CARE Booklet D

8/8/2019 CARE Booklet D

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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

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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.



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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



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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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Documents

CARE Booklet D