Preventing infant growth faltering through improvements in the government supplementary nutrition program and growth monitoring

An inspection of thegrowth of children in the first 5 years, from findings of the NFHS-4 survey,shows that they are born with a reasonable length for age (LAZ), but thenfalter in growth dramatically in the first 2 years of life. Thismeans the proportion of stunted children at birth is low but rises to about30-40% by the end of 2 years, and after that, they remain fairly stable, with astunting prevalence of about 30-40%. It is thusimportant to intervene before 2 years of life in order to prevent growthfaltering rather than chase stunting when it has already occurred. The factorsrelated to growth faltering are multifarious; nutrition and WASH are among themodifiable elements and have often been the focus of interventions to reduce stunting.Systematic reviews examining stunting as an outcome have emphasized theimportance of combining nutrition-specific and nutrition-sensitiveinterventions to tackle the problem. In this context, optimization ofcomplementary feeding is crucial for early life growth and development. Governmentprograms, mainly the ICDS, are comprehensive and targets beneficiaries(pregnant, lactating women and children <6 y) to improve their nutritionalstatus. Strengthening the nutrition-specific and -sensitive components of theprogram will yield additional benefits in light of the recent data available onprotein quality of complementary foods in children.

Childrenfrom 6 months to 2 years receive nutrition support through the supplementarynutrition program (SNP) of the ICDS in the form of a Take Home Ration (THR).The THR includes both raw food grains (rice, wheat, mung bean and otherlegumes) and a multigrain mix with or without added micronutrients. The qualityand/or quantity are considered poor by the demand side (community) and whenassessed for macronutrient quality. It is predominantly cereal-based, has poorprotein quality (unless milk protein is provided) and is particularly low infat. A detailed analysis of the situation and improvisation of the THR mightbenefit efforts in the reduction of growth faltering. An intervention thatfocuses on growth as the primary outcome requires robust methods of growthmonitoring. Although weight is regularly assessed in the ICDS program,length/height are not routinely assessed owing to the difficulty in measurementand unavailability of resources.   A combination of interventions are planned:

-  Useof an improvised or modified THR integrated into complementary feeding

- Regular and longitudinal growth monitoring

•  Regular feedback and alerts with achecklist-based approach to management of growth faltering

- Regular nutrition and WASH education

The design of the intervention and their interpretation will be sharedand discussed through roundtables with paediatricians and nutritionists whoadvise the state on THR (Food and Nutrition Board, MoWCD), with officials fromconcerned ministries. This will be facilitated by the involvement of the StateHealth University, which is closely linked to medical education, research andhealth policy engagement. This proposal aims toutilize learnings and efforts to produce a modified THR and a hand-held devicewith a monitoring app for linear growth monitoring in an intervention mode to reducegrowth faltering in <2 y children, in selected districts of Karnataka. Toensure adequate uptake andutilization of learnings at the policy level, from the proposed interventionsthe program will engage with government pediatricians and nutritionists(through collaboration with the Rajiv Gandhi University of Health Sciences,which is the nodal Health University of Karnataka, and to which all teachingGovernment Hospitals are affiliated), and with the Government officials(independently and through the University, which has several links with thehealth system), as well as with NIN and the National Technical Board forNutrition (NTBN) at the NITI Aayog. This is critical, so that the design of theinitial evaluations, and their interpretation, are completely participatory, forsubsequent leverage of findings, and stakeholder-based scale up to moredistricts and more states.