Assessment of Nutritional Status of under-five year rural children in ...

CONTENTSPage No.ACKNOWLEDGEMENTSPROJECT STAFFRESULTS AT GLANCEEXECUTIVE SUMMARYi -iii1. INTRODUCTION 1 - 31.1 Profile of Damoh District 32. OBJECTIVES 42.1 General Objective 42.2 Specific objectives 43. METHODOLOGY 4 - 63.1 Sampling Design 43.1.1 Sample size 43.1.2 Selection of Villages 43.1.3 Selection of Households 43.2 Investigations 53.2.1 Household demographic and socioeconomicParticulars 53.2.2 Anthropometry 53.2.3 Clinical examination 53.2.4 History of Morbidity 53.2.5 Maternal Particulars 53.2.6 Infant and Young child feeding practices 63.2.7 Coverage of children under various health & nutritionintervention Programmes 63.2.8 Spot testing of household cooking salt for Iodine 63.3 Recruitment, training, standardization of field Investigators anddata collection 63.4 Quality Control 63.5 Data Analysis 64. RESULTS 7 - 164.1 Coverage 74.2 Household Socio-economic and Demographic particulars 74.2.1 Community 74.2.2 Type of family 74.2.3 Family size 74.2.4 Literacy status of father 7Nutritional Status of

4.2.5 Literacy status of mother 74.2.6 Household landholding 84.2.7 Major occupation of father 84.2.8 Major occupation of Mother 84.2.9 Per capita monthly income 84.3 Household Physical facilities 84.3.1 Type of house 84.3.2 Household amenities 84.4 Iodine content of Cooking salt 84.5 Maternal characteristics 94.5.1 Age and parity of mother 94.5.2 Particulars of last Pregnancy (mothers of

ACKNOWLEDGEMENTSWe express our sincere thanks to Mr. B.R. Naidu, I.A.S, Principal Secretary,and Smt. Tinoo Joshi, I.A.S, and Dr. Loveleen Kacker, I.A.S, past PrincipalSecretaries, Women and Child Development & Social Justice Department,Government of Madhya Pradesh for providing us an opportunity to carry out thisstudy.Our thanks are due to Ms. Kamini Chauhan I.A.S, Deputy Secretary, Dr.Anupam Rajan, Director and Shri. Akshaya Srivatsav, Joint Director, Women andChild Development Department, Government of Madhya Pradesh for their supportduring the study.We are also thanksful to Shri. Gulshan Bamra, former Director, and Sri PraveenKumar Gangrade, former Jt. Director, Women and Child Development Department,Government of Madhya Pradesh, and their colleagues for extending their cooperation andhelp in the execution of this study.The infrastructural & logistic support extended by Prof. S.K. Trivedi,Executive Director, Mr. Gokul pal, Research Officer and their colleagues at IndianInstitute of Development Management (IIDM), Bhopal is gratefully acknowledged.Our thanks are also due to UNICEF-Madhya Pradesh and UNICEF-New Delhifor their support by providing anthropometric equipment for use in this study.The help and support provided by the Districts Project Officers, ChildDevelopment Project Officers, Supervisors, Anganwadi Workers (AWWs) andASHA worker (Health functionaries) of the concerned districts in the execution ofthe survey, is gratefully acknowledged.Our sincere thanks to the entire field staff for their commitment andsincere efforts in the collection of data.We grateful to Dr. B. Sesikeran, Director, N.I.N and Dr. Vishwa MohanKatoch, Director-general, I.C.M.R, and Secretary, Department of Health Research,Ministry of Health and Family Welfare, GoI, for their constant support andencouragement.We also thank Mr. G.Manohar Reddy, Research Officer, Mr. R. RaghunathBabu, Technical Assistant, Mrs. G.Madhavi, Technician, Ms. D.Sarala & G.MadhaviTabulators, NNMB-CRL, and Ms. D. Balamani, Ms. D. Saritha & Ms. M. VenkataRamanamma, Punch Operators, and Mrs. L. Rajeswari & Mr. M. Shashi Kumar Reddy,Data Entry Operators for their technical help.We are also thankful to Mr. G. Hanumantha Rao, and Mrs. G. Prashanthi,Personal Assistants for their secretarial assistance.Last but not least, we are extremely grateful to the community for theirunstinting cooperation, without which the study would not have been completedsuccessfully.Authors

PROJECT STAFFRESEARCH ASSISTANTSSl.No. Name1. Mr. Ganesh Behera2. Ms. Rachana Thakur3. Ms. Vijeta Sahu4. Mr. Antim MakwanaFIELD INVESTIGATORSSl.No.Name1. Mr. Mahadev Mewade2. Mr. Surendra JainNutritional Status of < 5 year Children Damoh Dt.- Madhya Pradesh

RESULTS AT GLANCE

RESULTS AT A GLANCEDISTRICT PROFILETotal population (2001 Census) 1083949Sex Ratio 901Population density (per sq km) 148Percent of Schedule caste 19.5Percent of Schedule Tribes 12.6Literacy status (%) 61.9Female literacy (%) 47.3SAMPLE CHARACTERISTICSHHs surveyed (n) 390Average Family size (n) 6.1Average per capita monthly income (Rs) 1125COMMUNITY (%)Scheduled Caste 18.2Scheduled Tribe 21.5TYPE OF FAMILY (%)Nuclear 52.8Extended Nuclear 10.5Joint 36.7LITERACY STATUS (%)Father 73.8Mother 53.1LAND HOLDING (% HHs)Land less Families 39.0Marginal Farmers 17.2Small Farmers 10.8Large Farmers 33.0(Contd… 2).Nutritional Status. of < 5 year Children Damoh Dt.- Madhya Pradesh

RESULTS AT A GLANCE (Contd…2)MAJOR OCCUPATION OF HOUSEHOLDPercentLabourers 43.1Cultivators 46.3Land Lords 0.0Artisans 0.5Service 4.9Business 4.4TYPE OF HOUSEKutcha 16.7Semi-Pucca 67.2Pucca 16.1SOURCE OF DRINKING WATEROpen well 27.4Tube well 44.4Tap 24.6HOUSEHOLD ELECTRICITY 92.1PRESENT AND USING SANITARY LATRINE 14.4IODINE CONTENT OF COOKING SALT0 ppm 57.7

DELIVERY CONDUCTED BYRESULTS AT A GLANCE (Contd…3)BREAST FEEDING AND COMPLEMENTARY FEEDINGInitiate of Breast feeding (hours)Age of initiation of complementary FeedingPercentM.O. PHC 39.7ANM/LHV 30.1Pvt. Doctor 0.9Untrained Dai/Others 29.3Low birth weight (% infants) 31.0

EXECUTIVE SUMMARY

Executive SummaryUndernutrition continues to be a major public health problem in the developingcountries, including India, the most vulnerable groups being women and young children.Proper nutrition is necessary for adequate growth and development of children.Undernutrition is of multi-factorial aetiology, which include both food and non-foodfactors.According to the recent reports of NFHS-3 (2005-06), the prevalence of underweightamong under five year children in the State of Madhya Pradesh was 60%, stunting was 50%and wasting was 35%, while according to NNMB surveys carried out during the same period(2005-06), the prevalence of underweight and wasting was lower (46% and 24%respectively) and that of stunting was more (59%). The prevalence of undernutritionespecially among under five year children may vary geographically. Therefore, for thedevelopment of area specific intervention strategies, district level assessment ofundernutrition is very essential. At the request of DWCD, Government of Madhya Pradesh,the National Institute of Nutrition, Hyderabad therefore, carried out the present study toestimate the prevalence of undernutrition among under five year rural children andinfant and young child feeding practices. It was a cross sectional study carried out usingmulti-stage random sampling procedure. A total of 390HHs covered from 20 villages,including 497children were covered for the present study.A majority (48%) of the HHs covered in the present survey belonged to BackwardCommunities followed by Scheduled Tribes (22%) and Scheduled Caste (18%). Morethan half of the HHs (53%) belonged to nuclear families. Nearly, half of the mothers(47%) were illiterate, 39% of the HHs did not possess any agricultural land and about43% were engaged in either agricultural or other labours. Majority (70%) of the womenwere housewives. About 67% of HHs lived in semi pucca houses and 17% in kutcha.About 44% of the HHs were using tube well water and 25% of HHs had access to tapwater. Only 14% were using sanitary latrine. All most all (99%) the HHs were usingfirewood for cooking purpose and 92% HHs had electricity. Only35% of the HHs wereusing free flowing salt and 21% were using adequately iodized salt (≥15 ppm).Nutritional Status of

About 67% of pregnant women had undergone Antenatal check-up (ANC) of whichabout 26% had ≥3 ANCs. About 35% pregnant women were registered for ANC before16 weeks of gestation. About three fourth (73%) of pregnant women received IFA tabletsduring pregnancy, 41% received more than 90 tablets and only about 17% reportedlyconsumed ≥90 tablets. Sixty eight per cent were institutional deliveries, either ingovernment or private hospitals. Majority (70%) of deliveries were conducted by healthpersonnel. Birth weights were recorded in 60% of infants, while records were availableonly for 36%. The prevalence of low birth weight was 31%.Most of the mothers (96%) fed colostrum to their new born. About 35% ofmothers initiated breastfeeding within 1hour and 26% did so within 1-3 hours of delivery.About 27% initiated breast feeding after 24 hours of delivery. Pre-lacteal feeds such asglucose/sugar water, honey, etc. were given in about 29% of the new borns.Among 6-11 months children, complementary feeding was initiated at 6 monthsof age in about 28%, while 26% children received during 7-12 months of age. About48% of children did not start complementary feeding.Of the 6-12 months infants, about 38% were receiving home made semisolids28% solids and 30% cow/buffalo milk, and about 32% were receiving such foods atleast 3 times a day. Among 12-35 months children, 69% received complementaryfeeding in addition to breast milk. Majority were receiving home made semisolids/solidsand 82% were receiving complementary foods at least 3 times a day.About 55% were completely immunized during 1 st year, while about 8% did notreceive any immunization. About 72% of 9-59 months children received at least onedose of Vitamin A during the preceding year. About 53% of 36-59 months childrenreceived the stipulated two doses.About 7% of 12-59 months children received ≥90 IFA tablets while only 4% of thechildren reportedly consumed ≥90 tablets during the previous one year.One per cent of the infants had Marasmus, while 1.6% of 12-59 months childrenexhibited the signs of Bitot spots indicating that vitamin A deficiency is a public healthproblem.Nutritional Status of

About 43% of children reportedly had one or more morbidities such as fever, ARIand diarrhoea during the preceding fortnight. The prevalence was relatively higheramong 6-11 months children, which tended to decrease with increase in age. About71% of the mothers reported that they generally consult private practitioner, while 26%went to PHC, to seek treatment for their sick children.The overall prevalence of undernutrition (

1. INTRODUCTIONIndia, in the past few decades, has witnessed rapid progress in terms ofindustrialization and agricultural production. Yet malnutrition, especiallyundernutrition continues to be a major problem of public health significance in thecountry. It is a major contributor to high rates of childhood mortality, maternalmortality and morbidities in the community 1 . Though, poverty is a major underlyingcause, scores of other factors such as socio-demographic, socio-cultural and lifestylepractices contribute significantly to the problem of malnutrition.Prevalence of low birth weight, mainly due to intrauterine growth retardationcontinues to be high, which is attributable to maternal undernutrition. This is furtheraggravated by inappropriate infant and young child feeding practices, such asdiscarding of colostrum, delayed initiation of breast feeding, early or delayedinitiation of complementary feeding, and sub-optimal complementary feedingpractices in terms of type of feed, quantity, and frequency.It has been found that non-exclusive breast feeding in the first six months oflife results in 1.4 million deaths and 10% of the disease burden among infants andyoung children every year in the developing countries 2 . It is also estimated that about10-15% of under five year deaths in resource poor countries could be prevented byachieving 90% of exclusive breast feeding alone 3 and 22% of neonatal deaths couldbe prevented if breast feeding is initiated within the first hour of birth 4 .About 21% of global deaths and DALYs (Disability Adjusted Life Years) inchildren younger than 5 years are attributed to stunting, severe wasting, andintrauterine growth retardation. Long term consequences of undernutrition during theearly stages of child growth and development include likelihood of short stature inadult life, low educational achievements, giving birth to smaller children, lowereconomic status and reduced physical work capacity and productivity in adulthood 5 .Further, the country is passing through a phase of rapid socio-economictransition leading to over nutrition in certain segments of the population, especially inthe urban communities. Changing lifestyles and dietary habits are contributing toincrease in the prevalence of overweight/obesity among children and young adultsexposing them to the risk of chronic degenerative disorders such as hypertension,Type 2 diabetes, coronary artery disease, stroke, cancers etc in the later part of life.More over undernutrition during early childhood can lead to overweight/obesity inadulthood, a risk factor for diet related chronic diseases 6 .The major nutritional problems of public health significance in the country are,protein energy malnutrition (PEM), vitamin A deficiency (VAD), iron deficiencyanaemia (IDA), and iodine deficiency disorders (IDD). Preschool children, adolescentgirls, women of reproductive age group, elderly, those belonging to socioeconomicallybackward groups such as scheduled caste and schedule tribeNutritional Status of

communities, communities residing in chronically drought affected rural areas arenutritionally the most vulnerable segments of the populations.Several nutrition programmes have been designed and are beingimplemented in India, through respective State Governments, during the past fewdecades for the prevention and control of both macro and micronutrient malnutritionin the population. They include supplementary feeding through ICDS, distribution ofiron and folic acid tablets, massive dose vitamin A supplementation, Mid-day mealprogramme etc. Also, several poverty alleviation and developmental programmesare being implemented by central and State governments, for the overallsocioeconomic development of the communities. In addition, Public DistributionSystem and TPDS are striving to provide essential commodities at affordable price,especially to those below poverty line throughout the year, all over the country, toensure household food security.Children, who are subjected to socio-economic and dietary constraints duringtheir critical years of growth and development, end up as adults with small body size.Such adults may be apparently healthy, but there is evidence to suggest that theirproductivity and earning capacity are impaired (Satyanarayana and Naidu, 1977 7 ).Repeat surveys by National Nutrition Monitoring Bureau (1999 8 ) in eight Statesrevealed that, despite very little or no change in the dietary intakes of rural populationover a period of time, there was a decrease in the prevalence of severe forms ofundernutrition among young children with concomitant increase in normal grades.However, the proportion of children with mild to moderate undernutrition remainedsimilar. Recent survey carried out by NNMB (2006 9 ) in the rural areas of nine Statesrevealed that about 40% under 5 year children were underweight, 45% were stuntedand 20% were wasted. The corresponding figures for the State of Madhya Pradeshwere, 46%, 59% and 24% respectively.According to NFHS-3 10 , in the State of Madhya Pradesh, 60% of

The type and magnitude of undernutrition may vary from district to district,depending on geographical and agro-climatic conditions and therefore, warrantregion-specific interventions. In order to devise and implement area specificintervention strategies and to monitor their impact over a period, it is necessary togenerate data base at district level.In this context, the Government of Madhya Pradesh is contemplating todevelop State Nutrition Policy and develop plan of action for implementation, in orderto improve the nutritional status of the communities. Therefore, at the request of theDepartment of Women & Child Development, Government of Madhya Pradesh, theNational Institute of Nutrition carried out survey in all the following 50 districts of theState, to assess the nutritional status of under 5 year children and infant and young childfeeding practices.Sl.Sl.Sl.Sl.Sl.DistrictDistrictDistrictDistrictNoNoNoNoNoDistrict1 Alirajpur 11 Chindwara 21 Indore 31 Neemuch 41 Shahdol2 Anuppur 12 Damoh 22 Jabalpur 32 Panna 42 Shajapur3 Ashokngar 13 Datia 23 Jhabua 33 Raisen 43 Sheopur4 Balaghat 14 Dewas 24 Katni 34 Rajgarh 44 Sidhi5 Barwani 15 Dhar 25 Khandwa 35 Ratlam 45 Singrauli6 Betul 16 Dindori 26 Khargone 36 Rewa 46 Shivpuri7 Bhind 17 Guna 27 Mandla 37 Sagar 47 Tikamgarh8 Bhopal 18 Gwalior 28 Mandsaur 38 Satna 48 Ujjain9 Burhanpur 19 Harda 29 Morena 39 Sehore 49 Umaria10 Chhatarpur 20 Hoshangabad 30 Narasimhapur 40 Seoni 50 VidishaThe results of the study carried out in Damoh district of Madhya PradeshState during February-August 2010, is presented in this report.1.1 Profile of Damoh DistrictThe existence of Damoh can be traced back to ancient times. It has beenmentioned in the Ramayana as Damayantipur. The district Jabalpur, Panna,Chattarpur, Tikamgarh, Sagar, Katni, and Narsinghpur surrounded Damoh. Thedistrict covers a total area of 7306 sq. km and is situated at a height of 34 metresfrom sea level. It consists of 4135 sq.km of forest area, 1655 sq.km of cultivatedarea, 832 sq.km of double crop area, and 917sq.km of irrigated area. The totalpopulation of the district is 10, 83,949 (2001 census), with a population density of148/sq.km. The district has a sex ratio of 901. The overall literacy rate is 61.9% with74.7% for males and 47.3% for females. Mostly the people depend upon agricultureand agricultural labour. Another source of income in the area is beedi making.Nutritional Status of

2. OBJECTIVES2.1 General ObjectiveThe general objective of the study was to assess the health and nutritionalstatus of

were surveyed by selecting a random start, starting from the Northeast corner ofthe area. In the selected HH, all the children of

3.2.6 Infant and Young child feeding practicesInfant and young child feeding practices such as initiation of breast feeding,feeding of colostrum, duration of exclusive breast feeding for

4. RESULTS4.1 CoverageA total of 390households from 20 villages were covered for the study (Table1). A total of 497 children (Boys:282; Girls:215)

4.2.6 Household landholdingAbout 39% of households did not posses any agricultural land. Thirty threeper cent were large farmers (≥ 5 acres), 11% small farmers (2.5 - 5 acres) and 17%were marginal farmers (

4.5 Maternal characteristics4.5.1 Age and parity of motherAbout 85% of mothers were between 18 and 29 years of age, while 14% werein the age group of 30-39 years. About 34% mothers were primi, 33% had 2 children,and 28% had 3-4 children, while 5% had ≥5 children (Table 5).4.5.2 Particulars of last Pregnancy (mothers having

4.6 Under five year children4.6.1 Profile of the Children CoveredBirth order and interval between last two birthsAmong the children surveyed, about 39% children were of first birth order,31% were of second birth order and 30% were of third birth order or more. Amongchildren of birth order of 2 or more, the birth interval between the last two childrenwas

70%Fig.1 Distribution (%) of 0-11 months Children according toTime of Initiation of Breastfeeding (BF)60504034.53025.926.72010011.21.7

complementary feeding with spoon. The feeding was supervised mostly by the mother(Table 12).4.6.2.2 12-35 month childrenAbout 69% of the children were currently receiving complementary foods in additionto breast milk, 31% of the children were not breast fed. The type of food being currentlygiven included home made semi-solids (95.5%) and/or solids (89.7%) cow/buffalomilk (75.8%). The most commonly used food groups included cereals & millets andpulses (97% each), GLV and other vegetables (93% each), fruits (92%), roots &tubers (87%), Milk & milk products (86%), fats & oils (79%), eggs (26%) and fleshfoods (17%). About 33% of the children were fed ≥ 4 times a day, 49% were fed 3times a day, while 18% were fed ≤ 2 times a day. About 40% of the childrenconsumed food themselves mostly with hands. About 57% of children were fed bytheir mothers, either by hand (53%) or with spoon (4%). In most cases, feeding wassupervised by their mothers (92%), followed by grand parents and elder siblings (4%each) (Table 13).4.6.3 Care of the ChildAbout 70% of mothers reportedly were taking care of their children by themselves athome, while 10% stated that they were cared by the grand parents and 7% by the oldersiblings (Table 14). About 11% of the mothers carried their children to the work-spot.4.6.4 Personal HygieneOnly 16% of mothers washed their hands with soap before feeding the child.About 31% of mothers were using soap for washing their hands after defecation(Table 14).4.6.5 History of MorbidityThe particulars of morbidity during preceding fortnight among

children reportedly had diarrhoea during the previous fortnight, while 4.2% receivedORS, either home made (1.4%) or that given by ANM/AWW (1.6%) or commercial one(1.2%). About 30% of children reportedly had acute respiratory infection, while only 6%had received co-trimoxazole.4.6.6 Participation in ICDS Supplementary feeding Programme.About 80% of the children of 6-59 months age group were participating in theICDS supplementary feeding programme, with 60% being regular. The extent ofparticipation was observed to be high (88%) among 36-59 months and 61% among6-35 months age group (Table 17). A higher proportion of older children were regular(73%), than younger counterparts (51%).4.6.7 Coverage for Immunization under UIPThe particulars of coverage of 12-24 months children for immunization underUniversal Immunization Programme (UIP) during the first year of life are provided inTable 18 and Fig. 3. About 55% of the children were fully immunized, 37% werepartially immunized, while 8% did not receive any immunization. About 70-85%received polio, DPT & BCG vaccines, while only 56% received measles vaccination.Major source of this information was from parents (45%), and mother and childprotection card (31%). The major reason for not immunized or partially immunized was‘not offered’ (23%), ‘not aware of the need’ (17%), or ‘time/place notknown/inconvenient’ (3%).4.6.8 Coverage for Massive dose of Vitamin A SupplementationThe National programme on Prevention and control of blindness due to VitaminA deficiency envisages that all the children between 9 to 60 months should receivebiannual massive dose of vitamin A. The particulars of coverage of children formassive dose vitamin A during the previous one year are provided in Table 19. Ingeneral, about 72% of 9-59 months children reportedly received at least one dose ofvitamin A, while the coverage was 63% among 9-17months, 75% among 18-35 and73% among 36-59 months children respectively. About 52% of 18-59 monthschildren received 2 doses during preceding one year, and 22% received one doseonly. In a majority of cases, the massive dose vitamin A was administered at AWC(59%), mostly by AWW (49%) or ANM (23%). The major reasons for non-receipt ofmassive dose of Vitamin A, were ‘unaware of the need’ (16%) or ‘not offered’ (14%).4.6.9 Coverage for Iron and Folic acid tablets SupplementationAbout 35% children of 12-59 months reportedly received IFA tablets duringthe preceding year, either from AWW or ANM (16%each). Only about 7% received ≥90 IFA tablets, while only 4% consumed ≥ 90 tablets (Table 20).Nutritional Status of

%10087.6Fig. 3 Coverage (%) of 12-24 months Children for Immunization underUniversal Immunization Program (UIP)908079.875.26983.7 80.669706055.854.6504036.930208.5100BCG DPT1 DPT2 DPT3 OPV1 OPV2 OPV3 Measles Full Imm. PartialImm.No Imm.Nutritional Status of

4.7 Nutritional status of children (

2016Fig.4 Distance charts for Weights - BoysMedian Wt - WHO StandardsMean Wt - Current StudyWt (Kgs)128400123456789101112-1718-2324-2930-3536-4142-4748-5354-59Age (Months)2016Fig.5 Distance charts for Weights - GirlsMedian Wt - WHO StandardsMean Wt - Current StudyWt (Kgs)1284001234567891011Age (Months)12-1718-2324-2930-3536-4142-4748-5354-59Nutritional Status of

120100Fig.6 Distance charts for Heights - BoysMeadian Ht-WHO standardsMean Ht -Current Study80Ht (Cms)60402000123456789101112-1718-2324-2930-3536-4142-4748-5354-59Age (Months)120100Fig.7 Distance charts for Heights - GirlsMeadian Ht-WHO standardsMean Ht -Current Study80Ht (Cms)604020001234567891011Age (Months)12-1718-2324-2930-3536-4142-4748-5354-59Nutritional Status of

Fig.8 Prevalence (%) of Undernutrition among

The overall prevalence of stunting among

Fig.10 Prevalence (%) of Undernutrition among

Literacy status of fatherThe nutritional status of children was found to be significantly associated withliteracy status of father. The prevalence of underweight was significantly (p

Fig.11 Prevalence (%) of Undernutrition among

Fig.13 Prevalence (%) of Undernutrition among

Fig.15 Prevalence (%) of Undernutrition among

Type of houseThe prevalence of underweight was significantly (p

5. DISCUSSION AND CONCLUSIONSNational population policy 2000 envisaged that about 80% of deliveries shouldbe Institutional and 100% should be conducted by trained personnel 16 . The presentstudy revealed that only 68% were institutional deliveries conducted by trainedhealth personnel. Sixty seven per cent of pregnant women had undergone antenatalcheck-up. However, 26% had undergone the minimum 3 ANCs. About 86% receivedTT immunization in the Damoh district of Madhya Pradesh. According to NFHS-3survey, about 80% of the pregnant women had undergone ANC in the state ofMadhya Pradesh 10 .Birth weights were recorded in about 60% of the newborns, but the recordswere available for only 36% of them. The proportion of low birth weight (LBW) wasabout 31% in the district. The birth weight of an infant is the single most importantdeterminant of new born survival and in developing countries; low birth weight infantsare at increased risk of being malnourished at one year of age, become victims of“infection-malnutrition cycle” which leads to further physical stunting and impairedgrowth and development. 17 In addition, children born with intrauterine growthretardation are at higher risk of developing overweight/obesity and associatedchronic degenerative disorders during adulthood 6 .Infant and young child feeding practices have a significant impact on childhealth and survival. Appropriate feeding including early and exclusive breastfeedingand optimal complementary feeding practices such as right time of initiation, righttype and quantity of complementary foods and frequency of complementary feedingis important for proper physical growth and mental development of the child. In itspolicy statements, the American Academy of Paediatrics (1997) 18 stated that themother’s milk is uniquely superior for infant feeding.Epidemiological research showed that mother’s milk and breastfeeding ofinfants provides advantages with regard to general health, growth and developmentwhile significantly decreasing risk for a large number of acute and chronic diseases.In this study, breastfeeding was the common practice among the mothers. About35% of the mothers reportedly initiated breastfeeding within one hour after deliverywhich is higher than that reported by NFHS-3 (16%), while 26% of mothers initiatedbetween 1-3 hours. Pre-lacteals were given in about 29% of the newborns. Prelactealfeeds might harm the immature gut of the child, especially if they arecontaminated. These undesirable newborn feeding practices observed in the districtis a matter of concern and requires due attention because, early initiation of breastfeeding is the primary determinant of maternal milk production and secretion.Avoidance of other fluids or foods is essential to optimize breast milk intake by thenewborn. Most of the other fluids or foods are less nutritious than breast milk andtherefore, if displacement occurs, the infant may be at a nutritional disadvantageeven if prepared hygienically 19 . In many communities, it is traditionally believed thatcolostrum is unhealthy and therefore is harmful to the baby. However in the presentNutritional Status of

study, colostrum was given by majority (96%) of mothers which is good for the child’shealth and nutrition and such desirable practices should be encouraged in thecommunity.Breast milk can contribute significantly as a source of energy, fat, high qualityprotein and micronutrients, especially when the quality of available complementaryfood is low (Academy of Educational Development, 1999 19 ). WHO 20 and UNICEF(1993a 21 ) recommends that complementary feeding should be initiated immediatelyafter 6 months of the infant’s age and breastfeeding should be continued well intothe second year of life and for longer duration, if possible. In this study, the motherscontinued to breastfeed for a longer duration (up to 2 years), however undesirablecomplementary feeding practices appear to be significant in the district of Damoh interms of initiation and frequency of feeding.The initiation of complementary feeding was unduly delayed. Only about 52%of the 6-11 months children were getting complementary feeds, while only 28%started receiving the same at the age of 6 months. The complementary foods beinggiven mostly included cow/buffalo milk and home made semi-solids. The frequencyof feeding was at least 3 times in 12% of the infants. Effective immunizationprogramme against the common communicable diseases are required for themajority of the susceptible populations particularly in the developing countries,wherein the risk of disability or death from preventable infectious diseases is amatter of concern. Therefore, coverage under universal immunization programmeshould be 100%. It has been observed in this study that only 55% were fullyimmunized.The programme for prevention of blindness due to vitamin A deficiencyenvisages distribution of massive dose vitamin A to all the children aged between 9-59 months, every 6 months. It was observed that about 39% of children between 9-11 months and 24% children between 12-59 months received at least one dosevitamin A during previous one year. Only about 53% of 36-59 months childrenreceived the suggested two doses during the preceding one year. The coverage foriron-folic acid supplementation was very low (35%), while only 7% received ≥ 90tablets indicating, poor coverage. Low compliance (only 4% consumed ≥ 90 tablets)indicates weak education component. There is a need to strengthen the servicedelivery and monitoring mechanisms for these programmes.The common morbidities such as ARI, fever and diarrhoea were reported by themothers with the prevalence being higher in the younger age group (6-11 months)compared to the older age group (12-23 months). The probable reasons for thiscould be due to the prevailing sub optimal infant and young child feeding practicescoupled with non-receipt of appropriate health care management.Consumption of adequately (≥15 ppm) Iodised salt is very poor in the district(21%) compared to National (51%) and State average (36%) (NFHS-3). NutritionalNutritional Status of

status of infants and young children is not only a vital health issue, but it is alsocentral to sustainable growth and development of the child 22 .In the present study, theprevalence of underweight, stunting and wasting was 43%, 40% and 27%respectively. It was observed that the nutritional status of children deteriorated asage advances especially from six months onwards. Undernutrition in all its threeforms continues to be a significant problem in the district of Damoh, even though thecurrent prevalence in the district is considerably lower than that reported for theState of Madhya Pradesh by NFHS-3 (2007) and NNMB (2006). Probably, factorssuch as, the energy and nutrient density of the complementary foods given, thefrequency and variety of foods offered, hygiene aspects of food preparation,personal hygiene, the amount of breast milk consumed at different stages ofcomplementary feeding, the frequency of breastfeeding and inappropriatecomplementary feeding during and after illness may have an important contributoryrole for the observed high prevalence of undernutrition in the district.The study revealed significant association between nutritional status anddifferent socio-economic variables, which indicate higher rates of undernutrition inthe households of vulnerable sections of society (SC & ST), among children oflandless labourers and illiterate fathers, and in households with no facility of asanitary latrine. Promotion of better infant and young child feeding and health carepractices is needed for improving the health and nutritional status of young children.Last but not least, there is a need to strengthen the programmes for incomegeneration to enhance household food and nutrition security.- o0o -Nutritional Status of

REFERENCES1. de Onis M, Blossner M, Borghi E, Frongillo EA, Morris R. Estimates of globalprevalence of childhood underweight in 1990 and 2015. JAMA 2004;291:2600-6.2. Black,RE, Allen LH, Bhutta ZA etal. Meternal and child undernutrition: globaland regional exposures and health consequencies. Lancet 2008; 371: 243-2603. Jones G, Steketee RW, Black RE etal. How many child deaths can we preventthis year? Lancet 2003; 362: 65-71.4. Edmond KM, Zandoh C, Quigley MA etal. Delayed breast feeding initiationincreases risk of neonatal mortality. Pediatrics 2006; 117: e380-e386.5. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Ritcher L and Sachdev HS.Maternal and child undernutrition: Consequences for adult health and humancapital. The Lancet 2008; 371:340-57.6. Barker DJP, Osmond C, Forsen TJ, Kajantie E, Eriksson JG. Trajectories ofgrowth among childrenwho have coronary Events as Adults. N Eng J Med2005; 353:1802-97. Satyanarayana K., Naidu AN., Chatterjee B., Rao BSN. Body size and workoutput. Am. J. Clin. Nutr. 1977; 30:322-325.8. National Nutrition Monitoring Bureau: Report of Second Repeat Survey –Rural. NNMB Tech. Rep. No. 18, 1999.9. National Nutrition Monitoring Bureau. Diet and nutritional status of ruralpopulation. NNMB Tech. Rep. No.24, National Institute of Nutrition (ICMR),Hyderabad, 200610. National Family Health Survey 2005-06.11. Ministry of Human Resource Development, Government of India, NationalNutrition Policy, New Delhi: Department of Women and Child Development,1993.National Plan of action12. Ministry of Human Resource Development, Government of India, National Planof Action on Nutrition, New Delhi: Food and Nutrition Board, Department ofWomen and Child Development, 1995.13. Jelliffee D.B. Assessment of nutritional status of community. WHO Monographseries No.53, 1966.14. World Health Organization. Measuring change in nutritional status, WHO,Geneva, 1983.Nutritional Status of

15. WHO Multicentre Growth Reference Study Group. WHO Child GrowthStandards based on length/height, weight and age. Acta Paediatr Suppl 2006;450:76-85.16. www.whoindia.org/EIP/policy/population.17. Black RE, Lindsay HA, Bhutta ZA, Caulfield LE, Mercedes de Onis, MajidEzzati, Colin Mathers, Juan Rivera. Meternal and child under nutrition: Globaland regional exposures and health consequences. Maternal and child undernutrition study group. The Lancet, 2008; 371:340-357.18. American Academy of Paediatrics. Breast-feeding and the use of Human milkAmerican Academy of Paediatrics, Work Group on Breastfeeding. Pediatr1997; 100:1035-1039.19. Academy of educational development. Recommended feeding and dietarypractices to improve infant and maternal nutrition. Linkages – Improvingnutrition and reproductive health. 1999.20. The optimal duration of exclusive breast-feeding. Report of an ExpertConsultation, WHO, Geneva, 2001.21. UNICEF. Breast feeding facts of life. UNICEF (1993a).22. Dewey KG, Heinig MJ, Nommsen LA, Lonnerdal B. Adequacy of energy intakeamong breast-fed infants in the DARLING study: relationship to growthvelocity, morbidity and activity levels. Davis Area Research on Lactation, InfantNutrition and Growth. J Pediatr.1991; 119:538-47.Nutritional Status of

TABLES

Table - 1Particulars of CoverageParticularsCoverage (n)Socio-economic particulars (HHs) 390Under 5 year children for anthropometry497(Boys: 282; Girls:215)Children below 12 months 116Children 12-35 months 223Children 36-59 months 158Spot testing of HHs salt for iodine 390Infant & young child Feeding PracticesMothers with

Table - 2Socio-economic Profile of the Households of Index childrenCommunityType of FamilyFamily SizeParticularsPercentn 390Scheduled Tribe 21.5Scheduled Caste 18.2Backward Community 47.9Others 12.4Nuclear 52.8Extended Nuclear 10.5Joint 36.71 -4 31.85 – 9 58.2 10 10.0Average Family Size 6.1Literacy status of FatherLiteracy status of MotherIlliterate 26.2Read & write 0.31 – 5 Class 13.86 – 7 Class 4.18 – 10 Class 40.5Intermediate 7.7Graduate & above 7.4Illiterate 46.9Read & write 0.51 – 5 Class 15.46 – 7 Class 6.48 – 10 Class 25.6Intermediate 2.8Graduate & above 2.3(Contd….)Nutritional Status of

Table – 2 (Contd…)Socio-economic Profile of the Households of Index childrenParticularsExtent of HH landholding (Acres)Major Occupation of FatherMajor Occupation of MotherPer capita monthly income (Rs)Percentn 390Nil 39.0Marginal farmers

Table - 3Physical facilities of the HouseholdsType of houseParticularsSource of Drinking WaterType of Cooking FuelPercentn 390Kutcha 16.7Semi Pucca 67.2Pucca 16.1Open Well 27.4Tube Well 44.4Tap 24.6Pond or Tank 0.5Stream or River 3.1Firewood 98.5LPG 1.5Household electricity present 92.1Sanitary LatrinePresent and in use 14.4Present and not in use 1.8Absent 83.8Separate Kitchen Present 45.6Nutritional Status of

Table – 4Distribution (%) of HHs according to use of Iodized salt and iodinecontentType of salt usedIodine ContentParticularsPercentn 390Powdered salt 12.6Crystal Salt 23.6Rock Salt 28.7Free-flowing 35.10 ppm 57.7

Table - 6Particulars of last pregnancy of mothers of < 6 months childrenParticularsPercentn 66Undergone Antenatal check-up (ANC)Total number of ANCsYes 66.7No 33.3One 16.7Two 24.3Three 12.1Four 12.1≥ five 1.5Not availed ANC 33.3Undergone First ANC at (Weeks of gestation)Place of ANC≤ 8 weeks 16.79- 12 weeks 4.513- 16 weeks 13.617-20 weeks 7.6>20 weeks 24.3Not availed ANC 33.3Home 7.6AWC 10.6Sub-centre 9.1PHC/CHC 21.2Taluk/Dist.hospital 15.2Private Clinic 3.0Not availed ANC 33.3ANC conducted byANM 31.8Medical Officer 33.3Pvt. Doctor 1.6Not availed ANC 33.3( Contd..)Nutritional Status of

Table – 6 (Contd…)Particulars of last pregnancy of mothers of < 6 months childrenParticularsPercentn 66Components of ANC*Physical Examination 60.6Weight Recording 40.9Urine Test 36.4Haemoglobin Estimation 36.4Blood pressure measurement 37.9Health & Nutrition advise given during ANCYes 42.4No 24.3Not availed ANC 33.3If yes, what advise*To attend for regular checkups 30.3To consume more GLVs 31.8To consume more Vegetables & fruits 30.3To take IFA tablets for 100 days 37.9Others 4.5Reasons for not availing ANCs*Not aware of the need 24.2No faith 4.5No ANC held in the village 3.0Timing are in convenient 4.5Place not accessible 7.6Loss of wages 1.5TT Immunization receivingYes 86.4No 13.6If yes, No. of dosesOne dose 7.6Two doses 78.8Not received 13.6Reasons for not receiving TTNot aware of the need 12.1* Multiple responses ( Contd..)Nutritional Status of

Table – 6 (Contd…)Particulars of last pregnancy of mothers of < 6 months childrenParticularsPercentn 66Received IFA tabletsYes 72.7No 27.3IFA tablets received fromANM 27.3AWW 31.8MO-PHC 12.1Private Doctor 1.5Not received 27.3No. of IFA tablets received

Table –7Particulars of last Delivery of mothers of

Table - 8Distribution (%) of < 60 months children according of Birth orderBirth orderPercentn 497First 38.8Second 31.0Third 15.7Fourth 8.5Fifth and above 6.0Table - 9Distribution (%) of < 60 months children having siblings according tointerval between last two birthsInterval between last two births(months)Percentn 304

Table - 10Distribution (%) of

Table - 11Distribution (%) of infants ( 6 months - 26.0Not yet started 98.5 48.0Type of complementary food currently being given** Multiple responsesCow/buffalo milk 1.5 30.0Formula milk - 6.0Commercial baby foods - 22.0Home made Semi-solids - 38.0Home made solids - 28.0Not yet started 98.5 48.0Nutritional Status of

Table - 12Distribution (%) of 6-11 months Children according to Feeding PracticesFeeding PracticesPercentn 50Foods generally included in home made complementary foods*Cereals & Millets 38.0Pulses 36.0Green Leafy Vegetables 28.0Other Vegetables 28.0Roots & Tubers 24.0Fruits 30.0Milk & milk products 30.0Eggs 6.0Meat & Chicken 4.0Fats & Oils 24.0Number of complementary feeds per dayMode of complementary feeding2 20.03 12.04 4.05 2.06-8 14.0Not yet started 48.0Mother with spoon 10.0Mother with hand 42.0Not yet started 48.0Supervision of complementary feeding by* Multiple responsesMother 52.0Not yet started 48.0Nutritional Status of

Table - 13Distribution (%) of 12-35 months Children according to FeedingPracticesFeeding PracticesPercentn 223Children currently Breast fed + complementary feeding 68.6Not breast fed 31.4Type of food currently being given*Cow/buffalo milk 75.8Formula milk 18.8Commercial baby food 23.3Home made semi-solids 95.5Home made solids 89.7Foods generally included in home made foods*Cereals & Millets 97.3Pulses & legumes 97.3Green Leafy Vegetables 93.3Other Vegetables 93.7Roots & Tubers 86.5Fruits 91.5Milk & milk products 86.1Eggs 26.0Flesh foods 17.5Fats & Oils 79.4* Multiple responses ( Contd….)Nutritional Status of

Table – 13 (Contd…)Distribution (%) of 12-35 months ChildrenAccording to Feeding (CF) PracticesFeeding PracticesNumber of complementary feeds per dayMode of feeding complementary foodSupervision of complementary feeding byPercentn 223≤2 18.43 48.9≥4 32.8Mother with spoon 4.0Mother with hand 52.5Self with spoon 3.1Self by hand 40.4Not yet started CF 0.0Mother 91.9Elder Sibling 3.6Grand parents 4.0Others 0.4Nutritional Status of

Table – 14Distribution (%) of mothers of 0- 59 months Children according toCare of the child and personal HygieneParticularsCare of the child when mother goes out for workAge group (months)

Table – 15Prevalence (%) of the Morbidity among 0- 59 months children duringprevious fortnight by age groupsAge Group(months)n Fever Diarrhoea ARIAt least onemorbidity0-5 66 13.6 9.1 15.2 24.26-11 50 34.0 20.0 42.0 58.012-23 130 23.1 11.5 34.6 47.724-35 93 19.4 7.5 29.0 41.936-47 106 20.8 5.7 29.2 40.648-59 52 28.8 1.9 32.7 48.1Pooled 497 22.3 9.1 30.4 43.1Nutritional Status of

Table – 16Distribution (%) of mothers of 0- 59 months Children according toCare of the child during SicknessParticularsPersonnel generally consulted during illness of the childMorbidity during previous fortnightAge group (months)

Table - 17Participation (%) in ICDS supplementation programme(6- 59 months children)ParticularsAge group (months)6-35 36-59 6-59n 227 158 385Participating 61.2 88.0 79.5Regular 51.5 72.8 60.3Irregular 22.0 15.2 19.2Not participating 26.5 12.0 20.5Nutritional Status of

Table -18Distribution (%) of 12- 24 months children according to Coverage forImmunization under UIPImmunization ParticularsPercentn 130Received all vaccines ( Fully Immunized) 54.6Partially immunized 36.9Not immunized 8.5Reasons for no / incomplete immunizationBCG 87.6DPT1 79.8DPT2 75.2DPT3 69.0OPV1 83.7OPV2 80.6OPV3 69.0Measles 55.8Unaware of need 16.9No faith 0.8Time & place not known/ inconvenient 3.1Source of informationNot offered 23.1Mother Busy 1.5Fully immunized 54.6Mother & child protection card 30.8Immunization card 6.9AW Record 5.4Parents 44.6Others 3.8Not immunized 8.5Nutritional Status of

Table - 19Distribution (%) of 9- 59 months Children According to receipt ofmassive dose vitamin A during previous one yearAge group (months)ParticularsReceipt of massive dose vitamin ANo. doses vitamin APlace of administration9-17 18-35 36-59 9-59N 78 158 158 394Yes 62.8 75.3 73.4 72.1No 25.7 16.5 10.8 16.0Do not remember 11.5 8.2 15.8 11.9One 62.8 24.7 20.3 30.5Two 0.0 50.6 53.1 41.6Not received 25.7 16.5 10.8 16.0Do not remember 11.5 8.2 15.8 11.9Home 2.6 8.2 9.5 7.6AWC 53.8 61.4 58.8 58.9SC 1.3 1.3 1.9 1.5PHC 5.2 4.4 3.2 4.1Others 0.0 0.0 0.0 0.0Not received/do not remember 37.2 24.7 26.6 27.9Massive dose vitamin A administered byAWW 42.3 51.9 48.1 48.5ANM 20.5 23.4 24.7 23.4Others 0.0 0.0 0.6 0.2Not received/do not remember 37.2 24.7 26.6 27.9Reasons for not receiving/incomplete massive dose vitamin AUnaware of need 12.8 16.5 18.4 16.5Not offered 10.3 18.4 10.1 13.5Time or place not convenient 1.3 4.4 2.5 3.0Child was sick 1.3 0.0 0.0 0.3Mothers was busy 0.0 1.3 0.0 0.5Others 0.0 0.6 0.0 0.2Nutritional Status of

Table - 20Distribution (%) of 12-59 months Children accordingto receipt of Iron & folic acid tabletsParticularsReceived IFA tabletsIFA tablets received fromNo. of IFA tablets receivedNo. of IFA tablets consumedAge group (months)12-35 36-59 12-59n 223 158 381Yes 36.3 32.9 34.9No 63.7 67.1 65.1ANM 17.5 14.6 16.3AWW 16.6 16.5 16.5MO-PHC 2.2 1.9 2.1Not received 63.7 67.1 65.1

Table - 21Prevalence (%) of nutritional deficiency signs among 0 - 59 monthschildrenClinical signsAge groups (Months)0-11 12-35 36-59 0-59No of children examined 116 222 158 496NAD 99.1 95.5 91.1 95.0Emaciation 0.0 0.0 0.0 0.0Marasmus 0.9 0.0 0.0 0.2Bitot spots 0.0 1.8 1.3 1.2Dental caries 0.0 2.7 7.6 3.6NAD: No Abnormality DetectedNutritional Status of

nTable -22Mean Height and weight of 0-59 months Children by age group and genderBOYSGIRLSAgeHeight (cm) Weight (kg) n Height (cm) Weight (kg)(Months)Mean ± SD Mean ± SD Mean ± SD Mean ± SD5 53.4 6.28 2.7 0.42

Table - 23Distribution (%) of 0-59 months Children according to nutritional statusby SD Classification: By Age groupUnderweight (Weight for Age)AgeGroup(months)nSevere(

Table -24Distribution (%) of 0- 59 months Children according to nutritional statusby SD Classification*: By GenderGenderWeight for Agen

ParticularsTable -25Distribution (%) of 0- 59 months Children by Nutritional status accordingto SD Classification: By Socio-demographic variables1. CommunitynWeight for age Height for age Weight for height

Table -25 (Contd...)Distribution (%) of 0- 59 months Children by Nutritional status accordingto SD Classification: By Socio-demographic variablesParticularsnWeight for age Height for age Weight for height

Table – 25 (Contd…)Distribution (%) of 0- 59 months Children by Nutritional status accordingto SD Classification: By Socio-demographic variablesWeight for age Height for age Weight for heightParticulars n