International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571

Review Article

Dimensions and Causes of Child Malnutrition

*Shakti, **Madhvi Daniel, **Shalini Kushwaha

*Assistant Professor, **Dept. of HDFS & **Dept. of Food Science & Technology, School for Home Sciences, BBAU, Lucknow

Corresponding Author: Shakti

Received: 27/03/2015 Revised: 22/04/2015 Accepted: 28/04/2015

ABSTRACT

Good nutrition is essential for healthy bodies as students grow, develop, and do well in school. Nutritional needs also vary from individual to individual. Improved nutrition has been the corner stone upon which all modern societies and economics were built. Growth during childhood is widely used to assess adequate health, nutrition and development of children, and to estimate overall nutritional status as well as health status of a population. Malnutrition in children is not affected by food intake alone; it is also influenced by access to health services, quality of care for the child and pregnant mother as well as good hygiene practices. Girls are more at risk of malnutrition than boys because of their lower social status. 1 in 3 of the world's malnourished children lives in India Malnutrition in early childhood has serious, long-term consequences because it impedes motor, sensory, cognitive, social and emotional development. Malnourished children are less likely to perform well in school and more likely to grow into malnourished adults, at greater risk of disease and early death. Around one-third of all adult women are underweight. Inadequate care of women and girls, especially during pregnancy, results in low- birth weight babies. Nearly 30 per cent of all newborns have a low birth weight, making them vulnerable to further malnutrition and disease.

Key Words: nutrition, food intake, malnourished children, disease, underweight.

INTRODUCTION accelerate economic development The future of the society depends on significantly will be unsuccessful (Raghava the quality of life of the children. The health 2005). of children and youth is of fundamental Once a child crosses the age of five, importance. Over 1/5th of our population they are considered more or less safe from comprises of children aged 5-14 years i.e. nutritional disorders. But little attention is the group covering primary and secondary paid to the quality of life. School age education. As today‟s children are the children are hardly thought of as “at risk” citizens of tomorrow‟s world, their survival, population but this period is a unique protection and development are the intervention point in the life cycle. prerequisite for the future development of Malnutrition is common among school humanity. Without ensuring optimal child children and is usually coupled with iron growth and development efforts to deficiency anemia. Asia has the largest

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number of malnourished children in the children suffering from malnutrition, after world (WHO-UNICEF 2004). About 21.8% Bangladesh (in 1998), where 47% of the of the country‟s population comprises of children exhibit a degree of malnutrition. school going children and there are still The prevalence of underweight children in about 21 million children who are unable to India is among the highest in the world, and attend school. According to NFHS-3, 90.1% is nearly double that of Sub-Saharan Africa of the 6-10 years & 74.2% of 11-14 years with dire consequences for mobility, old children attended primary school in mortality, productivity and economic 2005-06.Though the number of children of growth. The 2011 Global Hunger Index primary age group who were out of school (GHI) Report ranked India 15th, amongst has dropped by 33 million since 1999 still leading countries with hunger situation. It 72 million children worldwide were denied also places India amongst the three countries the right to education in 2007. where the GHI between 1996 and 2011 went Malnutrition is still considered one up from 22.9 to 23.7, while 78 out of the 81 of the major public health problems in many developing countries studied, including countries, affecting more than 30% of Pakistan, Nepal, Bangladesh, Vietnam, children under 5 years of age. Under Kenya, Nigeria, Myanmar, Uganda, nutrition is the most important cause of Zimbabwe and Malawi, succeeded in death in this age group in developing improving hunger condition (Global Hunger countries, in which nutritional deficit is Index Report, 2011). common. Generally, three anthropometric Form of Malnutrition: protein malnutrition indicators are often used to assess nutritional (kwashiorkor of hypoalbuminemic status during childhood: under weight (low malnutrition) and protein calorie (marasmus weight-for-age), stunting (low height-for- or protein - energy) malnutrition. The term age), and wasting (low weight-for-height). protein energy malnutrition applies to a Growth during childhood is widely used to group that included- assess adequate health, nutrition and  Kwashiorkor (protein malnutrition) development of children, and to estimate  Marasmus (deficiency in both overall nutritional status as well as health protein and calorie) status of a population. It is well documented  Marasmic kwashiorkor that chronic under nutrition is associated Kwashiorkor and Marasmus are the with slower cognitive development and two classical syndromes and severe PEM. serious health impairment later in life which They occur mostly in children between 1-4 reduce the quality of life. The majority of years when they are weaned from breast deaths associated with malnutrition occur in milk to the adult diet. Because of the bulk, a children who are marginally malnourished. child cannot consume adequate quantities of About 50% of the children under 5 years old the diet and fails to gain weight. in India are moderately or severely undernourished. Moreover, several studies Kwashiorkor: have shown that the degree of under The term kwashiorkor is taken from the nutrition is higher among the under Ga language of Ghana and means “the privileged communities. In general, tribal sickness of weaning”. Williams first used in populations are considered to be under 1933, and it refers to an inadequate protein privileged in India. intake with reasonable caloric (energy) Malnutrition in India intake. Kwashiorkor also called the disease The Word Bank estimates that India of weaning in a child when the mother fails is ranked 2nd in the world of the number of to supplement the proteins required but International Journal of Health Sciences & Research (www.ijhsr.org) 453 Vol.5; Issue: 5; May 2015

feeds the cereals and malt which are rich in Weaning (the deprivation of breast milk and carbohydrate but poor in protein. the commencement of nourishment with Signs and symptoms: other food) occurs during this high risk Growth failure: This is manifested by period. Weaning is often complicated by decreased body length and low weight in geography, economy, hygiene, public health, spite of retention of water in the body. culture and dietetics. Mental changes: The child becomes inactive and irritable. He/She is dull and Signs and symptoms: withdrawn and makes few attempts to talk Growth retardation: This is usually and move about general apathy and refusal very severe loss of weight is much more to food is very common. marked than decrease in height. The child is Oedema: Oedema occurs at first at the feet usually below 60% of the standard weight. and lower legs and then may involve the Wasting of muscle and of subcutaneous fat: hands, the things and face. The oedema is The subject is severely emaciated. The mainly due to lowered serum albumin and muscles are wasted. The arms are thin and probably also due to high sodium and low the skin is 100 se. subcutaneous fat is potassium levels in serum. practically absent. Muscle Wasting: Muscle wasting and Other Changes: The skin is dry and atrophic. constant feature of kwashiorkor and a The subject shows sign of dehydration. Eye reduction in the lesions due to vitamin A deficiency and Circumference of upper arm in usually anemia may be present. evident. Moon face: The full well-rounded face, Marasmic kwashiorkor: known as moon face, is often present in In countries where the incidence of kwashiorkor. protein calorie malnutrition (PCM) is high, Liver changes: Liver is slightly enlarged large number of cases shows signs and and fatty infiltration of liver is usually symptoms of marasmus and kwashiorkor. present. These intermediate forms are called Gastro-intestinal Tract: Loss of appetite marasmic kwashiorkor. In addition, the and vomiting are common. Diarrhea is interrelationship between two major present in most cases. syndromes is such that changing Skin and Hair Changes: The characteristic circumstances may result in a transition skin changes of kwashiorkor are known as from on a clinical picture to another. A child „crazy pavement‟ dermatitis. In the hair with early kwashiorkor can develop many changes like dispigmentation of hair, nutritional marasmus by severe infective easy pluckability of hair, flag sign. diarrhea and ill advised prolonged under feeding. In 2000, the WHO estimated that Marasmus: malnourished children numbered 181.9 The term marasmus is derived from million (32%) in developing countries. In the Greek word maramos, which means addition, an estimated 149.6 million children withering or wasting. Marasmas involves in younger than 5 years are malnourished when adequate intake of protein and calories and measured in terms of weight for age. In is characterized by emaciation. Marasmus south central Asia and Eastern Africa about most commonly occurs in children younger half the children have growth retardation than 5 years. This period is characterized by due to protein energy malnutrition. increased energy requirements and increase Causes of Poor Nutritional Status in susceptibility to viral and bacterial infection. Urban Slum Children International Journal of Health Sciences & Research (www.ijhsr.org) 454 Vol.5; Issue: 5; May 2015

1. Inadequate food intake • Improper infant feeding practices Classification Of Pem • Lack of exclusive breastfeeding PEM is a spectrum of conditions • Late introduction of solid mushy foods ranging from growth failure to overt • Dilution of milk marasmus or kwashiorkor, hence • Poor caloric and nutritional content of classification has to be based on arbitrary food cut-off-points. It is to identify children • Inequitable intra-familial distribution requiring nutritional or health interventions. (Age and gender differences) Some of the classifications are as follows: 2. Illness (Recurrent diarrheal and ARI Gomez’s classification morbidity) Gomez‟s classification is based on • Poor environmental and housing weight retardation. It locates the child on the conditions. basis of his or her weight in comparison • Lack of hygiene and sanitation facilities with a normal child of the same age. In this • Inadequate access and utilization of system, the “normal” reference child is in health care the 50th percentile of the Boston standards. • Poor food hygiene The cut-off values were set during a study of 3. Deleterious caring practices risk of death based on weight for age at • Absence of responsible adult caregiver. admission to a hospital unit. This • Lack of knowledge regarding food classification therefore, has a prognostic requirements. value for hospitalized children. • Traditional beliefs Weight for age (%) = weight of the child/weight • Parental illiteracy of a normal child of same age × 100 Between 90 and 110% : normal nutritional status • Poverty st 4. Service issues Between 75 and 89%:1 degree, mild • Lack of reach and co-ordination of malnutrition Between 60 and 74%:2nd degree, moderate public sector services. malnutrition • Inadequate training and supervision of Under 60%: 3rd degree, severe malnutrition service providers in nutritional counseling. Weight is widely recorded and the • Missed opportunities for counseling. classification is easy to compute. The • Compromised efficiency of services and disadvantages are (a) A cut-off-point of 90 programs (Urban ICDS, PDS and others). per cent of reference is high (80 per cent • Inadequate targeting of the urban poor. being approximately equivalent to -2 SD or Malnutrition is the condition that the 3rd percentile), thus some normal results from taking an unbalanced diet in children may be classified as 1st degree which certain nutrients are lacking, in excess malnourished. (b) By measuring only weight (too high an intake), or in the wrong for age it is difficult to know if the low proportions(Arthur 2003). A number of weight is due to a sudden acute episode of different nutrition disorders may arise, malnutrition or to long-standing chronic depending on which nutrients are under or under nutrition. overabundant in the diet. In wealthier Waterlow’s classification nations it is more likely to be caused by When a child‟s age is known, unhealthy diets with excess energy, fats, and measurement of weight enables almost refined carbohydrates. Because it instant monitoring of growth: measurements contributes to both over nutrition and under of height assess the effect of nutritional nutrition, malnutrition is said to be a “double status on long-term growth. burden”(Shafique, 2007). International Journal of Health Sciences & Research (www.ijhsr.org) 455 Vol.5; Issue: 5; May 2015

Waterlow‟s classification defines two The Government of India has started groups for protein energy malnutrition: a program called Integrated Child  Malnutrition with retarded growth, in Development Services (ICDS) in the year which a drop in the height/age ratio 1975. ICDS has been instrumental in points to a chronic condition- improving the health of mothers and shortness, or stunting. children under age 6 by providing health and  Malnutrition with a low weight for a nutrition education, health services, normal height, in which the weight supplementary food, and pre-school for height ratio is indicative of an education. The ICDS national development acute condition of rapid weight loss, program is one of the largest in the world. It or wasting. reaches more than 34 million children aged This combination of indicators makes it 0–6 years and 7 million pregnant and possible to label and classify individuals lactating mothers. Other programs impacting with reference to two poles : children with on under-nutrition include the National insufficient but well-proportioned growth Midday Meal Scheme, the National Rural and those with a normal height, but who are Health Mission, and the Public Distribution wasted. System (PDS). Weight/Height (%) = Weight of the child/Weight of a National Children's Fund normal child at same height × 100 The National Children's Fund was Height/Age (%) = Height of the child/Height of a created during the International Year of the normal child at same age × 100 Child in 1979 under the Charitable

Nutrition status Stunting Wasting Endowment Fund Act, 1890. This Fund (% of height/age) (% of weight/height) Provides support to the voluntary Normal > 95 > 90 Mildly impaired 87.5 – 95 80 – 90 organizations that help the welfare of Moderately impaired 80 – 87.5 70 – 80 children. Severely impaired < 80 < 70 National Plan of Action for Children Source: K. park (2009) India is a signatory to the 27 survival Programs To Address The Causes Of and development goals laid down by the Malnutrition In India World Summit on children 1990. In order to The Government of India has implement these goals, the Department of launched several programs to converge the Women & Child Development has growing rate of under nutrition children. formulated a National Plan of Action on They include ICDS, NCF, National Health Children. Each concerned Central Mission. Ministries/Departments, State Governments/ Midday meal scheme in Indian schools U.Ts. and Voluntary Organisations dealing In order to tackle the malnutrition, with women and children have been asked the Government of India initiated the school to take up appropriate measures to meal program which is called as MDM (Mid implement the Action Plan. These goals Day Meal). This school based meal program have been integrated into National is going on in Gujarat since 1984. There was Development Plans. a need to relook at the nutritional scenario of United Nations Children's Fund children with regard to the prevalence of Department of Women and Child malnutrition and IDA (Iron Deficiency Development is the nodal department for Anemia). UNICEF. India is associated with UNICEF Integrated child development scheme since 1949 and is now in the fifth decade of cooperation for assisting most disadvantaged children and their mothers. Traditionally, International Journal of Health Sciences & Research (www.ijhsr.org) 456 Vol.5; Issue: 5; May 2015

UNICEF has been supporting India in a deficiencies, excess or imbalance in the number of sectors like child development, intake of energy, protein and other nutrients. women's development, urban basic services, The Government has accorded high priority support for community based convergent to the issue of undernutrition and is services, health, education, nutrition, water implementing several programmes of & sanitation, childhood disability, children different ministries/departments through in especially difficult circumstances, State Government/UT Administration, information and communication, planning which have the potential to improve the and programme support. nutrition situation in India. National Rural Health Mission The National Rural Health Mission of India REFERENCES mission was created for the years 2005–  Arthur Sullivan; Steven M. Sheffrin 2012, and its goal is to "improve the (2003) Upper Saddle River, New Jersey availability of and access to quality health 07458: Pearson Prentice Hall. care by people, especially for those residing Economics: Principles in action pp. 481. in rural areas, the poor, women, and  Global Hunger Index Report(2011) children." International Food Policy Research Institute (IFPRI). The subset of goals under this mission are: http://www.ifpri.org/sites/default/files/p  Reduce infant mortality rate (IMR) ublications/ghi11.pdf and maternal mortality ratio (MMR)  Park, K. (2009) Text Book of Preventive  Provide universal access to public and Social Medicine.20th edition, pp health services 554.  Prevent and control both  Raghava, .P K. (2005) Assessment of communicable and non- School health. Indian journal of communicable diseases, including community medicine ,vol. 3 pp 1-3 locally endemic diseases  Shafique, S; Akhter, N; Stallkamp; De  Provide access to integrated Pee, S; Panagides, D and Bloem, M. W. (2007). Trends of under- and overweight comprehensive primary healthcare among rural and urban poor women indicate the double burden of CONCLUSION malnutrition in Bangladesh. It is concluded from the study the International Journal of Epidemiology problem of malnutrition is very common in 36 (2): 449–457. India. Many parameters are used to assess  WHO-UNICEF (2004) joint statement. the malnutrition. Adequate nutrition is Focusing on anemia:Towards an essential for human development. integrated approach for effective Malnutrition includes both undernutrition as anaemia control. well as overnutrition and refers to

How to cite this article: Shakti, Daniel M, Kushwaha S. Dimensions and causes of child malnutrition. Int J Health Sci Res. 2015; 5(5):452-457.

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International Journal of Health Sciences & Research (www.ijhsr.org) 457 Vol.5; Issue: 5; May 2015