<h1>Shree  Swami Samarth</h1>

Malnutrition among Pre-School Children & Women in India

Methodology

Nine villages near the hospital with-in a radius of 20kms from the hospital have been selected in order to implement the project. All the children attending the 'anganwadis' (Marathi word for play groups )  and 'balwadis'( Marathi Word for Nursery )  as well as other children of these villages form the study group in the project. Out of this the undernourished children will form the target group of the project. Each undernourished child of the project is supplemented daily with diet providing more than 300kcals along with 10 to 12 grams of proteins. This diet will be supplied for at least 300 days in a year. In addition monthly weight monitoring is being carried out and is plotted on Road to Health Chart.

All the under-six children in the selected nine villages are surveyed. Their date of birth, weight, height, head circumference, chest circumference, mid-arm circumference, clinical signs of malnutrition, physical complaints and clinical features are recorded. Weight for age criteria is used to grade the children for malnutrition. The W.H.O classification is   used to grade the children to indicate their nutritional status. This classification is adopted by the Indian Academy of Pediatrics and the Integrated Child Development Scheme (ICDS). It has four reference curves. The topmost curve corresponds to the median (50th percentile) of the WHO reference standard which represents the level of optimum growth. The lower lines represent 80%, 70% and 60% of that standard. 80% of the median is approximately equivalent to 2SD below the median (or mean) which is the conventional lower limit of the normal range. If a child’s weight is between 80% and 70% lines, it indicates First-degree or mild malnutrition. If the weight is in between 70% and 60%, it indicates Second-degree or moderate malnutrition. If the weight is below 60% line it indicates Third-degree or severe malnutrition. In addition Grade IV below 50% is also added. Any weight between the top two lines is considered satisfactory.

The child has to be weighed every monthly. A single weight record only indicates the child’s size at the moment; it does not give any information about whether a child’s weight is increasing, stationary or declining. Periodic weighing is therefore necessary, starting at birth or as soon as possible afterwards to interpret the progress of growth.

Each child is de-wormed once in six months. Vitamin A supplements will be provided to the children every 6 monthly according to the WHO protocol. Each child will be given multivitamin supplements containing especially Vitamin D and minerals like iron and calcium, which are necessary for their growth and development. This would be supplied every two months in six months period.  Referral by a Pediatrician will be sought as and when needed for a particular child. Thus care will be taken to meet the child’s nutritional as well as medical needs. But this will have only short-term effect in improving nutritional status of the child and will benefit only the selected children. In order to bring about a lasting effect in the community, nutrition education to the mothers and nutrition demonstration sessions in the community will be carried out. Thus we expect to wipe out under nutrition as a cause of childhood morbidity and mortality totally from the community.  Malnutrition is one of the major causes of Infant and Child mortality in the country and it is necessary that improvement of the nutrition of the mother should receive the highest priority.

The supplement provided to the children is based on the following food recipe,

Wheat-green gram  'ladu '( Marathi Word meaning a spherical eatable )

Ingredients

Ingredient

 

Whole wheat

300 g

Green gram ('dal' ) 

300 g

Ragi  ( Nachani )

200 g

Groundnuts

80 g

Pure Ghee

80 g

Jaggery

400 g

     

Method:

Roast the wheat, green gram dhal, nachani and groundnuts separately and powder them. Mix the powder add ghee and make the mixture into balls with thin syrup prepared from jaggery. 30 'ladus' are prepared from the above mixture. The total weight of the above mixture is 1360 grams. Thus each 'ladu' weighs 45.33 grams.

The calorie distribution is as follows :

Item

Weight

Calories

Rich source of

      Whole wheat

300 g

1038

Carbohydrates and Vitamins

      Green gram dhal

300 g

1044

Proteins

      Nachani

200 g

454

Calcium

      Groundnuts 

80 g

1532

Proteins & fats

      Pure Ghee 

80 g

656

Fats

      Jaggery

400 g

720

Iron

      Total

1360

5444

 

Thus 5444 kcals are provided by 30 'ladus'. One 'ladu' provides 181.46 kcals. This recipe is devised by National Institute of Nutrition, Hyderabad and is modified by Walawalkar Trust Hospital so as to suit the local conditions. The earlier experience of the Hyderabad based Institution has revealed that the incidence of malnutrition among pre-school children can be considerably reduced with such preparation which are much cheaper than proprietary and processed foods. 

Weight of each child is recorded on a Growth Chart. For children with Normal weights and those in Grade I monthly weight monitoring, six monthly deworming, six monthly vitamin A supplementation combined with nutritional education for their parents is used as an interventional measure. For children in Grade II category dietary supplementation with two 'ladus' each prepared from the above recipe is carried out. This provides them 362.92 kcals daily. This diet is supplementary to the meals that child receives daily and is not a replacement diet. Each child of Grade III and Grade IV receives 3 'ladus' daily providing 544.38 kcals. In addition monthly weight monitoring, six monthly deworming  ( medication given to get rid of worms ) , six monthly vitamin A supplementation, multivitamin supplementation combined with nutritional education for their parents will be carried out. Each child will be given multivitamin supplements containing vitamins specially Vitamin D and minerals like iron and calcium, which are necessary for their growth and development. This would be supplied every two months in six months period.  Referral by a Paediatrician will be sought as and when needed for a particular child.

In Ratnagiri district each village is divided into 10 to 20 'anaganwadis', consisting of 25 to 50 hutments. Each anganwadi is located at far of distance. For this project to be successful the nutritional supplement is to be provided at 5 to 6 places in each village. This project will be backed up with nutrition education and nutrition demonstration sessions at each centre at-least once in a month. In addition health quiz for the village women, cooking competitions etc. will also be arranged.

The details of the initial survey of children between one to six years are as follows :

(children between 0 to 1year are excluded from the table below as they cannot consume the supplementary diet.)

Village

No. of children surveyed

Normal

Grade I

Grade II

Grade III

Grade IV

Dervan

156

52

49

35

18

02

Kosabi

128

52

44

23

08

01

Munde

126

52

38

26

08

02

Hadkani

129

32

42

42

12

01

Phurus

147

22

35

64

22

04

Durgewadi

160

52

49

48

10

01

Kudap

88

32

26

23

07

00

Kondmala

114

30

44

32

06

02

Kutare

219

64

58

59

33

05

All the 1267 children surveyed will receive deworming, 352 with Grade II malnutrition will receive supplementary nutrition with 2 'ladus' daily, 142 with Grade III and Grade IV malnutrition will receive supplementary nutrition with 3 'ladus' each daily, 142 children with Grade III and Grade IV malnutrition will receive multivitamin supplements. 1267 children under survey will receive deworming and vitamin A supplementation every six monthly. Totally parents of 1267 children will receive nutrition education. 

The second beneficiary group is the pregnant and lactating mothers. All pregnant ladies and lactating mothers of the nine villages will receive 3 'ladus' each providing 544.38 kcals daily. Each pregnant women will receive Tetanus Immunisation and oral medication containing Iron, Calcium and Folic acid. 

Village

Pregnant women

Lactating mothers (during first six months )

Total

Dervan

24

08

32

Kosabi

16

06

22

Munde

09

03

12

Hadkani

08

03

11

Phurus

12

05

17

Durgewadi

30

11

41

Kudap

10

04

14

Kondmala

21

08

29

Kutare

38

15

53

Nutritional supplementation of pregnant and lactating women will improve nutritional status of mothers and infants and will reduce Infant Mortality Rate and Maternal Mortality Rate.