Nutrition & Child Care: A Practical Guide Shanti Ghosh
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1Nutrition and Child Care: A Practical Guide2
3Nutrition and Child Care: A Practical Guide
Second Edition
Shanti Ghosh
4Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
EMCA House, 23/23B Ansari Road, Daryaganj
New Delhi 110 002, India
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Nutrition and Child Care: A Practical Guide
© 2004, Shanti Ghosh
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
First Edition: 1997
Second Editon: 2004
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A-14, Sector 60, Noida
In the ultimate analysis the real strength and standing of a nation will be determined by the “quality” of its human resources. Infants and children of today are our precious human resources of the future. The manner in which we nurture them today, will determine the quality of our human resources tomorrow.
Reduction in child mortality and better child survival have been the yardsticks which we have used for measuring our achievements in the field of child health and we have had a fair measure of success in this respect. While these “successes” are welcome, it must now be recognized that we have reached a stage in our developmental transition when these yardsticks have become inadequate. The quality of our human resources will certainly not be improved by an expanding pool of sub-standard “Survivors”. Over 50 percent of under fives in our country are children who have “survived” but remain stunted. It is time that we raise our sights and set for ourselves new and more ambitious targets. We want our children not just to “survive” but to “live” and to grow into physically strong, mentally alert adults who will contribute to our National well being.
In order to achieve this ambitious new goal, the present mind-set and pattern of functioning of our health agencies, especially those engaged in maternal and child health operations, must undergo a radical change. Our present (child) health system is largely designed to achieve the limited goal of child survival. National programs in the field of child health in actual practice, are being pursued largely as short-term relief operations rather than as developmental programs designed to bring about durable improvement in child-feeding and child rearing practices in our homes. As a result of modern advances in health technology death control strategies such as oral-rehydration, immunization and treatment of acute disease can now be effectively applied to bring about reduction in mortality and better child survival even in the continuing context of poor diets, poor child feeding and child-rearing practices. In spite of substantial reduction in child mortality and better child survival, we have no convincing evidence of significant improvement in the quality of diets in poor homes in our country-side. Bringing about changes in child feeding and child rearing practices alone would result in durable improvement in child health and this will call for sustained inputs of a different order from those needed for death control strategies.6
Our health system must now lay far greater emphasis on health/nutrition education than hitherto. Health workers must be specially trained and motivated to advise mothers on improved child feeding and child rearing practices and to use locally available inexpensive foods in a judicious manner to improve the nutritive value of household diets. Diets of pregnant women and of lactating mothers, and in late infancy and early childhood, stand in need of improvement. All this will call for sustained efforts and motivation on the part of health workers, and demand close interaction between them and the community. What we urgently need is, a new culture in our health system, in which emphasis will be on health promoting activities rather than death control strategies. The challenge is to bring about this change.
Health/nutrition education cannot bring dramatic instant results and does not lend itself to achievement audit. In our present “impersonal” health system where health workers are burdened with routine chores and by “distractions”; imposed by commercial interests, it is to be expected that the personal and community approach towards improvement of diets, and living conditions of mothers and children in our poor rural homes gets the back seat.
Dr Shanti Ghosh, the author of this book is one of India's leading experts in the field of child health. She headed the pediatric department in the Safdarjung Hospital with great distinction and dedication and in later years she has served as consultant in child health on a number of National and International bodies. In all her writings and lectures her emphasis has always been on practical approaches towards ensuring child health in our national context. This book contains up-to-date scientific information presented in an easily readable form. The book will benefit all those interested in child health programs in our country and it is a must for child health workers. The book could help to educate and motivate them to bring about the much needed “cultural” change in our health system.
C Gopalan
FRS MD (Madras) DSc (London)
FRCP (London and Edin.)
Nutrition Foundation of India
7Preface to the Second Edition
Writing the preface for this new edition of the book after six years, one had hoped that one could cite some real progress in the health and nutrition scenario compared to the earlier edition. While one sees some light at the end of the tunnel, we still have a long way to go. The most glaring problem is the widespread malnutrition among young children, even though the situation is a little better than before. The intergenerational cycle of malnutrition is as widespread as before—girls getting married in their teens, resulting in pregnancy at a young age and the birth of a low weight baby, who in turn grows more slowly and swells the ranks of undernourished children. One-third babies have low birth weight, poor nutritional status of the mother, anaemia and repeated pregnancies contribute to it. We have had an anaemia prophylaxis and treatment program for more than twenty years, but it has not made much difference because of poor implementation of the program.
Malnutrition among young children is rampant—more in rural (49.6%) than in urban (38.4%), according to the National Family Health Survey, 1998-99. Infant feeding practices remain as unsatisfactory as ever—median duration of exclusive breastfeeding is about three months in urban areas and a little more in the rural areas. Complementary feeding is also unsatisfactory—only one-third babies being offered any semisolid food between six and nine months. In some states the figure is as low as 15-20 percent, but it cannot be called satisfactory anywhere. The amount offered at a feed is very small and hardly any effort is made to modify it for the young child. It is well known that mortality is 4-5 times higher among the malnourished children compared to the better nourished children. They are prone to repeated infections and the nutritional status worsens further as a consequence.
Each successive evaluation in India by the National Nutrition Monitoring Bureau as well as the National Family Health Survey 1 and 2 has shown some improvement in the nutritional status. Some micro nutrient deficiencies have reduced considerably, e.g. vitamin A and iodine, but anemia is a major problem among all the groups studied—pregnant women, adolescent girls and young children. Anemia is a major cause of maternal mortality and among young children it would compromise their cognitive function and learning skills apart from poor general health. The health workers, particularly ANMs, LHVs and the ICDS functionaries have to be trained regarding the nutritional needs of children, the 8importance of exclusive breastfeeding for six months and timely, and adequate complementary feeding.
Our population has crossed one billion and various strategies are being discussed as to how to slow the march. Crude birth rate (CBR) has fallen slowly but steadily and was 25.8 in the year 2000. With a large proportion of young population rapid fall in CBR is difficult to achieve. Instead of pressing panic buttons, if sustained health services of good quality were made available to the community, not only the infant child and maternal mortality would come down, but CBR would fall as well. Even though RCH program is supposed to cater to all health needs of mothers and children, the concentration is on reduction of fertility by temporary or permanent methods aimed mainly at women.
Immunization coverage has had a setback but is now catching up again. A great deal of effort is going into eliminating poliomyelitis and four or more immunization rounds are held in a year. However, laudable the aim of eliminating polio, this interferes with the normal health delivery programme for mothers and children including immunization. Reports indicate that 25 percent of children have not received any immunization at all.
The situation regarding safe water supply has improved. Nearly 83 percent households (94% urban and 79% rural) have access to improve sources of drinking water.
Birth registration remains unsatisfactory—only 35 percent children below five years are reported to as having been registered at birth. In some states it is below 10 percent.
Awareness regarding HIV/AIDS is low. Only 33 percent rural and 68 percent urban women have heard of it. The role of education in increasing awareness is obvious in that 87 percent women who have completed middle school have heard of HIV/AIDS as against 18 percent of illiterate women. Now government has launched a Sarva Shiksha Abhiyan with the objective of increasing literacy levels and 5-6 years of schooling. Supreme court has directed that a cooked mid-day meal be given to all the children to allay hunger so as to facilitate learning and school attendance as well as improve nutritional status. The status of Tamil Nadu, Andhra Pradesh, Karnataka, Gujarat, Rajasthan and Maharashtra are implementing it. Other states have not implemented it yet, but hopefully will follow the Supreme Court's directive before long.
The adverse sex ratio in almost every state is a cause of concern. Technology is being used to identify the sex of the fetus and eliminate the female fetus. This will have tremendous social implications in the years to come. The situation is worse in the economically more developed states.9
Information on the most recent vital statistics, and other health and education-related parameters is provided in the text as well as annexures. Information on the nutritive value of commonly eaten foods as well as the quantities of food, a young child needs to eat is provided. For more detailed information, some reference material is also included.
The use of “She” throughout the book while referring to a child is not a gender bias, but an attempt to draw attention to the discrimination against the girl child.
Use of UNICEF photographs as well as the Faridabad project of the All India Institute of Medical Sciences is gratefully acknowledged.
Shanti Ghosh
11Preface to the First Edition
India has just celebrated 50 years of independence and we have much to be proud of. The vital rates have improved considerably, but the quality of life of almost one-third population is deplorable. While infant mortality rate has fallen from 146 in 1951-61 to 74 per 1000 live births and under 5 mortality rate (U5MR) mortality from 236 per 1000 in 1960 to 109 in 1993. The nutritional status of a large number of children is a cause of concern. More than half the children are malnourished, and the most crucial period of malnutrition is 6 months to 2 years. This is due to the lack of understanding of the young child's food requirements during this period of rapid growth, and the common foods that can make up the intake deficit.
Most health workers have very little idea of how much food a young child needs and how often. So, malnutrition beginning at about six months of age, when breast milk alone is no longer sufficient for the child's needs, is allowed to get progressively worse over the next two years or so. This period of dependency on others to feed her and not being able to express her sense of hunger is the crucial period of malnutrition, and one cannot entirely blame the inadequate family resources for it. It is futile to depend on supplementary nutrition prog rams to deal with this, as these programs mainly cater to the older children, and even then their impact is questionable.
According to the 1991 census, child population under 15 years is 305 million of which 111 million are under five years. Of the 25 million children born every year, close to 2.7 million die before completing five years. Of these close to 2 million die before reaching the age of one. Four states—Uttar Pradesh, Madhya Pradesh, Bihar and Rajasthan account for 47 percent of children born and for more than 50 percent of infant deaths (The Progress of Indian States, UNICEF, New Delhi, 1995). Infant mortality rate in rural areas (82/1000) is almost double than that in urban areas (45/1000).
In a large country like India, there are bound to be regional and state differences, e.g. neonatal mortality is 15.5 percent in Kerala and 64.7 percent in Orissa, and infant mortality varies from 16 to 103 in the two states, and life-expectancy of a girl born in Uttar Pradesh is 20 years less than that of a girl born in Kerala.
While almost all women breastfeed their children, the period of exclusive breastfeeding is short, partly because of lack of awareness about the benefits of breastfeeding, but partly because of the need for women to work and be away from home. There are hardly any facilities for child care centers.12
Even though the incidence of diseases preventable by immunization has come down considerably, and we are hoping to make India polio myelitis free, diarrheal and respiratory diseases still take a heavy toll.
A combination of infections and malnutrition results in high levels of mortality among young children. Even in mild malnutrition, the risk of death is doubled and mortality goes on increasing as malnutrition becomes more severe. With 13 percent children under five years of age, the mortality load is very high, access to healthcare is insufficient, and the quality leaves much to be desired.
One-third babies have low birth weight which is due to poor maternal nutrition, anemia and repeated pregnancies with a short interpregnancy interval. Lack of information and awareness and poor access to contraceptive services are contributing factors. Exclusive breastfeeding for the first five to six months helps in delaying the next pregnancy. According to some population experts, breastfeeding has helped to prevent more births than all the contraceptives put together.
There is a great deal of gender bias starting with fetal sex determination resulting in female feticide, female infanticide, higher malnutrition and higher death rates among the females, which is an indicator of their poor access to healthcare.
Nutrition is poorly taught at every level—doctors, nurses, health auxiliaries, anganwadi workers and others. The emphasis is on disease rather than health, with the result that advice given is often inaccurate and conflicting. Besides, there is very little understanding of the constraints and prejudices of the community. This book aims to fill some of these lacunae and provide practical knowledge and information to all those concerned with health and nutrition. It explains why preventive care and improvement in the health and feeding of infants, young children, and their mothers is necessary, and how this is best done. It is therefore addressed to medical doctors, nurses, auxiliary nurses, midwives, multipurpose health workers, dietitians, home economists, functionaries of the Integrated Child Development Services (ICDS) program and others working with mothers and children, and anyone else involved in maternal and child care, and through them to the community which they serve.
Information on the most recent vital statistics, and other health and education-related parameters is provided in the text as well as annexures. Information on the nutritive value of commonly eaten foods as well as the quantities of food, a young child needs to eat is provided. For more detailed information, some reference material is also included.
The use of “She” throughout the book while referring to a child is not a gender bias, but an attempt to draw attention to the discrimination against the girl child.
Use of UNICEF photographs is gratefully acknowledged.
Shanti Ghosh