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    SRI LANKA

    Nutritional Status of Pre-School Children in SriLanka

    Department of Census and Statistics

    Concluding WorkshopRETA 6007: Enhancing Social and Gender Statistics

    24-27 June 2003Bangkok, Thailand

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    Contents

    Page

    About the Project 3

    Summary 4

    I. Background 6

    II. Determinants of Malnutrition 11

    III. Differentials and Levels of Stunting 14

    IV. Differentials and Levels of Wasting 19

    V. Differentials and Levels of Underweight 24

    References

    Appendix: Prevalence rates of Stunting, Wasting and Underweight

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    3

    About the Project

    The Research and Special Studies Division of the Department of Census

    and Statistics, Sri Lanka, undertook a methodological study to investigate

    the prevalence of malnutrition in children under five years of age, and the

    factors contributing to such a situation. This study is supported by the

    Regional Technical Assistance (RETA 6007) of the Asian Development

    Bank.

    The main objectives of the study are as follows:

    (i) Identify determinants of short term and long term

    malnutrition in children

    (ii) Examine the relationship between the selected variables and

    the incidence of malnutrition

    (iii)Use small area estimation methods to estimate malnutrition levels

    at district level

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    4

    Summary

    Malnutrition has been identified as a major health problem in post independent SriLanka, and it still continues to be a serious health concern in the island nation.According to the Demographic and Health Survey 2000, 22% of ever married women inthe reproductive age group are malnourished, with 17% of children under five yearshave been born as low birth weight babies.

    Although food intake influences the nutritional status of an individual to a great extent,it is not the only critical factor responsible for malnutrition, particularly in the case ofchildren under five years of age. Living standards, water and sanitation, birth weight,birth interval, parity, sex of child, weaning practices and mothers education, are a fewof the important contributory factors which have been identified from research studiescarried out on the subject, in the recent past. However dietary inadequacy is certainly

    the basic cause of malnutrition in pre school children, and many of the above identifiedfactors directly or indirectly contribute to the incidence of malnutrition.

    The situation of malnourishment in pre school children has somewhat improved overthe years, with stunting or long term nutritional deficiencies declining to one third ofwhat it was in the early nineteen eighties. However wasting or short term nutritionaldeficiencies have remained more or less static during the past two decades.

    A regression analysis carried out to identify significant determinants of stunting,wasting and underweight, show that the following variables are predominant in theincidence of malnutrition in pre -school children.

    Stunting

    1. Number of living children in the family.2. Age of child.3. Sector of residence.4. Work status of mother.5. Access to media by mother.6. Mothers educational level.7. Type of latrine.8. Child given colostrum9. Mother washes her hands with soap after child defecated.

    Wasting

    1. Age of child.2. Sector of residence.3. Work status of mother.4. Access to media by mother.5. Mothers educational level.6. Sex of child.7. Access to safe drinking water.8. Type of latrine.

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    Underweight.

    1. Number of living children in the family.

    2. Age of child.3. Sector of residence.4. Work status of mother.5. Access to media by mother.6. Mothers educational level.7. Mother washes her hands with soap after child defecated.8. Type of latrine

    Overall 14% of children below five years are moderately or severely stunted, while another 28%are found to be mildly stunted.

    ?? 35% of estate children are either moderately or severely stunted.

    Over 25% of pre school children are reported to be stunted (moderate and severe) when:

    ?? Mother has not gone beyond primary level of education.?? There are more than five children in the family.?? The household has no access to toilet facilities.?? Mother does not use soap after child defecated.?? Mother does not wash her hands before feeding her child.

    Overall 14% of children below five years are moderately or severely wasted, while another 39%are found to be mildly wasted.

    Incidence of wasting (moderate and severe) is most prevalent (Approx 20%) when :

    ?? Children are in their second year of life.?? Children are born with low birth weight.

    ?? There are more than five children in the family.?? Mother herself is undernourished .?? Mother does not use soap after child defecated

    Overall 30% of children below five years are moderately or severely underweight, whileanother 36% are found to be mildly underweight.

    Nearly 50% of pre-school children are reported to be underweight (moderate and severe)when :

    ?? Children are born with low birth weight.

    ?? There are more than five children in the family.?? Mother does not use soap after child defecated.

    ?? Mother does not wash her hands before feeding her child.?? Sector of residence is Estate.

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    I Background

    1.1 Assessment of the Problem

    Malnutrition has been identified as a major health problem in post independent Sri Lanka. In

    spite of the many achievements reported in demographic characteristics such as the drastic

    reduction in fertility rates, maternal and infant mortality levels, and improvement in

    educational attainments particularly of women; malnutrition continues to be a serious health

    concern.

    Malnutrition is a multifaceted problem. According to the Demographic and Health survey

    2000, 22% of ever married women in the reproductive age group are malnourished, with 17%

    of children under five years have been born as low birth weight babies. Obviously mothers

    nutritional status affects the unborn child, and a low birth weight child would show a higher

    vulnerability to ill health, and retarded mental and physical growth in the most decisive years

    of life, and tend to become an anaemic woman in later years, if the child happens to be a

    female. Hence a vicious cycle of malnutrition is formed.

    The nutritional status of a person depends largely on the quantity and quality of food

    available in the market, purchasing power of the household which would determine the

    accessibility to food, and the distribution of food within the household. According to the

    findings of the Income and Expenditure survey conducted in 2002, nearly one fourth (23.9%)

    of households in Sri Lanka falls into the category of poor households in terms of adequacy

    in energy intake, which provides ample evidence to the insufficient food intake in many a

    household.

    Although food intake influences the nutritional status of an individual to a great extent, it is

    not the only critical factor responsible for malnutrition particularly in the case of children

    under five years of age. Living standards, water and sanitation, birth weight, birth interval,

    parity, sex of child, weaning practices and mothers education, are a few of the important

    contributory factors which have been identified from research studies carried out on the

    subject, in the recent past. However dietary inadequacy is certainly the basic cause of

    malnutrition in pre school children, and many of the above identified factors directly or

    indirectly contribute to the incidence of malnutrition.

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    1.2 Aspects of malnutrition

    Chronic malnutrition

    It is a measure of height with the age of the child and shows retarded linear growth for age,

    as compared to a healthy reference population, commonly known as stunting. This situation

    defines long term nutritional deficiency.

    Acute malnutrition

    It is a measure of weight with the height of the child and shows low body mass for height, as

    compared to a healthy reference population, commonly known as wasting. This situation

    defines short term nutritional deficiency.

    Stunting: A child whose height-for-age lies in the interval (-1, -1.99) standard deviations from

    the median of the reference population, is considered as mildly stunted. When this statistic

    lies in the interval (-2, -2.99) SD, the child is known to be moderately stunted and if the

    statistic is 3SD or below that, the child is considered as severely stunted.

    Wasting: A child whose weight-for-height lies in the interval (-1, -1.99) standard deviations

    from the median of the reference population, is considered as mildly wasted. When this

    statistic lies in the interval (-2, -2.99) SD, the child is known to be moderately wasted

    and if the statistic is 3SD or below that, the child is considered as severely wasted.

    Underweight: Retarded weight for age is seen as a consequence of concurrent short term

    and long term malnutrition. A child whose weight-for-age lies in the interval (-1, -1.99)

    standard deviations from the median of the reference population, is considered as mildly

    underweight. When this statistic lies in the interval (-2, -2.99) SD, the child is known to be

    moderately underweight and if the statistic is 3SD or below that, the child is considered as

    severely underweight.

    Usually only the moderate and severe conditions (-2SD or below) are considered as states of

    malnourishment.

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    1.3 Trends in malnutrition

    Table 1.1 and Figures 1.1, 1.2 and 1.3 presents the levels of malnourishment is pre school

    children in the past two decades. Overall the situation has improved with long term nutritional

    deficiencies declining to one third of what it was in the early nineteen eighties. However

    wasting or short term nutritional deficiencies has remained at more or less the same level

    over the years. It appears that malnutrition, both chronic and acute states, develop during the

    weaning period and rise sharply in the second year of life. Thereafter the affliction rates show

    a decline to some degree in the third year, to rise again in the fourth and fifth years when the

    child attends Montessori School. The same trend pattern is observed in all survey data since

    80/81.

    The retardation of growth which commences in the latter half of the first year, points to the

    grim reality that weaning food given to babies, may not be nutritionally adequate to meet the

    special dietary needs of the growing child.

    Table 1.1 : Incidence of stunting , wasting and underweight by agegroup for survey

    periods 80/81 , 1987 , 1993 and 2000

    Age Stunted Wasted Underweight

    (months) (-2 SD or below) (-2 SD or below) (-2 SD or below)

    80/81 1987 1993 2000 80/81 1987 1993 2000 1987 1993 2000

    03-05 7.8 4.9 3.9 1.9 3.1 1.3 3.7 5.8 0.7

    06-11 18.57 15.2 11.8 5.7 14.1 3.9 6.8 10.3 23.4 17.9 20.2

    12-23 34.04 31.1 25.7 16.2 21.6 19.3 18.2 18.2 42.5 36.3 28.8

    24-35 33.66 34.0 23.8 12.4 10.9 13.3 15.1 13.3 47.9 42.4 34

    36-47 41.35 27.5 13.4 4.1 18.2 13.9 46.7 30.7

    48-59 48.52 28.7 19.1 6.6 17.6 15.9 43.0 37.9

    Average 36.58 27.5 23.8 13.5 12.1 12.9 15.5 14.0 38.1 37.7 29.4

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    Figure 1.1 - Trends in Stunting

    0

    10

    20

    30

    40

    50

    4 8.5 17.5 29.5 41.5 53.5

    Age in months

    (%)

    80/81 1993 2000

    Figure 1.2 - Trends in Wasting

    0

    10

    20

    30

    40

    50

    4 8.5 17.5 29.5 41.5 53.5

    Age in months

    (%)

    80/81 1993 2000

    Figure 1.3 - Trends in Underweight

    0

    10

    20

    30

    40

    50

    4 8.5 17.5 29.5 41.5 53.5

    Age in months

    (%)

    1993 2000

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    The high incidence of low birth weight babies is another cause for the faltering of growth

    during the early years of life. Anaemic conditions among pregnant women are one of the

    main reasons for the birth of low birth weight babies. Figure 1.4 illustrates the incidence of

    low birth weight babies in the last decade.

    Diarrhoea is also an illness which has a negative effect on growth and development in early

    childhood years. Diarrhoeal diseases are still very common among children in Sri Lanka

    although case fatality rates has dropped greatly in the past two decades. According to the DHS

    survey 2000, seven percent of children under five years of age, had suffered from at least one

    attack of diarrhoea in the two week reference period. Prevalence rates are highest and stands

    at 13% for children in the (6-11) months age group, when solids are introduced to the childs

    diet. Figure 1.5 presents hospital (Government only) statistics related to diarrhoea cases in the

    last two decades.

    Figure1.4 - Incidence of low birth weight babies by year

    23%

    19% 18%16%

    0%

    10%

    20%

    30%

    40%

    50%

    1990 1993 19991996

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    Figure 1.5 - Diarrhoea patients by year

    150134

    121111

    145

    0

    50

    100

    150

    200

    250

    Note : Northern and Eastern provinces are not covered fully in

    1990 and 1995

    in'000

    II Determinants of malnutrition

    2.1 Source of data

    Information on anthropometric measurements of weight and height of children in the age

    interval (3-59) months, collected in the Demographic and Health Survey (DHS) in year 2000

    was used for the study. As the DHS survey was not conducted in the conflict affected areas

    of the island, the coverage of this study is confined to the Southern areas only, and excludesthe Northern and Eastern provinces. The dataset includes information pertaining to 2,576

    children in the target group, canvassed from 8,169 households.

    2.2 Methodology

    In the computation of indicators of malnutrition ie. stunting, wasting and underweight, the

    reference population defined by the National Centre for Health Statistics (NCHS) of the

    United States was used, as local reference standards are not available. The procedure of

    transforming the anthropometric data into Standard Deviation scores (SD) usually mentioned

    as Z - scores was adopted. The cut-off points used for the indicators are (-2, -2.99) SD for

    moderate and -3SD and below for severe states.

    2.2 Energy protein malnutrition

    The occurrence of energy protein malnutrition in children under five years of age depends on

    many factors of which a few are biological. It is largely a phenomenon brought about by

    adverse socio - economic conditions. Many of these factors are inter related and are linked to

    1980 1985 1990 1995 2000

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    abject poverty, the result being dietary imbalances in the food intake of children, either

    through ignorance of parents or sheer incapability to provide a nutritionally adequate diet.

    The following variables were used in a regression to decide on their influence on the

    incidence of stunting, wasting and underweight in children in the specific age cohort.

    1. Access to safe drinking water

    2. Access to sanitation

    3. Sector (Urban / Rural / Estate)

    4. Sex of child

    5. Educational level of mother

    6. Age of child

    7. Birth weight of child

    8. Number of living children in the family

    9. Work status of mother

    10. Usage of mass media by mother

    11. Whether mother used soap after child defecated

    12. Whether child received Colostrum

    13. Whether exclusive breastfeeding practised

    14. Mothers Body Mass Index

    15. Whether mother washed her hands before feeding child

    2.4 Results of the regression analysis

    The aim of the exercise was to find out factors, which show a significant effect at 5% level of

    significance on the incidence of each of the three indicators of malnutrition. A number of

    models were checked using the forward selection method and those which showed the best

    fit are summarized below.

    Model summary

    No.of R2 Adj. Std Error

    of

    Statistic independent value R2 Estimate

    variables

    Stunting 12 0.396 0.393 1.1136

    Wasting 10 0.560 0.559 0.9524

    Underweight 12 0.625 0.623 1.0768

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    2.5 Key determinants of stunting

    The following nine factors are found to have an influence on chronic malnutrition status

    among children under five years.

    1. Number of living children

    2. Age of child

    3. Sector of residence

    4. Work status of mother

    5. Access to media by mother

    6. Mothers educational level

    7. Type of latrine

    8. Child given colostrum

    9. Mother washes her hands with soap after child defecated

    2.6 Key determinants of wasting

    The following eight factors are found to have an influence on acute malnutrition status among

    children under five years.

    1. Age of child2. Sector of residence3. Work status of mother

    4. Access to media by mother5. Mothers educational level6. Sex of child7. Access to safe drinking water8. Type of latrine

    2.7 Key determinants of underweight

    The following eight factors are found to have an influence on concurrent chronic and acute

    malnutrition status, among children under five years.

    1. Number of living children

    2. Age of child

    3. Sector of residence

    4. Work status of mother

    5. Access to media by mother

    6. Mothers educational level

    7. Mother washes her hands with soap after child defecated

    8. Type of latrine

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    III Differentials and Levels of Stunting

    Overall 14% of children below five years are moderately or severely stunted. Another 28% are

    found to be mildly stunted.

    An analysis of differentials is presented below in respect of the incidence of moderate and severestunting.

    3.1 Educational level of mother

    ?? Proportion stunted is as high as 27%when mother has not gone beyondprimary level of education.

    ?? The affected proportion has droppeddown to 11% when the mother has

    had at least secondary education.

    27%

    11%

    0%

    10%

    20%

    30%

    40%

    50%

    Primary or below Secondary or

    higher

    3.2 Age of child

    ?? Stunting is not a critical healthconcern for children under sixmonths.

    ?? Stunting is closely associated withthe introduction of weaning whichstarts at the age of five to sixmonths.

    ?? 16% of children in their second yearof life are stunted. Usually they starteating from the common pot at thisage.

    ?? Chronic malnutrition continue to behigh in the growing period, from thesecond year up to the fifth year.

    ?? One child out of every five childrenwho start schooling at five yearssuffer from long term malnutrition.

    3%6%

    16%13% 13%

    19%

    0%

    10%

    20%

    30%

    40%

    50%

    3-5

    6-11

    12-23

    24-35

    36-47

    48-59

    Age in months

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    3.6 Type of latrine

    ?? Proportion stunted is 10% in

    households using sanitary latrines.The affected proportion of childrenis double that figure in householdswith unsanitary latrines.

    ?? Chronic malnourishment appears tobe even higher (28%) in householdswith no access to toilet facilities.

    20%

    28%

    10%

    0%

    10%

    20%

    30%

    40%

    50%

    Sanitary Unsanitary None

    Type of latrine

    3.7 Sex of child

    ??Only marginal differences inproportion stunted are observed bysex of child. Girls show a slightlyhigher tendency of gettingstunted than boys.

    12%15%

    0%

    10%

    20%

    30%

    40%

    50%

    Boys Girls

    3.8 Work status of mother

    ?? Work status of mother appears to behighly co-related to the incidence of longterm malnourishment in their children.

    ?? Proportion stunted is lowest amongchildren of white collar workers (8%) . Itis thrice as high among children of bluecollar workers(24%).

    ?? Proportion stunted is 11% amongchildren of mothers who do not work for

    pay or profit.

    8 %11 %

    24 %

    0%

    10%

    20%

    30%

    40%

    50%

    Whitecollar

    worker

    Nonworking

    Bluecollar

    worker

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    3.9 Access to media

    ?? Mothers accessibility to media improves

    the nutritional level of children.?? Proportion stunted is below 10% when

    mother has access to both electronicand print media. It is 15% for mothersusing only electronic media.

    ?? One out of every five children showsigns of stunting when their mothershave no access to any media.

    9%

    15%

    20%

    0%

    10%

    20%

    30%

    40%

    50%

    Print &

    electronic media

    Electronic

    media only

    No access to

    media

    3.10 Use of soap after child defecated

    ?? Mothers sanitary habits has a stronginfluence on the nutritional level of herchildren

    ?? Proportion stunted is twice as high(26%) when mother does not use soapafter child defecated, as against thosewho use soap.

    13%

    26 %

    0%

    10%

    20%

    30%

    40%

    50%

    Uses soap Does not use

    soap

    3.11 Mother washes her hands beforefeeding the child

    ?? Data confirms the importance of goodpractices in mother to maintain childhealth.

    ?? Proportion stunted is twice as high(27%) when mother does not wash herhands before feeding the child, as

    against those who wash their hands(13%).

    13%

    27%

    0%

    10%

    20%

    30%

    40%

    50%

    Mother washes her

    hands

    Mother does not

    wash her hands

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    3.12 Exclusive breast feeding

    ?? Exclusive breastfeeding has not made a

    significant impact on the incidence ofstunting, during the fast developingperiod from infancy through childhoodyears. 12 %

    1 6 %

    0%

    10%

    20%

    30%

    40%

    50%

    Exclusive

    breastfeeding

    No exclusive

    breastfeeding

    3.13 Child given colostrum

    ?? Whether the child received colostrum ornot at birth appears to have only amarginal affect, on the incidence of longterm malnutrition in the first five years oflife.

    13%17%

    0%

    10%

    20%

    30%

    40%

    50%

    Colostrum

    received

    Colostrum not

    received

    3.14 Body Mass Index (BMI) of mother

    ?? Mothers nutritional status very amplyreflects that of her child.

    ?? Proportion stunting is lowest (9%) whenmothers BMI >25 and increases withthe decline in BMI, and stands at 17%for children whose mothers are undernourished (BMI < 18.5).

    9%12%

    17%

    0%

    10%

    20%

    30%

    40%

    50%

    > 25 18.5 - 25 < 18.5

    BMI of mother

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    3.15 Sector of residence

    ?? Incidence of long term malnutritiondepends largely on the area ofresidence

    ?? Long tern malnutrition is least commonin Urban dwellings (9%), compared to13% in Rural households and 35% inEstate households.

    ?? One out of every three preschoolchildren in the Estate sector are stunted.

    8% 9%

    13%

    35%

    0%

    10%

    20%

    30%

    40%

    50%

    Colombo

    metro

    Other urban Rural Estate

    IV Differentials and Levels of Wasting

    Overall 14% of children under five years of age suffer from moderate or severe wasting.Another 39% in the same age cohort are found to be mildly wasted.

    An analysis of differentials is presented below in respect of the incidence of moderate andsevere wasting.

    4.1 Educational level of mother

    ?? Mothers education has a milderinfluence on wasting than on stunting inpre school children. 17% of children ofmothers with at most primary educationare wasted, compared to 14% of therest of the children in the same agegroup.

    1 7 %1 4 %

    0%

    10%

    20%

    30%

    40%

    50%

    Primary or

    below

    Secondary or

    higher

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    4.2 Age of child

    ?? Incidence of wasting in children at

    different age intervals of growth,portrays the same pattern as that ofstunting.

    ?? One out of ten children are affected byshort term malnutrition after theintroduction of weaning.

    ?? Prevalence rates increase with age andby the fifth year, one child out of everysix children show signs of acutemalnourishment.

    1%

    10%

    18%

    13% 14%16%

    0%

    10%

    20%

    30%

    40%

    50%

    3-5

    6-11

    12-23

    24-35

    36-47

    48-59

    Age in months

    4.3 Birth weight

    ?? Similar to stunting, one fourth ofchildren with low birth weight arereported to be wasted.

    12%

    24%

    0%

    10%

    20%

    30%

    40%

    50%

    =>2.5 Kg < 2.5 Kg

    Birthweight

    4.4 Family size

    ?? Number of siblings appear to have anegative effect, on the state of wastingas well as stunting, in infants and small

    children. But the effect is less intense inthe case of wasting, with rates ofaffliction by number of children showinga narrower gap.

    14% 15%19%

    0%

    10%

    20%

    30%

    40%

    50%

    5

    No. of living children

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    4.5 Source of drinking water

    ?? Source of drinking water whether safe

    or unsafe, has negligible impact onshort term malnourishment of preschool children.

    14% 15%

    0%

    10%

    20%

    30%

    40%

    50%

    Safe Unsafe

    Source of drinking water

    4.6 Type of latrine

    ?? Proportion wasted stands at 13% forchildren using sanitary latrines,whereas it is 17% for those usingunsanitary latrines, and 16% forchildren without a latrine within theirhousing unit.

    13%

    17% 16%

    0%

    10%

    20%

    30%

    40%

    50%

    Sanitary Unsanitary None

    Type of latrine

    4.7 Sex of child

    ?? As in the case of stunting, the sex of achild has little bearing on his/hernutritional status. However boys show aslightly higher tendency of gettingwasted than girls.

    15%13%

    0%

    10%

    20%

    30%

    40%

    50%

    Boys Girls

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    4.8 Work status of mother

    ?? Same pattern exists for both short term

    and long term malnutrition, withmothers work status strongly linked tothe nutritional status of her child.

    ?? Proportion wasted is a high 18% forchildren of blue collar workers, and ishalf of that (9%) among children ofwhite collar workers.

    ?? Wasting is relatively high (14%) amongchildren of non- working mothers aswell.

    9 %

    1 4 %

    1 8 %

    0%

    10%

    20%

    30%

    40%

    50%

    White

    collar

    worker

    Non

    working

    Blue collar

    worker

    4.9 Access to media

    ?? The role of mass media as a mitigatingfactor in the occurrence of malnutrition,is evident from the prevalence rates ofwasting as well as stunting.

    ?? Proportion wasted stands at 13% whenmother has access to both electronicand print media, 14% when motheruses only electronic media and 17%when mother has no access to anymedia.

    1 3 % 1 4 %17 %

    0%

    10%

    20%

    30%

    40%

    50%

    Print &

    electronic

    media

    Electronic

    media only

    No access

    to media

    4.10 Use of soap after child defecated

    ?? mothers sanitary habits would certainlycontribute towards protecting the childfrom wasting, but to a lesser degreethan in the case of stunting.

    ?? Proportion wasted is estimated as 18%when mother does not use soap afterchild defecated, while the affectedproportion is 14% when mother usessoap.

    14%

    18%

    0%

    10%

    20%

    30%

    40%

    50%

    Uses soap Does not use soap

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    4.11 Mother washes her hands beforefeeding the child

    ?? A marginal increase in the incidence ofacute malnourishment could beobserved, when mother does not washher hands before feeding her child(16%), than when she has the habit ofcleaning them (14%).

    1 4 %1 6 %

    0%

    10%

    20%

    30%

    40%

    50%

    Mother washes

    her hands

    Mother does not

    wash her hands

    4.12 Exclusive breastfeeding

    ?? Similar to the occurrence of chronicmalnourishment, exclusivebreastfeeding cannot be identified as amitigating factor, in the occurrence ofacute malnourishment in the earlychildhood years.

    13%16%

    0%

    10%

    20%

    30%

    40%

    50%

    Exclusive

    breastfeeding

    No exclusive

    breastfeeding

    4.13 Child given colostrum

    ?? Only a two percentage points increaseis observed in the incidence of wasting,for non recipients of colostrum at birth,as against those who receivedcolostrum. 14%

    16%

    0%

    10%

    20%

    30%

    40%

    50%

    Colostrum

    received

    Colostrum not

    received

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    4.14 Body Mass Index (BMI) of mother

    ?? As in the case of stunting, mothers BMI

    shows a close association to theprevalence rates of wasting in herchildren.

    ?? Proportion wasted is lowest (10%)when mothers BMI > 25. Itincreases with the decline in BMI andhas almost doubled (19%), whenmothers BMI is less than 18.5.

    10%14%

    19%

    0%

    10%

    20%

    30%

    40%

    50%

    >25 18.5 - 25

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    5.1 Educational level of mother

    ?? Mothers education could bring about anoteworthy reduction in the incidence ofunderweight in pre school children.

    ?? Proportion underweight stands at 43%for children whose mothers have had noformal education or gone up to primarylevel only, as against 27% for childrenwhose mothers have had at leastsecondary education.

    43%

    27%

    0%

    10%

    20%

    30%

    40%

    50%

    Primary or below Secondary or

    higher

    5.2 Age of child

    ?? Similar to the pattern of stunting andwasting, prevalence rates of underweightshow a rapid increase after the age of 6months.

    ?? One child out of every five children showssigns of underweight as they approachtheir first birthday.

    ?? The situation worsens with age and the

    prevalence rate doubles by the fifth yearof life.

    0%

    21%

    29%

    35 %

    30 %

    39%

    0%

    10%

    20%

    30%

    40%

    50%

    3-5

    6-11

    12-23

    24-35

    36-47

    48-59

    Age in months

    5.3 Birth weight

    ?? Low birth weight babies show a highervulnerability to be underweight (47%)than their counterparts (25%), in the firstfive years of life. 25%

    47%

    0%

    10%

    20%

    30%

    40%

    50%

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    5.4 Family size

    ??Similar to stunting and wasting, proportionunderweight rises steadily with theincrease in the number of living children inthe family.

    ?? One child out of every four children isunderweight in small families with one ortwo children.

    ?? One child out of every three children isunderweight in families with three or fourchildren.

    ?? Every other child is underweight when thenumber of siblings are five or more.

    2 7 %

    3 6 %

    4 6%

    0%

    10%

    20%

    30%

    40%

    50%

    5

    No. of living children

    5.5 Source of drinking water

    ?? Safe drinking water could have amitigating effect on the prevalence ofunderweight. Prevalence rate iscomparatively low at 27% for childrenprovided with safe drinking water, asagainst 38% for their counterparts withoutthe facility.

    27%

    38%

    0%

    10%

    20%

    30%

    40%

    50%

    Safe Un safe

    Source of drinking water

    5.6 Type of latrine

    ?? Access to sanitation could make aconsiderable difference in the incidenceof underweight in pre school children inthe household.

    ?? Prevalence rates are estimated as 25%and 38% with regard to households with

    sanitary latrines and unsanitary latrinesrespectively, while it is as high as 44% forhouseholds without a latrine.

    25%

    38%

    44%

    0%

    10%

    20%

    30%

    40%

    50%

    Sanitary Unsanitary None

    Type of latrine

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    5.7 Sex of child

    ?? Incidence of underweight in pre

    school children appear to be genderneutral. Nevertheless girls (6%) show ahigher tendency to be severelyunderweight than boys (3%).

    2 9% 3 0 %

    0%

    10%

    20%

    30%

    40%

    50%

    Boys Girls

    5.8 Work status of mother

    ?? As in the case of stunting and wasting,work status of mother has a greatinfluence on the incidence ofunderweight in her child.

    ?? Proportion underweight is as high as43% for children of blue collar workers.In contrast, the affected proportion is low(18%) among children of white collarworkers.

    ?? Prevalence of underweight is 28% forchildren of non working mothers.

    18%

    28%

    43%

    0%

    10%

    20%

    30%

    40%

    50%

    White collar

    worker

    Non

    working

    Blue collar

    worker

    5.9 Access to media

    ?? The importance of the use of massmedia in controlling malnutrition is furtherconfirmed, in respect of the incidence ofunderweight in pre school children.

    ?? Proportion underweight stands at 22%when mother has access to bothelectronic and print media, rises to 32%when mother uses only electronicmedia and further increases to 39%when mother has no access to anymedia.

    22%

    32%

    39%

    0%

    10%

    20%

    30%

    40%

    50%

    Print &

    electronic

    media

    Electronic

    media only

    No access to

    media

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    5.10 Use of soap after child defecated

    ?? Mothers sanitary habits appear to behighly co-related to the status ofunderweight in her child.

    ?? Every other child tend to becomeunderweight when mother does notadhere to the healthy habit of using soapafter child defecated.

    ?? Proportion of underweight children dropsto half when mother uses soap.

    28 %

    4 9 %

    0%

    10%

    20%

    30%

    40%

    50%

    Uses soap Does not use

    soap

    5.11 Mother washes her hands beforefeeding the child

    ?? Great emphasis needs to be laid onmothers cleanliness in controllingdiseases and improving child health.Nearly 50% of pre school children, whosemothers are not in the habit of washingtheir hands before feeding their children,are underweight; as against 28% ofchildren whose mothers are concernedabout their cleanliness.

    28 %

    4 8 %

    0%

    10%

    20%

    30%

    40%

    50%

    Mother washes

    her hands

    Mother does

    not wash her

    hands

    5.12 Exclusive breast feeding

    ?? Exclusive breast feeding appears to haveno great influence on the incidence ofunderweight in pre school children.

    28%

    32%

    0%

    10%

    20%

    30%

    40%

    50%

    Exclusive

    breastfeeding

    No exclusive

    breastfeeding

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    5.13 Child given colostrum

    ?? Recipients of colostrum display aslightly lower tendency of gettingunderweight in their early childhoodyears, than their counterparts who didnot receive colostrum at birth.

    2 8%

    3 4 %

    0%

    10%

    20%

    30%

    40%

    50%

    Colostrum

    received

    Colostrum not

    received

    5.14 Body Mass Index (BMI) of mother

    ?? Mothers BMI provides a proxy to theliving standards of the family,particularly the domestic foodavailability.

    ?? As such it is closely associated withthe status of underweight in herchildren.

    ?? Proportion underweight is lowest(19%) when mother is overweight(BMI >25), increases steadily with thedecline in BMI and doubles (38%)

    when mother is herself malnourished(BMI 25 18.5 - 25 < 18.5

    BMI of mother

    5.15 Sector of residence

    ?? Apparently the living environment isan important determinant of the statusof underweight, in the most decisivestage of growth of the lifespan of ahuman being.

    ?? One out of every five children residingin urban areas are underweight.

    ?? One out of every three childrenresiding in rural areas areunderweight.

    ?? One out of every two children residingin the estates are underweight. Infactone fifth of the afflicted are in a severestate of underweight.

    1 8 %

    2 3 %

    31 %

    4 5 %

    0%

    10%

    20%

    30%

    40%

    50%

    C o l o m b o

    m e t r o

    O t h e r

    u r b a n

    R u ra l E s t a t e


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