Recent recognition of the early onset and high prevalence of wasting (30%) and stunting (20%) among infants 0–5 months in India draws attention to the need to understand the causes and develop prevention strategies. Such growth failure has dire consequences in the short (increased mortality) and long-term (loss of human capital and increased risk of chronic diseases). Food interventions before 6 months will increase morbidity/mortality through contamination in settings of poor sanitation and hygiene. Waiting to improve nutrition only after the initiation of complementary feeding at 6 months is a missed opportunity and may permanently alter life trajectory and potential. This underscores the importance of maternal nutrition. Iron and folic acid and protein energy supplementation during pregnancy are interventions that can improve maternal nutrition and birth outcomes. Maternal supplementation during lactation should be considered as a means to improve maternal and child outcomes, although the evidence needs strengthening. Support and counseling are also required to improve maternal diets and promote exclusive breastfeeding. Programs focused on improving maternal nutrition across the continuum of preconception, pregnancy and lactation are likely to have the greatest impact as mothers are central gatekeepers to the health and future of their children.
The high prevalence of childhood malnutrition in India has long been recognized. Despite impressive economic growth, malnutrition remains unacceptably high and is a ‘national shame’ according to Prime Minister Manmohan Singh.1 According to the latest Indian National Family Health Survey, 45% of children under 3 years are stunted and 23% are wasted.2 Despite recent modest reductions in stunting (National Family Health Survey 3:2005–06, 45%; National Family Health Survey 2:1998–99, 51%), there does not appear to be signs of significant improvement in wasting over time; in fact, the prevalence of wasting has actually increased slightly from previous National Family Health Survey surveys (23–20%).2
In addition, an emerging concern are the striking levels of growth failure found in the first months of life among Indian infants.3 Growth failure in infants less than 6 months of age represents a public health challenge as both the determinants and solutions are unclear. The magnitude of this problem was only recognized with the use of the 2006 WHO growth curves (based on breastfed infants) in comparison with the previous 1976 WHO/National Center for Health Statistics growth reference (based on bottle-fed infants). As illustrated in Figure 1 (reproduced with permission), use of the new growth curves led to a twofold increase in stunting (10–20%) and a dramatic fourfold increase in wasting (8–30%) among infants 0–5 months.3 In addition to the increased prevalence of growth failure, there are also differences in the pattern and onset of wasting by age in India with the new growth curve and these changes have important policy and program implications. With the National Center for Health Statistics reference, peak wasting occurred during the second year of life and was commonly attributed to the process of weaning and infectious diseases. However, with the new WHO growth curve, peak wasting occurs among infants 0–5 months, with decreasing prevalence thereafter; this pattern requires further investigation to understand the problem. Stunting likewise starts off high in the first 6 months but unlike wasting continues to increase, reaching peak levels at 18–23 months (58%) with a slight decline in prevalence thereafter. The high prevalence of both wasting and stunting in the first 6 months of life has distinct implications for preventative interventions as direct child feeding is not appropriate for this population of breastfeeding infants and the pattern suggests a need to look at prenatal and early postpartum factors.3
Poor condition of women
Before 6 months of age the mother is the key nutrition portal for the infant. The mother’s diet and nutritional reserves are the sole source of nourishment for the developing fetus and for the exclusively breastfed infant. Poor maternal nutritional status (low body mass index, short stature) and low gestational weight gain due to insufficient and poor quality dietary intake during pregnancy have been shown to be major determinants of low-birth weight (LBW) in low and middle income countries.4 This is especially true in India where the condition of women is particularly poor. A 2012 TrustLaw poll ranked India among the worst countries to be a woman (based on female feticide, child marriage, discrimination in health and education and violence among other factors).5 The cycle of the poor nutritional status of women starts in childhood where gender inequality leads to girls being less likely to be fully immunized and among literate mothers, less likely to receive a nutritious diet compared with their brothers.6, 7 Girls (6–17 years) are less likely to attend school compared with their male counterparts and this gender discrepancy increases with age (sex ratio of girls attending school per 1000 boys: 957 for 6–10 years, 884 for 11–14 years and a low of 717 for 15–17 years).6 Despite increased government recognition of the importance of the health of adolescent girls 56% are anemic and 58% are underweight (low body mass index <18.5 kg/m2).2 Furthermore, almost 50% of girls marry before 18 years and have their first child shortly thereafter (Table 1).2 The young adolescent may still be growing and developing herself and the added nutritional burden of pregnancy and lactation exacerbates her poor nutritional status. The practice of closely spaced multiple births, likewise places further demands on women giving them little time to recover; often, pregnancy and lactation may overlap, placing great metabolic demands on the mother.8 The poor condition of women (15–49 years) in India is evident from the high prevalence of anemia (58% of pregnant women and 63% of lactating women), reduced height (<145 cm, 11%) and low body mass index (33%). Short maternal height is a product of the women’s poor nutritional status as a child and is an important predictor of their own child’s health as well; for example, in India maternal height is associated with child mortality, growth failure and anemia9 and in rural Guatemala, shorter women have more children but fewer survive past infancy.10 Malnutrition prevalence is not uniform across India, varying by state, level of food insecurity, poverty and caste. For example, in Bihar among scheduled caste members the prevalence of low body mass index among women increases from the national average of 33% to over 58%, while in Sikkim only 11% of women are underweight.2, 11 The high levels of maternal malnutrition in India may be a contributing factor to the over 7 million infants (28%) born LBW each year.12
Poor child feeding practices
Unfortunately for many the circumstances do not improve much after birth and poor early child feeding practices add to the already suboptimal nutritional status of infants. Over 76% of the infants have delayed (>1 h after delivery) breastfeeding initiation and less than 46% of infants 0–5 months are exclusively breastfeed.2 The practice of giving a prelacteal feed is also quite high with 57% of infants receiving foods/liquids other than breastmilk in the first days after birth. The lack of exclusive breastfeeding decreases the child’s breast milk consumption and foods/drinks other than breastmilk are often contaminated in poor environmental conditions and hygiene, thus increasing the young child’s risk of infection and disease.13
Collectively, the poor condition of women and poor early child feeding practices may be in part responsible for the alarming levels of growth faltering found among children less than 6 months of age. However, limited data currently exist and there is no clear guidance on how to prevent growth failure in young infants.
Why early growth failure is important
Although our understanding of the causes of the high levels of early growth failure in India remains limited, the consequences of growth failure are well established. Early malnutrition and growth failure is associated with increased mortality, reduced human capital, increased risk of chronic disease and has long-term intergenerational consequences.14 An estimated 2.2 million deaths and 21% of disability-adjusted life-years for children younger than 5 years are attributed to stunting, severe wasting and intrauterine growth restriction.15 Malnutrition can impair the child’s ability to fight off infections and a malnourished child will be sick more often and the illnesses will be more severe. Children with severe wasting (weight-for-height z-score<−3 s.d.) are particularly vulnerable and have a ninefold greater risk of death (compared with children with weight-for-height z-score>−1 s.d.).15
Mortality has been called the ‘tip of the iceberg’ of the devastating impact of malnutrition and growth failure, below the surface lays a more silent crisis robbing counties of developmental potential and human capital.16 The critical window of opportunity (pregnancy and first 2 years of life) for growth corresponds with the period of rapid brain development.16 The rapidly developing brain is vulnerable to nutritional deficiencies17 and early insults to brain development may have long-term effects on the brain’s structural and functional capacity.16, 18 Thus, the first 1000 days is a critical period where nutrition can have the greatest impact on child growth and development. Compelling evidence from a review of five key cohort studies across the globe has demonstrated clear relationships between small size at birth and childhood stunting with diminished intellectual functioning, lower attained schooling and reduced earnings.14 In Guatemala, a nutritional supplement provided to children 0–24 months resulted in a reduction in stunting and an increase in wages by 46% in males, however, supplementation from 36–72 months had no impact on wages.19 As highlighted by Cusick and Georgieff ‘early intervention is better, and early might be earlier than we first thought’.17 For example, a study by Pongcharoen et al.,20 examined the influence of prenatal (size at birth), early infancy (birth-4 months), late infancy (4months–1year) and late postnatal (1–9 years) growth on intellectual function at 9 years of age. Growth during early infancy was the strongest predictor of intelligence quotient later in childhood (followed by growth in late infancy and at birth), however late postnatal growth had no impact on later intelligence quotient. This highlights the importance of the first few months of life for the developmental potential of children.
There has been growing concern on the implications of fetal undernutrition and early growth patterns with risk of chronic disease in adulthood.21 In addition to the high prevalence of undernutrition in early life, the unique body composition of the Indian infant (‘thin-fat-baby’) characterized by small abdominal viscera and low muscle mass yet, relatively preserved body fat may likewise predispose the infant to chronic disease.22 This of particular concern in India where chronic disease is now among the leading causes of death and according to recent projections may account for almost three quarters of all deaths by 2030.23 Children are at high risk for chronic disease when they are undernourished during the first 1000 days and then then put on weight rapidly in later childhood and adolescence.14 However, rapid growth within the first 1000 days poses no increased risk of chronic disease14 and emerging evidence suggests efforts to increase birth weight and linear growth during infancy may actually offer some protection against chronic diseases in addition to improved school attainment.24
Failing to prevent growth failure in young children may not only have long-term and irreversible consequences on their own development and disease risk but also place future generations at risk as well.25 Girls who are undernourished during childhood have shorter adult heights and girls born with LBW tend to have babies with LBW, thus perpetuating the vicious cycle of growth failure to the next generation.26
Program and policy implications
The unacceptably high levels of growth failure among Indian infants 0–5 months calls for a re-examination of program focus, as our thinking on child nutrition needs to move beyond just child-centered nutrition interventions. WHO recommends that children below 6 months of age receive only breastmilk;27 so the challenge is determining what approach to take in early infancy that follows this recommendation. The timing of early growth failure points to the importance of prenatal and early postpartum periods with a focus on maternal nutrition during preconception, pregnancy and lactation.
Maternal nutrition receives limited attention by policy and program decision makers despite the growing evidence on its importance for maternal, newborn and child health outcomes.28 Our understanding of maternal preconception nutrition is limited but current evidence does suggest a key role.29 A women’s prepregnancy size (height/weight) is associated with increased risk of preterm delivery and of having a small for gestational age baby and the provision of vitamin and mineral supplements during the preconceptional and periconceptional periods have been associated with reduced risk of delivering LBW, small for gestational age and preterm babies.29 The age of the mother at the time of conception and the time period from the previous pregnancy may also influence the mother’s preconceptional nutritional status.29 India’s polices surrounding adolescent health and family planning should be strengthened as young age at first birth and close birth spacing remain key problems in India30, 31 and have likewise been associated with adverse maternal and infant outcomes.32, 33
The barriers and opportunities of public health interventions to improve women’s nutrition in India are multiple.30, 31 India has extensive nutrition and family planning programs, many of which involve maternal health; however, these programs often do not receive the priority required to make meaningful progress, resulting in poor implementation and coverage.30, 31 For example, two key interventions that have significant potential to improve both maternal and child nutrition are iron and folic acid and protein energy supplementation. Daily iron and folic acid supplementation during pregnancy is associated with nearly a 70% reduction in maternal anemia and a 20% reduction in LBW.34 However, despite policies in place since the 1970s implementation in India is poor, only 37% of pregnant women consume iron and folic acid for 90+ days.2 Similarly, protein energy supplementation during pregnancy is associated with increased birthweight (73 g), reduced incidence of LBW (↓32%), small for gestational age (↓34%) and stillbirths (↓38%).35 India has policies in place to provide to provide supplemental food to pregnant women; however, only 20% of women have benefited from this program2 and the food quality is questionable. These are examples of two low-hanging fruits to improve maternal nutrition in India. The Government of India has been active in developing evidence based policies that have the potential to make important strides in maternal and child nutrition. However, vast improvements in translating policies into programmatic actions at scale are required in order to see improvements in birth outcomes. These interventions may be necessary but insufficient by themselves and need to be part of a comprehensive program. For example, a growing area of research is the role of maternal infection.36 Current evidence suggests an impact of maternal immunization on child birth outcomes (prematurity, small for gestational age, birth weight).37, 38 Further research is required however to understand these mechanisms and potential impact on early growth failure.
Beyond the preconception and pregnancy periods, increased priority to mothers during lactation is required. Given the poor state of early child feeding practices counseling on early and exclusive breastfeeding is vital. India has comprehensive programs in place for education and counseling,30, 31 however the reach is limited and only 11% of pregnant women and 8% of lactating women reported receiving health and nutrition education through India’s Anganwadi Centers.2 Furthermore, given the high levels of malnutrition among women in India, a question that needs to be examined further is whether the poor condition of women is impacting breast milk quality and quantity. For too long the assumption has been that poor, thin women in rural India can produce as much milk as the child demands and that the quality of the milk produced, except perhaps for water soluble vitamins and fat, is fine. One wonders whether behavior change counseling alone is sufficient to improve the status of infants. Lactation performance is an area with limited research but with high potential to influence policies and programs. Early growth-faltering is often attributed to feeding with non-breast milk foods or infections; however the potential for maternal supplementation during lactation to improve infant growth and nutritional status has not been studied systematically39 but is suggested by animal research.40 Human experimental research is limited; however, observational studies find associations with maternal body weight and composition with breastmilk quantity and fat/energy concentrations41 and several micronutrient deficiencies are associated breastmilk composition.39, 42 In a 1987 study of Burmese women, maternal supplementation during lactation resulted in improvements in maternal skinfolds and higher milk outputs and infant intakes.43 However, the intervention lasted only 2 weeks leaving questions unanswered about sustained impact and potential to improve child growth. In a 1988 study, Guatemalan women who received a protein and energy supplement during two consecutive pregnancies and the interim lactation period gave birth to infants about 300 g heavier compared with women receiving a low-energy supplement.44 Furthermore, in a 1998 study among undernourished (as evidence by calf circumference) Guatemalan women, a high-energy supplement (in comparison with low-energy supplement) resulted in significant improvements in infant milk intake, energy intakes as well as extended duration of exclusive breast feeding.45 Although the research is limited, it does suggest that improving maternal nutrition can improve lactation performance; however many questions remain. Often pregnancy and lactation are examined separately while in reality these are not isolated time points; it is the continuum of maternal health over these critical time periods, indeed including preconception that is likely to impact child growth. Thus, in order to recommend appropriate interventions to reduce growth failure further research is required (Table 2).
The recognition of early onset and high prevalence of wasting and stunting among infants 0–5 months in India draws our attention to the need to understand the causes and develop prevention strategies. Such growth failure has dire consequences in the short (increased mortality) and long-term (loss of human capital and increased risk of chronic diseases). Waiting to improve nutrition after the initiation of complementary feeding at 6 months is a missed opportunity and may permanently alter their life trajectory and potential. Maternal nutrition interventions before, during and after pregnancy may be an overlooked solution to improve early child health.
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The authors declare no conflict of interest.
This publication is based on research funded in part by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation.
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Young, M., Martorell, R. The public health challenge of early growth failure in India. Eur J Clin Nutr 67, 496–500 (2013). https://doi.org/10.1038/ejcn.2013.18
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