 Hello everyone, welcome to my session 1 on Mutual Infant Young Child Nutrition and Experience from Fields. Here in this session I will be discussing about NFHS4 and 5Data which has just come out. I will be talking about what is the definition of Mutual Infant Young Child Nutrition. I will also touch base upon our data from different projects that we have done in urban slums as well as in rural areas, tribal areas, you know, at a district level. Now we are also doing project at a state level. So I will be discussing that and I will also discuss about what are the important, what are the frameworks, you know, on what frameworks we created this program specifically in urban slums. So I will be discussing about the framework of Mutual Infant Young Child Nutrition, the implementation of programs and why all these skills are important, you know, on maternal nutrition, breastfeeding techniques, complementary feedings. So today we will be more of an introduction to the course and I am more than happy to, you know, discuss this burning issue of poor nutrition among maternal and young children in our country. So talking about introduction objectives, basically what is MIYCF? MIYCF is maternal infant young child nutrition. Mutual means pregnant mothers and lactating mothers nutrition and health of course and your infant which is your children between birth to one year of age and their children, young children that is under two years of age. So that encompasses basically, you know, feeding practices of not just, you know, young children but also maternal nutrition to your pregnant and lactating mothers. And why it is important? Because this is one of the very important phase in human being's life, you know, where baby is kind of being formed in the womb, you know, during pregnancy and then basically there's a tremendous amount of growth occurring in baby's brain, baby's physical growth, you know. And unfortunately in India, you know, MIYCF practices are not kind of followed correctly. And that's why we have so much of under nutrition, so much of malnutrition, our IYCF indicators, you know, are pretty, very poor actually in India. And I'll be discussing that also a little bit of data on that and what can be done in the field. So our own experience of what we did at NGO levels, at district level, and now we're working at, you know, at a state level. So I will be discussing about that data also and, you know, how we have implemented this program, you know, what can be done, what are the learnings, and we're still learning. It's not that I know everything, but, you know, I'm just discussing basically what we have learned so far. Okay. So coming to our NFHCHES4 data, now what is NFHCHES? NFHCHES is your National Family Health Survey, which is kind of conducted, this is a national level survey, which is conducted every four to five years of, you know, a time period. And recently, NFHCHES5 data just came out yesterday. In fact, I'm talking about the national level data. So far we had about 22 state and union territory data coming from NFHCHES5, which was conducted around, say, around November 2019 or so during that time frame period. Okay. But since it just came out yesterday, I don't have a lot of slides on NFHCHES5, which I will eventually have by probably by three or four weeks, you know, on the third or fourth session actually. But let's discuss about NFHCHES4. Okay. And I want to kind of show you what is the problem, you know, at a grassroot level when you look at, you know, all these children, what data basically came out from NFHCHES4. Okay. So here is one slide where we have basically plotted children's nutrition indicators. Okay. So I would say in this case, malnutrition indicators. Okay. And then looking at the percentage wise that how many children are malnourished in India as far as NFHCHES4. Okay. So looking at the age wise, so here this is your red line is your wasting. Okay. Again, I'll be talking about wasting in my, you know, growth chart session. And also in second session, which will be on, you know, nutrition science of nutrition, malnutrition. And I'll be discussing about what are the types of malnutrition. So looking at, you know, just general viewpoint of how children are doing as well NFHCHES4 data. So our red line indicates children are too thin. Okay. Too thin for the height. Okay. That is also called wasting. Then you have this yellow bar, which is your underweight. So children basically weigh less than what they are supposed to be at that age. Okay. So that's weight for age is basically your underweight area. And blue line is stunting. Stunting means short. Okay. How short children are. So if you look at the age wise data, look at this red line. Okay. We'll follow red line first, which is children are too thin. Okay. For the height or length. So zero to two months of age, you can see there's a 34.3% children are too thin for the height. In under two years, actually, we call it length. So they are too thin for the length. Look at this. This line is highest when it comes to age wise criteria. So zero to two months is 34.3. As child become older, so three months, four to five months, six months, seven to 12 months, you can see there's not much change, slight change in those wasted children. Okay. That means that for six months of age, children are not getting proper nutrition. What I mean is that of course, many of our children are breastfed, but with proper breastfeeding, this wasting should come down. They should start gaining weight pretty quickly, you know, when children and mothers are taught proper breastfeeding skills. So this is not happening in dinner. You know, almost those children who are born wasted, they kind of taste wasted, not many children come out of it. In fact, many children may come out it, but lot more children have growth faltering. So, you know, when we work in the field and when we collect data, we see there's a tremendous amount of children, there is a growth faltering. Now growth faltering, you know, may not be so much that it shows up on this graph, but there is definitely a lot of growth faltering occurring in most of our children, you know, and many of the children are not breastfed. So they are on cow's milk. So they do get a lot of diarrhea. They get, you know, a lot of other problems of formula feeding or cow milk feeding and that I will discuss more detail when I come to that session. Okay. So, and then what happens after one to two years of age, this kind of wasting goes down, as you can see from 27%, it went down to 21.6%, then 18.7% and 17.8%. But, you know, coming from my experience, this, the SAM, you know, this acute malnutrition also called wasted children or toothed children, they basically get mask because what happens is when you look at their blue, blue line, okay, now blue line, look at this is stunting, stunting with children are born short. Born short or they stay short or they become short, any of the three could be possibility, okay. So, stunting at birth, I say between zero to two months is almost 20%, okay. Now the stunting kind of stays similar till six months of age. That means there is no reversal of stunting. And in fact, many children probably are falling into a stunting under six months of age. And when children don't have proper milk transfer, milk transfer means transfer from mothers to babies, then, you know, as wasting increases, as underweight increases, your stunting starts showing up, okay. Stunting is more of a long term, it's a long term phenomenon. It's not something which is acute, it takes time for child to not grow, you know, first the weight will not grow, and then the height will not grow or the length will not grow, okay. So, here what we are seeing is basically by seven to 12 months of age, look at the stunting level going up, okay, from 19.11 at six months to 24.8. That means this section, seven to 12 months is the time period where mother is introducing solid food, okay. So, in the setting of poor nutrition under six months of age, when children are now not fed proper food, okay, which are diversely, I mean, diverse diet I would call, those children then should continue to not grow or they become the stunting sets in, you know, in fact, the stunting sets in from for six months. And I would in fact go back to even a mother's nutrition, if mother's nutrition is not good, you know, stunting sets in at birth, and then poor milk transfer or, you know, basically formula intake or, you know, even of those, you know, cow milk. In our setting in India, it causes, I mean, of course, it causes problem in any child, anywhere in the world. But in developing world, what we have is basically we don't have clean water, we don't have access to, you know, good sanitation, we don't have very good wash program. So, this shouldn't they get frequent diaries, frequent pneumonia as in a children who are on formula fact. Now, what problem we see in us, you know, where I come from us, where most of the children are on formula feeding, but because of good nutrition, you know, they continue to grow well. But problem with formula feeding is it is basically highly ultra process food, you know, so this children are very high risk of developing, you know, not only cow milk protein allergy, but also allergic diseases, you know, asthma, we see a lot of this skin problem, you know, something called like Zima. We also see this children are very obese, you know. In fact, you know, by one, two years of age, they are overweight, they're obese and we are type two diabetes and by three to four years of age in US now, you know. So, basically, formula or cow milk protein is absolutely no no for in any country, but in India specifically, definitely no, because we don't have access to clean water in, you know, in our public health system, you know, so the children are very high risk of diarrhea. Okay. But now look at, you know, now we have almost, you know, NFS, NFS 5 data came out and we have exclusive breastfeeding rate up to 62%. So even those children who are exclusively breastfed are not getting proper milk transfer because of inadequate skills and mothers and healthcare workers. Okay. And when in that setting, when children are children, they start growing by seven to 12 months of age, the introduction of complementary feeding is so poor that, you know, the children, they just don't do well even after seven months of age. So the stunting congenital increase, your underweight, you know, underweight is your yellow color. So you can see the underweight also kind of remains the same, you know, 24.7% at birth to almost 26% at six months. So again, you know, that milk transfer has not occurred well. And then by six months after six months, as you can see, poor introduction of solid food causes decrease in, you know, poor weight gain in children. And because of poor introduction of solid food, look at what happens at one to two years of age, tremendous for growth faulting in terms of weight and length of this children. Okay, length we call it for under two years of age, height is between two to five years of age. So look at this almost doubling of, you know, stunting, which is your height, poor height from nine from 20% to 43%. So more than double. Okay. Why this sudden increase and stunting, because this stunting has not started just from one year of age, it has the stunting setting has started from literally from, from mother's nutrition to, to birth to first six months to six to 12 months. So everything has gone wrong. And this is when you're showing up, you know, child is showing up as a kind of severely stunted or moderately stunted, you know, at one year of age. And again, the underweight goes up. So you can see, see how children are just not growing. And the underweight continues to rise, you know, your stunting, basically, there is no change whatsoever in stunting level also. And, you know, because children are stunted so much, so as per that length of the child, you know, child weight is absolutely lower, lower, obviously, because children are, you know, small, the pain, the bone weight is low, you know, there's lean mass, which is not enough. Okay. So those children are going to be obviously kind of underweight. So when you look at the, compare the data of length for, or the weight for length, or the weight for height, these children, because they're bones, they are small, so their weight is small. Okay. So these children are undernourished. But when you look at the acute malnutrition, when you look at, when you compare the weight for length criteria, these children may look okay. Okay. So here, that's why you were seeing that, you know, the sand children or man children wasting is going down, but it's just masking. You know, basically, what you're not seeing is acute malnutrition so much, you know, although this 21% is pretty high, because 21% it's an emergency, you know. But we have to look at the holistic way of that child, because many times a tall child, you know, this is what I'm talking about my experiences right now, is when you have a tall child who is, you know, sit clean, but he is, he has good nutrition going in, he has good lean mass and all, but he may be tall and lean. Now, those children may show up in wasting. Okay. They may show up as though, you know, for that height that weight is not enough. But if child is metabolically healthy, child does not get infection, child continues to do well, you know, cognitively wise, you know, intelligence wise, then I'm not very too much. Yes, I'm definitely worried about the severe acute malnutrition, but you know, just wasting by itself at just cross point data. I'm not concerned. I'm concerned more about the stunting part and the underweight part, not so much for weight for length or weight for height. Okay. This is my personal view. So this is why we need to take this course to understand the issue and the problems that we are facing in the field and what are the solutions. Okay. So if you can actually fix this area over here, fix mothers nutrition, fix your, you know, breastfeeding skills and fix your complementary feeding intake in children, then basically we will get rid of at least stunting and underweight part. Wasting, wasting is very dynamic. Okay. Wasting is thin for the height or length. It's very dynamic. So dynamic means if a child gets say one episode of diarrhea, okay. And the diarrhea is very severe. Suddenly the child will lose weight. So that child may not kind of, you know, the height will maintain, okay. The length will maintain, but suddenly, you know, child loses weight because of some illness. Child, you know, say refuse to eat for a week in term, in case of diarrhea, pneumonia or any other acute illnesses, then that child will lose weight. So that child will show up in your probably man or Sam, but you know, those are cute illnesses. So once you treat those illnesses, metabolically healthy child will come back right out right out of Sam, man. Okay. It's not again, the bottle line children I see in my experiences, they come out right back once you treat those infections very quickly with, you know, whatever medicine which need to be given, you know, for diarrhea, ORS and zinc work beautifully, you know, but children who are chronically malnourished, children who are metabolically unhealthy, those children once they go into wasting, you know, they stay there. Even if you give them say any of those treatment which are recommended by WHO and UNICEF, you know, those children, they can, they may come out momentarily from those, from that malnutrition, acute malnutrition, but as soon as you stop that treatment, they go back again into Sam, man. I mean, this is a huge issue in India, you know, that means what we're doing is what we're doing for those wasted children, you know, that acute malnutrition, we're momentarily patching them, you know, by giving them calories, giving them protein and all. But what happens? Once you stop it, they go fall back because they're just, they're not healthy to begin with. So my focus is really make them healthy, make them strong, make the lean mass, you know, grow them tall, make them metabolically healthy. And then even if they have minor illnesses, they will come back right out as soon as they, you know, that illnesses go away because appetite comes back. Okay. So that's why, again, my focus is very much on prevention of wasting, prevention of stunting, prevention of underweight. And that's what this I'm going to discuss in this topic. Now, let's start with infant feeding, specifically breastfeeding. Okay, I will come to maternal nutrition in one of my session, but I don't want to discuss that right now. I'm going to talk about basically very, very important issue of breastfeeding. Okay, because what I've seen in my experience, if babies were breastfed well, even if they were born small, even if they were born low birth weight, even if they were born, say, you know, premature, but once that breastfeeding skills were taught to the mother, okay, by healthcare workers or anybody, you know, those babies were absolutely growing very beautifully. Okay, this, this is, we have shown in many projects, you know, and in fact, we are doing this one study, which is almost over. So I'll be analyzing that data, even in that preliminary data, we show that low birth weight babies and even borderline underweight babies, they were growing beautifully on just breastfeeding proper breastfeeding latch. Okay. So here what I want to show you, this is NFHS for data again. So this green bar is basically your exclusive breastfeeding. Okay, this is age wise data that I'm showing you. Okay, the blue one dark blue is your breastfeeding and other milk. So other milk could be your, you know, cow's milk or, you know, your formula or any other animal milk. Okay, red line that the red bar, the dark red is not breastfed at all. Okay, the light red one is breastfeeding and plain water. Okay, so some of these babies were getting water. Okay, there are a lot of myths which are present in people. They feel that when it's hot, you should take, give breast milk, a breast, you know, water with size breast milk. So this are some of the percent of children who get breast milk and plain water. And then some mothers or some families, they start breastfeeding with complementary feeding. Can you imagine they start by less than two months of age, you know? And this is absolutely because of lack of awareness. Okay, so here's, this is the data for less than two months of age. Now, as you can see as the age advances, the exclusive breastfeeding weight goes down. Okay, so look it over here up to four to five months of age, because this is what is the children should be exclusively breastfed. Okay, and look at this, the complementary feeding intake increases, your plain water increases, of course, under six months of age, you know, your complement, your breastfeeding and other milk prevalence increases. But look at your exclusive breastfeeding weight going down tremendously. Why should it go down if babies are gaining weight on breastfeeding? Why should mothers start anything else but breast milk, right? And this is where the issue is that a lot of these babies are not putting on a lot of weight. There's tremendous amount of growth for breastfeeding. And with, and because of that, there is no other choice but mother feel that my baby is not gaining weight, I'm not getting enough milk, you know, and they start top feeds. Okay, and this is the issue. This is the issue I faced in India, really working in slums in tribal areas. Okay, and by six to eight months of age, you can see that now, you know, baby should be started on complementary feeding, you know? So complementary feeding is not started in all the children by a time child is, you know, completing six months, only about I would say less than 50% of children are started complementary feeding. So now you see children are still kind of some children are on exclusive breastfeeding, you know, even up to eight months of age, when they should have been started on complementary feeding. A lot of the children are only getting breast milk and plain water, you know, some of them are getting breast milk and so look at the poor starting point of complementary feeding. Okay, and similarly at nine to 11 months of age, literally almost about 30% of children are not started on complementary feeding. Okay, and this is the important stage after six months, we have to start very nutrient dense complementary food for this children. Okay, so this is the issue in India. This is basically up to one year of age, our IYCF does not start well in India. Okay, this is the NFHS4 data. Now, this is the data of again NFHS4 data. If you look at your minus three standard deviation, okay, which is your weight for length, this is again, you know, your infant would wait for length, the lesson minus standard deviation. And look at the number of children who are acutely malnourished. Okay, acutely malnourished means they are too thin for their length, and this is minus three standard deviation, they are acutely malnourished. Okay, so I'll discuss more what are the standard deviation, you know, why do children become so malnourished, I'll discuss that later. But you know, this are SAM children, so we are good malnourished children. So here, you know, this is your blue zone is your low birth weight babies, low birth weight means less than 2.5 kg. Okay, this is your yellow zone, which is your newborn weight infant. Okay, so this is your, you know, like children who are more than 2.5 kg. And this is your newborn is a normal birth weight. I'm sorry about that. And then green zone is your all infant. So all children basically are normal birth weight as well as your low birth weight babies are basically in green zone. So if you look at, you know, look at the SAM, the average SAM, okay, at around, I would say, under six months of age is almost 20%, you know. And it basically, you can see there's not much difference in SAM status, okay. And this is as per WHO criteria, say similarly for, you know, normal birth weight, you can see similarly, it's similar. There is not much difference, you know, and average, it's around 20%, okay. And there's not much change slight improvement at around five months of age, you know, again, because children are not growing at all. So the, so the length is not increasing. And as per that, you know, basically, it's SAM is just getting mask, okay. And similarly for all weight children, you know, there is not much change in SAM status, that is, in Indian children. Talking about complementary diversity and if it's just five data, I'm just going to talk about 22 states and unit territories, which data had come out in almost few months ago. So I'll be discussing more about that. You know, look at this few states data, okay. So here is basically, this slide is on complementary food initiation for children age six to eight months. This means how many children were started on complementary food between six to eight months. Now, recommendation is to start as soon as baby finishes six months, which is 180 days. So post 108, on 181 day, the child should be started on complementary feeding, okay. But here, look at this. This is how the number of children who are not started complementary feeding from six to eight months of age, okay. So kind of solid or semi-solid food, you know, is not started. So look at this, Manipura has, you know, so your brown color or your gray color is your NFHS4 and your yellow color, I would say orange color is basically NFHS5. So if you look at it, you know, Manipura has a very good initiation. So pretty much, you know, almost 80% children, they are started on complementary feeding between six to eight months of age. But as we go down, you know, look at Tripura or Bihar, okay. Of course, there is an improvement in Bihar from NFHS4 to NFHS5. But if you look at it, you know, it's only about, you know, I'd say around 40% children are getting initiated on complementary feeding at the right age, okay. Tripura also remarkable improvement in complementary feeding, you know, but I don't see much improvement in Telangana, you know, I don't see much improvement in, you know, many of these other states, in Mizoram, the complementary feeding state is not doing very well, okay. So this is our data of some of the, some of the states. Now, this is a slide on breastfeeding children. So children who are breastfed between six to 23 months of age, who are receiving adequate diet, okay. So adequate diet is your dietary diversity and frequency, okay. And that basically any amount of course. So this is what it shows that in Meghalaya and this is the difference between NFHS4 and NFHS5 data, okay. So you can see that, you know, literally look at this, you know, most of our children are not kind of given minimum medical diet, MAD, we call it MAD, minimum medical diet. So they are not getting minimum medical diet and a lot of these children, you know, recently data just came out and only about 11 to 12% children in NFHS5 data are receiving minimum medical diet. That's very, very, very low, okay. In some states like Gujarat, we have only 5% children who are getting minimum medical diet. That is your minimum dietary diversity. I will discuss that later in my other sessions. But only 5% children in Gujarat. Gujarat is economically advanced state, okay. One of the very advanced state. I'm talking about economy-wise. And if those children are getting only 5% of, only 5% children are getting minimum medical diet. So you can just imagine what must be happening at the state. But it just again, the lack of knowledge is not the access to food in most of these areas, you know, because I worked in again, a lot of areas, urban slums, you know, tribal areas. So there is access to food. It's not that there is no access. It's just that it is kind of, you know, lack of awareness from when it comes to mothers, families, members and, you know, healthcare workers. And we can improve that remarkably, okay. This is basically, as you can see, in NFHS5, 17 out of 22 states have improved total dietary diversity. But we can definitely do better, okay. Again, you can see, you know, most of the states, they have about, you know, say, 22, between 15 to 22% minimum medical diet in children, local children. And of course, look at this different other states like Andhra Pradesh, you know, Gujarat, minimum medical diet is very, very low. Okay. So WHO growth charts, I'll be discussing this in detail in next session. Hi, everyone. I hope you liked my first part of the first session. Here I discussed about NFHS4 and NFHS5 data. And I'm sure you understood, you know, our young children are really undernourished. 30% of them are undernourished. That is quite a lot. In fact, severely malnourished children who when they are admitted in, you know, NRCs, NRCs are basically nutrition rehabilitation centers. You know, these are centers created by government to take care of this really malnourished, acutely malnourished children. And, you know, those are basically for under five years. But 30% of children who are admitted in this NRCs are under six months of age. So you can imagine that how important this first six months is because, you know, one third children were malnourished from this age group. So that's why I discussed a lot about breastfeeding and, you know, kind of stunting, wasting and underweight under six months of age. So thank you so much. Now I'll be, you know, talking about the second part of the first session. And I'll see you then. Thanks.