Tag Archives: malnutrition

CK Starts Routine Deworming

We introduced an exciting new component to our young child health initiative that we hope will help improve the health status of children in Fakir Bagan.  During our Growth Monitoring and Promotion (GMP) camp this week, Calcutta Kids carried out routine deworming of preschool age children. We have been discussing this idea for several months now after our data analysis showed a high prevalence of worm infestation in a group of malnourished children enrolled in our nutrition pilot program (YChiNG). At the time, we dewormed the children in the YChiNG program, but realized that there were many more children in our catchment area who could benefit from deworming.

Nasreen helping a father give deworming medicine

We were motivated in part by a Government of India mass deworming campaign in New Delhi earlier this year, which included deworming not only school-age children in government schools, but also pre-school age children in ICDS/Anganwadi (government health) centers. During last month’s GMP in Fakir Bagan, we conducted a survey with mothers of children 1-3 years old, asking them to report if their child had an incidence of intestinal worms in the past 6 months. A resounding 43% of mothers answered yes, which reflected a clear need for an intervention.

Intestinal worms, which are pervasive in India, can have devastating effects on a child’s physical and mental growth. In low-income urban areas like Fakir Bagan, where sanitation and hygiene are poor and many children walk around without shoes for protection, the most common type of intestinal worms are soil transmitted helminthes. Once in the body, these parasitic worms feed on host tissues, including blood, leading to a loss of iron and protein. They also hinder the absorption of nutrients. The result is diarrhea, anemia, and malnutrition, all which have a detrimental impact on child health, growth, and development. To counter the negative effects of worms, the WHO recommends periodic drug treatment (deworming) of all children living in endemic areas. (1) Studies have shown that routine deworming of children can have significant positive outcomes on nutrition, growth, and cognitive performance.

A child excited about the new deworming medicine

School-age children are thought to have a high burden of worm infestation. Fortunately, they are easy to reach for deworming because schools serve as pre-established distribution networks. The evidence shows that routine deworming makes a difference. One landmark study showed that deworming can reduce school absenteeism by 25%. Furthermore, children who are regularly dewormed earn over 20% more as adults and work 12% more hours, while those infected are 13% less likely to be literate. (2) Global campaigns now target pre-school age children, who are tougher to reach but also a vulnerable group in terms of exposure to worms. Studies conducted in Indian slums show that there is substantial weight gain in young children (pre-school age) who are dewormed regularly. (3)

Apart from the mass campaign in Delhi this year, which followed mass campaigns in Bihar and Andhra Pradesh a few years back, deworming campaigns have not been widely organized in India. Given that deworming is extremely cost-effective at only a few cents per pill, and provides both short-term and long-term physical and cognitive benefits to a child, India could see great benefits by ramping up state deworming campaigns, which can be effectively carried out through government schools and ICDS/Anganwadi health centers. The WHO includes intestinal worms among “the 17 neglected tropical diseases” which WHO Director General Margaret Chan described as “diseases that are largely silent, as the people affected or at risk have no political voice.”. The WHO launched its “neglected tropical diseases” campaign to raise awareness among policy makers and donors, in hopes of stimulating more action, like deworming campaigns. For Calcutta Kids, this new deworming initiative marks a proactive step to address the “neglected disease” that is most prevalent in our community.

The first round of deworming this week marked the beginning of our commitment to ensure routine deworming every 6 months to each preschool aged child in Fakir Bagan. We reached each of the 311 children between 1-3 years old, but missed some children who had traveled to the village with their families, but they should be covered in future rounds. Between rounds, we will immediately treat any children who present with worms. Parents at the camp were positive about the deworming intervention. The results were telling. In the words of one father, “My child was feeling sick and her stomach was swollen from worms. I am happy that she is now getting medicine to make her better.” – Danya Sarkar

1. http://www.who.int/elena/titles/deworming/en/
2. http://www.dewormtheworld.org/why-deworm/the-evidence-for-school-based-deworming
3. Effects of Deworming on Malnourished Preschool Children in India: An Open-Labelled, Cluster-Randomized Trial. Shally Awasthi, Richard Peto, Vinod K. Pande, Robert H. Fletcher, Simon Read, Donald A. P. Bundy. PLOS Neglected Tropical Diseases, April 2008, Volume 2, Issue 4

The Story of Puja Yadav

I will never forget the image of Puja on that first day of YCHING (Young Child Nutrition Group) in April 2011: Her mother Rinku set her down on the ground, and she took off, a whirlwind of 11 month old energy, tottering on slightly bowed legs, eyes bright with promise, grinning ear to ear. She was a radiant child.

Puja in April 2011

Fast forward to January 2012: Puja’s family came back to Fakir Bagan after a 10 month stay in the village during which time Rinku delivered her fourth child, Prince. Rinku had conceived again when Puja was just 9 months old, and the family–which included Rinku, her husband, Puja’s older brother and sister, and Puja–decided to return to the village for the pregnancy and delivery and to be close to extended family at home. The next time we saw Puja in January, we were shocked to see her condition–gone was the sunny, energetic girl we knew a year back. The new Puja was sullen, lethargic, and irritable. There was a clear reason: after taking her measurements we found that Puja had dropped off her growth curve, plummeting from -2.2 in weight for age z-score (WAZ) in April 2011 to -3.6 WAZ in January 2012. She was severely underweight and obviously suffering from infection. We counseled her mother and urged her to bring Puja in for examination and treatment, but with the new baby, plus Puja and her older siblings, Rinku was overwhelmed and decided to return to the village before we could intervene.

The family reappeared in Fakir Bagan in June 2012 and we were dismayed to see that Puja, now at 27 months, had taken a turn for the worse.  She was now -4.8 WAZ, very severely underweight, and also severely wasted at -3.03 weight for height z-score (WHZ). She suffered from both chronic and acute malnutrition- she was very weak, had raspy, labored breathing, a swollen abdomen, and chronic fever. She urgently needed help. We were sure she would not survive if she continued on this downward spiral.

Puja in June 2012

The Calcutta Kids doctor examined Puja and we quickly put together a treatment plan for Puja. First, we referred and accompanied her to Hope Hospital in Kolkata where she could be seen by a specialist pediatrician. The pediatrician diagnosed her with severe protein energy malnutrition (PEM), severe anemia, and chronic infection, and suspected that she had TB. He ordered a battery of tests and we sent Puja to the local DOTS (Directly Observed Therapy) center for TB screening. Though her Mantoux test was negative, her chest x-ray showed severe infection in the lung.

In consultation with the Hope pediatrician, Puja is now taking a 3 month course of level I anti-tuberculosis drug for her lung infection and therapeutic micronutrient supplements. Rinku brings her to the Calcutta Kids clinic everyday for an energy and protein dense, nutritious meal. Our health workers visit her home regularly for follow up and counseling on care, hygiene, and nutrition with the family.

Puja and her mother Rinku, July 2012

Puja Yadav, like all our children at Calcutta Kids, was never just a ‘case’ to be managed. She was a child at risk, a child trying desperately to survive the odds around her–a life that would not only be lost, but discounted, if someone did not intervene. Our entire team rallied together with Puja’s family.  We had intense discussions, we shed a few tears, and we cheered when Puja started gaining weight, slowly but surely; started smiling again; and even laughing. We are very happy to report that Puja has started to blossom again, and is slowly starting to resemble the girl we met over a year ago. In two months, she gained 1.5 kg, and shot up from -4.8 WAZ to -3.5 WAZ. She has improved from severe wasting (-3.03 WHZ) to mild wasting (-1.38 WHZ), a remarkable turnaround. And all of this has happened with home-based care, which is much harder to adhere to and manage than institutionalized rehabilitation, an option that the family would not consider, because it would mean leaving the other children at home without a full-time caregiver.

Like Puja, the family has started to change as well. Initially, both father and mother did not want to take Puja to the DOTS center three days a week for medication. They feared Puja would be labeled as a TB patient and ostracized by their neighbors. Calcutta Kids counseled them and gave them confidence to explain to their neighbors why they sought treatment for Puja. The community around them has also seen the changes in Puja and supports the family’s actions. Furthermore, as Puja’s health has improved, her younger brother Prince has also made remarkable strides. He, too, had been severely underweight when they came back from the village in June 2012. In the past 2 months, Prince moved up to the moderate category, gaining 1.2 kg, going from -3.47 to -2.4 in z-score (WAZ). We believe that this is another testament to change that has occurred in the family and especially in Rinku, who now seems less burdened, more confident, and proud of her children. When she brings Puja to the clinic she is delighted when Puja calls our health workers ‘amar didi’ (my elder sisters) and when Puja holds her hands to us in ‘namashkar.’

Puja now–August 2012

Puja is a true fighter. She is still the vibrant spirit who caught our attention long ago. She and her family just needed some extra attention. We at Calcutta Kids feel privileged that we were able to provide that additional help. We are committed to making sure that Puja remains on this trajectory of growth and nutrition, a critical foundation for a healthy and productive future. –Danya Sarkar

Puja’s Weight for Age Z score.
(Ideal is a straight line at 0)

Puja’s Weight for Height Z score.
(Ideal is a straight line at 0)

Calcutta Kids in Kathmandu

As one of 21 recipients of the 2009 South Asia Region Development Marketplace Awards to “Innovate for Nutrition” Calcutta Kids was invited to participate in a World Bank sponsored conference titled “Knowledge Sharing Forum on Infant and Young Child Nutrition” which took place in Kathmandu Nepal on June 12th and 13th. I went with our director, Noah to represent Calcutta Kids.

Along with representatives from the other 20 award winning organizations, the forum was attended by nearly two hundred representatives from governments, international NGO’s, and civil society organizations working to alleviate the horrific nutrition indicators which plague South Asia. The forum was also attended by journalists from throughout South Asia with the idea that in order for the public to care about nutrition, media information must be accurate and urgent.

The conference was jointly organized by the World Bank, UNICEF, SAFANSI, and presentations were made by representatives from all those organizations as well as those from organizations such as FAO, CARE, DFID, and the Micronutrient Initiative. It was interesting and fun to meet some of the world famous nutritionists and development workers whose work we regularly use and are inspired by at Calcutta Kids.

While nothing particularly new to those of us committed to improving nutrition, some of the important and shocking truths which we were reminded about and which should be shared whenever possible were:

  • Julie McLaughlin, Sector Manager for Health, Nutrition and Population in the South Asian region of the World Bank informed us that the latest estimates show that over 336 million people in South Asia are facing chronic hunger.
  • It was also discussed that the South Asian region, has the highest prevalence of malnutrition in the world and the child malnutrition in the region is estimated at 46 percent. It is worse than in Sub-Saharan Africa where the corresponding figure is 26 percent.
  • Melanie Galvin, Regional Director of MI, reminded us that that entrepreneurship cannot be possible without healthy population. If the population is deficient of vitamin A and iodine for example, how they can move forward for entrepreneurship?

Noah and I found two of the presentations particularly exciting.

The first by Tina Sanghvi, the Bangladesh senior country director of Alive and Thrive said, “The crisis (of malnourishment) is here and the solution is in our hands”. She continued by saying that the knowledge gap is the main reason of high rates of malnutrition in South Asian countries. Another point she highlighted was that many mothers have no idea that a malnourished mother can also breast feed properly and that is a serious problem. Tina also shared some terrific TV commercials on health messages that Alive and Thrive has created and now show regularly on Bangladeshi television channels. Calcutta Kids was able to get copies of some of these high quality commercials and we plan on using them with our beneficiaries.

The second was by Leslie Elder, Senior Nutrition Speci alist at the World Bank who gave a fantastic presentation on responsible and effective ways to scale up programs. When Calcutta Kids is ready to scales up its programs, the framework that Leslie shared with us will certainly be an invaluable resource. Leslie’s presentation can be found here.

For those of you who might be interested, you can see all the presentations given at the forum by visiting here.

It was a fantastic experience to participate in the forum and to be surrounded by so many people who deeply care about the very same issues we care about at Calcutta Kids. -Sumana Ghosh

Programs to Address Malnutrition

Despite the progress that has been made on other fronts, including infant and child mortality, in India over the last decade, nutrition remains a major public health challenge and nutrition indicators for young children have barely changed. There are many factors that complicate ongoing efforts to implement successful community nutrition programs–including inadequate access to food, unhealthy environment and exposure to infectious diseases, and inappropriate care and feeding practices. Since its inception, MYCHI has targeted the nutritional status of young children in Fakir Bagan during the first 1,000 days of their lives, primarily through preventive care and counseling along with curative care as needed.

The earliest data on nutritional status of children based on weight for age was collected in October 2009. It showed that 33.3% of children 0-3 years old were normal weight, while 32.7% were mildly, 21.6% were moderately, and 12.3% were severely underweight. Two and a half years later, in May 2012, the percentage of severe underweight children has dropped by more than half—from 12.3% to 5.5%, a remarkable success. Data is currently being analyzed to explore the specific factors that have had contributed to the reduction of the severe underweight in our catchment area, but it is clear that the MYCHI approach to deliver key health interventions during pregnancy and young childhood coupled with close counseling, education, and preventive health have made a significant impact in our community.

Although we have made progress, there are still improvements to be made to our child health initiative in order to fully integrate nutrition and growth. This year, we began efforts to systematically address malnutrition and move away from short-term trials, which consumed disproportionate resources and time at the expense of our regular programs. We have made several recent changes to make it easier to monitor and track malnourished children, which we hope will help us reach every child at risk of improper nutrition and growth:

– Early this year, we began generating our lists for monthly home visits by health workers on the basis of the nutritional status of children. Children having a z-score of -3 and below in weight for age (severely underweight) are referred to Swastha Kendra for clinical examination. This also ensures that our health workers have nutrition and growth on their minds as they enter the home of each child and can provide appropriate and intensive counseling to the family.

– At Swastha Kendra the referred child is provided care to resolve any associated medical problems and given supplements for micronutrient deficiencies. Follow up homes visits are carried out by our health workers two days after the doctor’s visit to check up on the child.

– Last month, we designated a space in Swastha Kendra as a nutrition corner, where mothers can freely breastfeed younger children and feed older children when they come for a doctor’s visit. We offer a meal of kichuri and egg in this corner to malnourished children who have been referred by the health workers. The privacy of the corner also enables close counseling with the family.

– Child health community meetings have been re-started in our new community center for mothers of children 0-12 months with an increased focus on complimentary feeding, as we recognize that children begin growth faltering at the time of weaning and introduction of semi-solid foods.

We are optimistic that these changes will enhance MYCHI’s efforts to improve child nutrition in Fakir Bagan. – Danya Sarkar

Saving a Severely Malnourished Child

Ajay was born on August 20, 2011 in a village outside of Kolkata. Sadly, his mother died shortly after childbirth, and he was sent to be raised by an aunt, also in the village, who had two other children. Over time, Ajay grew malnourished and his aunt was unable to provide proper care for him. In late 2011, he was sent to live with another aunt named Pramila in Fakir Bagan, where we work. Pramila has been married for many years, but has never had any children of her own.

Ajay and Pramila in late January, 2012

Pramila learned about Calcutta Kids and on Friday, January 20, she brought Ajay in for his first immunizations at five months old. Our triage nurse was quickly alarmed; his distended stomach, loosely hanging skin, bulging eyes, skinny limbs, and lethargy made her nervous about the inoculation. Weighing in at 3.79kg (~8.4lbs), he had a weight-for-age Z-score (WAZ) of -5.392, which was off the growth charts in the severely malnourished category. Bringing him to the attention of our health workers and doctor, Ajay received a thorough examination and a counseling and nutrition plan began. Ajay’s dirty bottle and diluted cow’s milk were replaced with clean bottles and newborn formula. Thankfully, he was hungry and eager to recover.

Starting the following Monday, Pramila brought Ajay to the Swastha Kendra (health center) daily for supervised feeding of Ajay. CK mothers are always encouraged to exclusively breastfeed, but in this case, without a lactating mother and with the severity of Ajay’s malnutrition, formula became the only viable option. Thanks to generous donors, CK supplies Ajay with all of his formula, which is expensive but critical to his growth. Almost immediately, we also started complementing his formula feeding with kicheri (lentils, rice and vegetables), which he ate well. Our community health workers conducted regular home visits to make sure that feedings were successful in the home. By February 1, Ajay weighed 4.5kg (~9.9lbs), and had a WAZ of -4.49. Making great progress, he was looking healthier and had more energy.

Ajay in late February, 2012

Pramila was also taken in by our mother’s support group. They were eager to help her, and invited her to attend their meetings. At one meeting, they taught Pramila various ways to make household ingredients into baby food. As a first-time mother of a very fragile child, the women in the support group also took the initiative to visit her and make sure she had what she needed. On March 1 he weighed 5.7kg (~12.6lbs) and had a WAZ of -3.633. His cheeks and limbs were starting to fill out, he was able to roll over on his own, and his smile could light up a room.

Ajay and Pramila in late March, 2012

Ajay and Pramila have continued coming to Swastha Kendra 2-3 days per week for counseling and food. On March 20, two months after Ajay’s first visit to Calcutta Kids, he weighed 5.97kg (~13.2 lbs) with a WAZ of -2.95, and was officially out of the “severely malnourished” category. Throughout the whole process, Pramila has worked very hard, heeding the counsel of Calcutta Kids, and has expressed her gratitude for our programs.

Ajay and Pramila in late March, 2012

Sitting in Swastha Kendra, I am fortunate to be able to see Ajay and Pramila regularly, observing the feeding, assessing his progress, and enjoying their company. The transformation in this sweet child over these 2+ months has been remarkable to witness. Thanks to the great work of Calcutta Kids, he continues to grow well, and is reaching both physical and developmental milestones. – Margy Elliott, Fellow, American India Foundation

A Mother’s Story

Rekha with Rani at the start of YChiNG and shortly after the birth of Madhu

Rekha Shaw is an out-going, energetic woman who participated actively in the YChiNG trial. Her two youngest children were malnourished and were in a terrible condition when we enrolled them in the program. Rani, at 29 months, weighed 7.31 kg (a little over 16 pounds) with a weight for age z-score (WAZ) of -4.296. Rani was stunted and developmentally delayed—she could not stand up, let alone walk. Her younger sister Madhu was faring slightly better but was still severely underweight: at 16 months, she weighed 6.58 kg (about 14.5 pounds) with a WAZ of -3.3. Both girls were very anemic, had high worm loads, and suffered from frequent acute infections.

Their mother, Rekha, has six daughters, a result of repeated pregnancies in an attempt to have a son. Tragically, she did have a son (born after the first four daughters), but he died just after birth for reasons she does not know. She lives with a mother-in-law who is not supportive and pressures her to bear a son. She also lives with a husband, who drinks and does not care for her or the children. She says, ‘There is nothing good about that man. He does nothing. He beats me.’ As her husband’s income was not sufficient, she began working outside of the home as caretaker (for an ill person) in order to provide for her children.

Rani and Madhu with mother Rekha at the YChiNG graduation

Despite all odds, Rekha was determined to give her youngest daughters a chance to succeed…. and we were determined to help her. After six months in YChiNG, the two girls have made significant gains in growth and development. Rani is still in the severe underweight category but her WAZ has improved to -3.207. Most importantly, she has learned to stand up and now she walks! Madhu’s weight has increased tremendously and she moved from severe to moderate to mild underweight in the past six months, a remarkable achievement. They have both improved in anemia status, have increased appetites, and learned to feed themselves with a spoon. We are so proud of Rekha for her courage, and so pleased to see Rani and Madhu now running, drawing, and playing in our center! -Danya Sarkar

YChinG Graduation Event

Recently Calcutta Kids held a graduation program for children who participated in a 6 month trial to address severe malnutrition in Fakir Bagan. The thirty-three children enrolled in YChiNG (Young Child Nutrition Group) were invited to a weekly feeding and GMP session at the DTC. They had access to the Calcutta Kids pediatrician, free medications and micronutrient supplements, and free routine and follow-up pathological tests. Read more about the YChiNG trial here.

Mothers listen to program coordinator Sumana Ghosh and mother Rekha Shaw

The graduation program marked the close of the YChiNG trial and was an opportunity to celebrate with the mothers and children who had participated in the program. Some children made remarkable strides in weight gain and growth, while those who did not fare as well (mainly due to lack of attendance) were given encouragement and asked to return for weekly meeting sessions.

The graduation program was a fun event that mothers and children enjoyed thoroughly. The MYCHI Program Coordinator, Sumana, talked about the YChiNG program and its impact. She thanked the mothers for participating and working hard to better the nutritional status of their children. Three mothers shared their stories and experiences with YChiNG. Rekha Shaw, whose youngest daughters Rani and Madhu participated, spoke about the improvements she had seen in her girls because of the program. Shanti Shaw, whose son Sujay had been hospitalized a year earlier due to severe malnutrition, described his recovery and how they were assisted by Calcutta Kids. Sabitri Prajapati spoke about her son Ayush who was born with low birth weight and was not growing well until he participated in the YChiNG program.

Mothers and children had lunch together, with mishti (sweets) and tea afterwards. We listened to Hindi music, and watched the children dance. At the end of the program, Calcutta Kids gave each child a colorful melamine bowl and spoon to encourage enjoyable, active feeding at home. -Danya Sarkar

Flip-Charts, Training and a Community Center – Oh MY(CHI)!

Originally posted in the Fall 2011 Newsletter

The Maternal and Young Child Health Initiative (MYCHI) staff has been working diligently over the past nine months to make our programs even more effective. Danya and Sumana have been revising the pregnancy care program to reflect changes in international maternal and neonatal health guidelines and to utilize the lessons we have learned over the past 6 years. We now have two excellent flip charts that are culturally appropriate to help counsel families about best practices and the early detection of problems.

In May, we had an in-depth training on the new pregnancy care program with all of our community health workers and other MYCHI staff. In this training, we were able to explain exactly why each type of data is collected; to provide refresher information on the complications that can occur during pregnancy, delivery and the first few months of life; and to talk through specific problems that have arisen in our area. In the course of the training, we also were able to strengthen the bonds that have enabled us to work as a team and to have fun together!

We are also working to revise the child health program to better tackle the non-food related causes of malnutrition as well as to update the program more generally. During the past six months, we worked with a small sample of severely malnourished children to find out with precision the causes of their malnutrition. We found that many of these children were suffering from anemia, a high worm load, several micronutrient deficiencies and stress in the home, all of which hinder the absorption of nutrients and, in turn, impede affect mental and physical development. We now can use this information to inform our protocols as we redesign the child health program. We are very excited about the new community center, located in Fakir Bagan itself, which will be opening in December – a safe, clean and attractive site where we can hold our regular community meetings and gatherings of small support groups – a space for women and children to come together comfortably for support and information.