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WCD: Circular and Notifications


Schemes

Child Development
MIS for ICDS


Mother and Child Protection Card Under ICDS and MHRM


Women Related Acts


Child Related Acts


Hiring of Vehicles under ICDS Scheme


Office Order/ Information/Instructions For Anganwadi Workers and Anganwadi Helpers

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Common Micronutrient Deficiency Diseases


In order to provide more comprehensive and meaningful search results on our site, several reports are available for viewing and download directly. Kindly visit the main sites of the author organisations for more complete and updated information. We acknowledge our gratitude to the many people and sources whose work has been drawn freely upon. We thank them all. This information table is from the Sphere Project - Humanitarian Charter and Minimum Standards in Disaster Response


Anaemia


Micronutrient deficiency disease          Anaemia 
Nutrient deficiency                               Iron deficiency 


Clinical signs and symptoms of the disease :

  • Pale conjunctivae (inner eyelid), nailbeds, gums, tongue, lips and skin
  • Tiredness
  • Headaches
  • Breathlessness 

Populations at risk of becoming deficient 

  • Populations from regions where malaria and intestinal parasitic infestation are prevalent
  • The most at risk groups are women of child-bearing age and young children 

Preventive behaviours for a healthy family 

  • Increase Iron intake:
    • Eat iron-rich vegetables like cowpeas, spinach, millet, beans, pulses, pumpkin seeds and other greens
    • Eat meat like beef, liver, goat or chicken
    • Eat "iron helpers" such as guava, oranges, lemon or little meat to help your body use the iron
    • Try not to eat "iron blockers" like tea, coffee and milk for one hour before and one hour after eating an iron-rich meal
  • Prevent malaria:
    • Sleep under treated mosquito nets
    • Get treated for malaria immediately
  • Prevent hookworm:
    • Take de-worming tablets twice a year
    • Wear shoes to avoid hookworm
    • Dispose faeces properly
    • Wash your hands and your nails thoroughly before preparing food and eating
  • Take iron tablets as directed by a health worker:
    • Pregnant women should take one tablet of iron and folic acid every day for six months 

Goitre and Cretinism


Micronutrient deficiency disease          Goitre and Cretinism 
Nutrient deficiency                               Iodine deficiency 


Clinical signs and symptoms of the disease 

  • Goitre:
    • Grade 0: No palpable (can't feel) or visibly enlarged thyroid
    • Grade 1: A palpable but not visibly enlarged thyroid with neck in normal position
    • Grade 2: A palpably and visibly enlarged thyroid with neck in normal position 
  • Cretinism:
    • Neurological cretinism:
    • Mental deficiency
    • Deaf mutism
    • Spasticity
    • Ataxia (lack of muscular coordination)
  • Hypothyroid cretinism:
    • Dwarfism
    • Hypothyroidism 

Populations at risk of becoming deficient 

  • Populations from mountainous areas where there is limited access to seafoods and iodised salt
  • Goitre is highest in adolescence, particularly girls 

Preventive behaviours for a healthy family 

  • Purchase packaged iodized salt
  • Store packaged iodized salt faraway from heat and from moisture
  • Add salt before serving the food 

Xerohthalmia

Nutrient deficiency                     Vitamin A deficiency 
                  Bitot's Spot
            Corneal Ulcerations - Keratomalacia


Clinical signs and symptoms of the disease 

  • Night blindness
  • Eye dryness accompanied by foamy accumulations on the conjunctiva (inner eyelids), that often appear near the outer edge of the iris (Bitot's spots)
  • Eye dryness, dullness or clouding (milky appearance) of the cornea (corneal xerosis)
  • Eye softening and ulceration of the cornea (keratomalacia). This is sometimes followed by perforation of the cornea, which leads to the loss of eye contents and permanent blindness 

Populations at risk of becoming deficient 

  • Populations who have no access to fresh fruit and vegetables
  • Children suffering from measles, diarrhoea, respiratory infections, chickenpox and other severe infections are at increased risk 

Preventive behaviours for a healthy family 

  • Increase Vitamin A intake through consumption of yellow and orange fruits and vegetables
  • Mothers should take Vitamin A within 8 weeks after giving birth (200,000 IU)
  • Children from 6 to 59 months should get Vitamin A supplementation orally every six months. (6 months - 1 year; 100,000 IU, >1 year; 200,000 IU)
  • Infants should be exclusively breastfed for the first six months and continue to be breastfed up to twenty-four months 
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Malnutrition : Signs and Symptoms

Malnutrition is a broad term which refers to bothundernutrition (subnutrition) and overnutrition. Individuals are malnourished, or suffer from undernutrition if their diet does not provide them with adequate calories and protein for maintenance and growth, or they cannot fully utilize the food they eat due to illness. People are also malnourished, or suffer from overnutrition if they consume too many calories.

Malnutrition can also be defined as the insufficient, excessive or imbalanced consumption of nutrients. Several different nutritiondisorders may develop, depending on which nutrients are lacking or consumed in excess.

According to the World Health Organization (WHO), malnutrition is the gravest single threat to global public health.

This text will focus more on the undernutrition aspect of malnutrition, rather than overnutrition.

Subnutrition occurs when an individual does not consume enough food. It may exist if the person has a poor diet that gives them the wrong balance of basic food groups.

Obese people, who consume more calories than they need, may suffer from the subnutrition aspect of malnutrition if their diet lacks the nutrients their body needs for good health.

Poor diet may lead to a vitamin or mineral deficiency, among other essential substances, sometimes resulting in scurvy- a condition where an individual has a vitamin C (ascorbic acid) deficiency. Though scurvy is a very rare disease, it still occurs in some patients - usually elderly people, alcoholics, or those that live on a diet devoid of fresh fruits and vegetables. Similarly, infants or children who are on special or poor diets for any number of economic or social reasons may be prone to scurvy.

According to the National Health Service (NHS), UK, it is estimated that over two million people are affected by malnutrition (subnutrition).

According to the Food and Agriculture Organization (FAO), the number of people globally who were malnourished stood at 923 million in 2007, an increase of over 80 million since the 1990-92 base period.

The World Health Organization (WHO) says that malnutrition is by far the largest contributor to child mortality globally, currently present in half of all cases. Underweight births and inter-uterine growth restrictions are responsible for about 2.2 million child deaths annually in the world. Deficiencies in vitamin A or zinc cause 1 million deaths each year.

WHO adds that malnutrition during childhood usually results in worse health and lower educational achievements during adulthood. Malnourished children tend to become adults who have smaller babies.

While malnutrition used to be seen as something which complicated such diseases as measles, pneumonia and diarrhea, it often works the other way round - malnutrition can cause diseases to occur.

Globally, as well as in developed, industrialized countries, the following groups of people are at highest risk of malnutrition (subnutrition):
  • Elderly people, especially those who are hospitalized or in long-term institutional careIndividuals who are socially isolated
  • People on low incomes (poor people)
  • People with chronic eating disorders, such as bulimia or anorexia nervosa
  • People convalescing after a serious illness or condition
According to Medilexicon's medical dictionary:

  • Malnutrition is "Faulty nutrition resulting from malabsorption, poor diet, or overeating."
  • Undernutrition is "A form of malnutrition resulting from a reduced supply of food or from inability to digest, assimilate, and use the necessary nutrients."
What are the signs and symptoms of malnutrition?
A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. Signs and symptoms of malnutrition (subnutrition) include:
  • Loss of fat (adipose tissue)
  • Breathing difficulties, a higher risk of respiratory failure
  • Depression
  • Higher risk of complications after surgery
  • Higher risk of hypothermia - abnormally low body temperature
  • The total number of some types of white blood cells falls; consequently, the immune system is weakened, increasing the risk of infections.
  • Higher susceptibility to feeling cold
  • Longer healing times for wounds
  • Longer recover times from infections
  • Longer recovery from illnesses
  • Lower sex drive
  • Problems with fertility
  • Reduced muscle mass
  • Reduced tissue mass
  • Tiredness, fatigue, or apathy
  • IrritabilityIn more severe cases:
  • Skin may become thin, dry, inelastic, pale, and cold
  • Eventually, as fat in the face is lost, the cheeks look hollow and the eyes sunken
  • Hair becomes dry and sparse, falling out easily
  • Sometimes, severe malnutrition may lead to unresponsiveness (stupor)
  • If calorie deficiency continues for long enough, there may be heart, liver and respiratory failure
  • Total starvation is said to be fatal within 8 to 12 weeks (no calorie consumption at all)
Children - children who are severely malnourished typically experience slow behavioral development, even mental retardation may occur. Even when treated, undernutrition may have long-term effects in children, with impairments in mental function and digestive problems persisting; in some cases for the rest of their lives. Adults whose severe undernourishment started during adulthood, usually make a full recovery when treated.
What are the causes of malnutrition?
Malnutrition, the result of a lack of essential nutrients, resulting in poorer health, may be caused by a number of conditions or circumstances. In many developing countries long-term (chronic) malnutrition is widespread - simply because people do not have enough food to eat.

In more wealthy industrialized nations malnutrition is usually caused by:
  • Poor diet - if a person does not eat enough food, or if what they eat does not provide them with the nutrients they require for good health, they suffer from malnutrition. Poor diet may be caused by one of several different factors. If the patient develops dysphagia (swallowing difficulties) because of an illness, or when recovering from an illness, they may not be able to consume enough of the right nutrients.
  • Mental health problems - some patients with mental health conditions, such as depression, may develop eating habits which lead to malnutrition. Patients with anorexia nervosa or bulimia may develop malnutrition because they are ingesting too little food.
  • Mobility problems - people with mobility problems may suffer from malnutrition, simply because they either cannot get out enough to buy foods, or find preparing them too arduous.
  • Digestive disorders and stomach conditions - some people may eat properly, but their bodies cannot absorb the nutrients they need for good health. Examples include patients with Crohn's disease or ulcerative colitis. Such patients may need to have part of the small intestine removed (ileostomy). Individuals who suffer from Celiac disease have a genetic disorder that makes them intolerant to gluten. Patients with Celiac disease have a higher risk of damage to the lining of their intestines, resulting in poorer food absorption. Patients who experience serious bouts of diarrhea and/or vomiting may lose vital nutrients and are at higher risk of suffering from malnutrition.
  • Alcoholism - an alcoholic is a person who suffers from alcoholism - the body is dependent on alcohol. Alcoholism is a chronic (long-term) disease. Individuals who suffer from alcoholism can develop gastritis, or pancreas damage. These problems also seriously undermine the body's ability to digest food, absorb certain vitamins, and produce hormones which regulate metabolism. Alcohol contains calories, reducing the patient's feeling of hunger, so he/she consequently may not eat enough proper food to supply the body with essential nutrients.
In poorer, developing nations malnutrition is commonly caused by:
  • Food shortages - in poorer developing nations food shortages are mainly caused by a lack of technology needed for higher yields found in modern agriculture, such as nitrogen fertilizers, pesticides and irrigation. Food shortages are a significant cause of malnutrition in many parts of the world.
  • Food prices and food distribution - it is ironic that approximately 80% of malnourished children live in developing nations that actually produce food surpluses (Food and Agriculture Organization). Some leading economists say that famine is closely linked to high food prices and problems with food distribution.
  • Lack of breastfeeding - experts say that lack of breastfeeding, especially in the developing world, leads to malnutrition in infants and children. In some parts of the world mothers still believe that bottle feeding is better for the child. Another reason for lack of breastfeeding, mainly in the developing world, is that mothers abandon it because they do not know how to get their baby to latch on properly, or suffer pain and discomfort.
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Nutrition: What is Nutrition and Nutrients

Nutrition, nourishment, or aliment, is the supply of materials - food - required by organisms and cells to stay alive. In science and human medicine, nutrition is the science or practice of consuming and utilizing foods.

In hospitals, nutrition may refer to the food requirements of patients, including nutritional solutions delivered via an IV (intravenous) or IG (intragastric) tube.

Nutritional science studies how the body breaks food down (catabolism) and repairs and creates cells and tissue (anabolism) - catabolism and anabolism = metabolism. Nutritional science also examines how the body responds to food. In other words, "nutritional science investigates the metabolic and physiological responses of the body to diet".

As molecular biology, biochemistry and genetics advance, nutrition has become more focused on the steps of biochemical sequences through which substances inside us and other living organisms are transformed from one form to another - metabolism and metabolic pathways.

Nutrition also focuses on how diseases, conditions and problems can be prevented or lessened with a healthy diet.

Nutrition also involves identifying how certain diseases, conditions or problems may be caused by dietary factors, such as poor diet (malnutrition), food allergies, metabolic diseases, etc.


The human body requires seven major types of nutrients

A nutrient is a source of nourishment, an ingredient in a food, e.g. protein,carbohydrate, fat, vitamin, mineral, fiber and water. Macronutrients are nutrients we need in relatively large quantities. Micronutrients are nutrients we need in relatively small quantities.

Energy macronutrients - these provide energy, which is measured either in kilocalories (kcal) or Joules. 1 kcal = 4185.8 joules.




  • Carbohydrates - 4 kcal per gram
    • Molecules consist of carbon, hydrogen and oxygen atoms. Carbohydrates include monosaccharides (glucose, fructose, glactose), sisaccharides, and polysaccharides (starch). 
    • Nutritionally, polysaccharides are more favored for humans because they are more complex molecular sugar chains and take longer to break down - the more complex a sugar molecule is the longer it takes to break down and absorb into the bloodstream, and the less it spikes blood sugar levels. Spikes in blood sugar levels are linked to heart and vascular diseases.

  • Proteins - 4 kcal per gram
    • Molecules contain nitrogen, carbon, hydrogen and oxygen. Simple proteins, called monomers, are used to create complicated proteins, called polymers, which build and repair tissue. When used as a fuel the protein needs to break down, as it breaks down it gets rid of nitrogen, which has to be eliminated by the kidneys.
  • Fats - 9 kcal per gram
    • Molecules consist of carbon, hydrogen, and oxygen atoms. Fats are triglycerides - three molecules of fatty acid combined with a molecule of the alcohol glycerol. Fatty acids are simple compounds (monomers) while triglycerides are complex molecules (polymers). For more details on dietary fat, go to What is fat? How much fat should I eat?
Other macronutrients. 
These do not provide energy
    • Fiber
      • Fiber consists mostly of carbohydrates. However because of its limited absorption by the body, not much of the sugars and starches get into the blood stream. Fiber is a crucial part of essential human nutrition. 
    • Water
      • About 70% of the non-fat mass of the human body is water. Nobody is completely sure how much water the human body needs - claims vary from between one to seven liters per day to avoid dehydration. We do know that water requirements are very closely linked to body size, age, environmental temperatures, physical activity, different states of health, and dietary habits. Somebody who consumes a lot of salt will require more water than another person of the same height, age and weight, exposed to the same levels of outside temperatures, and similar levels of physical exertion who consumes less salt. Most blanket claims that 'the more water you drink the healthier your are' are not backed with scientific evidence. The variables that influence water requirements are so vast that accurate advice on water intake would only be valid after evaluating each person individually.
    Micronutrients
    • Minerals
      • Dietary minerals are the other chemical elements our bodies need, apart from carbon, hydrogen, oxygen and nitrogen. The term "minerals" is misleading, and would be more relevant if called "ions" or "dietary ions" (it is a pity they are not called so). People whose intake of foods is varied and well thought out - those with a well balanced diet - will in most cases obtain all their minerals from what they eat. Minerals are often artificially added to some foods to make up for potential dietary shortages and subsequent health problems. The best example of this is iodized salt - iodine is added to prevent iodine deficiency, which even today affects about two billion people and causes mental retardation and thyroid gland problems. Iodine deficiency remains a serious public health problem in over half the planet. 
      • Experts say that 16 key minerals are essential for human biochemical processes by serving structural and functional roles, as well as electrolytes: 
      • Potassium
        • What it does - a systemic (affects entire body) electrolyte, essential in co-regulating ATP (an important carrier of energy in cells in the body, also key in making RNA) with sodium. 
        • Deficiency - hypokalemia (can profoundly affect the nervous system and heart). 
        • Excess - hyperkalemia (can also profoundly affect the nervous system and heart). 
      • Chloride
        • What it does - key for hydrochloric acid production in the stomach, also important for cellular pump functions. 
        • Deficiency - hypochleremia (low salt levels, which if severe can be very dangerous for health). 
        • Excess - hyperchloremia (usually no symptoms, linked to excessive fluid loss). 
      • Sodium
        • What it does - a systemic electrolyte, and essential in regulating ATP with potassium. 
        • Deficiency - hyponatremia (cause cells to malfunction; extremely low sodium can be fatal). 
        • Excess - hypernatremia (can also cause cells to malfunction, extremely high levels can be fatal). 
      • Calcium
        • What it does - important for muscle, heart and digestive health. Builds bone, assists in the synthesis and function of blood cells. 
        • Deficiency - hypocalcaemia (muscle cramps, abdominal cramps, spasms, and hyperactive deep tendon reflexes). 
        • Excess - hypercalcaemia (muscle weakness, constipation, undermined conduction of electrical impulses in the heart, calcium stones in urinary tract, impaired kidney function, and impaired absorption of iron leading to iron deficiency). 
      • Phosphorus
        • What it does - component of bones and energy processing. 
        • Deficiency - hypophosphatemia, an example is rickets. 
        • Excess - hyperphosphatemia, often a result of kidney failure. 
      • Magnesium
        • What it does - processes ATP and required for good bones. 
        • Deficiency - hypomagnesemia (irritability of the nervous system with spasms of the hands and feet, muscular twitching and cramps, and larynx spasms). 
        • Excess - hypermagnesemia (nausea, vomiting, impaired breathing, low blood pressure). Very rare, and may occur if patient has renal problems. 
      • Zinc
        • What it does - required by several enzymes. 
        • Deficiency - short stature, anemia, increased pigmentation of skin, enlarged liver and spleen, impaired gonadal function, impaired wound healing, and immune deficiency. 
        • Excess - suppresses copper and iron absorption. 
      • Iron
        • What it does - required for proteins and enzymes, especially hemoglobin. 
        • Deficiency - anemia. 
        • Excess - iron overload disorder; iron deposits can form in organs, particularly the heart. 
      • Manganese
        • What it does - a cofactor in enzyme functions. 
        • Deficiency - wobbliness, fainting, hearing loss, weak tendons and ligaments. Less commonly, can be cause of diabetes. 
        • Excess - interferes with the absorption of dietary iron. 
      • Copper
        • What it does - component of many redox (reduction and oxidation) enzymes. 
        • Deficiency - anemia or pancytopenia (reduction in the number of red and white blood cells, as well as platelets) and a neurodegeneration. 
        • Excess - can interfere with body's formation of blood cellular components; in severe cases convulsions, palsy, and insensibility and eventually death (similar to arsenic poisoning). 
      • Iodine
        • What it does - required for the biosynthesis of thyroxine (a form of thyroid hormone). 
        • Deficiency - developmental delays, among other problems. 
        • Excess - can affect functioning of thyroid gland. 
      • Selenium
        • What it does - cofactor essential to activity of antioxidant enzymes. 
        • Deficiency - Keshan disease (myocardial necrosis leading to weakening of the heart), Kashing-Beck disease (atrophy degeneration and necrosis of cartilage tissue). 
        • Excess - garlic-smelling breath, gastrointestinal disorders, hair loss, sloughing of nails, fatigue, irritability, and neurological damage. 
      • Molybdenum
        • What it does - vital part of three important enzyme systems, xanthine oxidase, aldehyde oxidase, and sulfite oxidase. It has a vital role in uric acid formation and iron utilization, in carbohydrate metabolism, and sulfite detoxification. 
        • Deficiency - may affect metabolism and blood counts, but as this deficiency is often alongside other mineral deficiencies, such as copper, it is hard to say which one was the cause of the health problem. 
        • Excess - there is very little data on toxicity, therefore excess is probably not an issue.
    • Vitamins
      • These are organic compounds we require in tiny amounts. An organic compound is any molecule that contains carbon. It is called a vitamin when our bodies cannot synthesize (produce) enough or any of it. So we have to obtain it from our food. Vitamins are classified by what they do biologically - their biological and chemical activity - and not their structure.

      • Vitamins are classified as water soluble (they can dissolve in water) or fat soluble (they can dissolve in fat). For humans there are 4 fat-soluble (A, D, E, and K) and 9 water-soluble (8 B vitamins and vitamin C) vitamins - a total of 13.
      • Water soluble vitamins need to be consumed more regularly because they are eliminated faster and are not readily stored. Urinary output is a good predictor of water soluble vitamin consumption. Several water-soluble vitamins are manufactured by bacteria.
      • Fat soluble vitamins are absorbed through the intestines with the help of fats (lipids). They are more likely to accumulate in the body because they are harder to eliminate quickly. Excess levels of fat soluble vitamins are more likely than with water-soluble vitamins - this condition is called hypervitaminosis. Patients with cystic fibrosis need to have their levels of fat-soluble vitamins closely monitored.
      • We know that most vitamins have many different reactions, which means they have several different functions. Below is a list of vitamins, and some details we know about them:
      • Vitamin A
        • chemical names - retinol, retinoids and carotenoids.
        • Solubility - fat.
        • Deficiency disease - Night-blindness.
        • Overdose disease - Keratomalacia (degeneration of the cornea).
      • Vitamin B1
        • chemical name - thiamine.
        • Solubility - water.
        • Deficiency disease - beriberi, Wernicke-Korsakoff syndrome.
        • Overdose disease - rare hypersensitive reactions resembling anaphylactic shock when overdose is due to injection. Drowsiness.


      • Vitamin B2
        • chemical name - riboflavin
        • Solubility - water
        • Deficiency disease - ariboflanisosis (mouth lesions, seborrhea, and vascularization of the cornea).
        • Overdose disease - no known complications. Excess is excreted in urine.
      • Vitamin B3
        • chemical name - niacin.
        • Solubility - water.
        • Deficiency disease - pellagra.
        • Overdose disease - liver damage, skin problems, and gastrointestinal complaints, plus other problems.
      • Vitamin B5
        • chemical name -pantothenic acid.
        • Solubility - water.
        • Deficiency disease - paresthesia (tingling, pricking, or numbness of the skin with no apparent long-term physical effect).
        • Overdose disease - none reported.
      • Vitamin B6
        • chemical name - pyridoxamine, pyridoxal.
        • Solubility - water.
        • Deficiency disease - anemia, peripheral neuropathy.
        • Overdose disease - nerve damage, proprioception is impaired (ability to sense stimuli within your own body is undermined).
      • Vitamin B7
        • chemical name - biotin.
        • Solubility - water.
        • Deficiency disease - dermatitis, enteritis.
        • Overdose disease - none reported.
      • Vitamin B9
        • chemical name - folinic acid.
        • Solubility - water.
        • Deficiency disease - birth defects during pregnancy, such as neural tube.
        • Overdose disease - seizure threshold possibly diminished.
      • Vitamin B12
        • chemical name - cyanocobalamin, hydroxycobalamin, methylcobalamin.
        • Solubility - water.
        • Deficiency disease - megaloblastic anemia (red blood cells without nucleus).
        • Overdose disease - none reported.
      • Vitamin C
        • chemical name - ascorbic acid.
        • Solubility - water.
        • Deficiency disease - scurvy, which can lead to a large number of complications.
        • Overdose disease - vitamin C megadosage - diarrhea, nausea, skin irritation, burning upon urination, depletion of the mineral copper, and higher risk of kidney stones.
      • Vitamin D
        • chemical name - ergocalciferol, cholecalciferol.
        • Solubility - fat.
        • Deficiency disease - rickets, osteomalacia (softening of bone), recent studies indicate higher risk of some cancers.
        • Overdose disease - hypervitaminosis D (headache, weakness, disturbed digestion, increased blood pressure, and tissue calcification).
      • Vitamin E
        • chemical name - tocotrienols.
        • Solubility - fat.
        • Deficiency disease - very rare, may include hemolytic anemia in newborn babies.
        • Overdose disease - one study reported higher risk of congestive heart failure.
      • Vitamin K
        • chemical name - phylloquinone, menaquinones.
        • Solubility - fat.
        • Deficiency disease - greater tendency to bleed.
        • Overdose disease - may undermine effects of warfarin.Most foods contain a combination of some, or all of the seven nutrient classes. We require some nutrients regularly, and others less frequently. Poor health may be the result of either not enough or too much of a nutrient, or some nutrients - an imbalance.
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    Malnutrition: Early Detection

    This section looks at feasible ways to timely detect and refer children with malnutrition from primary health care units and communities.

    Growth Monitoring Chart
    • Plotting the Weight on the Growth Monitoring Chart 
    • Interpretation of good or bad Growth 
    • Challenges with the Growth Monitoring Chart 

    Detection and Referral of Children with Acute Malnutrition
    • Screening for Acute Malnutrition 
    • Interpretation of Mid-Upper Arm Circumference (MUAC) indicators 
    • Setting up a referral system for Acute Malnutrition (community and facility level) 
    • MUAC Resources 

    Detection and Referral of Micronutrient Deficiencies
    • Clinical Signs of Iron Deficiency Anaemia, Vitamin A Deficiency and Iodine Deficiency Disorders 
    • Detection and Referral of Severe Anaemia

    Growth Monitoring Chart

    Plotting the weight on the Growth Monitoring Chart




    Growth Monitoring ChartGrowth Monitoring Chart
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    Three steps for appropriate plotting include:
    • Find the child's age on the chart 
      • The first box called "Born" on the horizontal axis should be filled with the name of the month the child was born (i.e. March). All the other boxes should be filled with the subsequent months (i.e. April, May, June, etc). Based on the month, mark a straight dotted line up the middle of the column.
    • Find the child's weight on the chart. 
      • The vertical axis of the growth chart indicates the weight of the child in kilos. Based on the child weight, follow the horizontal faint line across corresponding to the child weight (to the nearest 100g) across the card until it crosses the right month column. Put a dot in the middle of the column representing the month of weighing.
    • Draw the Growth Curve. 
      • Draw a line from the previous dot, if any, to the new one to make the child's growth curve.


    Interpreting Good or Bad Growth
    Good Growth

    • The child has gained enough weight if the curve is going up and the slope is parallel to one of the reference curves.
    • Even if the child is small, the growth curve should still go up and should be parallel to one of the reference curves to show the child is growing well.
    • If the child has missed one growth monitoring session, the "At 60 days" column of the Table of Minimum Expected Weight Gain should be used to calculate the child's expected weight, based upon his/her weight of two months before. The child's growth will be classified as adequate or inadequate.
    • If the child has missed two or more growth monitoring sessions, the child's weight should be plot on the growth card but it can not be joint with the previous dot. The "Adequate growth" can be assessed only in the next month.
    Bad Growth
    • The child growth is static if the curve is flat. This is a dangerous sign that need to be further investigated.
    • The child has lost weight if the child's growth curve shows a downward direction.
    • The child's growth is slowing and the weight gain is less than expected if the curve is less steep than the reference curve.

    Using the Table of Minimum Expected Weight Gain

    • Every child, whether big or small, should gain a known amount of weight each month if she/he is growing well.
    • The table of expected minimum weight gain gives the expected weights after one month and after two months. It is useful to check on a child's growth to determine whether a child has gained an adequate amount of weight or not.
    • Children should be referred for suspected acute malnutrition in the following cases:
    • They do not gain weight for more than two months.
    • They are losing weight.
    • They are falling below the bottom line:

    Challenges with the Growth Monitoring Chart

    • The birth weight is recorded for delivery at health facilities but seldom for home delivery.
    • The date of the weighing and the weight of child are not always recorded.
    • The weight is not always plotted in the chart.
    • Special events witch may affect children growth are not recorded.
    • After the immunization cycle is completed, children are not taken anymore on a monthly / two monthly bases making it difficult to plot their growth.
    • Very often nutrition counselling and health education is not given along the weighing session due to lack of time and personnel.
    • Even if the weight-below-the-curve indicates suspicion of acute malnutrition, it is not a diagnostic feature. 
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    Malnutrition: Impact

    Pregnant and lactating women and young children less than three years are most vulnerable to malnutrition.

    Scientific evidence has shown that beyond the age of 2-3 years, the effects of chronic malnutrition are irreversible. This means that to break the intergenerational transmission of poverty and malnutrition, children at risk must be reached during their first two years of life.

    Child malnutrition is the single biggest contributor to under-five mortality due to greater susceptibility to infections and slow recovery from illness.

    Children who do not reach their optimum height or consistently experience bouts of weight loss during childhood are affected in the long term in numerous ways. They do not reach their optimum size as adults (and so may have less physical capacity for work), their brains are affected (resulting in lower IQs) and they are at greater risk of infection (which kills many children during their early years).

    Child malnutrition impacts on education attainment. The degree of cognitive impairments is directly related to the severity of stunting and Iron Deficiency Anaemia. Studies show that stunted children in the first two years of life have lower cognitive test scores, delayed enrolment, higher absenteeism and more class repetition compared with non stunted children. Vitamin A deficiency reduces immunity and increases the incidence and gravity of infectious diseases resulting in increased school absenteeism.

    Child malnutrition impacts on economic productivity. The mental impairment caused by iodine deficiency is permanent and directly linked to productivity loss. The loss from stunting is calculated as 1.38% reduced productivity for every 1% decrease in height while 1% reduced productivity is estimated for every 1% drop in iron status (source Haddad and Bouis, 1990).

    Maternal malnutrition increases the risk of poor pregnancy outcomes including obstructed labour, premature or low-birth-weight babies and postpartum haemorrhage. Severe anaemia during pregnancy is linked to increased mortality at labour.

    Low-birth-weight is a significant contributor to infant mortality. Moreover, low birth-weight babies who survive are likely to suffer growth retardation and illness throughout their childhood, adolescence and into adulthood. Growth-retarded adult women are likely to carry on the vicious cycle of malnutrition by giving birth to low birth-weight babies.
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    Malnutrition: Underlying Causes

    The main underlying preconditions that determine adequate nutrition are food, health and care: the degree of an individual’s or a household’s access to these preconditions affect how well they are nourished

    Food quantity and quality:
    Food security exists when, at all times, everyone has access to and control over sufficient quantities and quality of food needed for an active and healthy life. For a household this means the ability to secure adequate food to meet the dietary requirements of all its members, either through their own production or through food purchases. Food production depends on a wide range of factors, including access to fertile land, availability of labour, appropriate seeds and tools and climatic conditions. Factors affecting food purchases include household income and assets as well as food availability and price in local markets. In emergency situations, other factors may come into play including physical security and mobility, the integrity of markets and access to land. (Reference: Measuring and interpreting Malnutrition and Mortality (manual); WFP and CDC; 2005)

    On an immediate level, malnutrition results from an imbalance between the required amount of nutrients by the body and the actual amount of nutrients introduced or absorbed by the body.

    Adequacy of food intake relates to:
    • The quantity of food consumed
    • The quality of the overall diet with respect to various macronutrients and micronutrients.
    • The energy density and palatability of the food consumed
    • How frequently the food is consumed.
    Health and Sanitation Environment:
    Access to good quality health services including affordability, safe water supplies, adequate sanitation and good housing are preconditions for adequate nutrition. Inadequate sanitation and hygiene is a major contributing factor for anaemia due to the link with intestinal worm infection.

    Health and nutrition are closely linked in a “malnutrition-infection cycle” in which diseases contribute to malnutrition, and malnutrition makes an individual more susceptible to disease. Malnutrition is the result of inadequate dietary intake, disease or both. Disease contributes through loss of appetite, malabsorption of nutrients, loss of nutrients through diarrhoea or vomiting. If the body's metabolism is altered the greater the risk is of malnutrition.

    Social and Care Environment
    The social and care environment within the household and local community also can directly influence malnutrition. Appropriate childcare, which includes infant and young child feeding practices, is an essential element of good nutrition and health. Cultural factors and resources such as income, time and knowledge also influence caring practices as well as attitudes to modern health services, water supplies and sanitation.

    While it is true that improving care for young children is vital, the emphasis on behavioural change should be accompanied by an understanding and commitment to addressing the economic constraints placed on caregivers.
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    Malnutrition: Micronutrient Deficiencies

    Iron Deficiency Anaemia (IDA)

    When people do not get enough iron in their diet, their blood becomes weak and cannot carry enough oxygen around the body. Iron Deficiency Anaemia affects women and children in particular, as well as adolescents and the elderly. It makes people feel exhausted and slows down learning in children. Anaemia increases the risk of problems for mother and baby during and after delivery.

    Signs of anaemia include a pale tongue and inside of the lips, tiredness and breathlessness.

    Key behaviours to prevent anaemia include:
    • Increase Iron intake through:
      • Iron-rich vegetables like dark green vegetables (spinach, parsley and broccoli), millet, beans, pulses, nuts, pumpkin seeds, dates, dried fruits, wholegrains and wheatgerm.
      • Red meat, organ meats (kidney and liver), egg yolks.
      • Fortified foods available in the market or use of sprinkles.
      • Eat "Iron Helpers" such as guava, oranges, lemon or other Vitamin-C sources
      • Avoid 'Iron Blockers' like tea, coffee and milk for one hour before and one hour after eating an iron-rich meal.
    • Prevent Malaria
      • Sleep under treated mosquito nets.
      • Get treated for malaria immediately.
      • Based on Ante-Natal Care Policy, get 2 doses of Intermittent Preventive Treatment (IPT).
    • Prevent hookworm
      • Take de-worming tablets twice a year.
      • Wear shoes to avoid hookworm.
      • Dispose faeces properly.
      • Wash your hands and your nails thoroughly before preparing food and eating
    • Take iron tablets as directed by a health worker:
      • Pregnant women should take one tablet of iron and folic acid every day for 6 months. Ante-Natal Care policy.
      • Children 6-24 months should take one dose daily for 6-18 months depending upon anaemia prevalence. Infants born premature or with low-birth-weight are expected to start at 2 months. IDA Management Protocol.


    All young children not on breast milk (especially those on animal's milk) should be screened regularly using pallor because they are at high risk of IDA.

    Women and children found with evident pallor need to receive treatment dose of Iron based on the National IDA Management Protocol:

    Vitamin A Deficiency (VAD)

    Vitamin A deficiency can occur when people do not eat enough foods containing vitamin A or fat. Vitamin A deficiency can cause night blindness and permanent damage to the eyes, blindness and even death.

    People at risk from vitamin A deficiency are mostly pregnant and breastfeeding mothers and children.

    Key behaviours to prevent Vitamin A Deficiency (VAD):
    • Increase Vitamin A intake through consumption of yellow / orange fruits and vegetables andfortified foods available in the market.
    • Because Vitamin A is fat-soluble you should ensure you get an adequate source of fat and oil. Good sources of these that can be grown at home include sunflower oil, nuts and seeds (ground-nuts, sesame seeds, round-nuts, sunflower seeds, pumpkin seeds), peanut butter and avocado.
    • Infants should be exclusively breastfed for the first six months and continue to be breastfed up to twenty-four months.
    • Mothers should take Vitamin A within 8 weeks after giving birth (200,000 IU).
    • Children from 6 to 59 months should get Vitamin A supplementation orally every 6 months (6 months - 1 year: 100,000 IU; >1 year: 200,000 IU).

    Adults with impaired immune systems and children suffering from measles, persistent diarrhoea, acute respiratory infection, chickenpox, severe malnutrition and xerophtalmia should receive treatment dose of Vitamin A according to the VAD Management Protocol.

    Iodine Deficiency Disorders (IDD)

    Iodine is found in fish that live in the sea or iodised salt. Iodine deficiency can cause growth problems in children as well as hinder brain development. Iodine Deficiency can lead to different grades of goitre and cretinism. Goitre (Grade 2) is characterized by a palpable and visibly enlarged thyroid with neck in normal position.

    All landlocked populations that can not access sea food are at risk of IDD. Goitre is highest in adolescence, particularly girls.

    Key behaviours to prevent Iodine Deficiency Disorders (IDD):
    • Purchase packaged iodized salt.
    • Store packaged iodized salt faraway from heat and from moisture.
    • Add salt before serving the food.
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    Malnutrition: Anthropometric Definitions

    Stunted: Stunted growth refers to low height-for-age, when a child is short for his/her age but not necessarily thin. Also known as chronic malnutrition, this carries long-term developmental risks.

    Under-weight: Under-weight refers to low weight-for-age, when a child can be either thin or short for his/her age. This reflects a combination of chronic and acute malnutrition.

    Stunted and Under-weight children are most likely to suffer from impaired development and are more vulnerable to disease and illness.

    Mothers should monitor their babies' growth from birth by taking them monthly to the local clinic where they will be weighed and have their growth plotted on a chart. This should ensure that correct information and advice are provided to mothers support the appropriate growth of their babies.

    Wasted: Wasted refers to low weight-for-height where a child is thin for his/her height but not necessarily short. Also known as acute malnutrition, this carries an immediate increased risk of morbidity and mortality. Wasted children have a 5-20 times higher risk of dying from common diseases like diarrhoea or pneumonia than normally nourished children.

    Based on anthropometric criteria, acute malnutrition can be divided into severe or moderate. Children with acute malnutrition need immediate medical attention. A child suffering from severe malnutrition is at risk of dying if not treated immediately.

    Marasmus: When children do not get enough energy-giving food their bodies become thin and they feel weak. Children with marasmus look old and wrinkled. Their skin is dry and their faces are thin, with sunken cheeks and large eyes. Their abdomen looks swollen. They present sagging skin on legs and buttocks. Children with marasmus cry a lot, are very irritable and have increased greedy appetite. They are liable to all kind of disease.

    Kwashiorkor: When children do not get enough variety of the right kind of food, for example when they eat only cereal-based porridge, their bodies (especially their stomachs and legs) swell so they may look fat. Micronutrient deficiency, particularly anti-oxidant nutrients, might be a probable cause. Sores develop on their skin and at the corner of their mouths. Their skin becomes pale and starts to peel off. Kwashiorkor children are most likely to lose their appetite and an interest in their surroundings.

    Kwashiorkor children present with what is called pitting oedema in both feet and lower limbs. Oedema can also expand to the whole body.

    Marasmus and kwashiorkor symptoms can be combined. A child suffering from these conditions is at risk of dying.
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