Transcript Dr. Harivansh Chopra
Prevention of Childhood Malnutrition
4/25/2020
Dr. Harivansh Chopra DCH, MD Professor Department of Community Medicine, LLRM Medical College, Meerut.
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Objectives
1.
2.
To study the magnitude of Protein Energy Malnutrition and causes associated with it.
To study methods of prevention, treatment, and rehabilitation of PEM.
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?
?
Whether this child will grow normally or become malnourished?
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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”.
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Nutritional Status of children below 3 years : NFHS II
20 15 10 5 0 50 45 40 35 30 25 46 47 16 Stunted Underweight
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50 40 30 20 10 0
Nutritional Status of children below 3 years : NFHS II
Urban Rural 48.6
49.6
35.6
38.4
13 16.2
Stunted Underweight
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Nutritional status of under-three children in relation to living index NFHSII
56.9
60 50 46.8
45.3
53.7
HIGH MEDIUM LOW 40 28.5
30 26.8
20 10 10.2
14.3
19.7
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0 UNDER WT STUNTED
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Nutritional status of under-three children in relation to age
60 50 58.5 58.4
57.5 56.5
40 30 37.5
30.9
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20 10 0 11.9
15.4
Underweight Stunted
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Dr. Harivansh Chopra < 6 months 6 - 11 months 12 - 23 months 24 - 35 months 9.3
13.2
21.9
13.2
Wasted
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Percentage of underweight children – Comparison between NFHS I & II
60 50 52 47 NFHS I NFHS II 40 30 20 10 0 20 18
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Underweight Severely Underweight
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Nutritional Status of children below 3 years : NFHS III
20 15 10 5 0 50 45 40 35 30 25 38 46 19
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Stunted Underweight
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Nutritional Status of children below 3 years : NFHS III
Urban Rural 49 50 40 30 20 10 0 31.1
40.7
36.4
16.9
19.8
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Stunted Underweight
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Percentage of underweight children – Comparison between NFHS II & III
47 50 45 40 35 30 25 20 15 10 5 0 46 46 38 16 NFHS II NFHS III 19
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Underweight Stunted
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Distribution of 1-5 years children (Gomez classification) Income HIG MIG LIG IL SLUM RURAL Weight as percentage of normal ≥ 90% 75 – 90% 60 – 75% < 60% 48.2
40.8
10.5
0.5
38.8
45.0
15.7
0.5
20.2
19.4
12.7
13.0
47.6
46.1
40.7
41.9
28.7
31.1
38.6
37.0
3.5
3.4
8.0
8.1
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Causes of Malnutrition
1.
Inadequate Food Security.
2.
Infection.
3.
4/25/2020 Low weight of adolescent girls.
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Causes of Malnutrition
4.
Low Immunization coverage.
5.
Maternal Anemia.
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Low literacy level in female.
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Causes of Malnutrition
7.
Poor sanitary conditions.
8.
Low birth weight.
9.
4/25/2020 Lack of knowledge regarding normal growth of children.
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Causes of Malnutrition
10.
Poor hygiene.
11.
Incorrect child rearing practices.
12.
Inaccessible and Inadequate health services.
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Causes of Malnutrition
13.
Lack of Comprehensive Child Health Care Programme.
14.
Lack of political will.
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1.
Big
problem needs a
Big
solution.
2.
3.
If one wants to
Win
the battle, the effort has to be intensive and focused.
So, it has to be a BIG WIN against MALNUTRITION.
4.
BIGWIN
approach is to be applied.
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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.
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Dr. Harivansh Chopra
The BIGWIN Approach
Exclusive
B
reast Feeding for 6 months.
I
nfection Prevention/Treatment and
I
mmunization.
G
rowth Promotion / Monitoring.
Appropriate
W
eaning Practice. Safe W ater 4/25/2020
I
ron Supplementation.
N
utrition education & Extra-
N
utrition in pregnancy & lactation, and illness in child.
N
o to next pregnancy. observerzparadise.com
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4/25/2020 Weight gain in the first five years of life
1st Year 2 - 5 years 8 Kg.
8 Kg.
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Weight gain in the first year of life
First 4 months Next 8 months 4 Kg.
4 Kg.
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4/25/2020 Weight gain in the next four years of life
2nd Year 3rd Year 4th Year 5th Year 2 Kg.
2 Kg.
2 Kg.
2 Kg.
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v/s Monitor the Weight
I F R S T S E C O N D 4/25/2020 Weight gain in 1 st year of life.
Weight gain in next 4 years of life.
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Exclusive Breast Feeding in India – NFHS II
Exclusive Breast Feeding Not Exclusively Breast-fed 55 45
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Exclusive breast feeding upto 4months
Immunization Coverage
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80 70 60 50 40 30 20 10 0 62.2
71.6
BCG 51.7
65.1
53.6
62.8
42.2
50.7
NFHS I NFHS II 35.5
42 DPT 3 OPV 3 doses doses
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Immunization Coverage
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78.2
80 70 60 50 40 30 20 10 0 71.6
BCG 55.1
55.3
62.8
78.2
50.7
58.8
NFHS II NFHS III 42 43.5
DPT 3 OPV 3 doses doses
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Anemia in Children
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Severe Dr. Harivansh Chopra 7
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Anaemia among Children Age 6-35 Months
Percent
50 40 30 20 10 0 90 80 70 60 74 79 4 5
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Any anaemia Severe anaemia NFHS-2
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NFHS-3 Dr. Harivansh Chopra
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4/25/2020 Iron Supplementation v/s Iron Therapy – Cost
Iron Supplementation Iron Therapy 70 30
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Empowering Women
Poor Perpetually Pregnant female 4/25/2020 Powerful Perceptive Problem-solving observerzparadise.com
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Empowering Women
1.
Mass Media 2.
Government Health System 3.
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Empowering Women
4.
NGOs 5.
Link Women 6.
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Empowering Women
7.
Health Worker 8.
School Health 9.
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Nutrition Education
1.
2.
Education is a learning process by which a change in behaviour is brought about.
For providing nutrition education, one must have sound knowledge of locally available foods.
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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.
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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. 4/25/2020 observerzparadise.com
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Nutrition Education
7. Vulnerable periods of life, specially infancy, pregnancy, and lactation must be taken into account.
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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.
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Principles of Nutrition Therapy
1.
Mild to moderate degree of malnutrition can be managed at home.
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Principles of Nutrition Therapy
2.
3.
Only severely malnourished children with complications need to be hospitalized first.
The aim is to provide 1.5 – 2 gms. of protein/ kg per day and 150 – 180 calories/kg/day.
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Management of mild to moderate degree of malnutrition This is usually done with the help of protein and calorie rich diets.
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1.
1. Besan Panjiri
Contents – Bengal gram flour, Wheat flour, Jaggery, Ghee (1 part each).
+ + +
2.
3.
Calories: 500 calorie/100gm.
Protein: 9gm/100gm.
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1.
2. Shakti aahar
Constituents: Roasted wheat 40gm, Roasted gram 20gm, Roasted peanuts 10gm, Jaggery 30gm.
+ +
2.
3.
Calories: 390 calories/100gm.
Protein: 11.4gm/100gm.
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1.
3. Hyderabad Mix
Constituents: Whole wheat 40gm, Bengal gram 16gm, Groundnuts 10gm, Jaggery 20gm.
+ + +
2.
3.
Calories: 330 calories/86gm.
Protein: 11.3gm/86gm.
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Management of severely malnourished children 1.
2.
With complications, they should be hospitalized.
Without complications, put straightaway on dietary management.
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1.
2.
1. Dietary Management – Initial Phase Feeding must start gradually.
Initially approx. 80 Cal/kg/day and 0.7gm protein/kg/day provided; actual body weight rather than expected body weight counted.
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1.
4. Sooji Kheer
Constituents: Toned milk 750ml, Sugar 100gm, Sooji 25gm, Oil 5gm (aqua add 1000ml).
+ +
2.
3.
Calories: 143 calorie/100gm.
Protein: 2.8gm/100gm.
+
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1. Dietary Management – Initial Phase 3.
4.
Small frequent feeds given.
Intake gradually increased to 100 Cal/kg/day and 1gm protein/kg/day.
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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.
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1. Dietary Management – Initial Phase 6.
7.
For enriching milk, generally coconut oil is used.
Fluids should be given with cup and spoon; bottle-feeding best avoided.
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2. Dietary management – Phase of High Energy Feeding 1.
2.
3.
Caloric intake gradually increased to 150 – 180 Cal/kg/day.
Child moved from predominant milk diet to semi solids/solid diet.
Protein intake increased to 1.5 – 2gm/kg/day. 4/25/2020 observerzparadise.com
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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.
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3. Dietary Management – Transfer to Family type diet 2.
3.
Involves nutrition education of parents.
Snacks made from peanuts, bengal gram, jaggery, and oil are useful.
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Nutritional Rehabilitation
1.
2.
Majority of children, after discharge from hospital, again become victim of Malnutrition.
To overcome this, Nutritional Rehabilitation is carried out.
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Nutritional Rehabilitation
Ambulatory Treatment Rehabilitation in “Nutrition Rehabilitation Centres” 4/25/2020 observerzparadise.com
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Ambulatory Treatment
1.
2.
3.
In most cases of malnutrition, education alone is sufficient to correct situation.
Identify the most serious errors in diet eg. distribution of available food in family, inadequate use of vegetables, etc. The problem may need assistance usually as Food Supplements.
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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 4/25/2020 malnutrition can be prevented.
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Nutritional Rehabilitation Centres (NRC) Day care NRCs Residential NRCs 4/25/2020 observerzparadise.com
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Day care NRCs
1.
2.
Similar to
crěche
or
kindergarden.
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 4/25/2020 weekly meeting at centre.
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Day care NRCs
4.
5.
Food stuffs and utensils used are familiar to the mothers, and available in local market.
Adequate medical supervision is essential at the centres.
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Residential NRCs
1.
2.
3.
Larger staff and equipments than day-care NRCs.
Children & their mothers live in these as inpatients.
Serves mostly children discharged from hospital after treatment for severe malnutrition.
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Nutrition Supplementation
1.
Approach by which both prevention and treatment of malnutrition can be met.
2.
Supplementary food supplies 300 Cal/day and 10 – 12 gm protein/day to children, and 500 Cal/day and 25 gm protein/day to mothers for 300 days in an year.
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Nutritional Surveillance
1.
Surveillance is defined as “Data Collection for Action”.
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Objectives of Nutrition Surveillance 1.
2.
To aid long term planning in health and development.
To provide input for programme management and evaluation.
3.
To give timely warning and intervention to prevent short-term food consumption 4/25/2020 crisis.
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Triple-A approach
Perceptions & Understanding Resources ACTION
based on the analysis and available resources
ASSESSMENT
of the situation
Capabilities
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ANALYSIS
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Conclusion
1.
2.
3.
4.
Malnutrition is a preventable problem.
Shift in strategy is the need of the hour.
Infants must be made the focus of attention in totality.
Application of multiple interventions like BIGWIN will produce the desired result.
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MCQs
1.
1.
Following is false about weight gain in first year of life except: Weight gain is 4 kg in 1 st year.
2.
Weight gain is 4 kg in 1 st 4 months.
3.
4.
4/25/2020 Weight gain is maximum during 6 – 12 months of age.
None of the above.
Ans. – 2.
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MCQs
2.
1.
“Hyderabad Mix”, an energy dense supplement, used for malnourished children does not contain : Bengal gram.
2.
3.
4.
Groundnut.
Soyabean.
Jaggery.
Ans. – 3.
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MCQs
2.
1.
“Hyderabad Mix”, an energy dense supplement, used for malnourished children does not contain : Bengal gram.
2.
3.
4.
Groundnut.
Soyabean.
Jaggery.
Ans. – 3.
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MCQs
3.
1.
2.
In dietary management of malnutrition, following is provided to children : 100 Cal/kg and 1gm protein/kg. 180 Cal/kg and 2 gm protein/kg.
3.
4.
300 Calorie and 15 gm protein.
500 Calorie and 25 gm protein.
Ans. – 2.
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MCQs
4.
1.
NRC is : Nutrition Rehabilitation Centre.
2.
Nutrition Rehabilitation Council.
3.
4.
Natural Resources Council.
Natural Rights of Community.
Ans. – 1.
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MCQs
5.
1.
2.
Giving “timely warning” about food consumption crisis is an objective of : Disaster Management.
Food Census.
3.
4.
Nutrition Surveillance.
Food & Agriculture Research.
Ans. – 3.
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