected areas

68. 7. Supplementary Feeding Programme
through ICDS
• The Supplementary Nutrition is one of the six
services provided under the Integrated Child
Development Services (ICDS) Scheme which is
primarily designed to bridge the gap between
the Recommended Dietary Allowance (FDA)
and the Average Daily Intake (ADI).
• Supplementary Nutrition is given to the
children (6 months – 6 years) and pregnant
and lactating mothers under the ICDS Scheme.

69. Revised feeding and cost norms

70. World Food Program (WFP)
• The world Largest food aid organization
working with goal “ a world in which every
man, woman and child has access at all times
to the food needed for an active an healthy
life”
• In India under a new country strategic plan
2015-18, WFP supporting the GOI under
national food security act ( NFSA), including
ICDS Scheme/MDM Programme/TDPS.

71. Management of children with SAM
• Severe acute malnutrition (SAM) can be
categorized into:
1. SAM with medical complication.
2. SAM without medical complication.
• Nutrition rehabilitation centers( NRC) has
been established for SAM at district level.
• Community based programme should be in
place.

72. Prevention and control of under
nutrition
8. Growth monitoring and promotion .
children below the age of three year weighed
once in month and 3-6 years, once in three
month.
9. Food production and distribution.
Graduating from “ food security” to “
household food security” to “Nutrition and
health security” of all.

73. 10. Public distribution system
evolution
1. Public distribution System ( 1960)
2. Revamped Public Distribution System (RPDS)
was launched in June 1992 in 1775 blocks
throughout the country.
3. Targeted Public Distribution System (TPDS) was
introduced with effect from June 1997.
4. Antyodaya Anna Yojana” (AAY) was launched in
December, 2000 for one crore poorest of the
poor families.
5. Food security bill ( 2013)

74. Annapurna Scheme
• To providing food security to meet the requirement of
those senior citizens who though eligible have
remained uncovered under the National Old Age
Pension Scheme.
• The target group receives 10 kgs of food grains per
month free of cost.
• Gol has fixed a numerical ceiling of 64,800
beneficiaries under the scheme for the entire State.
• Target Group:
Senior citizens of 60 years and above, who are eligible
for all old age pension schemes, but not covered under
the same.

75. •The Mahatma gandhi National
Rural Employment Guarantee
Act (MNREGA) is an Indian job
guarantee scheme, enacted by
legislation on August 25, 2005.
•The scheme provides a legal
guarantee for one hundred days
of employment in every
financial year to adult members
of any rural household willing to
do public work-related unskilled
manual work at the statutory
minimum wage of 120 (US$2.43)
per day in 2009 prices.
11. Mahatma Gandhi national rural
employment gurantee act and scheme

76. DIDYOUKNOW?What are the Unique Features of NREGA?
•Time bound employment guarantee and wage payment within 15 days
Incentive-disincentive structure to the State Governments for providing
employment as 90 per cent of the cost for employment provided is
borne by the Centre
•payment of unemployment allowance at their own cost and emphasis
on labour intensive works prohibiting the use of contractors and
machinery.
•The Act mandates a 33 per-cent participation for women.

77. WORKING GROUPS IN PER-CENT
40
36
26
62
0
10
20
30
40
50
60
70
women SC ST SC/ST

78. 12. Fight against Hidden Hunger(
Micronutrient deficiency)
• Should focus on food based approach rather
than food fortification.
• Micronutrient supplementation programme of
Vit-A and IFA should be focused and targeted
to 1-3 years children.
• Universal Iodized salt consumption should be
strived.

79. Summary
• Integrated health, nutrition, educational
approach.
• Convergence of ICDS/self help groups/ village
panchayat at village level.
• EBF/supplementary feeding
• Eating clean/immunization/response to
infections.
• Supporting mothers and building their
capacities at household level.

80. BYE !THANKS!