MODULE 6 IDENTIFICATION, MANAGEMENT, AN D PREVENTION OF COMMON NUTRITIONAL DEFICIENCIES

LEARNING OBJECTIVES

After studying this chapter, taking part in the discussions, and doing the exercises, a community health worker should be able to: · Recognize the main types of protein-energy malnutrition in order to be able to take appropriate action. · Explain the main causes of protein-energy malnutrition to the mothers. · Identify children at risk of developing protein-energy malnutrition and advise their parents. · Help parents to improve the diet of those children who are suffering from moderate malnutrition. · Identify children with vitamin A deficiency, those at risk of developing this deficiency, and take action to treat and prevent vitamin A deficiency. · Identify children with anaemia and those at risk of becoming anaemic, and take action to treat and prevent anaemia.

TRAINING CONTENT

Recognizing the main types of protein-energy malnutrition

A person develops protein-energy malnutrition when: (a) his diet does not contain enough protein- and energy-giving foods; (b) the absorption of energy-giving nutrients and protein is reduced because of illness; and (c) increased need for protein and energy-giving nutrients in illness is not met. Energy deficiency is probably more common and important than protein deficiency. Usually if a diet is adequate in energy, it will contain enough protein. Protein-energy malnutrition is a very common condition among children under 5 years of age in poor communities. In some countries 4 out of 5 young children have some degree of this malnutrition, and 1 out of 10 will be seriously affected by it. This means there are millions of children with protein-energy malnutrition in the world. Children with such malnutrition have a much higher death rate than adequately nourished children. Protein-energy malnutrition and infectious diseases often occur together; this is discussed further in Module 7.

It is important to identify children with malnutrition at the earliest possible stage in order to cure them more effectively.

The first sign of all forms of protein-energy malnutrition is growth failure. The importance and methods of measuring growth are described in Module 2. Growth failure can be seen most clearly on a child's growth chart. Weeks or months before a child looks malnourished he will have stopped growing. Weighing a child regularly, plotting the weights on a growth chart, and noting the direction of the growth line are the most important steps in recognizing early malnutrition. The severe forms of malnutrition are described below, but a community health worker should be able to identify cases of malnutrition at an early stage when there is growth failure. The severe forms will never occur if the community health workers take appropriate measures at the first sign of growth failure.

Growth failure is the earliest sign of protein-energy malnutrition.

There are two severe types of protein-energy malnutrition: nutritional marasmus (Fig. 29) and kwashiorkor (Fig. 30).

Marasmus

Children with marasmus are very thin and wasted. They have been called "skin-and-bone children". The fat under the skin has been used up, and there are loose folds of skin over the arms, legs, and buttocks. The muscles are wasted and as a result the arms and legs are thin and all the bones stand out. The abdomen is distended, partly because the abdominal muscles are weak. The face is also wrinkled and the bones stand out. The child looks like a "worried old man". The hair is usually normal in colour, but may be rather sparse (not thick). Marasmic children are usually hungry.

The growth chart of a typical marasmic child is shown in Fig. 31. The growth failure starts early in life (most marasmic children are between the ages of 6 and 24 months).

Malnutrition is a chronic condition. When a child has been malnourished for a long time the growth failure can be seen in several ways. He is not only thinner than a normal child of the same age (wasted), but also shorter (stunted) (Fig. 32).

Children from poor families fed on bottle milk from the early months of life often develop marasmus. This is usually because the milk is diluted too much or repeated infections in the child reduce his appetite and the child refuses to eat or drink. Diluted milk does not have enough energy and other nutrients in it. Furthermore, the milk is fed through dirty bottles and as a result the children often suffer from diarrhoea. This leads to marasmus, and the children weigh about half the weight of healthy children of their age.

FIGURE

FIGURE

Kwashiorkor

This is the more serious form of protein-energy malnutrition. The most evident sign of this condition is body swelling (called oedema), especially swelling of the face, forearms, hands, legs, and feet. The abdomen, and genitals may also be swollen. It is possible to make a mistake and think that these children are fat. Test the swelling over the front of the lower leg bone. Press with your thumb for half a minute. There will be a hollow depression when you remove your thumb. This does not happen with a child who is just fat.

Children with kwashiorkor are always unhappy and often irritable. Many of them cry for long periods. They sit still and take no interest in anything, not even in food. Many of them have no appetite. Some children with kwashiorkor have abnormal skin and hair. The skin is often paler than normal, and over the legs there may be lines and cracks. Sometimes, dark patches of chocolate or brown colour appear on the skin. Sometimes the skin peels off in small pieces like old paint. Some children have sores from which fluid flows. The hair of some children with kwashiorkor is pale, brownish, white, and sparse, and the hairs are thin and break easily.

Kwashiorkor is also associated with other conditions, including infections. The growth chart of a typical child with kwashiorkor is shown in Fig. 33. Kwashiorkor may occur at a later age than marasmus, often in children aged between 18 and 48 months. In Fig. 32 notice that the child was growing quite well until he was over 2 years old. Then he had an attack of measles, and soon after that he developed kwashiorkor. Children with kwashiorkor may also have anaemia and vitamin A deficiency that affects the eyes (see sections on vitamin A deficiency and anaemia below).

While examining a child suspected of suffering from kwashiorkor, look carefully at the upper arms, shoulders, and chest. If there is wasting and the bones stand out, the child is said to have marasmic kwashiorkor. Because of the swelling, the wasting of the legs is not seen.

The signs of protein-energy malnutrition (wasting, swelling, changes in skin and hair) are all quite easy to see. Remember, however, that the most important and early sign of malnutrition is growth failure. This will only be detected if children are weighed regularly and their weights are plotted on growth charts each time they are weighed.

Regular weighing of children is the best way to detect protein-energy malnutrition.

FIGURE

FIGURE

Understanding the causes of protein-energy malnutrition

General factors

Malnutrition is caused by a number of complex and closely related factors which relate to the social and economic condition of the family. Some of the general factors are: poverty, ignorance, superstition, lack of food, inadequate hygiene (lack of cleanliness), and infectious diseases in the area where the family lives. The interrelationship of these factors is complex and the community health workers need not go into the details. However, these factors cause specific problems about which a community health worker can do something.

Repeated infections and insufficient dietary intake are the main causes of growth failure.

The simplest way of understanding how these factors cause the development of protein energy malnutrition is to take an example of a typical family in a poor community. The family can be big or small. Since the family is very poor both the mother and the father have to go out to work, and often the mother is away from home for the whole day. Their small baby is left at home without any breast milk or any good alternative food for the period the mother is away. Since the baby does not suck frequently enough at the mother's breasts, the mother is not producing enough milk. The family has some incorrect beliefs (superstitions) about feeding any solid food to the child until he is 1 year old. The parents are ignorant and do not have the time to take their children for immunization. As a result the baby is not getting enough breast milk or any other alternative food. He is left alone without his mother. Furthermore, he has not had any immunization and as a result he frequently falls ill with infectious diseases. The combined effect of all these things is protein-energy malnutrition. It is important to note that the community health worker can do a number of things to reverse the effects of poverty, superstition, and ignorance on this child.

FIGURE

Specific factors

So far we have considered some of the general factors that lead to malnutrition. Let us look now at some specific factors:

· Age. Between the ages of 6 months and 48 months, the risk of protein-energy malnutrition is great because the child is growing fast and the food commonly given to the baby is not adequate. On top of this, infectious diseases are very common.

· Sex. In many cultures boys are valued more than girls for social and economic reasons. Girls may be consciously or unconsciously neglected.

· Many children. In large families there is often less food for each person. The smaller children may be neglected because the mother has too much work.

· Short interval between births. If a mother becomes pregnant when her previous baby is only 6 months old, she may neglect the older child. Her breast milk will get less and her time and attention will be concentrated more on the new baby.

· Low birth-weight. Babies who are small at birth have not had enough nourishment in their mother's womb. Many of them become malnourished.

· Twins. These children have a combination of high-risk factors. They are small and may receive only
half as much milk and attention from the mother as a single baby.

· Poor growth in the first few months. This can only be judged by weighing the baby regularly. A child should gain at least 500 grams a month in the first 3 months of life. Many children who gain less weight become malnourished. There may be a number of reasons for this, but the most important is the mother's failure to breast-feed.

· Failure or stoppage of breast-feeding. This may be inevitable if the mother dies soon after the baby is born. Often, however, the mother stops breast-feeding because of the false belief that bottle feeding is modern and therefore good. Sometimes she has to start outside work very soon after the baby is born and there is nowhere to breast-feed him at her place of work.

· Delay in introducing additional food. Breast milk is best and should be given up to 2 years of age. However, other foods should be started after 4 months and increased in amount as the child grows older. If this is not done growth will slow down, and this may be the start of malnutrition.

· Infectious diseases, especially repeated diarrhoea, whooping cough, or measles. Infectious diseases themselves, may result in malnutrition directly or indirectly be cause it is often wrongly thought that a sick child should be given less food than a healthy one.

The risk factors in different communities will vary. Study the economic and social situation of the families of malnournished children. This will show what are the specific causes of malnutrition in a particular area.

Identifying children at a high risk of developing protein-energy malnutrition

A community health worker is responsible for the care of every child born in the community. For each child she must ask herself "Is this child at high risk of malnutrition?" If the answer is "Yes", time and care must be concentrated on that child. Less time will be devoted to those children who are well and are not at risk.

Consider two extreme examples. The only boy child born to the village chief (who owns much land and whose wife is a healthy high-school graduate) has a very low risk of becoming malnourished. On the other hand, the twin daughters of an unemployed labourer whose wife died soon after giving birth to these children are at a very high risk of becoming malnourished and dying. The community health worker must visit these girls very often. Whoever looks after the girls will need much help and encouragement.

Sometimes all the malnourished children may belong to one specific group in the community. For example, these may be the children of landless labourers and their mothers may be illiterate. In such a situation the community health worker should concentrate her attention on that group.

How can the community health worker help the high-risk children and their mothers? The main resources of a community health worker are her knowledge about feeding children and her desire to help. She should make friends with mothers of children at high risk. She should visit these children frequently, especially from 4 months of age. That is when mothers should start introducing other foods. She should gently and repeatedly advise about feeding (see Module 4). Finally she should weigh the children each month. The supervisor should visit the community occasionally and show interest in the progress being made; this will encourage the community health worker and the persons she serves. A programme of visits can be worked out according to the number of children to be visited. In a programme in one large community, visits were made monthly until the malnourished children in that community were 5 months old, then every 2 days until the children had started taking food regularly several times a day, and then about once a week to make sure that the amount of food was being increased. This simple schedule greatly reduced the number of malnourished children in that community. Simple nutritional knowledge combined with concern and compassion can achieve much.

A list of factors increasing the risk of malnutrition is described in Module 1, page 24.

A community health worker can help most children with mild or moderate malnutrition.

Management of children suffering from protein---energy malnutrition

Two groups of children need special help from the community health worker. The first- children at risk of developing protein energy malnutrition-have been considered above. The second group is the children already suffering from protein-energy malnutrition. They can be identified by regularly visiting the homes of high-risk families, by observing the growth charts of children, and by examining children with infectious diseases like measles and diarrhoea. These children can be easily treated at home through better feeding. What the parents can do is described on the following pages.

Modification and improvement of the diet is one method a community health worker can use to manage malnutrition. But it will fail unless the family, and especially the mother of the child, cooperates actively. Convincing the parents that a modified diet is essential for the child may be the most difficult task of the community health worker. The mother should be convinced that what her child needs is not medicine, but a diet which she can afford but which needs careful preparation. A community health worker may know what foods a child should eat' hut the mother must also believe in this and must be willing to make the best use of foods available to the family. Involving the family in the process of recovery is the best way to teach about malnutrition and prevent its recurrence. The parents will learn about better nutrition by seeing their children recover and become healthy. It is important to find out from the mothers why less food is being given to their children and why they follow certain feeding patterns. Proper advice will depend on such understanding.

Some instructions for the better feeding of malnourished children are:

· Give more of the food you are already giving. This is particularly useful if the child is already eating a mixed diet of cereal and legumes, and preferably some vegetables.

· Increase the number of meals per day. This is one good way of giving the child more food. A child with malnutrition should eat 5-6 times a day. Each meal should be substantial and not simply a snack.

· Increase the variety of foods being given. If a child is eating mainly cereals and legumes, gradually add leafy green and other vegetables.

· Add edible oil to the diet if possible. This can be vegetable oil or butter. This will not only increase the energy content of the diet, but also make it tasty and acceptable; as a result, the child will eat more Since oils have high energy, their addition to an infant's diet will make it possible to reduce the bulk of the diet.

· If possible, give some foods which come from animals. Even small amounts of eggs, milk, meat, or fish will help a malnourished child recover rapidly. Usually foods from animals are expensive and poor families do not eat them regularly. Emphasize that these foods are not essential, but will help when the child is seriously malnourished.

Regular weighing is a good way to know the progress of a malnourished child.

The effects of better feeding can be very encouraging to both the parents and the community health worker. Improvement can be seen by regular weighing of the child. Watch for the gain in weight and discuss this with the parents.

Supplementary feeding programmes can be used specifically to help malnourished children. In many countries there are special programmes in which milk or meals are distributed to children below school age. To make the most of the foods available in these programmes, the supplements should be specifically provided to malnourished and high-risk children. The selection of children in the community who really need such supplementary food should be done in consultation with supervisors and community leaders. Mothers should understand that the needs of a malnourished child are urgent, and that the supplementary food should not be shared with the whole family.

The help of the community may be required in the case of malnourished children of very poor families. The community health worker and the health supervisors may be able to persuade community leaders and wealthy farmers to help. These people may provide food for specific children or families in need of urgent help. In the end, better nutrition of the whole community will depend on education and on social and economic development, but there are many useful things a community health worker can do immediately.

Some children needing special care should be referred to the supervisor or health centre.

Some children need very special care because their lives are in great danger. These children should be referred to the supervisor or the health centre. However, they will still need the support and help of the community health worker. The children who need to be referred to the supervisor or the health centre are described below:

· Children with severe malnutrition. These include very wasted marasmic or greatly swollen kwashiorkor children who will not eat.

· Children with complications of malnutrition. These include children with anaemia and eye damage due to vitamin A deficiency (see sections on vitamin A deficiency and anaemia below), and children with signs of infections, high fever, distressed breathing, and repeated diarrhoea.

· Children with moderate malnutrition who do not improve with the feeding and help suggested below. These are children who have some infection which is difficult to diagnose, e.g., tuberculosis. Refer these children to the supervisor or to the health centres.

Identifying children in danger from vitamin A deficiency

A young child needs protein and energy in food to build tissues and to be healthy. To remain healthy the body also needs small amounts of special substances. These are called vitamins and are found in various foods. Vitamin A is one of these special substances which is especially important for the health of the eyes in small children.

Vitamin A deficiency is the main cause of blindness in some countries. Blindness in children can result in a lifetime of misery. Blind children cannot care for themselves and they are a burden on the family. Many blind children are neglected and become malnourished and die. The community health worker can do much to improve this sad situation. She can identify children suffering from early vitamin A deficiency and can recommend treatment. She can prevent vitamin A deficiency by giving suitable dietary advice.

When a child or a person has vitamin A deficiency he cannot see very well in the dark. This condition is called night blindness. This is an early stage of vitamin A deficiency. Ask mothers if they have noticed that their children cannot see properly in late evenings or in semi-darkness. In some areas this disease is so common that there is a local name for it.

Examine the eyes carefully. A child who has vitamin A deficiency has eyeballs which, unlike normal ones, are not moist, smooth and shiny. This condition is called xerophthalmia. This is the early stage of vitamin A deficiency, when foamy patches appear on the sides of the eyeballs. The patches, usually triangular in shape, pearly white or yellowish in colour, are found in both eyes. These are called Bitot's spots (Fig. 34). These spots may persist even after treatment.

At these early stages, an improved diet can prevent serious eye damage. It requires considerable practice to detect vitamin A deficiency. Supervisors should work closely with community health workers in detecting the early signs until the community health workers are well trained.

In the later stages the eyeball becomes soft and an ulcer may form. The eye finally bursts and is permanently damaged. This is known as keratomalacia.

Certain groups of children are at special risk of vitamin A deficiency. These include children with protein energy malnutrition and children with certain infections. Measles affects many body tissues including the eyes. Diarrhoea affects general nutrition and also the absorption of vitamin A from the bowel. Vitamin A deficiency often appears after measles or diarrhoea. If the community health worker knows who may develop the deficiency she can act to prevent the disease.

Action to treat and prevent vitamin A deficiency

Treatment of vitamin A deficiency

Vitamin A deficiency should be treated urgently. The early stages of xerophthalmia (dry eyes) can lead to total eye damage within a very few days. If a child has dry eyes, the community health worker should act quickly.

· Give an oily preparation of vitamin A (200 000 International Units) by mouth. This may be in the form of drops or a capsule. This form of vitamin A is absorbed nearly as fast as a dose of vitamin A in water given as an injection. In some countries community health workers keep stocks of such vitamin A.

· If no vitamin A is available, take or send the child to the nearest health centre or a place where it is available.

· Teach the parents of children treated with vitamin A for dry eyes about prevention.

Prevention of vitamin A deficiency

Prevention can be for an individual or a community group that is at risk of vitamin A deficiency.

· An appropriate diet is the most important preventive measure.

· Vitamin A can be made in the body from a compound called carotene, which is found in vegetables and fruits. A lot of carotene is found in yellow or orange vegetables and fruits, leafy green vegetables, and red palm oil. Vitamin A is present in animal products such as eggs, liver, milk, and fish-liver oils.

· Vitamin A supplementation programmes have been started in some countries. In these programmes all children between 6 months and 5 years of age should receive oily preparations of vitamin A (200 000 International Units) by mouth, every 6 months. This may be in the form of drops or capsules. Such large doses of vitamin A can cause some children to feel unwell for a brief period. They may have headache, vomiting, and fever. The effects however, pass off quickly. Give the child half a tablet of aspirin and reassure the mother. It is dangerous to give a bigger dose, or to give vitamin A more often than once in 6 months. Keep vitamin A preparations out of reach of children. It is important to record how often these big doses of vitamin A are given to children.

· When using individual growth charts, a large A should be written at the bottom of the column of the month in which the dose was given. In this way it is easy to see when the last dose was given, and when the next dose is due.

All cases of vitamin A deficiency in children should be treated urgently.

Identifying children with anaemia and those at risk of becoming anaemic

Children with anaemia

An anaemic child has weak or pale blood. Many children and women of poor families in developing countries have anaemia.

Fig. 35. Where to look for signs of anaemia

How can a child with anaemia be identified?

A child with anaemia is less active than a normal child. He may be pale, and if the condition is severe, he will be breathless and have some swelling of the face, body, and limbs. The best way to detect anaemia is by examining the inside of the lips and the inside of the lower eyelids. They will be pale, light pink, or whitish instead of red (Fig. 35). A good time to gently pull down the eyelids of a child and to look at the colour is when he is feeding at the breast. The above test is very simple and every sick child should be examined for anaemia. Identification of anaemia in pregnant women is described in Module 5.

There are many possible causes of anaemia in children:

· The most common cause of anaemia is a diet deficient in food that contains iron. The body cannot make enough blood if it does not have enough iron. A growing child needs a lot of iron. He needs iron to make blood, but his main food is milk, and milk contains very little iron. Unfortunately, many children do not much like the foods which are rich in iron, for example, leafy green vegetables.

· A child may become anaemic because of loss of blood. Often the blood loss is not seen. For instance, a child may lose much blood because he has worms in his intestines which suck the blood.

· Anaemia may result from red blood cells being damaged in a number of ways. Malaria parasites are one serious cause of damage to blood cells.

· Anaemia may also occur in babies if they start life with too small a store of iron. If a mother is healthy, in the last weeks of pregnancy she will pass on to the baby a store of iron. If the mother is anaemic, she will not have much iron to pass on to the baby. If the baby is born prematurely, he will not receive the store of iron.

Children at risk of anaemia

From the causes of anaemia it is possible to identify the groups of children at risk of this disease. They include children who are premature (born early), those with anaemic mothers, those who have been fed too long on milk only, and those who have not been given a mixed diet including iron-containing foods. Children who are not protected from parasites, particularly malaria and hookworm, will develop anaemia.

Action to treat and prevent anaemia

Treatment of anaemia

· A diet which is rich in iron-containing foods like leafy vegetables is a good start, but it is unlikely to provide sufficient iron to cure anaemia.

· Iron tablets or syrup preparations easily increase the intake of iron. If the community health worker has a supply of iron tablets or syrup for children, she should give the recommended dose, as directed by the local supervisor or the doctor in charge.

Occasionally iron tablets upset digestion. This effect is less if the iron tablets or syrup are taken at the same time as food Warn mothers that their children's stools will be black while they are taking iron medication, lron tablets or syrup can cause harm if too large a dose is taken at one time. Always keep iron preparations out of reach of children. It is best to keep iron and other medicines locked in a cupboard.

· In severe cases of anaemia the patient is swollen, breathless, and very pale. These children or adults should be referred to a hospital. They need special care, and possibly blood transfusion.

· Treatment of any cause of blood loss or damage is essential. Malaria and hookworms should be treated. The possibility of these infestations should be thought of in any case of anaemia. It will be necessary to take or send patients to a health centre or hospital for diagnosis and treatment of such infections.

Prevention of anaemia

· A good diet during pregnancy is the foundation for prevention of anaemia. This will build up the mother's iron supply so that she can pass on a full amount to her child in late pregnancy. It will enhance full development of the child in the mother's womb and decrease the chance of a premature birth.

The diet should be rich in iron-containing foods-leafy green vegetables, legumes, whole grain cereals, and molasses. If animal products are acceptable and can be afforded, eggs, meat, and liver can be given. Pregnant women frequently need supplements of iron in addition to a good diet (see Module 5).

· Premature babies have inadequate iron stores and should be given small doses of iron in the first 3 months of life. Suitable iron mixtures will have to be obtained from a health centre.

· Infants should have a mixed diet containing iron-rich foods from about 6 months of age (see Module 4).

· Hookworm infestations can be prevented by improved hygiene, use of latrines, and wearing some form of footwear.

· Malaria control measures are being undertaken in many countries. Some services use anti-malarial tablets to prevent malarial infections. If this is being done in the community, issue anti-malarial tablets to children and record it on the individual growth charts.

TRAINING METHODS

1. Lecture: Training content. Use photographs or other visual aids.

2. Demonstration in a clinic or health centre: Identification of cases of moderate protein-energy malnutrition, marasmus, kwashiorkor, vitamin A deficiency, and anaemia.

3. Community survey: Identifying cases of protein-energy malnutrition, marasmus, kwashiorkor, vitamin A deficiency, and anaemia in the community, and their major causes.

4. Group discussion: Findings of the survey and what could be done about the problems.

EXERCISES

Exercise 1. Identifying malnourished children in the community

In this exercise the trainees carry out a survey to identify all malnourished children below the age of 5 years in a community. There are two important points to consider. First, the survey should cover the whole community. Secondly, each trainee should visit at least 10 homes.

At each visit the trainee first counts the total number of children in the family. Then she notes down the number of children below the age of 5 years. Now by measuring the upper arm circumference (see Module 2) or by looking at the growth charts of the children and judging from either the weight of the child at its present age or the direction of the growth line, she decides which children are malnourished. One of these two methods should be decided upon before undertaking the survey but it should be remembered that measuring the upper arm circumference is not suitable for children less than 1 year old. Upon completing the survey the trainees add up their results and discuss the following questions.

(1) What proportion of children below the age of 5 years in the community are malnourished?

(2) Are there common features among the families having malnourished children?

(3) How can these children and their families be helped?

(4) How often should the community health worker visit each child?

(5) Do most malnourished children come from one group in the community (e.g., one caste or profession)?

Exercise 2. Identifying children with marasmus and kwashiorkor

If any cases of marasmus or kwashiorkor are detected while Exercise 1 is being done, ask the permission of the parents of these children to allow the whole training group to see the children. Then discuss how the appearance of these children differs from that of healthy children of the same age.

In the second part of this exercise the trainees work in pairs. Each pair is given an illustration showing one of the two conditions. The trainees are then asked to answer the following questions:

(1 ) What kind of malnutrition does the child in the illustration have?
(2) What nutrition education would you give to the parents of this child?
(3) What else could you do to help the families?

Ask the trainees to exchange the illustrations and correct each other's answers.

Exercise 3. Identifying causes of malnutrition and their prevention

In this exercise trainees can work in pairs or singly. They visit the homes of children diagnosed as having moderate or severe malnutrition. Ideally, one whole day should be spent in or near each home. The purpose of the visit is to try and find out why the child became malnourished by observing how the family lives. In preparation for this visit, the trainees should outline the type of information to be collected.

The trainees should then meet, present the observations they have made in the different families, and discuss the findings. Particularly, they should consider, for each family, what changes in the way of life would prevent the child from becoming further malnourished. The following questions will be useful in the discussion.

(1) Will it help to change the pattern of meals (frequency and timing of meals) in the home?

(2) Are the parents spending their money on the right kinds of food?

(3) Is the child immunized against the childhood diseases? If not, will immunizations help?

(4) Do the parents have enough time to adopt the feeding and child care practices that will be necessary?

Exercise 4. Detection of anaemia and vitamin A deficiency

The trainees with their supervisor should visit a nursery school, baby clinic, or an outpatient hospital where there are many small children. With the permission of the person in charge, they should examine the eyes, the lower eyelids, and lips of all the children there. Probably some children will show signs of anaemia and vitamin A deficiency. The normal children can be compared with those who have deficiencies.

Remember it is important to help the families of the children who are found to have anaemia and vitamin A deficiency. They should receive advice about diet and, if possible, vitamin A and iron tablets or syrup.

Exercise 5. Visit to a nutrition rehabilitation unit

If possible the trainees should work in a nutrition rehabilitation unit for some days. The purpose of these visits is to observe:

(1) How malnourished children are helped to recover; and
(2) How parents of malnourished children may be taught to feed children so that they grow well.

In such a unit the trainees will see how local foods are prepared in order to make them especially suitable for small malnourished children, how often the children are fed, how much they need to eat, and how mothers are taught to take care of their children so that they do not suffer from malnutrition in the future.

Exercise 6. Developing positive attitudes of women towards feeding children green and yellow vegetables and fruits

The trainees should interview a number of women to find out their attitudes and beliefs towards feeding children green and other vegetables. There are often strong beliefs about giving these items to children. The trainees should then discuss how to overcome any problems they find. For example, are leafy vegetables acceptable to mothers and children when mixed in a curry? Are carrots and pumpkins acceptable when made into a sweet? Is mashed, fresh papaya given to children?

Exercise 7. Role-play about diet and malnutrition

(1) Recognizing kwashiorkor or marasmus

Characters:	A mother
	A child with kwashiorkor or marasmus
	A clinic nurse

The mother describes how she believes her child became ill. The child displays the characteristics of kwashiorkor, acting miserable, apathetic, etc. The nurse points out the features of the illness and explains what caused it and what can be done to help the child to recover and what actions should be taken to avoid relapse.

(2) Changing the family diet pattern

Characters:	A mother
	A father
	A grandmother
	A community health worker

The purpose is to show how to overcome the personal desires and prejudices of different family members. Father wants the sort of food that he likes. Mother wants to make changes for the sake of her malnourished child. Grandmother objects, saying that certain foods will be bad for the child. The community health worker advises gently and helps to find a compromise within the cultural pattern with which the family members agree. There is scope for the use of proverbs, jokes, and songs.

Exercise 8. Identifying a family at high risk of malnutrition

Each trainee should describe one family she knows in which she believes the children are at high risk of malnutrition. She should explain why she believes it is a high-risk family.