Children who suffer from malnutrition need to be targeted and treated in a systematic way that takes into account the varying degrees, manifestations, and causes of malnutrition apparent in the community. A large number of children in Fakir Bagan are underweight for their age or are stunted (an indicator of chronic malnutrition). Some children are also acutely malnourished (both moderately – MAM and severely wasted- SAM). Since its inception in 2005, MYCHI has rolled out several initiatives targeting malnourished children. When MYCHI first began in 2005, we did not measure baseline data on nutrition status. The earliest data was collected in October 2009. Of children 0-3 years old in Fakir Bagan (based on weight for age), 33.3% were normal, 32.7% were mildly, 21.6 % moderately, and 12.3% severely malnourished.
Since 2005, Calcutta Kids has rolled out several initiatives to address malnutrition in Fakir Bagan which have had varying degrees of success.
Current Approach to Nutrition
Based on previous trial interventions, it is clear that MYCHI’s nutrition intervention efforts need to be revised and expanded in different ways to have a larger impact and capture more children who are in need of additional support in the Fakir Bagan area. Furthermore, a focus on preventive care is necessary to target children before they begin faltering and becoming malnourished. A holistic nutrition approach to address all the different nutritional needs of children in Fakir Bagan is currently being developed under the new Child Health Initiative. Calcutta Kids is a learning organization and as such our programs continually evolve based on lessons learned, evidence-based best practices, and accepted international public health guidelines. As we re-design our nutrition approach, we will be taking into account what we have learned about the identification of growth faltering and malnourished children, complementary feeding, micronutrients, Behavior Change Communication, and having a community-driven approach.
The first step for community-based nutrition interventions is to mobilize an effort from the within the community, so that mothers are completely invested and participating in the growth monitoring and the nutrition status of their children. We are conducting pilot group meetings with mothers of malnourished children to form support groups that can initiate change from within and develop sustainable solutions to address malnutrition in the community. This pilot group will also help us further determine how best to design a program that works well within the needs and priorities of the community.
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Identification of Growth Faltering and Malnourished Children
Growth faltering and malnourished children have always been detected through GMP; however, appropriate follow up on nutritional status in the home visits was not occurring because our health workers did not have the nutritional status information on their home visit lists. We were thus also unable to ensure that these children were receiving the extra medical and counseling support they needed. We have developed a better identification system through our database that now generates child lists by age and nutritional status. Our health workers use these lists during the monthly home visits, to ensure proper identification of vulnerable children, appropriate counseling, and follow up. It ensures that we also ‘catch’ children at risk of becoming malnourished, and not just children who have already become moderately or severely malnourished.
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After six months of age, when children start receiving semi-solid foods, intake of several micronutrients (vitamins and minerals) can be insufficient to meet the infant’s requirements and thus increase their risk of developing anemia and other micronutrient deficiencies, having an impact on their nutritional status and growth. In Fakir Bagan, we have observed that children often start growth faltering and falling off of their growth trajectory during this critical weaning time. Although complimentary feeding education has been incorporated fully into home visit and community meeting counseling sessions, we are still witnessing the impact of improper feeding practices in the community. For the revised Child Health Initiative, we plan to hold education sessions for mothers of 4-6 month old babies to impart crucial complimentary feeding knowledge, and practical experience in feeding these babies new foods. We anticipate that, if we can ensure proper complimentary feeding behaviors, we may be able to prevent this post-weaning growth faltering that so many children face.
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Urban poor children suffer from multiple micronutrient deficiencies, particularly IDA. The blood testing component of the YChiNG showed that malnourished children in our catchment area were suffering from IDA. The major health consequences of IDA in children are impaired physical and cognitive development, and increased risk of morbidity. The WHO recommends the intermittent use of iron supplements (once, twice, or thrice a week on non-consecutive days) to prevent anemia and improve iron status in settings where the prevalence of anemia in preschool or school age children is 20% or higher. Calcutta Kids has started giving iron supplements to severely malnourished children since April 2011, and we plan to expand supplementation efforts to reach moderately malnourished children as well.
Through the YChiNG trial, we found that many malnourished children in our catchment are calcium-deficient, with some manifestations of rickets in the community. We now provide calcium supplements to such children to correct this deficiency.
We found that Vitamin A deficiency (VAD) is prevalent in the Fakir Bagan community. VAD is the leading cause of preventable blindness in children and increases the risk of disease and death from severe infections. Scientific research on vitamin A has demonstrated its benefits to immunological function. In fact, analysis of the CK baseline survey indicated that children who received at least one dose of vitamin A were less likely to experience respiratory illness than their counterparts who did not receive any vitamin A. In March 2011, vitamin A supplementation was added to the Calcutta Kids immunization schedule.
Studies elsewhere have shown that prophylactic zinc supplementation reduces incidences of diarrhea and pneumonia. The WHO recommends zinc supplementation to reduce acute diarrhea and for severe malnutrition, but there is not yet a recommendation for prophylactic use of zinc in children. Calcutta Kids uses zinc supplementation along with ORS for the treatment of diarrhea. We are considering the use of zinc as a short-term prophylactic for children who are malnourished and frequently suffer acute infections.
Through health camp visits and the YChiNG trial group, we have found that many children, particularly malnourished children, have a high worm load. In order to reduce the worm burden, WHO recommends periodic drug treatment (deworming) of all children living in endemic areas, health and hygiene education, and the provision of adequate sanitation. In April 2011, we initiated the practice of deworming severely malnourished children who come for extra care. We will soon implement a routine deworming intervention, to be carried out every six months during GMP sessions.
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Behavior Change Communication
Sprinkles Trial Intervention:
Calcutta Kids conducted a Sprinkles intervention in its catchment area from June to November 2008. Through this intervention, mothers of 145 children (6-36 months) in CK’s catchment area were provided Anuka Sprinkles sachets, which would fortify their child’s food four times per week for 15 weeks. The Sprinkles are a formulation of iron, zinc, vitamin A, and vitamin C, to be used for fortification of home cooked foods. We carried out this Sprinkles trial because we observed a high prevalence of iron deficiency anemia, diarrhea, and faltering growth after the introduction of complimentary foods. Furthermore, mothers were asking Calcutta Kids for vitamins and tonics for their children. Calcutta Kids promoted the Anuka product, organized a distribution system for the sachets, and monitored compliance rates. Baseline and endline data were collected to evaluate whether the intervention had high compliance rates among the target population and also what effects it had on growth faltering.
Overall demand for Sprinkles (both pre- and post- intervention) was high, as was consumption. However, drop out was also high—39 out of 145 dropped out midway. Most children dropped out due to migration. But in some cases mothers interpreted a causal link between the Sprinkles and child illness if their child experienced an episode of illness during the trial, and no longer wanted to participate. Mothers whose children had regularly taken the Sprinkles were able to point out tangible differences they observed in their children. The mothers emphasized two points: that their children had increased appetites and increased energy levels. According to CK’s data, children that participated in the interventions had an average grade level change for weight for age (WFA) of 0.36 (95% confidence interval going from 0.22 to 0.50).* The results of this trial show that Sprinkles can be an effective method to ensure that children in Fakir Bagan are consuming the micronutrients they need, which have the potential to correct micronutrient deficiencies, boost immunity, and improve growth in young children. The main goals in the use of Anuka Sprinkles are to prevent and correct iron deficiency anemia, vitamin A deficiency, and improve zinc status in children. However, during this trial we did not in fact determine if micronutrient deficiencies had been corrected. Recommendations for future use are to reassess the impact on micronutrient deficiencies. Furthermore, as a community-wide approach Anuka Sprinkles are a costly intervention. Therefore we need more information on cost-effective delivery mechanisms and sustained consumption to reach every child in need in the Calcutta Kids catchment area.
For more information on the Sprinkles trial, please contact us at firstname.lastname@example.org
Supplementary Feeding Camp: To address substandard growth among children in Fakir Bagan, Calcutta Kids was inspired by the success of the Bangladesh Integrated Nutrition Program (BINP) to start a daily nutrient-dense supplementary feeding program for underweight and faltering children in March 2009. In the larger public health community, there is no consensus as to the benefit for supplementary feeding (except in emergency situations). It is also understood that food alone will not improve growth patterns, but that an integrated approach with food and intensive observation and counseling can improve the long term growth trajectory of children. Therefore Calcutta Kids introduced the supplementary feeding camp as a case-control study to determine the viability of an integrated feeding and counseling program. Fakir Bagan is divided into 3 areas, and children from areas 1 and 2 were invited to the feeding camp if they were underweight (-2 SD and below WAZ). In area 3, only children suffering from severe malnutrition (-3 SD and below WAZ) were invited to the feeding camp, as it would be unethical to exclude these children from a potentially beneficial program. Analysis of feeding camp data in July 2011 showed that there was no difference in faltering or malnutrition between areas 1 and 2 and area 3, which was the control group. We suspended the Feeding Camp on July 28, 2011 because the program did not have an impact on growth faltering and malnourished children.
Nutrimix Trial Intervention:
In June- August 2010, a Nutrimix trial was conducted for a sample of severely malnourished children. Twenty-two children were enrolled and given Nutrimix (an energy dense nutrient mix) for 12 weeks, and their mothers were provided counseling on childcare and feeding practices in community meetings for malnourished children. We anticipated the children would gain weight in order to help them get back on track in terms of growth trajectory. Of the 22 children who were invited to participate, only 11 completed the program. The positive results of the trial were that there was an increase in both weight and WAZ over the 12 weeks in 7 of 11 children in the program compared with an increase in weight and WAZ in only 2 of 10 comparable children who chose not to enroll in the Nutrimix program. This trial showed that Nutrimix can be used to improve the weight of severely malnourished children, but its efficacy as a community intervention will be diminished if participation and compliance are low. There were challenges for CK staff and mothers participating in the trial. Community health workers were burdened with extra work, partially because the program entailed multiple home visits to ensure compliance. Mothers were burdened with the task of preparing a special/extra meal for the child three times a day, finding fuel to cook the Nutrimix (as it is not ready-to-eat) and the child not liking the taste of Nutrimix.
YChiNG Trial Intervention:
The Young Child Nutrition Group (YChiNG) was conceptualized in March 2011 following a qualitative study on the causes of severe malnutrition in children in the CK catchment area of Fakir Bagan. Based on the study findings, YChiNG was developed as a comprehensive program targeting severely malnourished children, which included not only nutrition/food support but also medical intervention, close counseling and group support with the mothers of severely malnourished children. Children enrolled in the program were invited to a weekly feeding and GMP session at the DTC. They had access to the CK pediatrician, free medications and micronutrient supplements, and free routine and follow-up pathological tests. YChiNG ran as a six month trial for children identified as being severely malnourished or at high risk for becoming severely malnourished using WAZ, WHZ, and HAZ criteria. The trial started with 33 children in April 2011 and ended in September 2011. Unfortunately overall attendance was low. Only 15 children had more than 50% attendance, while 4 children left Fakir Bagan and 3 dropped out.
We were not able to form cohesive support groups or provide close counseling because mothers came to the program at different times and did not have enough interaction with each other. However, the results show that YChiNG made some impact in the recovery of children who participated fully in the program. There was a close correlation between attendance and improved weight. Of the children who improved in WAZ (Weight for Age z-score), 86 percent had also attended more than half the sessions. The majority who attended the program less than 50% of the time remained the same or worsened in WAZ.
The most important lesson from the trial is that we were able to find out the causes of malnutrition in Fakir Bagan children with precision. Through blood tests and clinical assessments, we found that children suffered from anemia and other micronutrient deficiencies, a high worm load, and frequent acute infections (gastrointestinal and respiratory) which both cause and result in malnutrition. Maternal behaviors such as feeding practices (particularly during weaning and introducing complimentary foods) and hygiene practices are problematic. Environmental factors such as living close to sewers, poor sanitation, and proximity to animals were also established as indirect causes of malnutrition. Finally, domestic issues in the home such as lack of family support in child care, mothers working outside of the home, lack of an appropriate primary caregiver, violence in the home, all had an impact on the nutritional status of the child.
However, at the close of YChiNG it was determined that a weekly program alone is not enough to address all of the issues that lead to severe malnutrition in Fakir Bagan. We can now use this information to direct our guidelines and protocols for malnourished children as we re-design the child health initiative.