Today’s children are tomorrow’s assets for any nation and hence their optimal development ought to be a focal concern in framing welfare policies. Such policies are usually grounded in research, and so understanding the evolution of this research is critical to shaping future policies. Here, we discuss the evolution of children’s malnutrition research and how India’s battle against child malnutrition warrants urgent policy action in the wake of covid.
Priorities in research on child under-nutrition have changed over the years. Calorific deficiency was considered the primary cause of child under-nutrition from the early till mid-1950s. Micronutrient deficiency as an important cause of under-nutrition had been prominent since the 1940s. Research up until the 1950s concentrated on vitamin deficiencies and then moved on to include protein deficiencies till the mid-1970s. Over time, it was discovered that child malnutrition is more than just a function of calorific and micronutrient deficiency, and hence multi-sectoral nutritional planning started to gain prominence from the late 1970s. A big push in investment materialized once freedom from hunger and malnutrition was recognized as a basic human right in 1984. This recognition of nutrition as a basic right led to the ratification of a set of goals for countries participating in United Nations (UN) conventions. In 1992, the UN collated all the seminal research done to establish the factors influencing child health and developed a conceptual framework for child malnutrition. This was an important step towards a formal understanding of the multi-sectoral factors affecting children’s health beyond calorific and micronutrient deficiencies.
The framework acknowledged that inadequate dietary intake and diseases are the immediate causes of malnutrition. Diseases impact absorption of food consumed as well as the bodily utilization of its nutrients. The next group of factors are referred to as ‘underlying causes’, which impact child health either directly or indirectly through immediate causes. These include the child’s environment (basic health services and healthy environs that include good sanitation), as well as access to adequate maternal care. Basic causes form the third group. These impact child health directly as well as indirectly by interacting with the immediate and underlying causes. These subsume basic socioeconomic characteristics like wealth, religious practices and various household resources available to children.
In 2010, a seminal paper by Victora et al in the journal Pediatrics established the importance of the first 1,000 days of child health. The study showed that the phenomenon of growth faltering—that is, children growing slower physically than expected by World Health Organization standards—is more pronounced in the very first two years of a child’s life. Such growth faltering is shown to lead to irreversible cognitive and physical damage, a problem that is also passed on to the next generation, as girls with faltering growth in childhood grow up to be mothers with underdeveloped wombs who often give birth to stunted children. Hence, the window of opportunity for intervention to eliminate malnutrition should be seized during pregnancy and the first two years (equating to 1,000 days of a child’s life).
This finding has formed the basis of India’s Poshan Abhiyan. When the National Family Health Survey (NFHS)-4 found nearly 40% of India’s children to be stunted in 2015-16, the highest in the world, it drove policymakers to take a comprehensive approach towards battling malnutrition. The Poshan Abhiyan was launched in 2018 with the aim of eradicating malnutrition by 2022.
It acknowledged both the multi-sectoral nature of child malnutrition as well the importance of the first 1,000 days of life. It aimed to provide adequate nutrition (through hot-cooked meals) to children and thereby increase their dietary intake, apart from vaccinating them against diseases, providing pregnant women with antenatal care and enhancing awareness of the benefits of breastfeeding, among other objectives.
However, this programme, much like other such welfare schemes, was negatively impacted by covid and the shutdown of schools and Anganwadi centres it resulted in. Even though states adjusted to lockdowns and initiated the provision of take-home rations and cash transfer schemes, the rigour with which Anganwadi workers worked for the Poshan Abhiyan’s success was indeed commendable. Yet, we face a huge challenge. The disruption of schemes combined with financial stress means that children from economically-weaker homes find it harder to obtain adequate calories and nutrients.
A study by Robert et al published in Lancet based on data from 118 low- and middle-income countries predicted (under its least severe scenario) that a decline of 10-20% in coverage of essential maternal and child health interventions and a 10% increase in ‘wasting’ of children for over six months would lead to an additional 250,000 child and 12,000 maternal deaths. Just as previous literature was important to frame policies to combat malnutrition, new policies should also be grounded in up-to-date research. India should explore the Poshan Abhiyan’s renewal with covid-safety protocols in place like physical distancing, sanitization, hand washing and mask wearing. Minimizing the dangers of localized covid outbreaks and preparing for such scenarios will ensure that children’s nutrition does not suffer. It’s crucial for the development of our country that child health is accorded due urgency.
Payal Seth & Palakh Jain are, respectively, a consultant at Tata-Cornell Institute, and a PhD Scholar and an associate professor at Bennett University
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