Sixty-eight per cent of under-5 child mortality in India is associated with malnutrition, and over one-third of under-5 children in the country are chronically undernourished or stunted. An insight into the child nutrition situation and determinants, revealed by the fifth National Family Health Survey (NFHS-5) 2019-20 for 22 States and Union Territories, is of extreme concern, say experts.

A rapid trend analysis report, published by the Observer Research Foundation, compares findings of NFHS-4 (2015-16) and NFHS-5. The report, authored by Sheila C. Vir and Shoba Suri, finds a reversal in the progress made on some of the key nutrition indicators in the country. These include an increased trend in chronic undernutrition (measured as stunting or height for age) in 13 States, as well as a rising trend in the percentage of overweight under-5 children in every State with the exception of one UT. The unexpected increasing trend in undernutrition in States such as Kerala, Goa and Himachal Pradesh where over 60 per cent women are reported to have completed at least 10 years of education is intriguing.

Child undernutrition is broadly determined by underlying and immediate factors. Data reveals that the underlying determinants that are most crucial for preventing chronic child undernutrition or stunting are women's education, height not less than 145 cms and right age of conception as well as improved antenatal care services and water-sanitation-hygiene (WASH) situation. The percentage coverage of nutrition-sensitive interventions focusing on underlying determinants -- comprising the status of women's empowerment, health care of women, and WASH practices -- have seen positive trends in the period of four years, between 2015 and 2019.

As per the latest NFHS-5 data, relatively more women today have access to safe and clean sanitation facilities, maternal health services and institutional delivery, possess their own personal mobile phones and bank accounts, and are able to stay in school for longer and delay conception till after they turn 18. Women owning mobile phones, and having bank accounts and access to clean fuel, considered by authors as proxy indicators of women's empowerment, show an unusually high coverage of over 60 per cent in more than half of the States and UTs and 9 states reporting over 80 per cent.

Why are child nutrition indicators not reflective of this progress?

The progress noted in underlying determinants in themselves are insufficient to address the problems of undernutrition. While they indirectly impact the immediate determinants, it is imperative to simultaneously address and expand the scope of interventions to directly address the immediate determinants. The latter include appropriate diet and infant and young child feeding (IYCF) practices as well as child health services. IYCF comprises breastfeeding and complementary feeding (CF). CF refers to shifting from exclusive breastfeeding for the first six months of life to introduction of semi-solid food items to a child along with the continuation of breastfeeding.

Appropriate CF comprises selection of the right food items from at least 4 diverse food groups, combined with continued breastfeeding and feeding adequate quantities of food 3-4 times a day. The ORF report highlights that CF practices continue to be insufficient, possibly contributing to the child undernutrition situation. Unaffordability does not appear to be the sole cause for poor CF practices. This is supported by the fact that as per NFHS-4 findings, 20 per cent children in the highest wealth index were also reported to be stunted. Lack of awareness to make the right food choices from appropriately diverse food groups, and caregivers not having adequate time to follow the recommended feeding practices as well as attraction to use meagre resources in commercial attractively packaged foods are argued to be the central cause of child undernutrition.

A family will accord priority to appropriate CF only if made aware of the serious consequences, i.e. largely irreversible impact not only on physical growth, but also on brain development. Moreover, generating awareness to address the rampant incorrect perception that an undernourished child is emaciated looking is crucial for ensuring that the 'not visible' but damaging problem of chronic undernutrition is not overlooked.

What are the policy needs?

The first 1000 days of life (from conception to first 24 months), are identified by experts as crucial to ensure optimal growth. Eighty per cent of the brain development occurs in this window, providing the opportune timeframe for investing in child nutrition, they argue. Any family with a pregnant woman or a child 0-24 months needs to be viewed as a family at high risk of child undernutrition. Timely efforts need to be specially directed at these families. Even though several nutrition-sensitive interventions and maternal and child healthcare services as well as to some extent breastfeeding practices have improved, CF practices remain largely neglected. Both food and feeding practices matter. The authors additionally make the case for community level mapping of households with pregnant or newly married women and children between 0-24 months of age.

The ORF report identifies the need to employ effective social and behaviour change communication (SBCC) to address misinformation and empower women and families to make the right affordable and locally applicable food choices to address all the three primary problems of child malnutrition -- undernutrition, overweight or obesity and micronutrient deficiencies.

Malnutrition is known to affect the cognitive development and future earning potential of children. To ensure reduction in chronic child undernutrition (stunting) and prevent adverse impact on growth and lifelong development of a child, the report calls for serious efforts to intensify measures for meaningful multi-sectoral convergence at family level of under twos for improving child feeding practices coupled with maternal nutrition care as well as measures for food and nutrition security and WASH services, and involving communities for appropriate complementary feeding practices.