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Indian Journal of Community Medicine

Malnutrition - A Missed Opportunity to Treat at Tertiary Care

Author(s): S. Mallik, S P Mitra, A Roy, SS Basu, A Saha, A K Munsi

Vol. 31, No. 3 (2006-07 - 2006-09)

S. Mallik1, S P Mitra2, A Roy3, S S Basu4, A Saha2, A K Munsi5


Despite India’s considerable social and economic progress over the decades, malnutrition continues to be a grave problem, particularly among vulnerable population of the community. The World Bank reported that India had 20% of the world’s population, out of which 40% were malnourished. NFHS data also showed that 46% of the under 3 years children had been suffering from malnutrition. The malnutrition is influenced by a variety of factors like lack of food, sanitation and health care some social and cultural customs and taboos and poor childcare practices at family level. Different Health and Nutritional Programs are trying to address this issue at community level. But it had been observed with great concern that when children attend the health facility for any health problem, associated malnutrition is ignored or grossly neglected by the practitioners both at private and government levels. The present study aimed to review how the malnutrition among the under five children was taken care at the level of a tertiary care hospital.

Materials and Methods

Institution based cross sectional studywas carried out in Pediatric OPD, of Medical College, Kolkata from 1st to 11th November 2000 among under five children attending Pediatric OPD

It was revealed from the attendance register of Pediatric Medicine OPD of Medical College, Kolkata that daily average attendance of under five children was approximately was 150 to 200. So for 10 days about 1500 to 2000 children less than five years old were supposed to attend the OPD for medical care, and 10%, of them were taken for the study. The children were selected by systematic random sampling technique and a total of 150 children were covered in the study in 10 days.

All the children were weighed by standard weighing machine and clinically examined for micronutrient deficiency. Weights were plotted in ICDS growth chart and IAP classification was used for grading malnutrition. Special emphasis was given on under 2. years children to collect data regarding exclusive breast-feeding and period of weaning. Parents of the studied population were asked about the advice given by the health care givers regarding nutrition, breast-feeding, weaning and referral.


Among the under five children attending the Pediatric OPD of Medical College, Kolkata, 51% were seen malnourished as per IAP classification. Out of them 29% were suffering from grade I, 14% from grade II, 6% from grade III and 2% from grade IV malnutrition. On clinical examination, it was observed that 52.7% children were suffering from pallor, 13.3% from angular stomatitis and 1.3% from night blindness. When some 5 known factors for malnutrition were considered in the study group, it has been observed that extent of malnutrition was significantly more among the Muslim compared to Hindu and children whose mothers were illiterate. Among the children less than two years, malnutrition was observed sigrtificantly more in those who were not exclusively breast fed than the children exclusively breast fed for 4- 6 months (Table I).

Table I: Some Socio-Economic Determinants and its Relations with Malnutrition Study Variables

Study variables Total no
of children
no. (150) .
P value
No (%)
Male 98 44 (44.9)  
Female 52 32 (61.5) > 0.05
Hindu 99 42 (42.4)  
Muslim 51 34 (66.7) < 0.05
Illiterate, 85 51 (60) < 0.05
Literacy Literate 65 25(38.4) (38.4)  
Illiterate 54 25 (46.3)  
Literacy Literate 96 51 (53.1) > 0.05
Per capita
< Rs 240 58 30 (51.7)  
Income per Month > Rs 240 96 46 (50)
Ocupation of mother
Working 15 5 (33.3)  
Housewife 135 71 (52.6) > 0.05
No of under Five in Family
One 69 33 (47.8) 7
Two 45 21 (46.7) > 0.05
> Two 36 22 (61.1)  
Age of Weaning
< 6 months 28 17 (60.7)  
> 6 months 9 6 (66.7)  
(n= 47)* Yet to wean 10 5 (50)  
Duration Exclusive Breast-feeding(n= 47)*
4-6 months 38 19 (50)  
No EBF 9 9 (100) < 0.05

In the Pediatric Medicine OPD of Medical College, Kolkata the children used to be recorded after doing the OPD tickets. Then they were examined by the medical officers or visiting physicians and sent to the Social Welfare Officer (SWO) sitting in the OPD for briefing about the prescriptions. The children who required advice on diet were asked to attend OPD on Tuesday on which day dietician was available. During exit interview of the parents, it was revealed that children didn’t undergo any sort of growth monitoring in the OPD, even the grade III and IV malnourished children were not given adequate importance on diet or referred to local ICDS centers. Nutrition education, advice regarding exclusive breast-feeding and timely weaning were very much lacking. Missed opportunity for immunization was also very high. The doctors were overburdened with treatment of the patients, so entire responsibility lied with the SWO. She was also busy in interpreting prescriptions and had no time to go for growth monitoring and nutrition education.


The present hospital based study showed that 51% of the under five children attending the Pediatric OPD were malnourished following the IAP classification. Sen3 also found 51.6% prevalence of malnutrition in a slum of Kolkata. But in a clinic based study in 6 Delhi, Rasania QC’ et al4 observed that 71.5%. children were malnourished as per weight for age criteria. As the children of the present study were suffering from various types of illnesses, so it was expected that they would suffer more from severe degree malnutrition.

It was seen as 8% similar to the observation of Rays in Kolkata slum. The present study found malnutrition more in female children, as also observed by Ray5 and Sen4. Similar to Rasania, et al, malnutrition6 was found more in the children not exclusively breast-fed and with delayed weaning. In the present study, 52.7% and 1,3% children were suffering from pallor and night blindness. National pilot program on micronutrient malnutrition6 had seen prevalence of mild to moderate anaemia as 66 to 70% among 6 months to 6 years children in states of East and North Eastern region and night blindness as 1.15% in West Bengal.

This picture of protein energy and micronutrient malnutrition revealed in a tertiary care institute is neither an exception nor an abnormal phenomenon as it reflects very much the worst situation in the community. But problem is that even in the tertiary care with such a big infrastructure, we almost always treat the diseases and the infections, but fail to give adequate importance on diet, growth monitoring and underlying causes of growth faltering. This situation can be improved by simply imparting nutrition education, management of minor illnesses at household level, Improvement of personal hygiene and correction of faulty feeding practices of the children during illness. If we can improve their nutritional status in this way, we can reduce the disease load and in long run reduce the load of attendance at Pediatric OPD. So by no means we should miss this opportunity to treat malnutrition at tertiary care.


The authors are deeply acknowledged to the Principal, Medical College, Kolkata and the doctors and all the staff of Pediatric Medicine OPD of Medical College, Kolkatta


  1. Mesham AR, Chatterjee M. Wasting away: The crisis of malnutrition in India. Washington DC: The World Bank, 1999.
  2. Patrice E, Dustagheer A, Shrivastava D. Malnutrition- Importance of care. JIMA 2000; 98 : 514- 5.
  3. Sen PK. Nutritional status of under five children in an urban slum community of Calcutta: Ind J Pub Health 1994; 4: 27- 30.
  4. Rasania SK, Sachdev TR. Nutritional status and feeding practices of children attending MCH center. Ind J Comm Med 2001; XXVI:145- 9.
  5. Ray SK, Roy S. Prevention of malnutrition. JIMA 2000; 98: 510-11.
  6. Chakraborty I, Ghosh K. Micronutrient malnutrition- Present status and future remedies. JIMA 2000; 98: 539- 42.

1 Deptt. of Community Medicine, Burdwan Medical College, WB

2 Deptt. of Community Medicine Medical College Kolkatta.

3 Deptt. of Medicine, IPGMER, Kolkatta.

4 Deptt. of Community Medicine, AOOHVPH, Kolkatta.

5 Distt. Hospital 24 Pgs (N), WB.

E-mail: [email protected]

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