Nutritional Status Of Preschool_sri_lanka

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SRI LANKA

“Nutritional Status of Pre-School Children in Sri Lanka”

Department of Census and Statistics

Concluding Workshop RETA 6007: Enhancing Social and Gender Statistics 24-27 June 2003 Bangkok, Thailand

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Contents Page

I.

About the Project

3

Summary

4

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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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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Summary Malnutrition has been identified as a major health problem in post independent Sri Lanka, 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 in the reproductive age group are malnourished, with 17% of children under five years have 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, part icularly 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 mother’s 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. The situation of malnourishment in pre school children has somewhat improved over the years, with stunting or long term nutritional deficiencies declining to one third of what it was in the early nineteen eighties. However wasting or short term nutritional deficiencies 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 var iables are predominant in the incidence 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. Mother’s educational level. 7. Type of latrine. 8. Child given colostrum 9. 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. Mother’s educational level. 6. Sex of child. 7. Access to safe drin king water. 8. Type of latrine.

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Underweight. 1. 2. 3. 4. 5. 6. 7. 8.

Number of living children in the family. Age of child. Sector of residence. Work status of mother. Access to media by mother. Mother’s educational level. Mother washes her hands with soap after child defecated. 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, while another 36% are found to be mildly underweight. Nearly 50% of pre-school when : ?? ?? ?? ?? ??

children are reported to be underweight (moderate and severe)

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 mother’s 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 mother’s 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 age group 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

5.7 14.1

3.9

6.8 10.3 23.4 17.9

20.2

06-11

18.57 15.2 11.8

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

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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

12.9 15.5 14.0 38.1 37.7

29.4

Average 36.58 27.5 23.8 13.5 12.1

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Figure 1.1 - Trends in Stunting 50 40 (%)

30 20 10 0 4

8.5 80/81

17.5

29.5

1993

41.5

53.5 Age in months

2000

Figure 1.2 - Trends in Wasting 50

(%)

40 30 20 10 0 4

8.5

17.5 80/81

29.5 1993

41.5

53.5 Age in months

2000

Figure 1.3 - Trends in Underweight 50

(%)

40 30 20 10 0 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.

Figure1.4 - Incidence of low birth weight babies by year 50%

40%

30% 23% 19%

20%

18%

16%

10%

0% 1990

1993

1996

1999

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 child’s diet. Figure 1.5 presents hospital (Government only) statistics related to diarrhoea cases in the last two decades.

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Figure 1.5 - Diarrhoea patients by year 250 200 in '000

150 150

145

134

121

111

100 50 0 1980

1985

1990

1995

2000

Note : Northern and Eastern provinces are not covered fully in 1990 and 1995

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 excludes the 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

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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. Mother’s 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

R

2

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. Mother’s 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 child 2. Sector of residence 3. Work status of mother 4. Access to media by mother 5. Mother’s educational level 6. Sex of child 7. Access to safe drinking water 8. 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. Mother’s 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 severe stunting. 3.1 Educational level of mother ?? Proportion stunted is as high as 27% when mother has not gone beyond primary level of education. ?? The affected proportion has dropped down to 11% when the mother has had at least secondary education.

50% 40% 27%

30% 20%

11%

10% 0% Primary or below

Secondary or higher

3.2 Age of child 50% 40% 30%

10%

13%

13%

36-47

16%

24-35

19%

20% 6% 3%

Age in months

48-59

12-23

6-11

0% 3-5

?? Stunting is not a critical health concern for children under six months. ?? Stunting is closely associated with the introduction of weaning which starts at the age of five to six months. ?? 16% of children in their second year of life are stunted. Usually they start eating from the common pot at this age. ?? Chronic malnutrition continue to be high in the growing period, from the second year up to the fifth year. ?? One child out of every five children who start schooling at five years suffer from long term malnutrition.

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3.3 Birth weight 50%

?? Nearly one out of four children born with birth weight lower than the standard 2.5 kg, show signs of long term malnourishment, in the first five years of their lives.

40% 30% 23%

20% 11%

10% 0%

=> 2.5 Kg.

< 2.5 Kg. Birthweight

3.4 Family size ?? Proportion stunted stands at 11% for small families with one or two children. It doubles when the number of siblings increases to 3 or 4. ?? The situation is still worse in families with five or more children.

50% 40% 27%

30% 21%

20% 11%

10% 0% <=2

3-4

>5

No. of living children

3.5 Source of drinking water ?? Incidence of stunting is twice as high in households using unsafe sources of water (22%), than in households using safe sources for drinking purposes.

50% 40% 30% 22%

20% 11%

10% 0% Safe Unsafe Source of drinking water

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3.6 Type of latrine ?? Proportion stunted is 10% in households using sanitary latrines. The affected proportion of children is double that figure in households with unsanitary latrines. ?? Chronic malnourishment appears to be even higher (28%) in households with no access to toilet facilities.

50% 40% 28%

30% 20%

20% 10%

10% 0% Sanitary

Unsanitary

None

Type of latrine

3.7 Sex of child ?? Only marginal differences in proportion stunted are observed by sex of child. Girls show a slightly higher tendency of getting stunted than boys.

50% 40% 30% 20% 12%

15%

10% 0% Boys

Girls

3.8 Work status of mother ?? Work status of mother appears to be highly co-related to the incidence of long term malnourishment in their children. ?? Proportion stunted is lowest among children of white collar workers (8%) . It is thrice as high among children of blue collar workers(24%). ?? Proportion stunted is 11% among children of mothers who do not work for pay or profit.

50% 40% 30%

24%

20% 10%

8%

11%

0% White collar worker

Non working

Blue collar worker

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3.9 Access to media ?? Mother’s accessibility to media improves the nutritional level of children. ?? Proportion stunted is below 10% when mother has access to both electronic and print media. It is 15% for mothers using only electronic media. ?? One out of every five children show signs of stunting when their mothers have no access to any media.

50% 40% 30% 20%

20% 10%

15% 9%

0% Print & electronic media

Electronic media only

No access to media

3.10 Use of soap after child defecated ?? Mother’s sanitary habits has a strong influence on the nutritional level of her children ?? Proportion stunted is twice as high (26%) when mother does not use soap after child defecated, as against those who use soap.

50% 40% 30%

26%

20% 13%

10% 0% Uses soap

Does not use soap

50%

3.11 Mother washes her hands before feeding the child

40% 27%

30%

?? Data confirms the importance of good practices in mother to maintain child health. ?? Proportion stunted is twice as high (27%) when mother does not wash her hands before feeding the child, as against those who wash their hands (13%).

20% 13%

10% 0% 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 of stunting, during the fast developing period from infancy through childhood years.

50% 40% 30% 20%

16% 12%

10% 0% Exclusive breastfeeding

No exclusive breastfeeding

3.13 Child given colostrum ?? Whether the child received colostrum or not at birth appears to have only a marginal affect, on the incidence of long term m alnutrition in the first five years of life.

50% 40% 30% 20%

17% 13%

10% 0% Colostrum received

Colostrum not received

3.14 Body Mass Index (BMI) of mother 50%

?? Mother’s nutritional status very amply reflects that of her child. ?? Proportion stunting is lowest (9%) when mother’s BMI >25 and increases with the decline in BMI, and stands at 17% for children whose mothers are under nourished (BMI < 18.5).

40% 30% 17%

20% 10%

9%

12%

0% > 25

18.5 - 25 BMI of mother

< 18.5

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3.15 Sector of residence ?? Incidence of long term malnutrition depends largely on the area of residence ?? Long tern malnutrition is least common in Urban dwellings (9%), compared to 13% in Rural households and 35% in Estate households. ?? One out of every three preschool children in the Estate sector are stunted.

IV

50% 40%

35%

30% 20% 13%

10%

8%

9%

Colombo metro

Other urban

0% Rural

Estate

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 and severe wasting. 4.1 Educational level of mother

?? Mother’s

education has a milder influence on wasting than on stunting in pre school children. 17% of children of mothers with at most primary education are wasted, compared to 14% of the rest of the children in the same age group.

50% 40% 30% 20%

17% 14%

10% 0% Primary or below

Secondary or higher

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4.2 Age of child

?? Incidence of wasting in children at 50% 40% 30% 18%

20%

13%

10%

14%

16%

10% 1%

48-59

36-47

24-35

6-11

12-23

0% 3-5

different age intervals of growth, portrays the same pattern as that of stunting. ?? One out of ten children are affected by short term malnutrition after the introduction of weaning. ?? Prevalence rates increase with age and by the fifth year, one child out of every six children show signs of acute malnourishment.

Age in months

4.3 Birth weight

?? Similar to stunting, one fourth of

50%

children with low birth weight are reported to be wasted.

40% 30%

24%

20% 12%

10% 0% =>2.5 Kg

< 2.5 Kg Birthweight

4.4 Family size

?? Number of siblings appear to have a negative effect, on the state of wasting as well as stunting, in infants and small children. But the effect is less intense in the case of wasting, with rates of affliction by number of children showing a narrower gap.

50% 40% 30% 20%

19% 14%

15%

<=2

3-4

10% 0% No. of living children

>5

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4.5 Source of drinking water

?? Source of drinking water whether safe or unsafe, has negligible impact on short term malnourishment of pre school children.

50% 40% 30% 20%

14%

15%

Safe

Unsafe

10% 0% Source of drinking water

4.6 Type of latrine 50%

?? Proportion wasted stands at 13% for children using sanitary latrines, whereas it is 17% for those using unsanitary latrines, and 16% for children without a latrine within their housing unit.

40% 30% 20%

17%

16%

Unsanitary

None

13%

10% 0% Sanitary

Type of latrine

4.7 Sex of child 50%

?? As in the case of stunting, the sex of a child has little bearing on his/her nutritional status. However boys show a slightly higher tendency of getting wasted than girls.

40% 30% 20%

15%

13%

10% 0% Boys

Girls

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4.8 Work status of mother

?? Same pattern exists for both short term and long term malnutrition, with mother’s work status strongly linked to the nutritional status of her child. ?? Proportion wasted is a high 18% for children of blue collar workers, and is half of that (9%) among children of white collar workers. ?? Wasting is relatively high (14%) among children of non- working mothers as well.

4.9 Access to media

?? The role of mass media as a mitigating factor in the occurrence of malnutrition, is evident from the prevalence rates of wasting as well as stunting. ?? Proportion wasted stands at 13% when mother has access to both electronic and print media, 14% when mother uses only electronic media and 17% when mother has no access to any media. 4.10

50% 40% 30% 18%

20% 10%

14% 9%

0% White collar worker

Non working

13%

14%

Blue collar worker

50% 40% 30% 17%

20% 10% 0%

Print & Electronic electronic media only media

No access to media

Use of soap after child defecated

?? mother’s sanitary habits would certainly contribute towards protecting the child from wasting, but to a lesser degree than in the case of stunting. ?? Proportion wasted is estimated as 18% when mother does not use soap after child defecated, while the affected proportion is 14% when mother uses soap.

50% 40% 30% 20%

18% 14%

10% 0% Uses soap

Does not use soap

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4.11 Mother washes her hands before feeding the child

?? A marginal increase in the incidence of acute malnourishment could be observed, when mother does not wash her hands before feeding her child (16%), than when she has the habit of cleaning them (14%).

50% 40% 30% 20%

14%

16%

10% 0% Mother washes her hands

4.12

Mother does not wash her hands

Exclusive breastfeeding 50%

?? Similar to the occurrence of chronic malnourishment, exclusive breastfeeding cannot be identified as a mitigating factor, in the occurrence of acute malnourishment in the early childhood years.

40% 30% 20% 13%

16%

10% 0% Exclusive breastfeeding

4.13

No exclusive breastfeeding

Child given colostrum 50%

?? Only a two percentage points increase is observed in the incidence of wasting, for non recipients of colostrum at birth, as against those who received colostrum.

40% 30% 20%

14%

16%

10% 0% Colostrum received

Colostrum not received

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4.14

Body Mass Index (BMI) of mother

?? As in the case of stunting, mother’s BMI shows a close association to the prevalence rates of wasting in her children. ?? Proportion wasted is lowest (10%) when mother’s BMI > 25. It increases with the decline in BMI and has almost doubled (19%), when mother’s BMI is less than 18.5.

50% 40% 30% 19%

20%

14% 10%

10% 0% >25

18.5 - 25

<18.5

BMI of mother

4.15

Sector of residence 50%

?? The living environment appears to be highly co-related with the incidence of short term malnutrition as well as long term malnutrition, in children in their early childhood years. ?? Incidence of wasting is relatively low and stands at 9% in urban areas, compared to 12% in the estates and 16% in the rural sector.

V

40% 30% 20% 10%

16% 10%

12% 7%

0% Colombo metro

Other urban

Rural

Estate

Differentials and Levels of Underweight

Nearly one third (30%) of the child population below five years, are found to be moderately or severely underweight for their age. Another 36% show signs of underweight to a lesser degree. On the whole, an alarmingly high proportion of 66%, accounting to two out of every three children in the target population, appear to be severely, moderately or mildly underweight. An analysis of differentials is presented below in respect of the incidence of moderate and severe underweight.

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5.1 Educational level of mother

27%

30% 20% 10% 0% Primary or below

Secondary or higher

50% 39%

40%

35% 30%

29%

30% 21%

20% 10%

Age in months

5.3 Birth weight ?? Low birth weight babies show a higher vulnerability to be underweight (47%) than their counterparts (25%), in the first five years of life.

50%

47%

40%

30%

25% 20%

10%

0% <=2.5Kg

<2.5Kg

Birthweight

48-59

36-47

0%

24-35

0%

12-23

?? Similar to the pattern of stunting and wasting, prevalence rates of underweight show a rapid increase after the age of 6 months. ?? One child out of every five children shows signs of underweight as they approach their first birthday. ?? The situation worsens with age and the prevalence rate doubles by the fifth year of life.

43%

40%

6-11

5.2 Age of child

50%

3-5

?? Mother’s education could bring about a noteworthy reduction in the incidence of underweight in pre school children. ?? Proportion underweight stands at 43% for children whose mothers have had no formal education or gone up to primary level only, as against 27% for children whose mothers have had at least secondary education.

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5.4 Family size ?? Similar to stunting and wasting, proportion underweight rises steadily with the increase in the number of living children in the family. ?? One child out of every four children is underweight in small families with one or two children. ?? One child out of every three children is underweight in families with three or four children. ?? Every other child is underweight when the number of siblings are five or more.

50%

46%

40% 30%

36% 27%

20% 10% 0% <=2

3-4

>5

No. of living children

5.5 Source of drinking water ?? Safe drinking water could have a mitigating effect on the prevalence of underweight. Prevalence rate is comparatively low at 27% for children provided with safe drinking water, as against 38% for their counterparts without the facility.

50% 38%

40% 30%

27%

20% 10% 0% Safe

Un safe

Source of drinking water

5.6 Type of latrine ?? Access to sanitation could make a considerable difference in the incidence of underweight in pre school children in the household. ?? Prevalence rates are estimated as 25% and 38% with regard to households with sanitary latrines and unsanitary latrines respectively, while it is as high as 44% for households without a latrine.

50%

44% 38%

40% 30%

25%

20% 10% 0% Sanitary

Unsanitary

Type of latrine

None

27

5.7 Sex of child 50%

??

Incidence of underweight in pre school children appear to be gender neutral. Nevertheless girls (6%) show a higher tendency to be severely underweight than boys (3%).

40% 30%

29%

30%

Boys

Girls

20% 10% 0%

5.8 Work status of mother

?? As in the case of stunting and wasting,

50%

work status of mother has a great influence on the incidence of underweight in her child. ?? Proportion underweight is as high as 43% for children of blue collar workers. In contrast, the affected proportion is low (18%) among children of white collar workers. ?? Prevalence of underweight is 28% for children of non working mothers.

40%

43%

28%

30% 20%

18%

10% 0% White collar worker

Non working

Blue collar worker

5.9 Access to media

?? The importance of the use of mass media in controlling malnutrition is further confirmed, in respect of the incidence of underweight in pre school children. ?? Proportion underweight stands at 22% when mother has access to both electronic and print media, rises to 32% when mother uses only electronic media and further increases to 39% when mother has no access to any media.

50% 39%

40% 32%

30% 22%

20% 10% 0% Print & electronic media

Electronic media only

No access to media

28

5.10

Use of soap after child defecated

?? Mother’s sanitary habits appear to be highly co-related to the status of underweight in her child. ?? Every other child tend to become underweight when mother does not adhere to the healthy habit of using soap after child defecated. ?? Proportion of underweight children drops to half when mother uses soap.

49%

50% 40% 30%

28%

20% 10% 0% Uses soap

5.11

Mother washes her hands before feeding the child

?? Great emphasis needs to be laid on mother’s cleanliness in controlling diseases and improving child health. Nearly 50% of pre school children, whose mothers are not in the habit of washing their hands before feeding their children, are underweight; as against 28% of children whose mothers are concerned about their cleanliness.

5.12

Does not use soap

48%

50% 40% 30%

28%

20% 10% 0% Mother washes her hands

Mother does not wash her hands

Exclusive breast feeding 50%

?? Exclusive breast feeding appears to have no great influence on the incidence of underweight in pre school children.

40% 30%

32% 28%

20% 10% 0% Exclusive breastfeeding

No exclusive breastfeeding

29

5.13 Child given colostrum

?? Recipients of colostrum display a slightly lower tendency of getting underweight in their early childhood years, than their counterparts who did not receive colostrum at birth.

50% 40%

34% 28%

30% 20% 10% 0%

Colostrum received

Colostrum not received

5.14 Body Mass Index (BMI) of mother

?? Mother’s BMI provides a proxy to the living standards of the family, particularly the domestic food availability. ?? As such it is closely associated with the status of underweight in her children. ?? Proportion underweight is lowest (19%) when mother is overweight (BMI >25), increases steadily with the decline in BMI and doubles (38%) when mother is herself malnourished (BMI <18.5).

50% 38%

40% 27%

30% 20%

19%

10% 0% >25

18.5 - 25

< 18.5

BMI of mother

5.15 Sector of residence

?? Apparently the living environment is an important determinant of the status of underweight, in the most decisive stage of growth of the lifespan of a human being. ?? One out of every five children residing in urban areas are underweight. ?? One out of every three children residing in rural areas are underweight. ?? One out of every two children residing in the estates are underweight. Infact one fifth of the afflicted are in a severe state of underweight.

50%

45%

40% 31%

30% 23%

20%

18%

10% 0% Colombo

Other

metro

urban

Rural

Estate