Correcting Nutritional Deficiencies in Children Below the Age of 36 Months

By Nachiket Mor

Given the strong links between nutritional levels in children below the age of 36 months and overall childhood development, there is a strong desire amongst the ICTPH and the SughaVazhvu staff to launch a nutrition-focussed intervention for this age group, living in the vicinity of the SughaVazhvu Rural Micro Health Centres (RMHCs) in Karambayam and Allakudi villages in the Thanjavur District of Tamil Nadu.  However, the following are several critical questions that need to be answered first:

1. What are the nutritional deficiencies in this age group? The hypothesis at this stage is that there is less an issue with calorie deficiency but there exist severe and almost universal deficiencies in micronutrients – particularly iron.  I understand though that this is not something that the Government of Tamil Nadu (and perhaps even the Government of India) is persuaded of, which is why the Integrated Child Development Scheme (ICDS) in Tamil Nadu does not include universal iron supplementation and the recommended guidelines and protocol require each child to be tested for anaemia before putting her on a supplementation regime.  Perhaps more empirical work is needed to ascertain the levels of anaemia amongst children of this age group.

2. What are the specific links and transmission paths between these deficiencies and the overall development of the child? For example, the current research shows that iron deficiency is associated with a number of adverse outcomes including, on average, a 13 point reduction in IQ levels.

3. For children below the age of 6 months (from conception to 6 months), the recommended guidelines are exclusive breastfeeding (post-birth to 6 months) and working with the iron levels of the mother from the pre-pregnancy stage to 6 months of age.  Is the standard Iron and Folic Acid (IFA) supplementation regime adequate for this?  What is the Government already doing about this and if the scheme is not working, what are the reasons for that? The hypothesis here is that there is very poor take-up amongst women on account of various perceived as well as real problems with following this regimen.  This would imply that alternate methods may need to be explored if iron supplementation is to be successful.

4. What are the various ways to address these nutritional gaps for children between 6 months to three years?  The hypothesis at this stage is that the significant gap to be addressed is in the area of iron deficiency and that a sprinkle-based universal food supplementation campaign needs to be launched aggressively and soon as time is of the essence.  Sprinkles appear to be an effective solution as they maintain the current dietary patterns of the child while merely adding more iron to the food intake in a manner that is easy for the child to ingest.  If this is done properly, what are the risks of possible adverse side effects amongst children – in terms of increased infection, increased diarrhoea, etc.?

5. If one does decide to pursue a sprinkle-based iron supplementation campaign for children between the ages of 6 months and 36 months, who would be the best partners to work with and what mechanisms should be used to ensure that this is a sustainable campaign and that we are able to find a “permanent” way to address this issue for the current cohort of children in this age group, as well as all subsequent cohorts? These logistical questions will be critical for ICTPH and SughaVazhvu staff to answer in planning this critical intervention strategy.

6. Food-based supplementation is the alternate route.  The hypothesis here is that fortified foods are not yet available to the population, at large, and more research is needed in this area.  Changes in dietary habits are also a possibility but our  current hypothesis is that (a) it would take a great deal of research to determine what the specific required changes would be and (b) for children below the age of 36 months it is simply impossible to supply an adequate amount of iron through non-fortified foods.

It is very important for us to get viable answers to these questions and we would be grateful for your detailed comments and guidance so that we may evolve a well-thought out action plan.