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Combating under-3 malnutrition

By Ramani Atkuri with Jan Swasthaya Sahyog

In the Jan Swasthya Sahyog's 72 creches across 30 Chhattisgarh villages, children aged six months to three years are given three meals that cover two-thirds of their daily requirement of calories and protein. The cost per child per day is Rs 17, but the payoffs in terms of their nutritional status and health are unquestionable

When we met Sumit last month at his home in Chaparwa village, he was busy grinding some pods of garlic on a flat stone. At the same time, he was consoling Vishnu, his two-year-old brother who was waiting impatiently to drink the gruel that Sumit would make with the garlic and water. Besides this, there was nothing edible in the house; their parents had left early in the morning for work. Vishnu was crying with hunger. Sumit himself was confident he could wait until his parents brought something home in the evening to eat.

Sumit grinds garlic for his younger brother Vishnu. Chaparwa village, Achanakmar Tiger Reserve, Bilaspur district

Sumit and Vishnu, who live in this remote corner of Bilaspur district in Chhattisgarh, are among the nearly 50% of children in India who are stunted and wasted. In other words, they are not only chronically malnourished and short for their age, but also underweight, signifying acute hunger. Half our children being undernourished means that half our children go to bed hungry every night. This is the reality in much of rural India, where both parents have to leave the house to earn every day, and there is no adult to look after young children.

Why be concerned about childhood malnutrition?

Undernutrition is perhaps the biggest problem India faces. It leads to increased chances of falling ill, and sometimes dying. It has been consistently shown that undernutrition -- both severe and non-severe -- is the underlying cause of over 50% of mortality in children under 5. When undernutrition occurs in early childhood it also leads to poor intellectual development, which is likely to have a lifelong effect. Undernourished children grow into undernourished adults who have poor work capacity, affecting their earning capacity and keeping them trapped in poverty. Undernourished girls who grow into weak mothers give birth to underweight babies, thereby maintaining the vicious cycle of poverty and ill-health.

Thus, in order to prevent these avoidable deaths, to make a dent in the poverty trap and to allow children optimal physical and mental growth, there is a pressing need to prevent and treat undernutrition in the community.

Importantly, undernutrition develops very early in life. In most parts of the country, the weight of children is normal in a majority of births. These children often maintain their weight improvement for the first six months of life, thanks to very high rates of breastfeeding. However, after six months most children do not get adequate complementary foods which are needed in order to grow well. The result is that children who are somewhat healthy become progressively weak, and by the age of two, many are significantly undernourished.

It is also true that most mental development occurs in early childhood, and most malnutrition sets in by the age of two or three. This affects the child's learning ability at school, worsening the consequences of early undernutrition.

Why don't our young children get enough complementary foods?

Various reasons have been identified:

  • Delayed introduction of complementary foods, possibly due to lack of sufficient knowledge about the need for it.
  • Where food is offered to the child, the portion is small, thanks to the misconception among adults that children cannot eat too much.
  • Absence of a caretaker during the day to feed the child at frequent intervals, especially when both parents go out to work during the day.
  • Frequent illness following poor nutritional status further worsens malnutrition.
  • Lack of purchasing power of the parents.

 

Though improper knowledge may be one reason, the most important reason is that there is no one to look after the child for the greater part of the day when both parents are out working. The result is that the child gets very little nutrition from an older brother or sister or an elderly grandparent appointed to look after the child.

In fact, purchasing power is not a critical factor in feeding young children, in the sense that if the family has money to buy enough food for themselves, the young child can be fed from the same food -- no special purchases are necessary. In the context of the widespread prevalent hunger that we see in this part of rural Chhattisgarh, where even adults have an insufficient and poor diet, the child's diet will also be insufficient for his/her needs. A slight increase in purchasing power will not necessarily translate into better child feeding and nutrition since the parents will still go out to work and there will be no one to look after the child. The child is therefore unable to get the necessary amount of food (ideally a child should be fed at least five times a day).

Many initiatives have tried to improve nutrition of young children. Almost all of them are predicated on the fact that the mother is the primary caretaker and hence must own primary responsibility for feeding and caring for the child.

  • Kitchen gardens: Where they work, they are a good source of vitamins and minerals, but they rarely provide all the supplementary calories or protein to the child or family.
  • Health education: It is well known that knowledge does not automatically translate into action for a number of valid reasons. A mother may have knowledge about child feeding but may not have the time or the means to put it into practice.
  • Take-home rations: This is often diluted at the family level.
  • Nutritional rehabilitation centres (NRCs): These address children with severe acute malnutrition (SAM), not mild and moderately malnourished children who make up the bulk of India's malnourished child population.

What we try to do through creches is ensure that children get complementary feeding. This means two things. First, there must be assured, child-targeted and adequate food. Second, there should be someone to ensure complementary feeding happens.

Nutrition rehabilitation centres (NRCs)

A child is kept in an NRC for roughly two weeks whilst any mild infection is treated (sick and severely malnourished children need to be admitted to hospital). The child is given a high-calorie, high-protein diet as required. The mother is also taught during this time how to cook and feed the young child at home using locally available foods.

While in many instances NRCs have served to dramatically improve the nutritional status of malnourished children, they have not been uniformly successful. Besides, their effect is not often sustained once the child is sent back home. The family is often unwilling or unable to stay the 10 days or two weeks that the child needs to be kept at the centre to start her off on the road to recovery. This may be because there are other children at home, crops or animals to take care of, or just the need to earn a wage every day. If the mother is able to stay, and cook and feed the child, there is a significant improvement, which is expected. But what happens when they return home is key: often, the mother does not have the luxury of staying with the child or feeding it through the day, and resumes her routine of going out all day to work. That is why weight gain in many children who show improvement at the NRC is not maintained.

ICDS anganwadis

The Integrated Child Development Services is the largest programme in the world, designed to provide a comprehensive package of services to adolescent girls, pregnant and lactating women, and to children under six. It was begun in 1975 in 33 blocks of the country and has now been expanded to all blocks of India, with 11,04,262 anganwadi centres operational as of end-2009 (1), with over 15 million pregnant and lactating women enrolled, and nearly 72 million children between six months and six years receiving supplementary nutrition.

Besides supplementary nutrition, the package of services under the ICDS includes growth monitoring, health and nutrition education to mothers, facilitating immunisation services, treatment of minor ailments, referral services where required, and pre-school education.

Though anganwadis were originally planned to be one per 1,000 population, in sparsely populated areas like tribal areas one centre has been sanctioned for a 500 population.

However, the anganwadi programme has been unable to significantly reduce levels of malnutrition in the country. According to the department's own information, in Chhattisgarh, only 47.5% of sanctioned projects and 56% of sanctioned AWCs were operational as of end-2009. Of the children weighed, Chhattisgarh reported 47% of children with normal weight for their age. The all-India figure for 'normal' children was 54% (2).

Several surveys have shown that the nutritional status of children in our country has slowly declined over the years, regardless of India's so-called economic progress in the 21st century. A health and nutrition discussion paper commissioned by the World Bank in 2005 (3) has looked critically at how the ICDS functions across the country, and how its poor functioning in northern and central Indian states has resulted in worse nutritional indicators for children here compared to states where the ICDS functions better (see Figure 2 ).

It has also identified several gaps in the current ICDS programme -- that it does not adequately address the most vulnerable children: those under three years of age; that it does not function effectively where it is most needed, ie in the poorest states; and that it focuses almost exclusively on supplementary feeding while ignoring other cheaper interventions like health education within the community.

Under the ICDS programme, children below three years (the exact period when malnutrition sets in) are not looked after at the anganwadi centres. The anganwadi worker hands over to the mother the take-home rations (THR) meant for the under-three child once a week or once a fortnight. These rations are often diluted among all the children in the household or all family members. Even if the entire ration is given to the child it is meant for, it does not overcome the issue of the child needing to be fed several times a day.

Children three to six years of age come to the centre for about four hours each day for pre-school activities and a meal (which varies -- sometimes it is a dry snack, other times it is meant to be a nutritious hot cooked meal). They are looked after by the anganwadi worker, while the food is cooked by a helper. There are, on average, 30 children who come to the centre each day. If more children than are eligible turn up, the worker is unable to refuse them food, as a result of which the food that each child gets is less than he/she should. A single worker, even with a helper, can in no way look after more children, especially if they are under 3, and have special needs.

Thus, if we want to prevent children from slipping into undernutrition and its lifelong consequences, we have to intervene early on.

JSS creche services

At Jan Swasthya Sahyog, we started a creche programme for children between six months and three years in consultation with the community. The programme began five years ago on a small scale, and is now spread over 30 villages covering 977 children in 72 creches.

What factors do we need to take into account when organising creche services for young children below six who have needs different from older pre-schoolers?

  • They need to be fed frequently -- at least five times a day.
  • Food needs to be of a consistency, taste and variety that they can eat.
  • Portions should be adequate: many parents feed their children small amounts, assuming that the child cannot digest too much.
  • They need to be picked up and dropped at the centre.
  • They have to be given food -- they cannot take it themselves.
  • Some need to be fed.
  • They need to be cleaned up after they have gone to the toilet.
  • Active children need to be in a 'safe' place and constantly watched.
  • The creche needs to be located close to the children's homes.
  • The woman taking care of the children has to be selected by the community -- someone they can trust with their children.

We initiated the creche programme five years ago, though in the beginning the response from the community was slow and only a few creches were started. However, the demand for these centres quickly increased, more in the remote cluster of villages located within the Achanakmar sanctuary. We found that in the poorer villages, the demand for creches was higher as both parents needed to go out to work every day.

The creche is run by a woman selected by the village community. We try and keep the caretaker-child ratio at 1:10. If there are more than 13 children in the creche, we engage a second caretaker. Sometimes, there are 20 children in one creche, with two women taking care of them.

The creche usually runs from 8 am to 4 pm, but timings are flexible depending on the season and work availability. In the summer months, children are dropped off at the creche at 4 am when parents go to the MGNREGS worksite. Children are fed a meal of sattu (made of roasted and ground chana, jau, wheat and sugar), and two meals of khichdi (made of rice and dal in the ratio of 1:5). Five ml of oil is added on top of the khichdi in each plate after it is served to the child. Each child thus gets 10 ml of oil a day. Emphasis is laid on cleanliness, especially on the caretaker washing her hands after cleaning the children in the toilet and before preparing the food; and handwashing of children before eating, or of the caretaker before she feeds a child.

We aimed to provide roughly 2/3 of the daily requirements of calories and protein at the creche. Assuming that the child eats something in the morning before coming to the creche and has a meal after going home in the evening, the three meals at the creche complete the five times feeding during the day. Twice a week, the children get a boiled egg each.

All children are weighed from birth by the village health worker at specified intervals. Children who enter the creche are weighed on entry and then each month by the health worker using a Salter scale. Heights are recorded every six months using a stadiometer. Data is entered and analysed using the WHO Anthro software (4) which is available as freeware and is user-friendly.

However, in some villages, the creche was seen more as a babysitting facility while the adults were at work: on days when they were unemployed, parents often did not send their children to the creche, saying they could look after them at home. The fact that the child at the creche gets supplementary nutrition rich in calories and protein was lost on the parents; it required several individual and village meetings to discuss the issue and emphasise the need to feed the child often and enough, whether the child is at home or outside.

Some positive outcomes have been:

  • Children have begun eating more, even at home, with parents realising that young children can eat and digest larger quantities of food than they thought possible. Older siblings have started going back to school. Both parents are able to go to work without worrying about the child, thus enhancing family income.
  • Children insist on handwashing before eating food even at home, forcing families to buy soap and bringing about a positive change.
  • The nutritional status of children has shown a positive change -- the cohort of children attending the creches regularly has shown a significant reduction in proportion of children underweight or wasted.

Graphs showing weight for age distribution of children going to JSS-run creches in 2009, and the same cohort in creches in 2011, compared to a standard normal population


2009 56% underweight


2011 44% underweight

The green curve shows the dispersion of weight for age for a large number of normal children. Children are equally distributed below and above the mean or average weight for age. Children whose weight for age falls between -2 SD (standard deviation) and +2 SD of the mean are considered to fall within the normal range of weight for age. The probability of a normal child having a weight for age less than -2SD is less than 2.2% (measured by the area of the curve beyond -2SD) and therefore such a child will be considered significantly undernourished.

In children attending the creche, we can see from the red curve that in 2009, 56% have a weight less than -2SD compared to a normal population. In 2011, among the same group of children, only 44% had weights that were significantly lower (below -2SD) than normal.

Similarly, if we look at the degree of acute hunger -- that is, the proportion of children whose weight is too low for their height -- there is a reduction among children attending phulwarees, from 26% in 2009 to 10% in 2011.

Graphs showing proportion wasted (low weight for height) in 2009 and 2011, among children going to JSS-run creches


2009 26% wasted


2011 10% wasted

Challenges

There have been many challenges, and we have learnt many lessons as the programme evolved. We began with the idea of community contributions and asked parents to send their child with a handful of rice to the centre each day. However, we found that the poorest families (the ones most in need of this facility) were not sending their children because they did not have the grain to spare. So we reversed that decision.

Ensuring the supply chain of sattu, rice, dal, oil and eggs to so many creches scattered deep in the forests has not been easy, especially in the monsoons when rivers and mountain streams are full. The delivery of eggs, twice a week, to all the centres was resulting in losses due to breakage while transporting the eggs over bad/non-existent roads and pathways. We have therefore started providing boiled eggs: the eggs are boiled at the sub-centre and then delivered to the creches on motorbike or bicycle.

Initially, the preparation of khichdi was explained to the workers but we found that different women used different proportions of rice and dal to make it. Now, we have standardised the measures for rice and dal for each child (ratio of 5:1), thereby ensuring a standard protein-energy mix in the meal.

Since the creche workers are all illiterate women, we have kept record-keeping by them to a minimum. A literate boy or girl in the village helps maintain the attendance records and record the weights of children (where the health worker is also illiterate). A small honorarium is paid to the helper for record-keeping.

The steep rise in the price of foodgrain over the past two years has resulted in us exceeding our budgets by a large margin, and having to make extra effort to raise funds. We are still unable to cover the poorest families who live in scattered single-hut settlements far from the village. Often, the children here are the most malnourished.

Can this model be replicated by government?

Sceptics have told us that this kind of initiative is not sustainable as it is too expensive (Rs 17 per day per child). However, the savings in terms of reduced expenditure on treating illnesses in malnourished children (nearly 60% of under-5 deaths here occur among children who are malnourished) is far greater than the cost of providing supplementary food to young children. Trying to prevent malnutrition in young children is something we cannot afford not to do.

Funds for this can be sourced from the Tribal Welfare Department, the Panchayati Raj Department, the Women and Child Development Department and under the National Rural Health Mission. The MGNREGS has funds to pay the creche worker, but not for any facilities at the creche -- this must be remedied. Whether foodgrain can be allocated under the public distribution system (PDS) especially for young children in creches per panchayat has to be discussed. Intersectoral coordination is key to the success of such an initiative. However, the programme will have to remain decentralised and be implemented with the active involvement of the community.

Future direction

We have been lobbying in different fora -- with the state government and the national government -- about the need to start creches for young children from poor families. While interest has been shown, it remains to be seen how the intersectoral coordination necessary for this can be brought about in a sustained manner.

In 2011, the National Advisory Council (NAC) group working on ICDS reforms invited our organisation to present a model for creches, and why we felt that this could, to some extent, address the problem of widespread childhood malnutrition. Another group that also had a day-care programme with child feeding also had an approximate cost of Rs 17 per child per day. The NAC recommended to the Planning Commission that provision be made for creches wherever there are working women unable to feed their young children through the day, and that the problem of young child malnutrition could not be effectively addressed unless this was done.

Acknowledgements

We wish to acknowledge all the women in our creches who spend their days and energy looking after the young children of the village; the field staff, supervisors and coordinators of JSS who ensure the smooth running of this activity; and all the individuals and donors who have shown their commitment to addressing the urgent and widespread problem of hunger in young children through financial and moral support

(Dr Ramani Atkuri did her MD in Community Medicine from the Christian Medical College, Vellore. Her area of interest has been maternal and child health in rural areas, and has focused on training village-level and paramedical workers, and traditional birth attendants. She has worked in rural Orissa and Madhya Pradesh and is now with the Jan Swasthya Sahyog in Bilaspur, Chhattisgarh state. Her article is based on the work of the JSS collective)

(Jan Swasthya Sahyog (JSS) is an organisation of health and allied professionals established in 1999 in Bilaspur district of Chhattisgarh. Its objective is to develop and provide a low-cost, effective, community-based model of primary healthcare. JSS runs a community health programme in 53 tribal villages using trained women health workers)

Endnotes
1 http://wcd.nic.in/icdsimg/sanoperAWCsbenf311209.pdf
2 http://wcd.nic.in/icdsimg/nutstatus311209.pdf
3 Gragnolati, M, Shekar, M, Das Gupta, M, Bredenkamp, C, Lee, Y-K. India's Undernourished Children: A Call for Reform and Action
4 http://www.who.int/childgrowth/software/en/

Infochange News & Features, July 2012