Dr. Harivansh Chopra
Whether this child will survive/ grow
normally or become malnourished?
? ?
11/29/2016 2

Dr. Harivansh Chopra
To which domain this child belongs ?
? ?
11/29/2016 3

Dr. Harivansh Chopra
DIARRHOEA
9%
PNEUMONIA
15%
INTRAPARTUM
RELATED
COMPLICATIONS
11%
MALARIA
7%
PRETERM BIRTH
COMPLICATIONS
17%
OTHERS
41%
CAUSES FOR UNDER 5 MORTALITY, WHO 2015
GLOBALLY, NEARLY HALF OF UNDER5 DEATHS ARE
ATTRIBUTABLE TO UNDERNUTRITION

Dr. 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”.
11/29/2016 5

Dr. Harivansh Chopra
Nutritional Status of children
below 3 years : NFHS II
0
5
10
15
20
25
30
35
40
45
50
Stunted Underweight Wasted
46 47
16
Percentage
11/29/2016 6

Dr. Harivansh Chopra
Nutritional Status of children
below 3 years : NFHS II
0
10
20
30
40
50
Stunted Underweight Wasted
35.6
38.4
13
48.6 49.6
16.2
Percentage
Urban Rural
11/29/2016 7

Dr. Harivansh Chopra
Nutritional status of under-three
children in relation to living index
0
10
20
30
40
50
60
UNDER WT STUNTED WASTED
26.8 28.5
10.2
46.8 45.3
14.3
56.9
53.7
19.7
Percentage
HIGH
MEDIUM
LOW
NFHSII
11/29/2016 8

Dr. Harivansh Chopra
Nutritional status of under-three
children in relation to age
0
10
20
30
40
50
60
Underweight Stunted Wasted
11.9
15.4
9.3
37.5
30.9
13.2
58.5 57.5
21.9
58.4 56.5
13.2
Percentage
< 6 months
6 - 11 months
12 - 23 months
24 - 35 months
11/29/2016 9

Dr. Harivansh Chopra
Percentage of underweight children –
Comparison between NFHS I & II
0
10
20
30
40
50
60
Underweight Severely Underweight
52
20
47
18
Percentage
NFHS I
NFHS II
11/29/2016 10

Dr. Harivansh Chopra
Nutritional Status of children below
3 years : NFHS III
0
5
10
15
20
25
30
35
40
45
50
Stunted Underweight Wasted
38
46
19
Percentage
11/29/2016 11

Dr. Harivansh Chopra
Nutritional Status of children below
3 years : NFHS III
0
10
20
30
40
50
Stunted Underweight Wasted
31.1
36.4
16.9
40.7
49
19.8
Percentage
Urban Rural
11/29/2016 12

Dr. Harivansh Chopra
Percentage of underweight children –
Comparison between NFHS II & III
0
10
20
30
40
50
Underweight Stunted Wasted
47 46
16
46
38
19
Percentage
NFHS II
NFHS III
11/29/2016 13

Dr. Harivansh Chopra
Malnutrition in children of
Bihar
62.6
21.8
60.9
52.2
25.4
58.455.9
27.1
55.6
43.9
20.8
48.3
0
10
20
30
40
50
60
70
UNDERWEIGHT WASTED STUNTED
NFHS-1 NFHS-2 NFHS-3 NFHS-4
11/29/2016 14

Dr. Harivansh Chopra
% of children under 3 years who
are breastfed within one hour of
birth (Bihar)
4
34.9
0
10
20
30
40
NFHS-3 NFHS-4
11/29/2016 15

Dr. Harivansh Chopra
Causes of Malnutrition
1. Inadequate Food Security.
2. Infection.
3. Low weight of adolescent girls.
11/29/2016 16

Dr. Harivansh Chopra
Causes of Malnutrition
4. Low Immunization coverage.
5. Maternal &Childhood Anemia
.
6. Low literacy level in female.
11/29/2016 17

Dr. Harivansh Chopra
Causes of Malnutrition
7. Poor sanitary conditions.
8. Low birth weight.
9. Lack of knowledge regarding
normal growth of children.
11/29/2016 18

Dr. Harivansh Chopra
Causes of Malnutrition
10. Poor hygiene.
11. Incorrect child rearing practices.
12. Inaccessible and Inadequate
health services.
11/29/2016 19

Dr. Harivansh Chopra
Causes of Malnutrition
13. Lack of Comprehensive Child
Health Care Programme.
13. Lack of political will.
11/29/2016 20

Dr. Harivansh Chopra
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.
11/29/2016 21

Dr. Harivansh Chopra
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.
11/29/2016 22

Dr. Harivansh Chopra
Exclusive Breast
Feeding
for 6 months
11/29/2016 observerzparadise.com 23

Dr. Harivansh Chopra
Infection
Prevention/Treatment
11/29/2016 observerzparadise.com 24
Immunization

Dr. Harivansh Chopra
11/29/2016 observerzparadise.com 25
Growth Promotion / Monitoring

Dr. Harivansh Chopra
Appropriate Weaning
Practice
11/29/2016 observerzparadise.com 26
Safe Water HandWashing

Dr. Harivansh Chopra
11/29/2016 observerzparadise.com 27
Iron Supplementation

Dr. Harivansh Chopra
Nutrition education
11/29/2016 observerzparadise.com 28
Extra-Nutrition in
pregnancy &
lactation,
and illness in child.

Dr. Harivansh Chopra
11/29/2016 observerzparadise.com 29
No to next
pregnancy.
No to teenage
marriage

Dr. Harivansh Chopra
The BIGWIN Approach
Exclusive Breast Feeding for 6 months.
Infection Prevention/Treatment and Immunization.
Growth Promotion / Monitoring.
Appropriate Weaning Practice. Safe Water
Iron Supplementation.
Nutrition education & Extra-Nutrition in
pregnancy & lactation, and illness in child.
No to next pregnancy.No to teenage marriage
11/29/2016 30

Dr. Harivansh Chopra
Weight gain in the first
five years of life
8
8
1st Year 2 - 5 years
Kg.
Kg.
11/29/2016 31

Dr. Harivansh Chopra
Weight gain in the first year of life
4
4
First 4 months Next 8 months
Kg.
Kg.
11/29/2016 32

Dr. Harivansh Chopra
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.
11/29/2016 33

Dr. Harivansh Chopra
v/s
Monitor the Weight
F
I
R
S
T
S
E
C
O
N
D
Weight gain in 1st year of life.
Weight gain in next 4 years of life.
11/29/2016 34

Dr. Harivansh Chopra
11/29/2016 35

Dr. Harivansh Chopra
11/29/2016 36

Dr. Harivansh Chopra
Exclusive Breast Feeding in India –
NFHS II
55
45
Exclusive Breast Feeding Not Exclusively Breast-fed
11/29/2016 37

Exclusive breast feeding upto
4months
0%
10%
20%
30%
40%
50%
60%
NFHS 1 NFHS 2 NFHS 3
51% 55%
45%

Dr. Harivansh Chopra
Exclusive breastfeeding in Bihar
(0-6 months)
28
53.5
0
10
20
30
40
50
60
NFHS-3 NFHS-4
11/29/2016 39

Dr. Harivansh Chopra
Complimentry feeding in Bihar
54.5
30.7
0
10
20
30
40
50
60
NFHS-3 NFHS-4
11/29/2016 40

Dr. Harivansh Chopra
Immunization Coverage
0
10
20
30
40
50
60
70
80
BCG DPT 3
doses
OPV 3
doses
Measles All
Vaccines
62.2
51.7 53.6
42.2
35.5
71.6
65.1 62.8
50.7
42
Percentage
NFHS I
NFHS II
11/29/2016 41

Dr. Harivansh Chopra
Immunization Coverage
0
10
20
30
40
50
60
70
80
BCG DPT 3
doses
OPV 3
doses
Measles All
Vaccines
71.6
55.1
62.8
50.7
42
78.2
55.3
78.2
58.8
43.5
Percentage
NFHS II
NFHS III
11/29/2016 42

Dr. Harivansh Chopra
Immunization status in Bihar
(BCG, measles, and 3 doses each of polio/DPT)
10.7 11.6
32.8
61.7
0
10
20
30
40
50
60
70
NFHS-1 NFHS-2 NFHS-3 NFHS-4
11/29/2016 43

Dr. Harivansh Chopra
Vaccination Status of Children in
Bihar (%)
36
64.7
91.7
42.2
82.4
72.9
24.9
46.1
80.2
16.2
40.4
79.4
0
10
20
30
40
50
60
70
80
90
100
NFHS-2 NFHS-3 NFHS-4
BCG POLIO DPT MEASLES
11/29/2016 44

Dr. Harivansh Chopra
Anemia in Children
31
62
7
Mild Moderate Severe
11/29/2016 45

Dr. Harivansh Chopra
0
10
20
30
40
50
60
70
80
90
Any anaemia Severe anaemia
74
4
79
5
NFHS-2 NFHS-3
Anaemia among Children Age 6-35 Months
Percent
11/29/2016 46

Dr. Harivansh Chopra
Anaemia in children in Bihar
81.1 78
63.5
0
20
40
60
80
100
NFHS-2 NFHS-3 NFHS-4
11/29/2016 47

Dr. Harivansh Chopra
Iron Supplementation v/s
Iron Therapy – Cost
30
70
Iron Supplementation Iron Therapy
11/29/2016 48

Dr. Harivansh Chopra
The BIGWIN Approach
Exclusive Breast Feeding for 6 months.
Infection Prevention/Treatment and Immunization.
Growth Promotion / Monitoring.
Appropriate Weaning Practice. Safe Water
Iron Supplementation.
Nutrition education & Extra-Nutrition in
pregnancy & lactation, and illness in child.
No to next pregnancy.No to teenage marriage
11/29/2016 49

Dr. Harivansh Chopra
Empowering Women
Poor Perpetually Pregnant female
Powerful Perceptive Problem-solving
11/29/2016 50

Dr. Harivansh Chopra
Empowering Women
1. Mass Media
2. Government Health System
3. Mahila Mandals
11/29/2016 51

Dr. Harivansh Chopra
Empowering Women
4. NGOs
5. Link Women
6. Anganwadi
11/29/2016 52

Dr. Harivansh Chopra
Empowering Women
7. Health Worker
8. School Health
9. BFCI
11/29/2016 53

Dr. Harivansh Chopra
Community medicine
? ?
11/29/2016 54

Dr. Harivansh Chopra
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.
11/29/2016 55

Dr. Harivansh Chopra
Nutrition Education
3. The timing of providing education is of
crucial importance.
4. All persons involved in decision making,
as well as responsible for cooking must be
sensitized.
11/29/2016 56

Dr. Harivansh Chopra
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.
11/29/2016 57

Dr. Harivansh Chopra
Nutrition Education
7. Vulnerable periods of life, specially
infancy, pregnancy, and lactation must be
taken into account.
11/29/2016 58

Dr. Harivansh Chopra
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.
11/29/2016 59

Dr. Harivansh Chopra
Principles of Nutrition Therapy
1. Mild to moderate
degree of
malnutrition can
be managed at
home.
11/29/2016 60

Dr. Harivansh Chopra
Principles of Nutrition Therapy
2. Only severely malnourished children with
complications need to be hospitalized first.
3. The aim is to provide 1.5 – 2 gms. of
protein/ kg per day and 150 – 180
calories/kg/day.
11/29/2016 61

Dr. Harivansh Chopra
Management of mild to moderate
degree of malnutrition
This is usually done
with the help of
protein and calorie
rich diets.
11/29/2016 62

Dr. Harivansh Chopra
1. Besan Panjiri
1. Contents – Bengal gram flour, Wheat flour, Jaggery, Ghee (1 part each).
2. Calories: 500 calorie/100gm.
3. Protein: 9gm/100gm.
+ + +
11/29/2016 63

Dr. Harivansh Chopra
2. Shakti aahar
1. Constituents: Roasted wheat 40gm, Roasted gram 20gm, Roasted
peanuts 10gm, Jaggery 30gm.
2. Calories: 390 calories/100gm.
3. Protein: 11.4gm/100gm.
+ + +
11/29/2016 64

Dr. Harivansh Chopra
3. Hyderabad Mix
1. Constituents: Whole wheat 40gm, Bengal gram 16gm, Groundnuts
10gm, Jaggery 20gm.
2. Calories: 330 calories/86gm.
3. Protein: 11.3gm/86gm.
+ + +
11/29/2016 65

Dr. Harivansh Chopra
Management of severely
malnourished children
1. With complications,
they should be
hospitalized.
2. Without complications,
put straightaway on
dietary management.
11/29/2016 66

Dr. Harivansh Chopra
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.
11/29/2016 67

Dr. Harivansh Chopra
4. Sooji Kheer
1. Constituents: Toned milk 750ml, Sugar 100gm, Sooji 25gm, Oil 5gm
(aqua add 1000ml).
2. Calories: 143 calorie/100gm.
3. Protein: 2.8gm/100gm.
+ + +
11/29/2016 68

Dr. Harivansh Chopra
1. Dietary Management –
Initial Phase
3. Small frequent feeds
given.
4. Intake gradually
increased to 100
Cal/kg/day and 1gm
protein/kg/day.
11/29/2016 69

Dr. Harivansh Chopra
1. Dietary Management –
Initial Phase
5. Milk is usually the starting food; for
lactose-intolerance, other foods like rice
gruel, chicken gruel, soya rice gruel, and
cereal pulse gruel are used.
11/29/2016 70

Dr. Harivansh Chopra
1. Dietary Management –
Initial Phase
6. For enriching milk,
generally coconut oil is
used.
7. Fluids should be given
with cup and spoon;
bottle-feeding best
avoided.
11/29/2016 71

Dr. Harivansh Chopra
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.
11/29/2016 72

Dr. Harivansh Chopra
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.
11/29/2016 73

Dr. Harivansh Chopra
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.
11/29/2016 74

Dr. Harivansh Chopra
Nutritional Rehabilitation
1. Majority of children, after discharge from
hospital, again become victim of
Malnutrition.
2. To overcome this, Nutritional
Rehabilitation is carried out.
11/29/2016 75

Dr. Harivansh Chopra
Nutritional Rehabilitation
Ambulatory Treatment Rehabilitation in “Nutrition
Rehabilitation Centres”
11/29/2016 76

Dr. Harivansh Chopra
Ambulatory Treatment
1. In most cases of malnutrition, education
alone is sufficient to correct situation.
2. Identify the most serious errors in diet eg.
distribution of available food in family,
inadequate use of vegetables, etc.
3. The problem may need assistance usually
as Food Supplements.
11/29/2016 77

Dr. Harivansh Chopra
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.11/29/2016 78

Dr. Harivansh Chopra
Nutritional Rehabilitation Centres
(NRC)
Day care NRCs Residential NRCs
11/29/2016 79

Dr. Harivansh Chopra
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.
11/29/2016 80

Dr. Harivansh Chopra
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.
11/29/2016 81

Dr. Harivansh Chopra
Residential NRCs
1. Larger staff and equipments
than day-care NRCs.
2. Children & their mothers live
in these as inpatients.
3. Serves mostly children
discharged from hospital after
treatment for severe
malnutrition.
11/29/2016 82

Dr. Harivansh Chopra
Nutrition Supplementation
1. Approach by which both prevention and treatment
of malnutrition can be met.
2. Supplementary food supplies 500 Cal/day and 12 –
15 gm(rs 4) protein/day to children,
3. Severely malnourshied 800 cal/day and 20-25gm
Proteins/day (rs 6)
1. .
11/29/2016 83

Dr. Harivansh Chopra
11/29/2016 84
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

Dr. Harivansh Chopra
Nutritional Surveillance
1. Surveillance is
defined as “Data
Collection for
Action”.
11/29/2016 85

Dr. Harivansh Chopra
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.11/29/2016 86

Dr. Harivansh Chopra
Triple-A approach
ASSESSMENT
of the situation
ANALYSIS
of the causes of problem
ACTION
based on the analysis
and available resources
Perceptions &
Understanding
Capabilities
Resources
Effective
Demand
11/29/2016 87

Dr. Harivansh Chopra
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.
11/29/2016 88

Dr. Harivansh Chopra
MCQs
1. Following is false about weight gain in
first year of life except:
1. Weight gain is 4 kg in 1st year.
2. Weight gain is 4 kg in 1st 4 months.
3. Weight gain is maximum during 6 – 12
months of age.
4. None of the above.
Ans. – 2.
11/29/2016 89

Dr. Harivansh Chopra
MCQs
2. “Hyderabad Mix”, an energy dense
supplement, used for malnourished
children does not contain :
1. Bengal gram.
2. Groundnut.
3. Soyabean.
4. Jaggery.
Ans. – 3.
11/29/2016 90

Dr. Harivansh Chopra
MCQs
2. “Hyderabad Mix”, an energy dense
supplement, used for malnourished
children does not contain :
1. Bengal gram.
2. Groundnut.
3. Soyabean.
4. Jaggery.
Ans. – 3.
11/29/2016 91

Dr. Harivansh Chopra
MCQs
3. In dietary management of malnutrition,
following is provided to children :
1. 100 Cal/kg and 1gm protein/kg.
2. 180 Cal/kg and 2 gm protein/kg.
3. 300 Calorie and 15 gm protein.
4. 500 Calorie and 25 gm protein.
Ans. – 2.
11/29/2016 92

Dr. Harivansh Chopra
MCQs
4. NRC is :
1. Nutrition Rehabilitation Centre.
2. Nutrition Rehabilitation Council.
3. Natural Resources Council.
4. Natural Rights of Community.
Ans. – 1.
11/29/2016 93

Dr. Harivansh Chopra
MCQs
5. Giving “timely warning” about food
consumption crisis is an objective of :
1. Disaster Management.
2. Food Census.
3. Nutrition Surveillance.
4. Food & Agriculture Research.
Ans. – 3.
11/29/2016 94

Dr. Harivansh Chopra
THERAPEUTIC FOOD
11/29/2016 95
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.

Dr. Harivansh Chopra
THERAPEUTIC FOOD
11/29/2016 96
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”.

Dr. Harivansh Chopra
11/29/2016 97