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Food Dole or Health, Nutrition and Development Programme?

Child malnutrition is intimately related to inappropriate infant and young child feeding practices, and its beginnings set in during the first two years of an infant's life. The ICDS programme should be used to spread the message of correct feeding practices for infants. It was never envisaged as a food dole programme that it has now become.

Food Dole or Health, Nutrition and Development Programme?

Child malnutrition is intimately related to inappropriate infant and young child feeding practices, and its beginnings set in during the first two years of an infant’s life. The ICDS programme should be used to spread the message of correct feeding practices for infants. It was never envisaged as a food dole programme that it

has now become.

SHANTI GHOSH

T
here is abundant data from India and other parts of the world to suggest that the onset of malnutrition is usually between the child’s sixth month and second birthday. In India the high prevalence of low birth weight (almost a third of the babies born in India weigh less than 2.5 kg at birth) is due to the young age and poor nutrition of the mother, which is compounded by the stress of repeated pregnancies. This causes an intergenerational cycle of malnutrition. According to the second National Family Health Survey (1998-99), 14 per cent of girls aged 15-19 years were married, and 61 per cent of all women were married before 18 years. According to WHO, children born to adolescent mothers are 40 per cent more likely to die during the first year of life, and have greater risk during the second year.

Mortality among these low birth weight babies is higher than in normal weight babies. According to NFHS-2, almost half of all children under four years are malnourished (-2SD) and 18 per cent are severely malnourished (-3SD). Maximum malnutrition is between six months and one and a half to two years. The main reasons are lack of awareness of the young child’s food requirements, poor living conditions, unsafe water and poor sanitation, resulting in repeated infections.

According to NFHS-2,1 only one-third of Indian children are offered any semisolid food between six and nine months. In Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan this proportion varied between 15 and 27 per cent. Even in prosperous Punjab, the figure was only 38.7 per cent and in Haryana 41.8 per cent. There is no concept of feeding the child modified family food. This sets the beginning of malnutrition, which is worst between six months and one and a half to two years, when the child is dependent on a caretaker to feed him/her, after which the situation tends to improve because now the child is mobile and can access food wherever it is in the household. Breastfeeding Promotion Network of India (BPNI) did a study in 49 districts in 2003.2 The study revealed that only 39.7 per cent of infants were exclusively breastfed for the first six months. The situation regarding introducing semi-solids was even worse.

It is not that there is no food in the household (except in extreme conditions of drought or floods). There is however no knowledge or awareness regarding the child’s requirements. Besides, many food items (dal, bananas, etc) are taboo because of folklore and misconceptions. While others in the family eat these items and share whatever there is in the household, the young child is deprived of them. In a study in rural Karnataka3 in which I was involved, it was shown that indepth and repeated nutrition education can improve nutrition of the young child significantly. The effect was more marked among female children. No food supplements were given, and nutrition counselling was based entirely on what was available in the household and what others were eating. Bhandari et al4 also succeeded in improving complementary feeding practices by nutrition education. There are so many myths and taboos about what foods are bad for the child that we need to prioritise nutrition education. There is no uniform concept of how much food or how many times a day a young child needs feeding. It has to be individualised, and nutrition education must be carried out at the household level.

It is important to know that child malnutrition is intimately related to inappropriate infant and young child feeding practices, and its beginnings set in during the first two years of an infant’s life.5 As more than 90 per cent of the brain actually develops during the first two years, its implications for child development are obvious. The Tenth Five-Year Plan (GoI 2002:337) document quoting NFHS-2 notes, “As a result of these faulty infant feeding habits, there is a steep increase in the prevalence of undernutrition from 16 per cent at less than six months, to 63 per cent in the 12-23 months age”. And this percentage does not change much after two years.

Energy required from complementary food is estimated to be approximately 275 kcal at 6-8 months, 450 kcal at 9-11 months and 750 kcal between 12-23 months.

According to the global strategy for infant and young child feeding, jointly developed by the WHO and UNICEF, and adopted by the World Health Assembly in May 2002, “malnutrition has been responsible directly or indirectly for

Economic and Political Weekly August 26, 2006

Child growth failure

Low birth weight baby Early pregnancy Low weight and height in teens

Small adult woman

60 per cent of the 10.9 million deaths annually among children under five. Well over two-thirds of these deaths, which are often associated with inappropriate feeding practices, occur during the first year of life. Unhygienic and unsafe environment, unsafe water, and lack of access to sanitation predispose the child to repeated infections. Lack of access to healthcare and poor immunisation coverage further compound the problem. According to recent evidence published in Lancet,6 universal practice of exclusive breastfeeding for the first six months and continued breastfeeding for 6-11 months could save about 13-15 per cent deaths in children under five years of age in India, which means well over 3,00,000 child deaths could be saved in one year. Adequate complementary feeding between 6 and 24 months could prevent an additional 6 per cent of all such deaths. A recent publication by Gupta and Rohde stresses the same point.7

I had suggested a simple practical way to improve feeding behaviour and health seeking behaviour at a World Bank meeting some years ago. In a few blocks (50 were suggested) we could experiment with two anganwadi workers (AWWs) per anganwadi centre (AWC). The second AWW would primarily monitor pregnant women, ensure they had antenatal check by auxiliary nurse midwife (ANM), received (and ingested) iron forte (IFA) tablets and made preparations for a safe delivery (ANM, PHC, Hospital and failing that a TBA), establish contact soon after birth to advise exclusive breastfeeding (no water, ghutti, gripe water, honey, etc), make sure the baby has complete immunisation and continues to be exclusively breastfed. At six months, home prepared complementary food would be advised and child’s health and weight monitored. The proposal was considered too expensive!

Universalisation with quality is now the objective for ICDS. I fully agree, but we have to look at every aspect of the ICDS programme and its quality. It was never envisaged as a food dole programme, but as a child health, nutrition and development programme in which the department of women and child development and the ministry of health were active partners. The minimal services envisaged were: Antenatal services; Strategies for reducing the level of anaemia; Tetanus toxoid 2 doses; Safe delivery; Care of the newborn; Complete immunisation; Exclusive breastfeeding for six months; Complementary feeding (softened home-based food) threefour times a day increasing quantity of household food after that; Treatment of illness; Facilities for sanitation and safe drinking water; Child development and supplementary feeding activities at the AWE.

These aspects have been highlighted much earlier by me and other researchers.8

For the first time in the Tenth Plan, the government of India has included state specific goals to improve infant and young child feeding practices to reduce infant mortality rates (IMR), malnutrition and promote integrated early child development. The Tenth Plan goals aim to increase the rate of initiation of breastfeeding within one hour to 50 per cent from the current level of 15.8 per cent, to increase the exclusive breastfeeding rate to 80 per cent during the first 6 months from the current level of around 41 per cent, and to increase the rate of complementary feeding to 75 per cent from the current level of 33.5 per cent.

Several community level studies have shown that this is feasible and can be done by taking the right messages to the families and communities. According to the Tenth Plan document, childcare and nutrition education of the mother is poor or nonexistent. There seems to be a clear relationship between feeding practices and nutritional status, as Table 3 illustrates.

Health and nutrition education is an important objective of ICDS, but the performance on this is dismal. The AWW often does not have the relevant training and knowledge. The food available at the AWC is neither suitable (very often ready to eat) nor can it be kept for feeding throughout the day. It can only serve some purpose for the older children, who can sit and eat at the AWC itself. Take home food also does not serve the purpose for which it is meant, because everyone in the family shares it. Ready to eat food is often of poor quality (from personal experience in Haryana and some other states).

What should be our primary thrusts to improve nutrition? A well-trained team of ANM and AWW, who will identify pregnant women, ensure antenatal care and IFA disbursement and compliance, facilitate safe delivery (through SC, PHC or a trained dai), strongly support exclusive breastfeeding from the time of birth and complementary feeding from six months. For preventing malnutrition, the crucial period is six months to two years, with stress on breastfeeding and complementary feeding from six months onwards.

In a village, there are not more than twothree births per month. The AWW should identify them, make sure that the babies are exclusively breastfed, and later given complementary feeding from six months onwards, as mentioned earlier.

Most women are engaged in some work, and are not available for breastfeeding, and

Table 1: Proportion (Per Cent) ofChildren Who Are Underweight by Age

< 6 months 1 6
6-11 months 4 3
12-23 months 6 3
24-35 months 6 2
36-47 months 5 9

Source: NFHS-2 (quoted in the Tenth Plan document).

Table 2

(Per cent)

NFHS-2 Tenth Plan Goal

Initiation of breastfeeding

within 1 hour 15.8 50.0 Exclusive breastfeeding

0-6 months 41.2 80.0 Complementary feeding

6-9 months 33.5 75.0

Table 3

Percentage Started Timely Breastfeeding Comple-Within One mentary Day of Birth Feeding Rate

Group A states (50 per cent or more

underweight) 32.0 21.4 Group B states (40-49 per cent underweight) 47.6 48.3 Group C states (30-39 per cent underweight) 58.1 56.9 Group D states (less than 30 per cent

underweight) 64.9 70.9

Economic and Political Weekly August 26, 2006 so the child is offered some other milk (usually diluted and often contaminated) by a child who acts as the caretaker and knows nothing of hygiene and cleanliness, and who should actually be in school. The same happens regarding complementary feeding. This brings to the fore the need of some day care centres, managed by village women and supported by the panchayat, where these young children can be cared for while their mothers are working (a simplified crèche). The mothers can come and breastfeed the child and go back to work. In the case of children who are six months to two years of age, some household semi-solid food can be offered every two-three hours while the mother is away. Unfortunately the ANM and the AWW have no knowledge regarding sound feeding practices and so cannot communicate these to the community.

If we are serious about preventing malnutrition, we have to focus on the age group of six months to two years. This age group cannot be addressed in the way ICDS functions at the moment. It has become a food dole programme, which is irregular and of poor quality. Even pregnant women cannot avail of it because they are out working and cannot wait for the AWC to start functioning (and then the food may not be there at all!). Taking home raw cereals, etc, also does not help, as the whole family shares it and the pregnant woman may get none or very little of it. It is common knowledge that there is a great deal of pilferage of the commodities offered and that can be prevented only if the community is a partner in the programme and has a stake in its success. It is also important that AWW is not roped into any and every programme that is going on or is envisaged. She should be allowed to do the job assigned to her with the full support of the community. In several urban areas, the community is not even aware of the existence of the AWC. Obviously the programme varies from place to place, and from AWC to AWC, but there is a certain minimum that has to be expected.

I must emphasise at the end that we have to look at the total functioning of ICDS, and the bottlenecks (training, supervision, accountability, etc) and not just the money sanctioned for food supplements. Even if the money is available, the modalities of the food reaching the target group have to be seriously considered. Just because the money to buy the food is there, it does not follow that it will automatically reach the target group for which it is meant.

ICDS is meant to be much more than a food disbursement programme – its main objectives were child development and improvement of nutrition by nutrition education, including exclusive breastfeeding for six months, and household semi-solid food supplemented by some food supplement at the AWC. We have to find ways and means to make it work.

EPW

Notes

1 National Family Health Survey-2 (1998-99).

2 Status of infant and young child feeding in 49 districts (98 Blocks) of India. Breastfeeding Promotion Network of India 2003.

3 Ghosh S, Kilaru A and Ganapathy S, ‘Nutrition Education and Infant Growth in Rural Indian Infants’, Journal of Indian Medical Association, Vol 100, 483-90, 2002. Kilaru A, Griffith P L, Ganapthy S, Ghosh S, ‘Community Based Nutrition Education for Improving Infant Growth in Rural Karnataka’ (in press).

4 Bhandari N et al, ‘An Educational Intervention to Promote Appropriate Complementary Feeding Practices and Physical Growth in Infants and Young Children’, American Society for Nutritional Sciences, 2342-46, 2004.

5 Ghosh S, ‘Preventing Malnutrition: The Critical Period Is 6 Months to 2 Years’, Indian Paediatry, 32, 1057-59, 1995.

6 Gupta A, Rohde J Bellagio, ‘Child Survival Study Group’, Lancet, (2003a), Vol 362, July 5, p 67.

7 Gupta A, Rohde Jon E, ‘Infant and Young Child Undernutrition: Where Lie the Solutions?’ Economic and Political Weekly, December 4, 2004.

8 Ghosh S, ‘Integrated Child Development Services Programme – Need for Reappraisal’, Indian Paediatry, 1997, 34: 911-18; Ghosh S, Integrated Child Development Services Programme, The National Medical Journal of India, Vol 16, Supplement 2, 2003; Ghosh S, ‘Child Malnutrition’, Economic and Political Weekly, October 2, 2004.

Economic and Political Weekly August 26, 2006

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