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CHILD MALNUTRITION IN

MAHARASHTRA (INDIA) AUGUST 2013- JANUARY 2014

SITUATION, EFFORTS, DECLINE AND CHALLENGES

A REVIEW

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A REVIEWFOR THE STATE NUTRITION MISSION

P O W E R P O I N T 2 / 6

T H E E F F O R T S

Dr Shyam Ashtekar, MD (Community Med)

shyamashtekar@yahoo.com

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THE EFFORTS TO REDUCE MALNUTRITION

IN MAHARASHTRA

The Important 1000 days window

THE IMPORTANT 1000 DAYS’ WINDOW

Pregnancy 300

2nd Year 365

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Only Breast feeding, 180 7 to 12

months, 145

2nd Year 365

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IMPROVING THE AWC

� First of all AWC (Anganwadi center) must retain and

improve it’s attendance.. And then extend the

services to the U2 group also.

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services to the U2 group also.

� This calls for improvement of building, equipment and

services. This was the effort.

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AWARENESS CAMPAIGNMalnutritio

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DASHAPADI OR THE TEN IMPORTANT RULES.

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TEN RULES FOR

PREVENTING

MALNUTRITIONInstitutional birth and

Breastfeeding

6 m Exclusive Breastfeeding

Complimentary feeding at 6m, 6m Birthday

Vit A doses

Complete Immunization

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Focus on 6m-3y child-nutrition

edn of the mother

Micronutrients Sachet

De-worming,

Illness treatment,

immunization

Hand-wash,

water safety,

Sanitation

Growth monitoring-wt/ht/muac

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HEALTH AND NUTRITION OF

ADOLESCENT GIRLS

�Health of adolescent girls is crucial for prevention of future child malnutrition, ALSO her own well being is no less important.

� Includes health and nutrition education, growth promotion and personality

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growth promotion and personality development.

�a weekly tablet of iron folic acid is given to girls outside school from the AWC

�At least 3 girls get THR for home use – the utility is not known.

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ANTE NATAL CARE

� Early diagnosis of pregnancy, at least 3 medical check ups and

treatment contacts.

� IFA provision for 90 days.

� Take Home ration provision every month. to improve meals at home.

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� Take Home ration provision every month. to improve meals at home.

� Detecting and action for smaller abdominal size foot-edema or hyper

tension, proteins in urine etc. These pregnancies lead to smaller

babies.

� Need to protect and promote health of mother and baby

� But only 75% pregnant women got the 3 essential visits.

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INSTITUTIONAL

CHILDBIRTH

� There is an effort to ensure institutional delivery for all cases.

� We have JSY program under NRHM for this.

� 102 ambulance is available in every district.

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� All care medicines for mother and children are free.

� Mothers also get some incentives for attending institutional

delivery.

� Some districts registered 90% institutional delivery rate.

� ASHA activists help this program.

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THE EFFORT TO IMPROVE BIRTH

WEIGHT

� Low Birth Weight was and is a major issue.

� 20%-50% babies have low birth weight in various

districts.

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districts.

� These babies tend to remain underweight.

� A limited but possible solution is to improve ANC

care. (But the LBW is a long term issue)

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PROMOTING NEONATAL

CARE UNITS-JSSK PROGRAM

� Low Birth Weight , prematurity and other neonatal

illnesses call for neonatal care units.

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illnesses call for neonatal care units.

� The ambulance ensures door to door service

� NICUs have been started in each districts by Health

dept..with all free care

� Follow up services are available

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EARLY BREAST FEEDING

� Need to start breast feeding within the 1st hour of birth.

� ASHA & AWC workers offer counseling for this from early stage.

� Mothers need to learn a proper technique of breast feeding

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Mothers need to learn a proper technique of breast feeding

� Need counseling for dispelling wrong concepts about breast feeding.

� There are special rooms for breast feeding mothers in all hospitals.

� However despite all this only 60% babies get timely initiation of breast

feeding.

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EXCLUSIVE BREAST FEEDING

TILL 6 MONTHS.

� No need to give any other feed till 6 months-actually

harmful.

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� But many families give water, honey, gripe water, extra

milk, baby food etc in the state of Maharashtra.

� This causes infections and triggers malnutrition.

� The CNSM survey reports only 58% of exclusive breast

feeding.

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HIRKANI KAXA FOR

PROMOTING BREAST

FEEDING ..

�Promoted separate rooms for breast

feeding in all public hospitals and 250 bus

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feeding in all public hospitals and 250 bus

stands

�This helped both breast-feeding mothers

and send the right message to community

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BETTER MANAGEMENT OF HOME FEEDING

More than improving the SNP (supplementaryNutrition Program) in the AWC, It was necessary to

� Early and Exclusive Breast feeding AND

Improve home feeding from 6 months to 6

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� Improve home feeding from 6 months to 6 years.

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SEMI SOLID FEEDS AFTER 6 MONTHS.

� After 6 months breast feeding is not enough for the baby.

� It is time to give semi solid substances like porridge.

� The CNSM (Comprehensive Nutrition Survey of

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� The CNSM (Comprehensive Nutrition Survey of

Maharashtra 2012 by IIPS) reports this at 63% --too low.

� Many children get liquids, milk etc. as supplements; this

triggers malnutrition.

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FREQUENT, PROPER FEEDS & FOOD VARIETY.� The baby should get at least 6-8 feeds every day besides breast

feeding. (6 months to 2 years age group.)

� The feed should include energy dense & proteins , iron and vitamins.

� The CNSM survey reports low compliance on this (10-34%).

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� Nutrition will not improve unless home feeding improves considerably.

� The AWC tried to promote this factor through mother education

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HYGIENE AND

SANITATION

� Use of toilets must improve. But countless villages continue

with open defecation.

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� This causes infections and triggers malnutrition.

� AWC is promoting a hand-wash before feeding the baby and

encourage children to do the same.

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MICRO NUTRIENTS

� Our meals lack iron, Zinc, Calcium, vitamins.

� To ensure this a sachet of Micro Nutrients is

added in the daily meals in the AWC

� These Micro Nutrients reduce illnesses and

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� These Micro Nutrients reduce illnesses and

promote growth.

� However the change of taste has made Micro

Nutrients less popular in some districts.

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TAKE HOME RATION (THR)

� Younger babies can not attend and sit in the AWC.

� THR is meant for this younger group.

� 3 packets of 1 KG THR are provided for children.

� At home it is expected that some portion of THR is mixed in hot water

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� At home it is expected that some portion of THR is mixed in hot water

or cooked and the child given a feed.

� But there are complaints about the quality of THR and hence it is

discarded or fed to cattle or chicken.

� Other families cook the entire packet and serve it to the entire family.

� Therefore THR utilization is unsatisfactory.

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SOME WAYS OF USING THR

� In some districts THR is used to prepare popular food

items like laddus and sweets.

� Frying in oil or ghee makes it more energy dense.

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� Frying in oil or ghee makes it more energy dense.

� Some families have liked this option. But many families

have no time for these niceties.

� That perpetuates the question mark on THR

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CRÈCHE

� Crèches have been started in some Tribal blocks.

� Crèche operates from 9 to 5 in the day time.

� Space is rented ensuring that it has a toilet.

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� 2 women assistants work on monthly honorarium of Rs. 1600/- each

� About 10-15 children are served with 4 meals a day in the crèche.

� The meals are made from THR and some other food-stuff

� The AWC Sevika checks Height and weight.

� The RBSK medical team attends the crèche once in 4 to 6 months.

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CCRÈCHERÈCHE

� Crèche is a valuable social facility.

� A Crèche ensures a safe baby–sitting with trained workers.

� This frees the mother for work and leisure.

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� This frees the mother for work and leisure.

� The Crèche service is free.

� But non tribal areas do not have this facility.

� We need a larger movement and system management for

Crèches everywhere.

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RBSK (RASHTRIYA BAL

SWASTHYA KARYAKRAM)

� Each block has a RBSK mobile team since 2013.

� RBSK has 2 doctors, a nurse & pharmacist

� Has a rented vehicle.

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� Has a rented vehicle.

� RBSK offers checkup from infants to

adolescence.

� RBSK offers treatment/referral for childhood

illnesses

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RBSK..RBSK..

�But the work load implies that it is at least 4-6 months before the next visit.

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4-6 months before the next visit.

�The RBSK generates lot of useful data but this must be put online for better research.

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IMMUNIZATION

� AWC has monthly immunization day.

� Complete immunization protection of the child

against 6 infections.

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against 6 infections.

� Hence immunization is important for prevention of

malnutrition.

� Measles was especially linked to malnutrition

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A PAGE

FROM

HEIGHT-WEIGHT

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WEIGHT

TABLE

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THE USUAL METHOD OF MALNUTRITION DETECTION.

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SCREENING FOR MALNUTRITION

� Every U 6 Child’s weight is recorded in the AWC every

month.

� The weight is plotted on growth charts against the age

in months. This helps in grading of nutrition.

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in months. This helps in grading of nutrition.

� About 8-10% children are malnourished in the state.

� Severely underweight child is rare in non tribal areas.

� Height is measured every three months to check

wasting with wt-height table

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MMALNUTRITIONALNUTRITION-- SUW, SAM, MAM, MUAC SUW, SAM, MAM, MUAC ETCETC..THE LINE LISTING OF MALNOURISHED CHILDREN IN A PHC AREA

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IF THE CHILD IS ALREADY MALNOURISHED..

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� We must ensure timely diagnosis and timely treatment.

� The AWC and RBSK do this by screening every baby

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The AWC and RBSK do this by screening every baby

� Children with MN are referred for rehab.

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SSCREENINGCREENING OFOF MMALNUTRITIONALNUTRITION

Severe Malnutrition is decided by one of

the 3 methods

� Severe wasting ( weight for height )

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� Severe wasting ( weight for height )

� MUAC less than 11.5 cm.

� Foot edema

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NUTRITION REHABILITATION

� If the Child is severely malnourished it is

necessary to start the management early. For

this we have rehab centers at the village or the

health center or the block or District hospital.

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BETTER MONITORING- GEOGRAPHIC INFO SYSTEM

RJMCHN has now has a GIS system for the entire state.

� This GIS is available on www//:mhnss.ind.in

� Basically it has all the 1206 boxes of the monthly progress Report-MP

This can help to

� Generate MIS from AWC to state level and update within 48 hrs

� Generate info for action on every level.

Malnutrition in Maharashtra-A Review 2014

progress Report-MP

� The AW sevika can get it done in 30 Rs provision and within 30 min.

� She can upload the AWC abstract info (5-7 KB file)on the site thru the Sangramsoftware at village level.

every level.

� It can generate both process and outcome indicators

� We can generate about 1500 reports from this data

� It also provides camera sites for physical verification at each AWC 35

CO-OPERATION OF VARIOUS

SECTORS/DEPARTMENTS

� ICDS/AWC

� Tribal Development

� Health Department

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� Health Department

� RJMCHMN

� and Unicef

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MY ESTIMATION OF MALNUTRITION PREVENTION EFFORTS

20

30

40

50

60

70

80

90

100

1

2

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1

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Necessary efforts 201 2020

1 Ante natal care 80 95

2Safe/Institutional births 87 95

3Better birth-weight 70 80

4Early Breastfeeding 60 90

0

10

20

4

5

6

7

8

Necessary efforts 2012 2020

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4 Breastfeeding 60 90

5

Exclusive breastfeeding till 6m 59 90

6Complimentary feeding after 6m 63 95

7 Immunization 69 95

8 Micronutrients 50 95

9Treatment of illnesses 60 90

10 Hygiene 50 9037

BEST WISHES

Dr Shyam Ashtekar (MD, Community Medicine)

21 Cherry Hills Society, Anandwalli,

Nashik 422013

shyamashtekar@yahoo.com

Cell +919422271544

Website: Website:

arogyavidya.org,

bharatswasthya.net

A study of Anganwadis and campaign against malnutrition in Maharashtra for and with support of

Rajmata Jijau Mission,

August to Dec 2013

Malnutrition in Maharashtra-A Review

2014

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