malnutrition classification and severe malnutrition management
Assessing Malnutrition in Juanga Tribe
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Assessing Malnutrition, Screening children for
developmental milestones and the effect of malnutrition on child development in the Juang
tribe in Kendujhar District of Orissa
( INDIA)
By
Dr Samrat Kumar
School of Public Health
SRM University
Centre for Children Studies
KSRM, KIIT University
Patia, Bhubaneswar
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Report
On
Assessment of Malnutrition, Child development and the effect of
malnutrition on child development in the Juang tribe of Orissa
Submitted to:
Centre for Children Studies,
KSRM, KIIT University, Bhubaneswar-751031
Submitted by:
Dr Samrat Kumar
MPH Scholar, School of Public Health,
SRM University.
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Dedicated to My Parents
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ContentsList of Tables and Bar Diagrams: 5
Acknowledgements: 6
Acronyms and Definitions 7
Developmental Milestones: 7
Introduction 8
Indian Context 10
Orissa Context: 11
Rationale of the study: 18
Objectives 19
Review of literature 20
Methodology 23
Data collection 24
Results and Discussion 25
Conclusions 35
Recommendations 36
Annexure 37
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List of Tables and Bar Diagrams:
Tables
Table 1 Adivasi Child Mortality 10
Table 2 Nutritional Status Children under 6 years 15
Table 3 Population of Orissa 15
Table 4 ST population Orissa 21
Table 5 Kendujhar Sub-division Population 21
Table 6 Socio-demographic Details 25
Table 7 Chi Square Analysis 26
Table 8 WHO guidelines on prevalence of malnutrition 34
Bar Diagrams
Bar Diagram 1 Nutritional status of children (India) 11
Bar Diagram 2 Fertility rate and wealth 12
Bar Diagram 3 Children receiving Anganwadi services 13
Bar Diagram 4 Trends in children nutritional Status 14
Bar Diagram 5 Anemia among women and children 15
Bar Diagram 6 Nutritional status of children( Juang Tribe) 26
Bar Diagram 7 Weight for age status 26
Bar Diagram 8 Weight for height status 28
Bar Diagram 9 Height for age status 29
Bar Diagram 10 Status of milestones achieved 30
Bar Diagram 11 Weight for age and milestones Status 31
Bar Diagram 12 Weight for height and milestones Status 32
Bar Diagram 13 Height for age status and milestones 33
Figure
Analytical Framework…………………………………… 22
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Acknowledgements:
I take this opportunity to thank Centre for children studies (CCS), KIIT School of Rural Management,KIIT University, Bhubaneswar and State Office of UNICEF Orissa, for allowing me to be a part of the
internship programme.
I have taken efforts in this project. However, it would not have been possible without the kind support
and help of many individuals and organizations. I would like to extend my sincere thanks to all of them.
I am highly indebted to Mrs Nandini Sen, Mrs Kalika Mahaptra, Mr Nihar Singh, Dr Unmesh Patnaik and
Prof. L K Vaswani for their guidance and constant supervision as well as for providing necessary
information regarding the project & also for their support in completing the project.
I would like to express my gratitude towards Dr Vishal, Fatma Alam, Bikash, my parents and my brother
for their kind co-operation and encouragement which help me in completion of this project.
Sincere thanks to Mr Trinath, Mr Dilip and all the Anganwadi workers and helpers in the Banspal area for
giving me such attention and time while data collection which made the fieldwork a valuable learning
experience.
My thanks and appreciations also go to my mentor Dr Rajan R Patil , Dr Anil I Krishna, Ms Geetha andmy colleague Emmanuel O Salawu for the help in developing the project and people who have willingly
helped me out with their abilities.
Finally, special thanks to CCS coordinator Mr Onkar Nath Tripathi who helped me at every stage from
beginning till the end. I extend my gratitude for his unrelenting support, inspirational guidance, light-
hearted humour and his concern for humanity. More than just a coordinator, he has been a mentor andguide to me during the entire study period.
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Acronyms and Definitions
AWC Anganwadi Centre
AWW Anganwadi Worker
ICDS Integrated Child Development Scheme
WHO World Health OrganizationW/A Weight for age
W/H Weight for Height
H/A Height for Age
NFHS National Family Health Survey
Developmental Milestones: Skills such as taking a first step, smiling for the first time, and waving "byebye" are called developmental milestones. Children reach milestones in how they play, learn, speak,
behave, and move (crawling, walking, etc.).
(CDC National Center on Birth Defects and Developmental Disabilities, Atlanta,US).
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Introduction
As children are the future of every country, their situation is always of concern to policy makers, their
parents and the general public. Ensuring children's health is a universally supported goal of development.
In developing countries, children and adults are vulnerable to malnutrition because of low dietary intakes,
infectious diseases, lack of appropriate care, and inequitable distribution of food within the households(1).
Malnutrition has long been recognized as a consequence of poverty. It is widely accepted that higher rates
of malnutrition will be found in areas with chronic widespread poverty. Malnutrition is the result of
marginal dietary intake compounded by infection. In turn, marginal dietary intake is caused by household
food insecurity, lack of clean water, lack of knowledge on good sanitation, and lack of alternative sourcesof income. It is also compounded by, inadequate care, gender inequality, poor health services, and poor
environment. While income is not the sum of total of people's lives, health status as reflects by level of
malnutrition is.
Because having good health condition is important precondition for escaping poverty and because
improved health and sanitation contribute to growth, investment in people's health and nutritional status is
fundamental to improving a country’s general welfare, promoting economic growth, and reducing
poverty(2). Meeting primary health care needs and the nutritional requirements of children are
fundamental to the achievement of sustainable development. In the United Kingdom and a number of
Western European countries about half their economic growth achieved between 1790 and 1980 has been
attributed to better nutrition and improved health and sanitation conditions (3). Malnutrition in childhoodis known to have important long-term effects on the work capacity and intellectual performance of adults.
Health consequences of inadequate nutrition are enormous. It was estimated that nearly 30% of infants,
children, adolescents, adults and elderly in the developing world are suffering from one or more of the
multiple forms of malnutrition, 49% of the 10 million deaths among children less than 5 years old each
year in the developing world are associated with malnutrition, another 51% of them associated with
infections and other causes(4). Recent studies have also pointed out those women who were malnourished
as children are more likely to give birth to low birth-weight children and thus there is an intergenerational
effect of child malnutrition. A practical advantage of using child malnutrition as a poverty indicator over
income level is that this measure does not have to be adjusted for inflation and would not be constrained
by any inadequacy of price data. Measures of child nutritional status can help capture aspects of welfare,
such as distribution within the household which are not adequately reflected in other indicators. Child
malnutrition standards are applicable across cultures and ethnicities.
Evaluation of nutritional status is based on the rationale that in a well-nourished population, there is a
statistically predictable distribution of children of a given age with respect to height and weight. In any
large population, there is variation in height and weight; this variation approximates a normal distribution.
Use of a standard reference population as a point of comparison facilitates the examination of differences
in the anthropometric status of subgroups in a population and of changes in nutritional status over time.
The use of a reference population is based on the empirical finding that well-nourished children in all
population groups for which data exist follow very similar growth patterns before puberty. Adequate
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nutrition is critical to child development. The period from birth to two years of age is important for
optimal growth, health, and development. At this age, children are particularly vulnerable to growth
retardation, micronutrient deficiencies, and common childhood illnesses such as diarrhea and acute
respiratory infections (ARI).
THE MAGNITUDE OF MALNUTRITION AND DIARRHEA Global mortality among children under the age of 5 years approximates 9.7–10.6 million deaths each year
(or 26,000–29,000 children each day), of whom 18% (i.e., 1.9 million per year or over 5000 per day) die
due to diarrhea(5). Moreover, fully 53% (5.6 million) of these deaths are associated with malnutrition.
Furthermore, it is estimated that maternal and childhood under nutrition is the underlying cause of 3.5
million deaths and 35% of the disease burden in children younger than 5 years, accounting for fully 11%
of the total global DALYs (disability adjusted life years)(5).We suggest that a substantial proportion of global malnutrition is due to impaired intestinal absorptive function resulting from multiple and repeated
enteric infections. These include recurrent acute infections as well as persistent infections, even those
without overt liquid diarrhea. Furthermore, impaired innate and adaptive host immune responses and
disrupted intestinal barrier function due to malnutrition and diarrheal illnesses likely combine to render
weaning children susceptible to repeated bouts of enteric infections leading to intestinal injury and,
consequently, nutrient malabsorption during the developmentally critical first 2 years of life. Evidence
from the existing literature suggest that the impact of heavy diarrheal burdens and multiple enteric
infections in the early formative years of childhood extends long beyond the infection itself and affects
both growth and cognitive development in affected children(5).
Malnutrition during childhood can also affect growth potential and risk of morbidity and mortality in later
years of life. Malnourished children are more likely to grow into malnourished adults who face
heightened risks of disease and death. Poor nutritional status of women has been associated with a higher
age at menarche(6) and a lower age at secondary sterility(6).
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Indian Context
Almost half of children under five years of age (48 percent) are stunted and 43 percent are underweight.The proportion of children who are severely undernourished (more than three standard deviations below
the median of the reference population) is also notable—24 percent according to height-for-age and 16
percent according to weight-for-age. Wasting is also quite a serious problem in India, affecting 20 percent
of children under five years of age. Very few children under five years of age are overweight. Less than 2
percent have a weight-for-height estimate more than two standard deviations above the median for the
reference population and less than 1 percent are more than two standard deviations above the median on
the weight-for-age indicator(1).
Under nutrition is substantially higher in rural areas than in urban areas. Even in urban areas, however, 40percent of children are stunted and 33 percent are underweight. Children who are judged by their mother
to have been small or very small at the time of birth are more likely to be undernourished than those who
were average size or larger. Under nutrition has a strong negative relationship with the mother’s
education. The percentage of children who are severely underweight is almost five times as high forchildren whose mothers have no education as for children whose mothers have 12 or more years of
education. Children from households with a low standard of living are twice as likely to be
undernourished as children from households with a high standard of living. Inadequate nutrition is aproblem throughout India, but the situation is considerably better in some states than in others. Even in
these states, however, levels of under nutrition are unacceptably high.
ST children in India: 53.9% stunted, 24.7 are wasted and 54.5% are underweight(1).
Table 1
The mortality in the tribal children had been found to be more in relation to their share of the totalpopulation in rural areas. The table above describes the situation in different communities as per NFHS
2005 data.
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Bar Diagram 1
The proportion of children under three years of age who are underweight decreased from 43 percent in
NFHS-2 to 40 percent in NFHS-3(1), and the proportion severely underweight decreased from 18 percent
to 16 percent. Stunting decreased by a larger margin, from 51 percent to 45 percent. Severe stunting also
decreased, from 28 percent to 22 percent.
Orissa Context:
All but 3 percent of households in Orissa have household heads who are Hindu. One percent of
households have Muslim heads and 1 percent had Christian heads. One-fifth of households belong to a
scheduled caste, 23 percent belong to a scheduled tribe, and 27 percent belong to Other Backward Classes
(OBC). Thirty percent of Orissa’s households do not belong to scheduled castes, scheduled tribes, orother backward classes. Compared to the national average, Orissa’s population is poor as 40 percent of
Orissa's population is in the lowest wealth quintile, compared to 20 percent of India's population. Forty-
two percent of Orissa’s households (48% in rural areas and 13 percent in urban areas) are in the lowest
wealth quintile and only 21 percent are in the two highest wealth quintiles combined (1).
51
20
4345
23
40
0
10
20
30
40
50
60
stunted wasted underweight
Percent of children under 3 years of age , India
NFHS 2
NFHS 3
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Bar Diagram 2
The average size of the family is high among the low income families, as shown above; it affects the
nutritional status of the child in the low income families. Source: NFHS-3(1)
The infant mortality rate in NFHS-3 is estimated at 65 deaths before the age of one year per 1,000 live
births, down from the estimate of 81 in NHFS-2 and 112 in NFHS-1. The under-five mortality rate is 91
deaths per 1,000 live births. Infant and child mortality rates in Orissa are higher than the nationalestimates. The higher rates of infant and child mortality in Orissa imply that, despite declines in mortality,
1 in 15 children still die within the first year of life, and 1 in 11 die before reaching age five. The ICDS
programme provides nutrition and health services for children under age six years and pregnant orbreastfeeding women, as well as preschool activities for children age 3-5 years. These services are
provided through community-based anganwadi centres. Among the 80 percent of children under six years
in Orissa who are in areas covered by an anganwadi centre, two-thirds (66%) receive services of some
kind from a centre. The most common services children receive are growth monitoring (56% of children
age 0-59 months), supplementary food (53% of children under six years of age), health check-ups and
immunizations (42-43% of children under six years of age). Twenty-eight percent of children ages 3-5
years receive early childhood care or preschool services. Thirty percent of mothers of children who wereweighed at an anganwadi centre received counseling from an anganwadi worker after the child was
weighed
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Bar Diagram 3
Children of mothers with less education and mothers in the lowest wealth quintile are most likely and
children of mothers who have completed high school or who are in the highest wealth quintile are least
likely to take advantage of the services offered at anganwadi centres. Children from scheduled castes and
scheduled tribes are more likely to receive services from an anganwadi centre than children from othergroups.
Infant feedingAlthough breastfeeding is nearly universal in Orissa, only 51 percent of children under 6 months are
exclusively breastfed, as the World Health Organization recommends(4). Eighty-two percent are put to
the breast within the first day of life, including 55 percent who started breastfeeding in the first hour of
life, which means that the majority of infants in Orissa received the highly nutritious first milk
(colostrums) and the antibodies it contains. Mothers in Orissa breastfeed for an average of 34 months,which is almost a year longer than the minimum of 24 months recommended by WHO for most children.
It is recommended that nothing be given to children other than breast milk in the first three days when the
milk has not begun to flow regularly. However, 42 percent of children are given something other than
breast milk during that period.
Children’s nutritional statusForty-five percent of children under age five are stunted, or too short for their age, which indicates that
they have been undernourished for some time. Twenty percent are wasted, or too thin for their height,
which may result from inadequate recent food intake or a recent illness. Forty-one percent are
underweight, which takes into account both chronic and acute.
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Bar Diagram 4
undernutrition. Even during the first six months of life, when most babies are breastfed, 26 percent of
children are stunted, 28 percent are wasted, and 36 percent are underweight. Children in rural areas aremore likely to be undernourished, but even in urban areas, more than one-third of children (35%) suffer
from chronic undernutrition. The majority of scheduled-tribe children are stunted (57%) or underweight
(54%). Girls and boys are about equally likely to be undernourished. Children’s nutritional status inOrissa has improved since NFHS-2 by all three standard measures of nutrition. Both chronic and acute
undernutrition was less widespread in Orissa at the time of NFHS-3 than they were seven years earlier.
Anaemia: Sixty-one percent of women in Orissa have anaemia, including 45 percent with mild anaemia,
15 percent with moderate anaemia, and 2 percent with severe anaemia. Two-thirds of women who are
pregnant (69%) and who are breastfeeding (65%) are anaemic. The prevalence of anaemia is lower among
the more educated and among those who are in the higher wealth quintiles; however, in every other groupmore than half of women are anaemic.
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Bar Diagram 5
Anaemia among children age 6-35 months was slightly higher in NFHS-3 than it was seven years earlier
at the time of NFHS-2. Around 71% of Schedule Tribe people have the lowest quintile in the wealth
index as per NFHS-3.
The Birth order of 4+ is 36.7% in ST Population, 30.7% in the lowest wealth quintile, 33.5 % among the
illiterate mothers.
Table 2
Children under 6 years (% age) Nutritional Status:
Height/ Age Weight/Height Weight/Age
< -3sd < -2sd Mean Z
score
< -3sd < -2sd Mean Z
score
< -3sd < -2sd Mean Z
score
ST 28.4 57.2 -2.1 8.2 27.6 -1.3 22.9 54.4 -1.9Source: NFHS-3
Table 3
Source: Census of India-2011
57% stunted and 54.4 % are underweight among the Schedule Tribe children of Orissa.
Population of Orissa: 41,947,358
1. Child Population (0-6 years): 5,035,6502. Child sex ratio(0-6 years): 934 females/1000 male children3. Literacy rate: 73.45% Male: 82.4% Female: 64.36%
Kendujhar District:1. Population:2. Child sex ratio(0-6yrs):3. Child population(0-6yrs):
1,802,777 (4.3% of Population of Orissa)
957 females/1000 males
253,418
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JUANGThe Juangs are mostly concentrated in Banspal, Telkoi and Harichandanpur Blocks. They claim
themselves to be the autochthons of the area from where they have migrated to other parts of the state.
They classify themselves into two sections, viz. the Thaniya (those who dwell in their original habitation)and the Bhagudiya (those who have moved away to other places). The Juangs believe that in ancient times
their tribe emerged from earth on the hills of Gonasika where the river Baitarani has its source, not far
from the village Honda in Keonjhar. In their language the word "Juang" means man. In other words, man
emerged from the earth at the same place where the river Baitarani emerged. The Juang also refer tothemselves as patra-savaras (patra means leaf). By this they mean that they are that branch of the Savara
tribe whose members used to dress themselves in leaves. They have got their own dialect which has been
described by Col. Dalten as Kolarian. They have acquired many Oriya words by coming in contact withthe Oriya speaking people. Most of them know and speak Oriya.
In the Juang society, the village is the largest corporate group with formally recognized territory. Within
the delineated land boundaries they possess their land both for settled and shifting cultivation and the
village forests for exploitation. They shift their village sites frequently as they consider it inauspicious tolive at a particular place for a longer period.
Each Juang village is marked by the presence of a dormitory known as Majang where their traditional
dance takes place and the village panchayat sits. It also serves as a guest-house for the visitors to the
village. The Pradhan who is the secular headman and the Nagam or Boita or Dehuri, the village priest
constitute the traditional village panchayat of the tribe. A group of neighbouring villages constitute a pirh
which is headed by a Sardar who decides inter-village disputes.
The Juangs are patrilineal and their society is marked by the existence of totemistic clans which are
divided into two distinct groups known as "Bandhu clans" and "Kutumba clans". The totem is never
destroyed or injured by its members. The clans are exogamous and marriage within the same clan is
considered incestuous. Monogamy is commonly prevalent while polygamy is not ruled out . Levirate and
sororate type of marriage is prevalent on the Juang society.A Juang husband generally worships the "Sajana"(drum stick) tree if his wife turns out barren and gives
her a paste made of "Sajana" flowers and seeds to eat or he ties a sevenfold cotton string with seven knots
round his wife's neck, believing this to be a kind of talisman which will cause conception. The Juangs do
not allow their pregnant women to go to "Devisthan". She must not tie up anything, must not weave mat
or plaster a house with mud.
The Juang cremate their dead. The corpse is laid on the pyre with the head to the south . The ashes may be
left on the spot of cremation, or alternatively they may be thrown into stream. For their livelihood they
depend mainly on primitive shifting cultivation and collection of minor forest produce.
The Juang life is marked by the celebration of a number of religious festivals in honour of their gods and
goddesses. For them Dharam Devta and Basumata are the supreme deities. The former is identified withSun God and the latter with Earth Goddess. Gramashree is the presiding deity of the village. There are
also a number of hill, forest and river deities in the Juang pantheon. They believe in the existence of
spirits and ghosts.
They observe Pusha Purnima as a mark of the beginning of the agricultural cycle, Amba Nuakhia as thefirst eating of mango fruits, Akhaya Trutiya as the ceremonial sowing of paddy, Asarhi, marking the
beginning of transplanting and weeding, Pirha Puja for the protection of crops, Gahma for the welfare of
domestic cattle and other auspicious days for the ceremonial eating of new rice harvested from differenttypes of lands . All these occasions are marked by dancing and singing. They use a kind of drum known
as changu at the time of dancing.
For the socio-economic development of the Juangs a micro-project has been established in the Juangpirh
at Gonasika. The project has assumed the responsibility for various development activities of the Juang.
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Gradually the Juangs have started settled cultivation with modern technology. The podu ravaged areas are
being covered with trees of different species. They have also started subsidiary occupation like tasar
cultivation, tasar reeling, weaving, tailoring etc.
Different infrastructural developments like communication, village electrification, social forestry, anddrinking water supply are being implemented for their benefit. Under social activities, education, health
care and preservation of the human values existing in them are being taken care of.
(http://kendujhar.nic.in)
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Rationale of the study:
The evaluation will show the magnitude of child malnutrition in the primitive Tribe ( Juang) of Orissa.Empirical studies show that child malnutrition is closely linked to income level and the socio-economic
status. A study also shows that child malnutrition is reflective and indicative of other desirable
development outcomes i.e. gender equality, intra-household distribution, and health environment quality.
That the relationship between child malnutrition and poverty is most sensitive at the lower end of the
income range makes child malnutrition a good indicator for development intervention projects and
programs, which generally target this section of the population.
While child malnutrition could not universally be adopted as a poverty indicator at this point of time due
to lack of universally available data, it's strength and relevance as a poverty indicator, particularly for
monitoring poverty impacts on the low income population, is gradually being recognized by governments
and international agencies around the globe. The Food and Agriculture Organization of the United Nation
(FAO) and the International Funds for Agriculture and Development has recently included child
malnutrition as one of the indicators to be assessed in their projects and programs.
India is experiencing a rapid economic boom due in part to the opening of its markets in the 1990s and the
emergence of a knowledge-based economy. However, this prosperity has not translated into well-being
among the country’s young children. The prevalence of underweight (a widely used indicator of
undernutrition) among children under age five in India is one of the highest in the world 43% in 2006
surpassed only by Bangladesh, Yemen and Timor(7). India is home to 55 million of the world’s
underweight children under age five about one third of the global burden of underweight in this age
group. During the prosperous 1990s, the average rate of decline in prevalence of underweight has been
around 0.9% per year among Indian children aged below five years, whereas in China, another Asian
country with a rapidly growing economy, it declined by approximately 5% per year. The nutritional status
of young children is an important indicator of health and development—it is not only a reflection of past
health insults but an important indicator of future health trajectories. Children under age three are
particularly vulnerable to undernutrition, and because the growth rate in this period is greater than any
other age period, it increases the risk of growth retardation. Furthermore, undernutrition among young
children captures the extent of development in a society and is thus a marker for the overall well being of
a population.
With this study, we are analysing the extent of malnutrition and its impact on child development in the
Juang tribe in rural areas of Orissa. We have screened the children for the developmental milestones forthe different age groups less than 3 years. The various intervention programs like ICDS, MDM and SNP
are working to lower down the malnutrition among preschool children. ICDS is also contributing for the
adequate child development by providing preschool education at the Anganwadi centers, which includes
the social, emotional, cognitive and motor skills in the children.
This study is an attempt to understand the level of malnutrition existing in the Juang Tribe, which is a
primitive tribe of Orissa, and as such there is no such nutritional data available specifically for the Juang
tribe. We are trying to find out the malnutrition and its coexistence with the poor performance in respect
of the Child development milestones. As studies have shown the nutrient deficiencies affect the normal
development of the child like cognition, motor skills and also the other skills like social and emotional
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which are related with the social and cultural environment. The various background characteristics of the
population affect the nutrition of the child as it is an environmental factor and similarly the child
development. The study will reveal the situation of the children in the Juang community, the prevalence
of malnutrition i.e. Underweight, Stunted and Wasted Children, the achievement of developmental
milestones and various factors associated with nutritional status of the children less than 3 years of age.
Objectives
To assess the status of Malnutrition in children less than 3 years of age in the Juang tribe inkendujhar district of Orissa.
To assess the level of Development in children less than 3 years of age in juang tribe.
To determine the impact of malnutrition on children development in the juang tribe.
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Review of literature
The various studies conducted to assess the nutritional status of the children explain about the various
underlying factors responsible for malnutrition.
Harishanker et al (8) found that the maximum overall prevalence of malnutrition was recorded in the age
group 13-24 months, prevalence of malnutrition was 56.63% in Schedule Cast population, low
educational status of parents, low socioeconomic status and large family size are the probable
precipitating factors. Poverty, illiteracy and ignorance are the main reasons which lead to malnutrition.
ICMR Bulletin 2003, A study carried out recently by RMRC, Bhubaneswar amongst four primitive tribes
of Orissa, revealed an infant mortality rate (per 1000 live birth) of 139.5 in Bondo, 131.6 in Didayi, 132.4
in Juanga and 128.7 in Kondha (Kutia); a maternal mortality rate (per 1000 female population) of 12 inBondo, 10.9 in Didayi, 11.4 in Juanga and 11.2 in Kondha tribe. The wide spread poverty, illiteracy,
malnutrition, absence of safe drinking water and sanitary conditions, poor maternal and child health
services, ineffective coverage of national health and nutritional services, etc. have been found, as possiblecontributing factors of dismal health condition prevailing amongst the primitive tribal communities of the
country
Guerrant et al.2008,(5) Global mortality among children under the age of 5 years approximates 9.7–10.6
million deaths each year (or 26,000–29,000 children each day), of whom 18% (i.e., 1.9 million per year or
over 5000 per day) die due to diarrhea. Moreover, fully 53% (5.6 million) of these deaths are associated
with malnutrition. Diarrhea and enteric infections impair weight and height gains, physical and cognitive
development. The longterm impact of malnutrition on economic productivity has recently been
documented by followup studies of 1–2-year-old male children treated with nutrient-dense atole in
Guatemala between 1962 and 1977; the individuals now earn 46% more than their peers at ages 25–42
years. Further intervention studies are needed to document the relevance of these mechanisms and, most
importantly, to interrupt the vicious diarrhea-malnutrition cycle so children may develop their fullpotential.
Subramanyam et al. 2010,(9) Social disparities in childhood undernutrition in India either widened or
stayed the same during a time of major economic growth. While the advantages of economic growth
might be reaching everyone, children from better-off households, with better educated mothers appear to
have benefited to a greater extent than less privileged children. The nutritional status of young children is
an important indicator of health and development—it is not only a reflection of past health insults but an
important indicator of future health trajectories. Children under age three are particularly vulnerable toundernutrition, and because the growth rate in this period is greater than any other age period, it increases
the risk of growth retardation. Furthermore, undernutrition among young children captures the extent of
development in a society and is thus a marker for the overall well being of a population. Social disparities
in childhood undernutrition in India either widened or stayed the same during a time of major economicgrowth. While the advantages of economic growth might be reaching everyone, children from better-off
households, with better educated mothers appear to have benefited to a greater extent than less privileged
children.
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Study Area: Orissa is regarded as the Homeland of Adivasis. More than 7 million tribal live in Orissa.
They cover 22.21% of the total population of orrisa. It is 11% of the total tribal population of the country.
Out of the 62 tribal communities in Orissa, 13 are the most primitive from cultural and technological
point stand. The State of Orissa occupies an important place in the country having a high concentration of Scheduled Tribe and Scheduled Caste population. In terms of ST population, it is the second biggest in
the country. Both Scheduled Tribe and Scheduled Caste constitute nearly 38.66% of the total State
Population (S.Ts 22.13% and S.Cs 16.53% as per 2001 Census). The population of the members of the
Scheduled Tribes and Scheduled Castes, as per 2001 Census(10) is as follows:
Table 4
TOTAL POPULATION OF THE STATE 36804660
SCHEDULED TRIBES (S.T.) POPULATION 8145081
PERCENTAGE OF S.T. POPULATION TO TOTAL
POPULATION
22.13
S.T. COMMUNITIES 62
Source: ST & SC Development Department, Government of Orissa
Percent of population of Kendujhar which comes under ST.
Kendujhar Total 44.50%
Kendujhar Rural 47.81%
Kendujhar Urban 23.56%
As per 1991 census there were 46 Scheduled Tribes in the district. Out of these the principal tribes were
Bathudi, Bhuyan, Bhumij, Gond, HO, Juang, Kharwar, Kisan, Kolha, Kora, Munda, Oraon, Santal, Saora,
Sabar and Sounti. These sixteen tribes constituted 96.12 % of the total tribal population of the
district. The concentration of Scheduled Tribes is the highest in Keonjhar and lowest in the Anandapur
Sub-Division. The study has been conducted in the Banspal Block in Kendujhar District of Orissa(India).The Juang villages are surveyed for the data collection in the Banspal block. The majority of
Juang population is located in the Banspal block, and random selection of children under 3 years of age
was done.
Table 5
KEONJHAR SUB-DIVISION POPULATION
RURAL
01. Keonjhar Sadar 58,036
02. Patna 41,972
03. Saharpada 39,732
04. Harichandanpur 54,340
05. Ghatagaon 55,122
06. Banspal 56,013
07. Telkoi 37,915
URBAN
01. Daitary Census Town 1,566
TOTAL :- 3,55,088
The total population of Juangs in Kyunjhar district is about 20000. It is supposed to be one of the main
poverty pocket of Orissa, just as kalahandi-naupada districts are considered to be the poverty sricken
pockets of the whole world.The juang inhabited panchayats are ravanapalsi, Badapalspal,
Pithagoda,Hunda, Janghira,Badagoara, Gonasika, Kodiposa and Banspal. The deaths due to hunger occur
regularly in these areas.
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RESEARCH DESIGN: Cross-sectional Study, Descriptive Study (Prevalence Study)
Research Framework:
Outcome that this study would produce
Child Malnutrition Child Development
Methods of Assessing Child
Malnutrition: (WHO Standards for
Children) Height for age (H/A)
Weight for age (W/A)
Weight for height (W/H)
Tools: Questionnaire as well as physical anthropometric assessment
Statistical Analyses: Descriptive Statistics (with emphases on Proportions); Inferential Statistics (with emphases
on Comparing 2 Population Proportions)
Screen the children for
Developmental
milestones less than 3
years of age inJuanga
tribe Odisha
Know whether
malnutrition has significant
effect on child
development
Prevalence of Malnutrition in children
less than 3 years of age
in Juang community
If yes, then to
what extent?
Method of Assessing Child Development:Assessing the child development
on the basis of developmental milestones
achieved by the child in the particular age
group.
(National Institute of public cooperation and
child development, New Delhi)
Minimum Sample Size: 105
Sampling Method adopted: Multistage sampling protocol was adopted. It was such
that 6 villages were selected randomly, then random sampling would be done within
each cluster
Will describe the
nutritional status of the
children in the Juang tribe
and the status of child
development .
To understand the social
and demographic details
of the target population.
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Methodology
The random selection of the children is done from the 7 Juang dominated villages in the Banspal block.
There are around 47 villages of Juangs in the Banspal block. We have randomly selected around 7villages and covered the households with at least one child under 3 years of age. The total of 105 children
under 3 years of age are observed for the milestones of development and the physical anthropometric
measurements were recorded as per the standard procedures. Supine measurements for length are taken
for the children under 2 years. The international System of units is followed.
Measuring Malnutrition in the targeted Children
Anthropometry: The measurements of weight and height of the children is done as per the guidelines
given by CDC, USA. The weight in Kilograms and height in Centimeters is recorded for all the children.
The most standardized indicators of malnutrition in children were used in this study. These indicators are
based on measurements of the body to know if growth pattern is normal and adequate.
• Height for age (H/A), is an indicator of chronic malnutrition. A child exposed to inadequatenutrition for a long period of time will have a reduced growth - and therefore a lower height
compared to other children of the same age (stunting).
• Weight for age (W/A), is a composite indicator of both long-term malnutrition (deficit inheight/"stunting") and current malnutrition (deficit in weight/ "wasting").
• Weight for height (W/H), is an indicator of acute malnutrition that tells us if a child is too thinfor a given height (wasting).
In each of the 3 indicators (W/H, W/A, H/A), A comparison of the individual measurements tointernational reference values for a healthy population (NCHS/WHO/CDC reference values) is done and
the cases with the values less than the -2SD from the median of the reference population of WHO are
categorized as malnourished. The cases with measured values less than -3sd are categorized as Severely
Malnourished.
Measuring the Level of Development in the targeted Children
Child development was assessed as per the status of developmental milestones achieved. The details of
the milestones achieved age wise as illustrated by the National Institute of Public cooperation and child
development, New Delhi.
A structured format for collecting the information on background characteristics of the household is used
along with anthropometric records of the child. Checklist of developmental milestones was used to screen
the child and observations for individual child are recorded in the response sheet.
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Data collection
This cross-sectional study was undertaken in Kendujhar district of Orissa in June 2011. The study was
intended to assess the nutritional status of children under 3 years of age and associated factors. A sample
size of 98 was required assuming a 60% prevalence of malnutrition, margin of error of 10% and a 20%
contingency for non response. A structured format for collecting the information on background
characteristics of the household is used along with anthropometric records of the child. Checklist of
developmental milestones was used to screen the child and observations for individual child are recorded
in the response sheet.
The questionnaire comprised three different parts: socio demographic, anthropometrics measurement
together with the screening of the child for developmental milestones. The data were collected with the
help of a translator who were trained for two days. The data were checked every day by the investigator
who stayed with data collectors for the duration of the survey, which was 10 days.
Measurements on weight and height were taken from children under 36 months. The socio-demographic
characteristics included in the questionnaire were: sex, caste, ownership of land, educational status of the
mothers, and household income. Digital weight scale was used for weighing the under three children
while height measure for older children above two years of age, and length of the young children and
infants below two years of age were measured by recumbence scale. The nutritional status of the study
children was assessed using the indicators weight-forage, weight-for-height, and height-for-age,
according to the NCHS (4;11)reference standard taking –2.S.D as the cut-off point indicating malnutrition
(under weight, stunting, and wasting).Verbal consent was obtained from heads of households.
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Results and Discussion
The study included a total 105 children out of which 55(52.3%) were males and 50(47.6%) were female.
The number of children in the age group of 12-35 months constituted more than 67% of the study
population. The socio-demographic characteristics of the study subjects are shown in Table 6.
Table 6
Socio-demographic
Characteristics
Age in months Total
1-2 3-5 6-8 9-11 12-17 18-23 24-35
No % No % No % No % No % No % No % No %
SexMale
Female
0
2
0
1.9
7
5
6.6
4.7
5
4
4.7
3.8
7
4
6.6
3.8
14
10
13.3
9.5
7
9
6.6
8.5
15
16
14.2
15.2
55
50
52.3
47.6
Education of mother
Illiterate
Literate
1
1
0.95
0.95
11
1
10.4
0.95
9
0
8.5
0
9
2
8.5
1.9
21
3
20.0
2.8
14
2
13.3
1.9
31
0
29.5
0
96
9
91.4
8.57
Birth order
1
2
3 or more
2
0
0
1.9
0
0
2
5
5
1.9
4.7
4.7
3
2
4
2.8
1.9
3.8
1
3
7
0.95
2.8
6.6
13
3
8
12.3
2.8
7.6
2
4
10
1.9
3.8
9.5
2
6
23
1.9
5.7
21.9
25
23
57
23.8
21.9
54.2
Monthly income
2000
1
1
0.95
0.95
6
6
5.7
5.7
2
7
1.9
6.6
6
5
5.7
4.7
12
11
11.2
10.4
11
5
10.4
4.7
11
19
10.4
18.0
49
54
47.5
52.4
Economic status
BPL 2 1.9 12 11.42 9 8.5 11 10.4 24 22.8 16 15.2 31 29.5 105 100
Total
2 1.9 12 11.42 9 8.5 11 10.4 24 22.8 16 15.2 31 29.5 105 100
According to the NCHS reference standard taking –2.S.D as cutoff point, the study children who fell
below –2 S.D. of the indicators (Underweight, Stunted, and Wasted) were computed as 92.3%, 45.8% and94.3%, respectively. In this study, there were no cases of over nutrition. In order to investigate the
association of selected demographic and socio-economic variables with the anthropometric results, Chi
square test of association was used. However, there was no statistically significant association with sex,
maternal education, birth order and monthly income (Table 7).
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Table 7 Chi square Analysis:
Variable Variabl
Malnutrition Sex of
Malnutrition Mother
Malnutrition Monthl
Malnutrition Birth o
Nutritional Status of Juang Tr
Bar Diagram 6
The status of children less thanscores for reference population
moderately underweight, 59% s
category. But in case of wasting
normal, 24.8% moderately w
malnutrition is stunting, there w
are moderately stunted and only
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
WFA(Underweig
7.60%
33.30%
59
le Chi square value( Calculated)
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Bar Diagram 7
The status of children in their rethat the peak prevalence of und
nearly 90% of children in age g
18-23 months, 68% in 24-35 mo
age of the child the proportion o
0
10
20
30
40
50
60
70
80
90
1-2
months
3-5
months
50
16.7
50
41.7
0
41.7
pective age groups showing the underweight pererweight children is between the age groups 6
roup 6-8 months, 72% in 9-11 months, 70.8% i
nths were severely underweight. It was observed
malnourished children increased as depicted in
6-8
months
9-11
months
12-17
months
18-23
months
24-
mon
0 0 0 0
9.711.1
27.3 29.2
18.822
88.9
72.7 70.8
81.3
Weight for Age Status
centage. It was observedonths to 35 months, as
n 12-17 months, 81% in
that with the increasing
he Bar Diagram 7.
5
hs
.6
67.7
Normal
moderate
severe
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Weight for Height Status (Chil
Bar Diagram 8
The weight for height which in
majority of the children in eacwasted children was observed in
0
10
20
30
40
50
60
70
80
90
100
1-2
months
3-5
months m
50
91.7
66
dren< 3 years):
icates the wasting percentage among the childr
age group are under the normal category. Ththe age group 18-23 months.
6-8
onths
9-11
months
12-17
months
18-23
months
24-35
months
.763.6
45.8
37.5
48.4
n observed, reveals that
e highest percentage of
Normal
Moderate
Severe
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Height for Age Status (Childr
Bar Diagram 9
Height for age status of the chil
of malnutrition was observed inchronic malnutrition prevalent i
73% in the age group 9-11 mont
and 68% in the age group 24-3increased age of the child depict
0
10
20
30
40
50
60
70
80
90
1-2
months
3-5
months
50
16.7
50
41.7
0
41.7
n
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Developmental Milestones Sta
Bar Diagram 10
The developmental milestones sthe children who had achieved
placed in the achieved category
guidelines were put in the categ
The poor performance of the
developmental level of the ch
described that with the advancin
0
10
20
30
40
50
60
70
80
90
100
1-2
months
3-5
months
100
75
0
25
us (%):
tatus of the children in their particular age groull the milestones as given in the guidelines of
and the children who could not achieve all the
ry of developing.
hildren in respect of the achievement of the
ildren whether they were normally developin
g age the developmental deficit is also increasing
6-8
months
9-11
months
12-17
months
18-23
months
24-3
mont
55.6
63.6
100
12.5
25.8
44.4
36.4
0
87.5
7
had been observed andIPCCD, New Delhi was
ilestones as given in the
ilestones indicated the
g or not. The diagram
.
s
.2
achieved
developing
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Weight for age and milestones
Bar Diagram 11
The coexistence of underweigh
reveals that among the normunderweight children 66% were
had yet to achieve the develop
moderate to severe underweig
compromised had increased con
0
10
20
30
40
50
60
70
80
Normal
50 50
status (%):
and developmental deficit had been shown he
l weight children around 50% were still destill developing and in severely underweight chil
ental milestones. The diagram shows the tren
ht category, the proportion of children who
iderably.
Moderate Severe
34
27
66
73
re in bar diagram 11. It
eloping, in moderatelydren 73% of the children
that as we move from
were developmentally
Achieved
Developing
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Weight for height and milesto
Bar Diagram 12
The comparative study of the
normal children around 65% ha
here as well that with the incre73% of children in the severe w
0
10
20
30
40
50
60
70
80
Normal
35
65
es (%):
status of wasting and the milestones achieved
ve not achieved the milestones yet. The similar
asing level of malnutrition the developmental dsted category had yet to achieve the milestones.
Moderate Severe
27 27.3
73 73
showed that among the
trend had been observed
ficit was also rising, as
achieved
Developing
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Height for Age and milestones
Bar Diagram 13
The 75% of the severely stuntethere existed a considerable d
malnutrition level, as 55.6% of
milestones corresponding to thei
0
10
20
30
40
50
60
70
80
normal
50 50
(%):
d children also failed to achieve all the milestovelopmental deficit. And this deficit was in
he children in the moderate malnutrition catego
r age group.
moderate severe
44.4
25
55.6
75
nes which indicated thatreasing with the rising
y had yet to achieve the
achieved
developing
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Key Findings:
The peak in prevalence of malnutrition is found in children between 6 months and 35months which indicate that with the advancing age and as soon as the breast feeding is stopped,the children suffer from malnutrition because there is no replacement for the mother milk in the
juang community. They don’t use cow milk for feeding children.
The developmental delays are most prominent in between 18 to 35 months. The delays indevelopment were also related with the advancing age of the children as it was observed that the
prevalence of malnutrition also increases with age as detailed above.
The developmental delays are mostly prevalent in the children in the severe malnutritioncategory, due to the reason that malnutrition is impacting the growth and development in the
juang community.
There was no significant gender difference in the prevalence of malnutrition. The study hasfound that malnutrition has no relationship with the sex of the child.
92.5% of children are underweight, which is a composite indicator of both chronic and currentmalnutrition.
The achievement of milestones is delayed with the increase in prevalence of malnutrition. Extremely high malnutrition prevalence in comparison to the normal population of Orissa
as per the data available from NFHS 3 for Orissa.
According to WHO guidelines for assessing the severity of malnutrition in a community:
Table 8
Indicator Severity of malnutrition by prevalence ranges (%) Findings of
study
medium high Very high
Stunting 20-29 30-39 >40 94.3
Underweight 10-19 20-29 >30 92.3
wasting 5-9 10-14 >15 45.8
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Conclusions
Extremely high prevalence of malnutrition among the Juang tribe Children (
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Recommendations
For nutritional interventions, ‘Catch’ the children young – before 3 years – before malnutritionsets in and before the child gets compromised regarding the overall growth and development.
Detection of malnutrition at an early stage, so that moderate cases may not progress to severeform of malnutrition.
Providing nutritional education to mothers regarding low cost, highly nutritive food stuffs. The high prevalence of malnutrition is also related to the purchasing power of the community, so
effort should be made to increase the income of the tribal families by various ways.
Special attention is needed for the primitive tribes like Juanga. The Tribal development is very much dependent on the status of the children, so we really need
look into the grave situation of the tribal children in particular, which is big hurdle to save the
primitive tribes from the danger of extinction.
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Annexure
Structured format for collecting Anthropometric measurement to assess nutritional status along with
checklist for the milestones of development for assessing the child development for different age
groups for the children between 0 to 3 years of age in the JUANG tribal community in KENDUJHAR
district of the state of Orissa, India
Sir/madam,
I am an Intern from Centre for children studies, KSRM, KIIT university is conducting a study to assess nutritional
status and child development in children under 3 years of age in the JUANG tribal community. The purpose to
conduct the study is to fulfill the academic requirement, to understand the level of malnutrition and the status of
child development; and to assess if there is any relationship between developmental delays and malnutrition in
children less than 3 years of age.
Date……………….. Time …………………. Sr. No…………………..
SOCIO-DEMOGRAPHIC DETAILS:
1. District2. Block 3. Village
House Hold factors:
4. Father’s name………………………………………5. Education of father………………………………6. Occupation of father……………………………7. Mother’s name……………………………………8. Mother’s education……………………………9. Cast
1. General 2. SC 3. ST 4. OBC10. Name of tribe……………………………………….11. Name of the child………………………………….12. Date of Birth………………………………………….13. Sex of the child….1)Male 2) Female
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14. Total no. of children……………………………..15. Birth order of child……………………………..16. Provided with nutritional Information during pregnancy………………17. No. of family meals per day…………………………18. Family status: BPL……………, APL……………..19. Family income ………………………from Agriculture……………………, Job……………….,
Labour……………, Land holdings…………………., any other source…………………
20. Expenditure …Food……………, education………………, Health………………..,Clothing…………, Festival…………………., Travel………………………..,
Other factors:
21. Distance of Anganwadi centre ………………22. AWC details:………………………………………….23. AWC/ICDS services availed………………......
Anthropometric Measurements
Sr No. Birth Weight
( W)
Age of the
child (A)
Weight(Kg)
(W)
Height(cm)
(H)1 Present Weight
2 One month before
3 Two months before
4 Three months before
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Developmental milestones status:
Age Group Codes of the Milestones achieved
1 month 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9
3 months 3.1
6 months 6.1
9 months 9.1
12 months 12.1
18 months 18.1
24 months 24.1
36 months 36.1
Check list for the Developmental milestones:
Yes…………………….1
No……………………..2
Age group (1) Milestones of Development YES NO
One month 1.1 Cries in hunger or discomfort1.2 Turns his head towards a hand that is stroking the child’s cheek or mouth
1.3 Brings both hands towards her/his mouth
1.4 turns towards familiar voices and sounds
1.5 suckles the breast and touches it with her/his hand
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Age group (9) Milestones of Development YES NO
Nine months 9.1 Sits up from lying position9.2 Picks up with thumb and finger9.3 Sits without support9.4 Crawls on hands and knees
Age group
(12)
Milestones of Development YES NO
One Year
( 12 months)
12.1 Stands without support12.2 Tries to imitate words and sounds12.3 Waves Bye -Bye12.4 Enjoys playing and clapping12.5 Says Papa & Mama
12.6 Starts holding objects such as a spoon or a cup and attempts self feeding
Age
group(18)
Milestones of Development YES NO
Eighteen
months
18.1 Walks well18.2 Expresses wants18.3 Stands one foot with help18.4 Points to objects or pictures when they are named ( e.g. eyes, rose)18.5 Starts saying names of objects
18.6 Puts pebbles in a cup
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Age group(24) Milestones of Development YES NO
Two Years 24.1 Walks, climbs and runs24.2 Says several words together24.3 Follows simple instructions24.4 Scribbles if given a pencil or crayon24.5 Enjoys simple stories and songs
24.6 Imitates the behavior of others on household work
24.7 Begins to eat by herself or himself
Age group
(36)
Milestones of Development YES NO
Three Years 36.1 Walks, runs, climbs, kicks and jumps easily36.2 Recognizes and identifies common objects and pictures by
pointing
36.3 Makes sentences of two or three words36.4 Says his/her own name and age36.5 Can name colours
36.6 Can understand numbers36.7 Uses make-believe objects in play36.8 Expresses affection36.9 Feeds herself or himself
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REFERENCE LIST
(1) GHOSH S. NATIONAL FAMILY HEALTH SURVEY-3 (2007). INDIAN PEDIATRICS
2007;44(8):619.
(2) WORLD B. WORLD DEVELOPMENT REPORT 1993. INVESTING IN HEALTH: WORLD
DEVELOPMENT INDICATORS. OXFORD UNIVERSITY PRESS; 1993.
(3) SETBOONSARNG S. CHILD MALNUTRITION AS A POVERTY INDICATOR: AN
EVALUATION IN THE CONTEXT OF DIFFERENT DEVELOPMENT INTERVENTIONS IN
INDONESIA. ASIAN DEVELOPMENT BANK (ADB) INSTITUTE DISCUSSION PAPER
2005.
(4) DE ONIS M, BL÷SSNER M. THE WORLD HEALTH ORGANIZATION GLOBALDATABASE ON CHILD GROWTH AND MALNUTRITION: METHODOLOGY ANDAPPLICATIONS. INTERNATIONAL JOURNAL OF EPIDEMIOLOGY 2003;32(4):518.
(5) GUERRANT RL, ORIΒ RB, MOORE SR, ORIΒ MOB, LIMA AAM. MALNUTRITION ASAN ENTERIC INFECTIOUS DISEASE WITH LONG-TERM EFFECTS ON CHILD
DEVELOPMENT. NUTRITION REVIEWS 2008;66(9):487.
(6) HOSSAIN MDG, ISLAM S, AIK S, ZAMAN TK, LESTREL PE. AGE AT MENARCHE OF
UNIVERSITY STUDENTS IN BANGLADESH: SECULAR TRENDS AND ASSOCIATION
WITH ADULT ANTHROPOMETRIC MEASURES AND SOCIO-DEMOGRAPHIC
FACTORS. JOURNAL OF BIOSOCIAL SCIENCE 2010;42(5):677.
(7) MISHRA VK, LAHIRI S, LUTHER NY. CHILD NUTRITION IN INDIA. 1999.
(8) HARISHANKAR1 SD, DABRAL SB, WALIA DK. NUTRITIONAL STATUS OF CHILDREN
UNDER 6 YEARS OF AGE.
(9) SUBRAMANYAM MA, KAWACHI I, BERKMAN LF, SUBRAMANIAN SV.
SOCIOECONOMIC INEQUALITIES IN CHILDHOOD UNDERNUTRITION IN INDIA:
ANALYZING TRENDS BETWEEN 1992 AND 2005. PLOS ONE 2010;5(6):E11392.
(10) GENERAL R. CENSUS COMMISSIONER. CENSUS OF INDIA 2001;2001.
(11) GRAITCER PL, GENTRY EM. MEASURING CHILDREN: ONE REFERENCE FOR ALL.
THE LANCET 1981;318(8241):297-9.
Websites:
• http://www.adbi.org/discussion-paper/2005/01/14/869.malnutrition.poverty.indonesia/measuring.malnutrition/
• http://www.who.int/en/ • http://www.cdc.gov/ • http://www.nfhsindia.org/ • http://www.unicef.org/india/state_profiles_4346.htm
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• SC/ST development, minorities & backward classes welfare Department, Govt. Of Orissa.
• http://censusindia.gov.in/ • www.kendujhar.nic.in/ • www.google.com • www.youtube.com • http://www.rchiips.org/ • http://nipccd.nic.in/