ore than six decades ago, Gabriela Mistral, the
Nobel Laureate from Chile wrote, "We are guilty of many errors and many
faults, but our worst crime is abandoning the children, neglecting the
fountain of life." India has marched more than six decades after
independence, but the morbidity and mortality of infants and children
are unacceptably high. It is right time that professionals like
pediatricians empower the paramedicals, Accredited Social Health
Activist (ASHA) workers and community volunteers to accomplish the
sustainable development goals. The truth is that the globe cannot
achieve the goals without India conquering it [1].
Currently, in India, 22% of newborns are born low
birth weight, 45% of children aged below three years are stunted and 23%
are wasted [2], 58% of pregnant mothers and 31% of adolescent girls are
anemic [3], only 41% babies are breast fed within an hour of birth with
26% exclusive breastfeeding during first six months [3], only 61% are
fully immunized [4], and >15% girls are married before 18 years of age
[3].
Malnutrition is a man-made disease; more often due to
faulty nurture and not by nature. We have to take the lead in the
crusade against protein energy malnutrition and micronutrient
malnutrition, especially nutritional anemia. Hence, a nutrition
education program (NEP) is being undertaken as the IAP Action Plan,
2015. By getting ourselves sensitized about the burden and assessment of
malnutrition, we are expected to conquer more than 50% of the way ahead.
Let us ensure basic steps like immunization, infant and young child
feeding (IYCF) practices, growth monitoring and recording of weight on
the mother and child protection (MCP) cards. A holistic assessment of
malnutrition, preferably using the ABCDEFQ scale is proposed [5].
The ABCDEFQ Malnutrition Assessment Scale
Anthropometric Measurements (A)
Let us procure and maintain the right equipments like
electronic scales, infantometers and start training our team. The
community/ICDS is screening weight-for-age and let the severely
underweight be referred with the label of failure to thrive (FTT) or
malnutrition. Then, further evaluation has to be done using
height-for-age for stunting, weight-for-height for wasting indicating
chronic and acute malnutrition, respectively, and also for body mass
index (BMI) among adolescents (Table I). IAP growth chart,
which incorporates WHO growth charts till 5 years of age, is recommended
for evaluation. Mid Upper Arm Circumference (MUAC) measurement is an
age-independent simple tool for use among children 6-60 months of age.
TABLE 1 Interpretation of Anthropometric Measurements
Parameter |
Interpretation |
Remarks |
Low weight-for-age |
Underweight |
Malnutrition/Syndromic/IUGR |
Low height-for-age |
Stunted |
Chronic malnutrition/ Syndromic/Short stature |
Low weight-for-height |
Wasted
|
*Acute malnutrition |
Low body mass index |
Thinness |
Chronic energy deficiency |
MUAC < 11.5 cm |
Severe acute malnutrition |
During 6-60 months of age |
*Weight-for-height < 70% or < 3 Z score indicates severe
acute malnutrition (SAM) and Weight-for-height 70-80% or between
2 to 3 Z score indicates moderate acute malnutrition (MAM);
MUAC: Mid-upper arm circumference. |
Biochemical and Laboratory Parameters (B)
An exhaustive battery of investigations is not
warranted in children with malnutrition. Complete blood counts, type and
severity of anemia, presence of malarial parasite, serum protein, serum
albumin, liver enzymes for associated fatty liver disease, blood urea,
serum creatinine, sepsis screen and HIV ELISA are recommended before
starting appropriate intervention.
Clinical Features (C)
Features of extreme wasting as evidenced by loose
skin folds in axilla, groin, thigh, buttocks, chest, back and loss of
buccal pad of fat, nutritional edema as evidenced by bipedal edema,
elicited by pitting on dorsum of foot using finger pressure, skin
changes, hair changes and specific micronutrient deficiency signs should
be recorded.
Dietary Evaluation (D)
For baseline information, a probe into the well-being
in utero as evidenced by the birth weight, breastfeeding and
complementary feeding practices and other IYCF components, including
care of the mother during pregnancy and adolescent period is
recommended. A 24-hour dietary recall is often done and intakes of
energy, protein and micronutrients are compared with the RDA as
recommended by ICMR [6]. However, this task is often very subjective. A
three day midweek recall is rated better due to wide variation in eating
and cooking habits during weekends within families. A scoring based on
interventions related to IYCF practices [7] and a Food Frequency Table
Scoring [8] are recommended.
IYCF score: it is done by scoring of the 10
desirable interventions related to IYCF practices as advocated by UNICEF
with a maximum score of 20; higher the score, better the outcome (Box
I).
BOX 1.
IYCF Score as Per the 10 Interventions Advocated by UNICEF
|
1. Timely initiation of breast feeding within 1hour of birth
2. Exclusive breastfeeding
during the first 6 mo of life.
3. Timely introduction of
complementary foods at 6 mo.
4. Age-appropriate foods for
children 6 mo to 2 y.
5. Hygienic complementary
feeding practices.
6. Immunization, and
bi-annual vitamin A supplementation with deworming.
7. Appropriate feeding for
children during and after illness.
8. Therapeutic feeding for
children with severe acute malnutrition.
9. Adequate nutrition and
support for adolescent girls to prevent anemia.
10. Adequate nutrition and support for
pregnant and breastfeeding mothers.
|
IYCF Score: Total Score 20 Higher the score, Better the
outcome; In each 10 interventions, the best practice is
to given a score of 2 and less optimum practice 1 and 0 if not
practising it; Item 9 and 10 refer to the respective mothers
care; Any item not applicable shall be removed from the
denominator and numerator while making the score %.
|
Food Frequency Table Score: All food groups with
standard servings as per the RDA, recommended by ICMR in the balanced
diet for infants, children and adolescents [6] should be recorded and
interpreted as follows:
Daily (7 days/week)
Frequently (4-6/week)
Occasionally (1-3/week)
Never
Ecological and Epidemiological Data (E)
The ecology of malnutrition is multifactorial ranging
from illiteracy, poverty, ignorance, abrupt stoppage of breastfeeding,
early or late complementary feeding, overdilution of feeds, wrong
information, lack of awareness, lack of environmental factors like safe
drinking water, disposal of waste and excreta, air pollution, radiation
exposure, and biologic hazards. Disease-specific morbidity, mortality,
IMR, U5MR should also be considered as outcome of nutritional status in
a community.
Functional Assessment (F)
Morphological assessment for >70% mutilated or
unrepaired cells in buccal smear, delayed bone age on radiological
assessment, night blindness due to vitamin A deficiency, and delayed
gross motor milestones due to muscle wasting and hypotonia, should be
assessed and recorded.
Quality of Life (Q)
This is the ultimate measure that decides prognosis
for growth, development and for life. As part of the National IAP Action
Plan, 2015, Nutrition Education Program (NEP), a new scoring system
IMPACT-IAP Malnutrition Proactive Assessment A Comprehensive Tool is
proposed (Table II). It has a score of 0-20 based on 6
items and suggests a broad plan of action for intervention based
on the risk categorization.
TABLE II IAP Malnutrition Proactive Assessment A Comprehensive Tool (IMPACT).
Item 1- Birthweight |
Score |
VLBW |
4 |
LBW/very small |
3 |
Small |
2 |
Not known |
1 |
Normal or large |
0 |
Item 2 -Underlying condition in the child that affects
nutritional status |
To a great extent |
4 |
To a moderate extent |
3 |
To a mild extent |
2 |
Not known |
1 |
Nil |
0
|
Item 3- Current nutritional intake |
Very poor <50% RDA |
4 |
Picky eating |
3 |
Poor eating 50-80% RDA |
2 |
Fair/Good, but not as per RDA |
1 |
Good and meets RDA |
0 |
Item 4- Weight for height/severe wasting/nutritional edema |
< 70%/< 1st centile / severe wasting/nutritional edema
|
8 |
70- 80%/ 1st-3rd centile |
6 |
80-90%/ 3rd-5th centile |
4 |
Overweight/Obesity |
2 |
Normal |
0 |
Item 5- Total score and risk stratification
|
High risk |
8 & above |
Medium risk |
5 to 7 |
Low risk |
1 to 4 |
No risk |
0
|
Item 6- Plan for intervention |
High risk- Refer/admit |
|
Medium risk - Evaluate/admit |
|
Low risk- Counsel |
|
No risk- Praise the mother |
|
The proposed NEP is expected to pave the way to a
behavioral change communication in the most relevant field of child
nutrition, and, early diagnosis and care of children with malnutrition.
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