S K Kabra , associate professor in the paediatric pulmonology division of All India Institute of Medical Sciences, New Delhi talks to Nidhi Jamwal about the relationship between malnutrition and diseases prevalent among children in India
How severe is the problem of malnutrition among children in India?
Malnutrition is a serious and very common problem. About 50 to 60 per cent of the children, who are below the age of five, suffer from malnutrition. On an average, these children suffer from moderate to severe malnutrition.
How does malnutrition lead to problems of respiratory diseases, mainly pneumonia, among children?
In case a child is suffering from pneumonia, then malnutrition increases the severity of the disease. It increases child morbidity and mortality. In case a child has both pneumonia and malnutrition, then his chances of dying are higher than a child who is suffering from pneumonia but is not malnourished.
Severe malnutrition decreases the muscle strength and muscle mass of a child. Secondly, it leads to decrease in the immunity or the resistance power of the child. The child's own local defenses get affected. The epithelial lining of the respiratory tract of the malnourished child gets affected due to severe malnutrition. The child becomes more vulnerable to diseases.
Second, body secretions contain antibodies called IgA. In a malnourished child, this IgA secretion level goes down. T-cells that help fight infection will also decrease. All these factors that improve systematic resistance are found lacking in malnourished children. So they become prone to infections. Naturally if there is no resistance, the children become prone to severe infections.
There is high incidence of malnourished children in developing countries than in developed countries. Deaths due to pneumonia is also higher in developing countries than in developed countries.
What are the reasons for malnourishment among children in India?
There are many reasons for this. Children are not given proper food and their calorie intake falls much below the minimum level. They are not breast fed for the first four to five months. This obviously acts as a disadvantage and the children's immunity systems do not develop. There are also other associated problems. Such children are thus more prone to diseases like diarrhoea. The important thing is that if a child is not breast fed for the first four to six months, but is given other food items, he/she can still develop diarrhoea. Complimentary feeding should start only after an age of four months.
Apart from pneumonia, what other diseases are caused or aggravated because of malnutrition in children?
Malnourished children are prone to contracting all kinds of infections including gastrointestinal infection. If a malnourished child catches an infection like measles or tuberculosis, then the chances are that the infection will get more severe. The duration of illness and chances of death are high.
How severe is the problem of respiratory disease among children in India?
Respiratory diseases are a leading cause of death in children below five years of age. Pneumonia is a leading cause of death. Diarrhoea is also a problem. Now with introduction of ors the problem has been brought under control. About three to four million children die in a year due to pneumonia in developing countries alone.
Do you think government has put in enough funds and will to understand the relation between malnutrition and other infections in India?
As far as the government is concerned, it is carrying out surveys to find out the extent of malnutrition in the country. About 40 to 50 per cent of the information and data available on malnutrition among children in India comes from government surveys only. Awareness about breast feeding is also being raised. But this is not the responsibility of the government alone. The whole medical community should be actively involved in this. It should be made compulsory that if a doctor is treating a child suffering from malnutrition, then he should provide complete information to the parents about the disease and ways to combat it. Medical fraternity is not doing its work properly in this regard. Due to various factors like work pressure, doctors only prescribe the medicines for the child patient and not give complete information including preventive information to parents. Poverty and lack of awareness is aggravating the problem of malnutrition among Indian children.
What is the relationship between Vitamin A and malnutrition?
There are certain vitamins that increase immunity. Vitamin A is one of them. Lack of Vitamin A exposes child to various infections. Vitamin A supplementation is one of the factors that may decrease the morbidity and mortality caused by respiratory illnesses. The Indian government has a programme on it called Vitamin A Supplementation.
The doses are given routinely. Whether it is cost effective to give Vitamin A supplement to all children, regardless of deficiency, is not clear. Because in urban areas the proportion of children having Vitamin A deficiency will be less, so if we give it to all of them, it may not have the intended impact and might be a waste of resources.
The programme needs planning. In case we find that in a particular area, Vitamin A deficiency in children is more than 10 per cent then it is a public health problem. In such an area, Vitamin A supplementation will give expected results.
Contrary to this, if there is only one per cent deficiency, then administering Vitamin A blindly to all will not solve the problem. The same thing applies in case of deficiences of other micronutrients like zinc. Sadly, at the moment, Vitamin A supplementation is given blindly to all children irrespective of whether they suffer from a deficiency of that vitamin or not.
It has been observed that different communities traditionally suffer from deficiencies of different vitamins and nutrients. Getting data on the deficiencies suffered by each and every community on the basis of which supplements would be given, is difficult. We need tailor-made plans for different communities.
What is the relationship between breast feeding and asthma?
We are undertaking a study to see what are the risk factors involved in the development of asthma and the risk factors that are needed for the development of severe asthma. We found that breast feeding was one of the important protective factors as far as development is concerned. Breast feeding needs to be done exclusively for the first four months. No other feeding should be given. It also protects the child from respiratory diseases and other allergies.
Do you think urban children are facing a double burden of malnourishment and pollution. For instance, on the one hand, they are malnourished. On the other hand, they are daily exposed to high levels of pollutants. Is it not taxing their health enormously?
Yes, this is true. The prevalence of asthma among school going children in Delhi was found to be 16 per cent. The same study was carried out some 35 kilometers away from Delhi in rural areas of Haryana in Ballabhgarh. There, the prevalence of asthma was only 2 per cent. So you can see the difference. There has to be a reason, such as pollution, lifestyle, or any other factor that leads to the prevalence of diseases like asthma. The difference of two per cent and 16 per cent needs to be studied further.
If we can tackle the problem of malnutrition among children, then we will win over many other diseases as well, as we will be building the immunity of children. We will be preventing many infectious diseases.
How can this twin problem of malnutrition and respiratory illnesses among children be minimised?
The first thing to do is to decrease the number of underweight babies. Since they are underweight , they are malnourished and predisposed to infections. The mother's health also needs to be restored. The second thing to do is to promote exclusive breast feeding for first four months. The third step is advising complimentary feeding of the baby after it has atttained four months. After all this, if due to some reason the child still develops malnutrition, then more stress should be placed on an increased intake of food, whatever that is available, to the child. The child could be fed on rice, dal, dalia. The problem is of awareness and availability of food.
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