|Year : 2012 | Volume
| Issue : 1 | Page : 27-32
Nutritional status of growth faltered children aged 0-6 years in rural Rangareddy district
G Enakshi1, N Sudha2
1 Department of Community Medicine, MediCiti Institute of Medical Sciences, Ghanpur (V), Medchal Mandal, RR District, India
2 MediCiti Institute of Medical Sciences, Ghanpur (V), Medchal Mandal, RR District, India
|Date of Web Publication||21-Mar-2012|
Assistant Professor, Department of Community Medicine, MediCiti Institute of Medical Sciences, Ghanpur (V), Medchal Mandal, RR District - 501 401
Source of Support: This study was supported financially by the ICMR under STS-2011 Grant., Conflict of Interest: None
Background: Malnutrition continues to affect children aged 0-6 years in large numbers in India. Many of these children lack proper nutrition at birth and in early childhood, which results in growth faltering. Growth monitoring is a good tool for visualization of growth in children, but episodes of growth faltering among healthy as well as malnourished children has failed to catch the attention of the Anganwadi workers so far.
Objectives: (1) To assess the magnitude of growth faltering among 0-6 years children in an adopted village of MediCiti Institute of Medical Sciences (MIMS) and (2) To study their nutritional status.
Materials and Methods: A large village in the field practice area of MediCiti Institute of Medical Sciences was conveniently selected. All children enrolled in three Anganwadis of the village were studied for growth faltering episodes and breast-feeding and dietary practices by interviewing their mothers through a predesigned and pre-tested proforma. Anthropometric measurements were taken. Data was analyzed using Epi Info Version 3.5.3.
Results: Sixty growth-faltered children were analyzed. The mean number of episodes of growth faltering was 1.13 episodes per child and 10% children's growth had faltered on more than one occasion. Most of them belonged to poor socio-economic status. Late initiation of breast-feeding was present in about 55% of these children, and they showed an overall dietary calorie and protein deficit. About 47% of the children were underweight, 57% were stunted, and 25% were wasted.
Conclusion: Growth of children aged 0-6 years may be improved by focusing on breast-feeding and nutrition. Further research is required to establish the correlates of growth faltering.
Keywords: Growth faltering, nutrition, anganwadi
|How to cite this article:|
Enakshi G, Sudha N. Nutritional status of growth faltered children aged 0-6 years in rural Rangareddy district. J NTR Univ Health Sci 2012;1:27-32
|How to cite this URL:|
Enakshi G, Sudha N. Nutritional status of growth faltered children aged 0-6 years in rural Rangareddy district. J NTR Univ Health Sci [serial online] 2012 [cited 2019 Dec 14];1:27-32. Available from: http://www.jdrntruhs.org/text.asp?2012/1/1/27/94172
| Introduction|| |
In the 21 st century of miraculous advances in science and technology, the world is busy in devising methods to combat malnutrition, which continues to affect children in whopping numbers. World statistics indicate that stunting affects 182 million (33%) and being underweight affects 150 million (27%) of the world's children;  these are associated with over half of the 10 million annual deaths of children under 5 years.  Developing countries account for almost all of this burden, with 70% of all early child mortality and malnutrition concentrated in sub-Saharan Africa and South Asia. Despite setting a goal of reducing malnutrition by 50% at the World Summit for Children,  few countries in these two regions will have been successful in achieving this goal by the end of the decade. And the Millennium Development Goals will thus, remain unachieved!
India is home to the largest child population in the world with around 157.86 million children, constituting 15.42% of India's population, who are below the age of 6 years.  A significant proportion of these children lives in low/poor economic and social environment, which predisposes them to poor nutrition and impedes their physical and mental development. 
Growth monitoring is an operational strategy adopted under integrated child development services (ICDS) Scheme for the promotion of health, which enables mothers to visualize growth or its lack in their children. It has been reported that Anganwadi workers perform excellently in the area of assessment of nutritional status. However, it has been observed that growth and growth faltering particularly are not provided the requisite attention. 
Information regarding growth faltering of the children attending Anganwadis is lacking, particularly from the state of Andhra Pradesh. It was imperative to collect data from the field practice area of a teaching institution to understand the dynamics of growth faltering where facilities are expected to be present. Hence, the present study was conducted to gain knowledge on the burden of growth faltering and its correlates among rural children aged 0-6 years in Rangareddy district. The present paper's objective was to assess the magnitude of growth faltering among 0-6 years children in an adopted village of MediCiti Institute of Medical Sciences (MIMS), and to study their nutritional status.
| Materials and Methods|| |
The present cross-sectional study was conducted from May 2011 through August 2011 in one of the 40 adopted villages of the MediCiti Institute of Medical Sciences, Rangareddy District, which has its Rural Health Training Center situated at Aliyabad. Aliyabad village, having a total population of 8000 and three Anganwadi centers, was selected conveniently. All children below the age of 6 years who were born between 31 st December 2005 and 1 st January 2011 and enrolled at the three Anganwadi centers in Aliyabad village were included in the study.
Growth faltering among the enrolled children was identified based on available growth charts where a child's growth line crossed a z-score line or a sharp decline in the child's growth line was observed or when the child's growth line was flat (stagnant), i.e., there was no gain in weight or length/height. However, it was found that the growth charts for the enrolled children were not maintained in one of the Anganwadis due to which previous episodes of growth faltering could not be recognized. These children, thus, had to be excluded from the study. Since in the remaining two Anganwadis, very few children (23) met any of the three conditions mentioned above, an additional criterion of single or multiple episodes of weight gain less than 300 grams over three consecutive months in these children was identified.  These criteria are identical to those used in the Tamil Nadu Integrated Nutrition Project (TINP) to select children for supplementary feeding. In this way, a total of 60 children were included for the study.
The investigator first visited the Anganwadi centers in Aliyabad village, where the Anganwadi worker was interviewed and registers were reviewed to secure information regarding the number of eligible children (0-6 years), their addresses, and also to record the events of growth faltering from the growth charts maintained at those centers. To identify growth faltering, growth points that are joined with a line to form a growth curve on the growth chart was seen for each child. Then, data was collected for the growth-faltered children by house-to-house visit, and a pre-tested, semi-structured interview schedule was administered in the local language by the investigator to the mothers to obtain the information regarding socio-demographic information, child feeding practices, and morbidity status of children. In the absence of the mother, any other responsible adult member of the family, who was involved in taking care of the child, was interviewed. Anthropometric measurements of the children were taken. The investigator received training in standard anthropometric measurement procedures in the Department of Community Medicine prior to conducting the study. The children's current weight and height was plotted as a growth point on the ICDS growth charts. The growth indicators, which were interpreted using these growth charts, are weight for age; height/length for age, and weight for length/height.
The data was entered and analyzed in Epi Info Software. Median time of growth faltering was calculated. The epidemiological correlates present have been expressed as percentages. Mean values and standard deviations have been calculated for other parametric data collected.
Ethical approval by the Institutional Ethics Committee of MediCiti Institute of Medical Sciences on Research Involving Human Subjects of the World Health Organization (WHO) was obtained. Informed consent was obtained prior to the enrollment of children (from mothers). Confidentiality of the information obtained from the Anganwadi workers and mothers was strictly maintained. The children found to be malnourished or ill during home visits were referred to Rural Health Training Centre, Aliyabad, for appropriate care.
| Results|| |
A total of 60 children were identified to be growth faltered from the available Anganwadi records, amongst whom 29 (48.33%) were male and 31 (51.67%) female children. Most of the children belonged to OBC caste (64%), followed by general (23%), scheduled castes (8%), and remaining were Muslims (5%). It was found that 85% children belonged to below poverty line category, ascertained by the presence of a white-colored ration card in the family. The remaining 15% did not have any ration card. The average annual family income during the previous year was found to be Rs. 50,847.00 in their families; 66.67% children belonged to joint family, whereas the remaining 33.33% belonged to a nuclear family. The background characteristics of the growth-faltered children are shown in [Table 1]. Mother was the caretaker of the children in 85% of the cases. In the remaining 15% cases, the child was taken care of by other members of the family, most commonly the grandmother (8%) and father (5%).
|Table 1: Baseline characteristics of the growth faltered children aged 0-6 years|
Click here to view
Birth weight was available from records of Anganwadis for all 60 children. It was seen that 32% children were low birth weight and the remaining 68% had birth weight more than 2500 g. It was also found that 16 (26.67%) children had a birth weight of 3.0 Kg or more.
Most of the growth-faltered children (88.33%) were found to have experienced a single episode, whereas another 10% children experienced two episodes. Each growth faltered 0-6 years' old child experienced an average of 1.13 episodes of growth faltering per child. The median age of growth faltering among these 60 children was found to be 36 months; 30% of the children had an episode of growth faltering at this age. However, 10% children had faltering at 2 months of age, 18.33% at 4 th month, 5% at 7 th and 16 th month, 6.67% at 18 th month, 11.67% at 43 rd month, and 13.33% at 50 th and 56 th month.
Exploration of the breast-feeding practices in these children revealed that most of the mothers (55%) initiated breast-feeding after 2 h of delivery. None of the mothers initiated within half an hour, whereas 26.67% initiated breast-feeding within 1 h. [Table 2] shows the breast-feeding practices of the growth-faltered children. The most common reason cited for not putting the child to breast early was that the mother was not producing enough milk (75.76%). Other reason was that child was too sick (9.10%). In 30% cases, pre-lacteal feeds were given to the baby. Colostrum was given to the baby in 97% cases, whereas it was discarded by the remaining 3% mothers. About 37% of the children were breast fed exclusively for a period of 6 months, and 15% were breast fed exclusively for 4 months. Complimentary feeding was initiated for only 18.34% babies at 6 months, whereas for majority of the infants (61.67%) it was begun below 6 months of age. For most of the babies, both homemade and readymade food was provided. Very few babies were fed on exclusive homemade food only. The nature of complimentary food was mostly semisolid and liquid; solid foods were avoided. Most of the children (55%) were found to be breast fed for 24 months or more, and 35% children were found to be breast-feeding still beyond the age of 2 years. Among the 28 children who are still breast-feeding, 14.29% were breast fed less than two times the previous night, and 21.43% were breast fed less than three times during the previous day. Majority of the mothers reported that their children (81.67%) were not bottle fed ever.
|Table 2: Breast-feeding practices of growth faltered children aged 0-6 years|
Click here to view
An enquiry into the eating patterns amongst the growth-faltered children revealed that the children ate soft foods 2.63 times on average on the previous day, and 9.3 times on average fruits were brought and/or consumed in the family during the previous month. Green leafy vegetables were cooked in the family 2.72 times on average during the previous week, depicting poor access to nutritive foods among these children. The mean calorie intake of the children was found to be 1218.13 k.cals (SD=735.86), and the mean protein intake was 22.64 grams (SD=13.89). [Table 3] shows the age-wise mean calorie and protein intake; 78.33 % of the children overall were found to have calorie deficit whereas 65% overall were found to have protein deficit. About 47% of the children were found to be underweight (weight for age ≤2SD), whereas 56.67% were stunted (height for age ≤2SD) and 24.65% were wasted (weight for height ≤2SD). Using MUAC, only 7.5% children were identified as undernourished. Among 56 children who were more than 6 months of age and enrolled in an Anganwadi, 25 (44.64%) children attended the Anganwadi, and 55.36% children received supplementary nutrition there. It was also found that few children (8.93%) received Vitamin A supplementation at the Anganwadi during the previous six months.
| Discussion|| |
Sixty children aged 0-6 years were found to be growth faltered in the present study. The average number of episodes of growth faltering was 1.13 episodes per child amongst them. The median age of growth faltering among these children was found to be 36 months; 30% of the children in our study had growth faltering at this age. This finding is comparable to other studies done globally to find the mean age of growth faltering. But lower means have also been reported. ,,,, Mamidi et al.,  have reported that most of the faltering takes place at birth; this is strikingly similar to the present study where most of the children had low weight for age at birth itself. But we have included growth faltering at birth under the category of low birth weight since this is a record-based finding because birth weights of children are not directly measured by the Anganwadi worker.
The study of socio-demographic characteristics showed that 33.34% of the growth-faltered children were infants, 20% were between 1 and 3 years, and about 38% were between 3 and 5 years of age. Caste-wise distribution showed that 64% of the children belonged to OBC caste. Choe and Anandaiah, similar to the present study, reported most of the growth faltered children to be from scheduled caste.  Other studies , also found association between poor socioeconomic status and growth faltering similar to our findings.
Study of the breast-feeding practices of the children revealed that only 27% mothers initiated breast-feeding within 1 h, which is nearly similar to the Andhra Pradesh state averages according to National Family Health Survey (NFHS)-3 where 24% rural children were breast fed within 1 h of birth.  It was also found from the study that 36.67% of the children were breast fed exclusively for a period of 6 months, and 15% were breast fed exclusively for 4 months, which is much lower when compared to the Figures from Andhra Pradesh state, where about 67% children are breast fed exclusively until 5 months of age, according to NFHS-3 data. 
Nationally, 65.5% of the children aged more than 6 months received semisolid complimentary food along with breast milk, but timely initiation of complementary feeding was done for only 53% children,  similar to the present study where 67% of the infants had received complementary feeds of semisolid or liquid nature below 6 months of age. Allen reported that the period of greatest faltering started at about 3 months after birth, and was essentially complete well before weaning period; and this early growth faltering is common to most developing countries.  The reason behind this finding is the faulty nature of initiation as well as constituents of complementary feeding. Other researchers ,, too have stressed on the importance of proper feeding. The present study also showed that 55% children were breast fed for 24 months or more. Thirty-five percent children were found to be still breast-feeding beyond the age of 2 years. Despite the inadequate frequencies of breast-feeding, the mothers reported that they breast fed their children on demand. Similar to the present study, NFHS-3 reports that bottle-feeding increases from 5% under age 2 months to 18% at age 9-11 months and declines at older ages. 
The mean calorie intake was found to be 1218.13 kcal (SD=735.86) among 0-6 years aged growth-faltered children. The mean protein intake was 22.64 g (SD=13.89). Age-wise difference in consumption pattern was seen. Overall, 78.33 % and 65% of the children were found to have calorie and protein deficit, respectively. Growth faltering has been associated with poor diet and nutrition-infection interactions as well as insufficient intake of weaning foods.  In the present study, 47% of the children were found to be underweight, 56.67% stunted, and 25% were wasted, which is much higher compared to Andhra Pradesh state NFHS-3 data, where about 33% are reported underweight, 41% stunted, and 15% wasted. The present findings, however, are closer to the national averages where 44% children are reported underweight, 47% are stunted, and 24% are wasted.  The reason behind this is clearly their compromised nutrition due to multiple reasons that resulted in previous episodes of faltering as well among these children.
Nationally, only 26% children were receiving supplementary nutrition and other services at Anganwadis despite a high coverage rate of 81%  in contrast to 55% children in the present study. Only 9% children received vitamin A supplementation at the Anganwadis during the previous 6 months. NFHS- 3 also reports only 28.2% children receiving vitamin A in the entire state of Andhra Pradesh,  which may be a reason for low vitamin A supplementation in the study area as well.
The role of inadequate nutrition in terms of improper breast-feeding and inadequate protein-energy intake among growth-faltered children aged 0-6 years is evident from this study. Further research is required to establish the correlates of growth faltering among these children.
| Acknowledgements|| |
The authors acknowledge the ICMR for granting permission and financial support for conducting this study.
| References|| |
|1.||United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition. Fourth Report on the World Nutrition Situation: Nutrition throughout the Life Cycle. Geneva, Switzerland: United Nations Administrative Committee on Coordination/Sub-Committee on Nutrition; 2000. |
|2.||Pelletier DL, Frongillo EA, Habicht JP. Epidemiologic evidence for a potentiating effect of malnutrition on child mortality. Am J Public Health 1993;83:1130-3. |
|3.||UNICEF. First Call for Children. Summit Declaration and Child Convention. New York, NY: UNICEF; 1990. |
|4.||Census 2001, Government of India [online]. Available at: www.censusindia.org Accessed on September 10, 2010. |
|5.||Integrated Child Development Services (ICDS) Scheme [online]. Available at: http://wcd.nic.in/icds.htm Accessed on September 18, 2010. |
|6.||Anuradha D, Sanjeev D, Utsuk D. Role of reorientation training in enhancement of knowledge regarding growth monitoring activities by anganwadi workers in urban slums of Delhi. Indian J Community Med 2008;33:47-9. |
|7.||Shekar M, Latham MC. Growth monitoring can and does work! An example from the Tamil Nadu integrated nutrition Project in rural South India. Indian J Pediatr 1992;59:5-15. |
|8.||Hernandez-Beltran M, Butte N, Villalpando S, Flores-Huerta S, Smith EO. Early growth faltering of rural Mesoamerindian breast-fed infants. Ann Hum Biol 1996;23:223-35. |
|9.||Schmidt MK, Muslimatun S, West CE, Schultink W, Gross R, Hautvast JG. Nutritional Status and Linear Growth of Indonesian Infants in West Java Are Determined More by Prenatal Environment than by Postnatal Factors. J Nutr 2002;132:2202-7. |
|10.||Shrimpton R, Victora CG, de Onis M, Lima RC, Blössner M, Clugston G. Worldwide Timing of Growth Faltering: Implications for Nutritional Interventions. Pediatrics 2001;107:e75. |
|11.||Allen LH. Nutritional influences on linear growth: A general review. Eur J Clin Nutr 1994;48:S75-89. |
|12.||Maleta K, Virtanen S, Espo M, Kulmala T, Ashorn P. Timing of growth faltering in rural Malawi. Arch Dis Child 2003;88:574-8. |
|13.||Mamidi RS, Shidhaye P, Radhakrishna KV, Babu JJ, Reddy PS. Pattern of Growth Faltering and Recovery in Under-5 Children in India Using WHO Growth Standards - A Study on First and Third National Family Health Survey. Indian Pediatr 2011;Mar 15. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21555805 Accessed on August 5, 2011. |
|14.||MoHFW. National Family Health Survey (NFHS-3), 2005-06, Government of India. International Institute of Population Sciences, Mumbai, September 2007. |
|15.||Anandaiah R, Choe MK. "Are the WHO Guidelines on Breastfeeding appropriate for India?". National Family Health Survey Subject Reports No. 16. Mumbai: International Institute for Population Sciences; and Honululu: East-West Centre; 2000. |
|16.||Meshram II, Arlappa N, Balakrishna N, Laxmaiah A, Mallikarjun Rao K, Reddy CG, et al. Prevalence and Determinants of Undernutrition and its Trends among Pre-School Tribal Children of Maharashtra State, India. J Trop Pediatr 2011, Available at: http://tropej.oxfordjournals.org/content/early/2011/05/04/tropej.fmr035.abstract Accessed on September 2, 2011. |
|17.||Gracey M, Sullivan H. Growth of remote Australian aborigines from birth to two years. Ann Hum Biol 1989;16:421-8. |
|18.||Zaman S, Ashraf RN, Martines J. Training in Complementary Feeding Counselling of Healthcare Workers and Its Influence on Maternal Behaviours and Child Growth: A Clusterrandomized Controlled Trial in Lahore, Pakistan. J Health Popul Nutr 2008;26:210-22. |
|19.||Reddy V. New growth norms for nutritional assessment of children. Available at: http://nutritionfoundationofindia.res.in/workshop_symposia/NutritioninLateinfancy_Early_Childhood.pdf Accessed on August 12, 2011. |
|20.||Devi PY, Geervani P. Determinants of nutrition status of rural preschool children in Andhra Pradesh, India. Food Nutr Bull 1994;15:335-42. |
[Table 1], [Table 2], [Table 3]