'Panicky' new mums take kids to doctors 16 times in 1st year!

The typical new mother makes 16 trips to the doctors in their child's first year, a study has revealed.

According to researchers, millions of mothers have confessed that they "panicked" and took their child to the doctors' surgery during their first 12 months, only to be told that the kid was suffering from minor ailments, the Daily Express reported.

The study, carried out by Benenden Healthcare Society, found that one in three mothers took the baby to the doctors with what turned out to be a common cold.

One in 10 even dashed to the surgery thinking that their baby was unconscious - only to be told that the child was sleeping!

Results showed that it took a new mum six and half months on average to become familiar to her child's different cries.

-yahoo

Ireland govt plans law to legalize abortion

Ireland has finally decided to allow termination of pregnancy in cases where the mother’s life is in danger. The Irish government said that it would bring legislation to allow abortions in hospitals when doctors determine that a mother’s life is at risk.

  The move comes seven weeks after the death of 31-year-old Savita Halappanavar, who was 17 weeks pregnant. She had a miscarriage and died of septicaemia three days after requesting an abortion at Galway hospital which she wasn’t allowed to undergo. 

 Abortion is banned in Ireland as per a papal diktat. It is one of two European Union countries — the other being Malta — where women cannot have an abortion even when their lives are in danger. 

Ireland’s cabinet made the announcement of legalizing abortion after intense public pressure came from secular elements following Halappanavar's death. The bill will be drafted in the New Year and debated by the Irish parliament’s health committee before it is voted upon in the house known as the Dail. 

-(The Times of India)

As a doctor I welcome the decision to legalize abortion. People who still argue that a ban on abortion is pro-life, Savita’s case should have made it clear by now that it can often end up taking lives that could have been saved otherwise.

For Clean Railway Premises

Dengue

Kolkata is reeling under its worst bout of dengue this monsoon season. Many people have succumbed to the infection and government and private hospitals are flooded with dengue patients.  (1) The city is facing one of its worst dengue outbreaks in recent times.

Nine-year old Sreeja Das was the first dengue victim in the state. The epidemic first struck in the second week of August.Several people in and around Kolkata have been hospitalized since then with symptoms similar to dengue. Many patients have died from the disease and the number of confirmed cases has gone up to 638 (2) and still counting.

Dengue is a Public Health Menace which is better prevented rather than being treated as is the case with all diseases.

There has been a recent surge in Dengue cases not only in Kolkata, but in various other parts of the world as well. The incidence of dengue has grown dramatically around the world in recent decades. Over 2.5 billion people (i.e. over 40% of the world's population) are now at risk from dengue. WHO currently estimates that there may be 50–100 million dengue infections worldwide every year (3).

Dengue also known as breakbone fever, is an infectious tropical disease caused by the dengue virus (4). There are four distinct, but closely related, serotypes of the virus that cause dengue (DEN-1, DEN-2, DEN-3 and DEN-4). Recovery from infection by one provides lifelong immunity against that particular serotype. However, cross-immunity to the other serotypes after recovery is only partial and temporary. Subsequent infections by other serotypes increase the risk of developing severe dengue (3).

Dengue is transmitted by the Aedes aegypti mosquito which is the primary vector of dengue. The virus is transmitted to humans through the bites of infected female mosquitoes. 4–10 days after getting infected, a mosquito is capable of transmitting the virus for the rest of its life. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes (3).

The Aedes aegypti mosquito lives in urban habitats and breeds mostly in man-made containers. Ae. aegypti is a daytime feeder; its peak biting periods are early in the morning and in the evening before dusk. Female Ae. aegypti bites multiple people during each feeding period (3).(Also called Fearless Day Biter.)

The rapid transmission of the dengue virus this year in Kolkata has led experts to believe that a new vector is stalking the city along with the primary carrier Aedes aegypti, especially in Salt lake, the fringe areas of the city and along the EM Bypass where hundreds have been infected. Aedes albopictus or the Asian tiger mosquito is a secondary vector of the dengue virus and as lethal as the Aedes aegypti. (5).  Aedes albopictus has also spread to North America and Europe largely due to the international trade in used tyres (a breeding habitat) and other goods (e.g. lucky bamboo). Ae. albopictus is highly adaptive and therefore can survive in cooler temperate regions of Europe. Its spread is due to its tolerance to temperatures below freezing, hibernation, and ability to shelter in microhabitats (3).

Rampant construction activities and chopping of trees along the Bypass (Kolkata) are responsible for a spurt in the number of tiger mosquitoes this year. The albopictus prefers old buildings and tree crevices. With buildings being pulled down for high-rises and trees being chopped to make way for the Garia-Dum Dum Metro corridor along Bypass, the secondary vector has turned active. More than 1500 trees have been felled along the Bypass since 2010 to make way for Metro pillars. Green activists believe this has upset the ecosystem of the area and contributed to the spread of diseases like malaria and dengue (5).

Albopictus mosquito rests in the vicinity of human dwellings. They tend to move into houses quicker than other vectors and are hence more difficult to eliminate (5).

A case of dengue may present as (6):

•     Classical dengue fever
•     Dengue haemorrhagic fever
•     Dengue shock syndrome

Classical dengue fever:  Dengue fever can occur in epidemics which often start during the rainy season when the breeding of the vector mosquitoes  is  generally  abundant.

All ages and both sexes are susceptible to dengue fever. Children usually  have  a  milder  disease  than  adults. The onset of the disease is sudden with chills  and high fever,  intense headache, muscle  and  joint  pains. There may be pain behind the eyes (Retro orbital pain).

Other  common symptoms  include  extreme  weakness,  anorexia,  constipation, altered  taste  sensation,  pain in abdomen,  sore  throat  and  general depression.

Fever  is  usually  between  39°C  and  40°C and is associated with generalized pain and a headache; this usually lasts two to seven days. At this stage, a rash occurs in 50–80% of those with symptoms. It occurs in the first or second day of symptoms as flushed skin, or later in the course of illness (days 4–7), as a measles-like rash (4). The Rash starts on the chest and back and may spread to the extremities and rarely to the face.  It may  be accompanied  by  itching and hyperaesthesia. The rash  lasts  for  2  hours  to  several  days  and may  be  followed  by desquamation (6).

 Recovery is  usually  complete (6).

Dengue haemorrhagic fever:  Dengue haemorrhagic fever (DHF)    is a severe form of dengue fever, caused by infection with more than one dengue virus. The    severe    illness    is thought to    be    due    to    double infection with dengue viruses - the first infection probably sensitizes the patient, while the second appears to produce an immunological catastrophe. It presents with the following  clinical  manifestations :

(a)  Fever  -  acute  onset,  high,  continuous,  and  lasting  2  to  7 days.

(b)  Haemorrhagic manifestations like petechiae, purpura, ecchymosis, epistaxis, gum bleeding haematemesis and/or melaena.

(c)  Enlargement of liver.

Blood examinations reveal Thrombocytopenia (Platelet count 100,000/mm3 or less).

And Haemoconcentration (haemotocrit increased by 20 per cent or more of base-line value.)

Dengue shock syndrome (DSS):  It is DHF (Dengue Haemorrhagic fever) plus Shock-manifested by rapid and weak pulse with narrowing of  the  pulse  pressure  (20 mm Hg  or  less)  or  hypotension, with the presence of cold, clammy skin and restlessness.

The diagnosis of dengue is typically made clinically, on the basis of reported symptoms and physical examination.  A doctor should be consulted immediately if any of the symptoms as mentioned above appears especially in as endemic area or if the zone is under an ongoing epidemic.  The warning signs of Dengue involve Abdominal pain Ongoing vomiting, Liver enlargement, Mucosal bleeding, High hematocrit with low platelets and lethargy (7).

The diagnosis should be considered in anyone who develops a fever within two week of being in the tropics or subtropics. The earliest change detectable on laboratory investigations is a low white blood cell count, which may then be followed by low platelets and metabolic acidosis (4).

Dengue fever may be diagnosed by microbiological laboratory testing (7). This can be done by virus isolation in cell cultures, nucleic acid detection by PCR, viral antigen detection or specific antibodies (serology) (8). Virus isolation and nucleic acid detection are more accurate than antigen detection, but these tests are not widely available due to their greater cost (7). All tests may be negative in the early stages of the disease (8). PCR and viral antigen detection are more accurate in the first seven days (9).

There are no specific treatments for dengue fever. Treatment depends on the symptoms, varying from oral rehydration therapy at home with close follow-up, to hospital admission with administration of intravenous fluids and/or blood transfusion (4). A decision for hospital admission is typically based on the presence of the "warning signs" discussed  above, especially in those with preexisting health conditions.

Dengue Shock Syndrome  is a medical emergency that  requires  hospitalization with prompt  and  vigorous  volume  replacement  therapy (6). Blood transfusion is initiated early in patients presenting with unstable vital signs in the face of a decreasing hematocrit, rather than waiting for the hemoglobin concentration to decrease to some predetermined "transfusion trigger" level (7).

The juice of the  papaya leaf has been seen to arrest the destruction of platelets that has been the cause for so many deaths from dengue. Chymopapin and papin - enzymes in the papaya leaf - help revive platelet count. The juice has to be prepared from fresh papaya leaves (10).

Prevention of Dengue infection depends on control of and protection from the bites of the mosquito that transmits it. The  vectors  of DF  and  DHF  (e.g.,  A.  aegypti)  breed  in  areas around houses and, in principle can be controlled by individual and community action, using various mosquito control measures (6). (The primary method of controlling A. aegypti is by eliminating its habitat. This is done by emptying containers of water or by adding insecticides or biological control agents to these areas.

The  personal  protection  measures  are like that of wearing  of  full sleeve shirts  and  full  pants;  use  of  mosquito  repellent  cream;  liquids,  coils, mats  etc.;  use  of  bed-nets  for  sleeping  infants  and young children during day time to prevent mosquito bites. So  far,  there  is  no  satisfactory  vaccine  and  no  immediate prospect of preventing the disease by immunization. (6).

The World Health Organization recommends an Integrated Vector Control program consisting of five elements to fight this menace:

• Advocacy, social mobilization and legislation to ensure that public health bodies and communities are strengthened,
• collaboration between the health and other sectors (public and private),
• an integrated approach to disease control to maximize use of resources,
• evidence-based decision making to ensure any interventions are targeted appropriately
• capacity-building to ensure an adequate response to the local situation (4).

References:

1.	[Online]. [cited 2012. Available from: http://ibnlive.in.com/news/kolkata-faces-dengue-outbreak-govt-apathetic/288029-3-231.html.
2.	[Online]. [cited 2012. Available from: http://www.newstrackindia.com/newsdetails/2012/09/01/286--Bengal-dengue-toll-goes-up-to-3-confirmed-cases-638-.html.
3.	[Online]. [cited 2012. Available from: http://www.who.int/mediacentre/factsheets/fs117/en/.
4.	[Online]. Available from: http://en.wikipedia.org/wiki/Dengue_fever.
5.	[Online]. [cited 2012. Available from: http://articles.timesofindia.indiatimes.com/2012-09-04/kolkata/33581433_1_dengue-virus-aedes-albopictus.
6.	Park K. Textbook of Preventive and Social Medicine.
7.	[Online]. Available from: http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf.
8.	[Online]. [cited 2012. Available from: http://www.nature.com/nrmicro/journal/v8/n12_supp/full/nrmicro2460.html.
9.	[Online]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22494122.
10.	[Online]. Available from: http://articles.timesofindia.indiatimes.com/2012-09-12/kolkata/33788187_1_platelet-dengue-patients-papaya.

Brief History of Medicine

MEDICINE IN ANTIQUITY 

In ancient times, health and illness were interpreted in a theological perspective. Medicine was dominated by magical and religious beliefs. Henry Siegerist has stated that every culture had developed a system of medicine, and medical history is but one aspect of the history of culture. Dubos says that ancient medicine was the mother of sciences and played a large role in the integration of early cultures. 
Since there is an integral relationship between medicine and human advancement, any account of medicine at a given period should be viewed against the civilization and human advancement at that time, i.e. philosophy, religion, economic conditions, form of government, education, science and aspirations of the people.

Primitive medicine 

It is said that medicine was conceived in sympathy and born out of necessity; and that the first doctor was the first man, and the first woman, the first nurse. The prehistoric man, motivated by feelings of sympathy and kindness, was always at the behest of his kindred, trying to provide relief, in times of sickness and suffering. 

Since his knowledge was limited, the primitive man attributed disease, and in fact all human suffering and other calamities, to the wrath of gods, the invasion of body by "evil spirits" and the malevolent influence of stars and planets. The concept of disease in which the ancient man believed is known as the "supernatural theory of disease". The medicine he practised consisted in appeasing gods by prayers, rituals and sacrifices, driving out "evil spirits" from the human body by witchcraft and other crude means and using charms and amulets to protect himself against the influence of evil spirits. There is also evidence that prehistoric man improvised stone and flint instruments with which he performed circumcisions, amputations and trephining of skulls. It is thus obvious that medicine in the prehistoric times (about 5000 B.C.) was intermingled with superstition, religion, magic and witchcraft. 

Primitive medicine is timeless. If we look around the world, we find that the rudiments of primitive medicine still persist in many parts of the world - in Asia, Africa, South America, Australia and the Pacific islands. The supernatural theory of disease in which the primitive man believed is as new as today. For example, in India, one may still hear the talk of curing snake bites by "mantras". Diseases such as leprosy are interpreted as being punishment for one's past sins in some cultures. Although primitive man may be extinct, his progeny -the so-called "traditional healers" are found everywhere. They live close to the people and their treatments are based on various combinations of religion, magic and empiricism.

Indian medicine 

The medical systems that are truly Indian in origin and development are the Ayurveda and the Siddha systems.Ayurveda is practised throughout India, but the Siddha system is practised in the Tamil-speaking areas of South India. These systems differ very little both in theory and practice. Ayurveda by definition implies the "knowledge of life" or the knowledge by which life may be prolonged. Its origin is traced far back to the Vedic times, about 5000 B.C. During this period, medical history was associated with mythological figures, sages and seers. Dhanvantari, the Hindu god of medicine is said to have been born as a result of the churning of the oceans during a 'tug of war' between gods and demons. According to some authorities, the medical knowledge in the Atharvaveda (one of the four Vedas) gradually developed into the science of Ayurveda. 

In ancient India, the celebrated authorities in Ayurvedic medicine were Atreya, Charaka, Susruta and Vaghbhatt. Atreya (about 800 B.C.) is acknowledged as the first great Indian physician and teacher. He lived in the ancient university of Takshshila, about 20 miles west of modern Rawalpindi. Ayurveda witnessed tremendous growth and development during the Buddhist times. King Ashoka (226 B.C.) and the other Buddhist kings patronised Ayurveda as State medicine and established schools of medicine and public hospitals. Charaka (200 A.D.), the most popular name in Ayurvedic medicine, was a court physician to the Buddhist king, Kaniska. Based on the teachings of Atreya, Charaka compiled his famous treatise on medicine, the "Charaka Samhita". Charaka mentions some 500 drugs. The Indian snakeroot (rauwolfia) was employed for centuries by the Indian physicians, before reserpine was extracted from the root and found spectacularly effective in the treatment of hypertension.

Among the many distinguished names in Hindu medicine, that of Susruta, the "father of Indian surgery" stands out in prominence. He compiled the surgical knowledge of his time in his classic "Susruta Samhita". It is believed that this classic was compiled between 800 B.C. and 400 A.D. Though this work is mainly devoted to surgery, it also includes medicine, pathology, anatomy, midwifery, ophthalmology, hygiene and bedside manners. The early Indians set fractures, performed amputations, excised tumours, repaired hernias and excelled in cataract operations and plastic surgery. It is stated that the British physicians learned the art of rhinoplasty from Indian surgeons in the days of East India Company. 

Of significance in Ayurveda is the "tridosha theory of disease". The doshas or humors are: uata (wind), pitta (gall) and kapha (mucus). Disease was explained as a disturbance in the equilibrium of the three humors; when these were in perfect balance and harmony, a person is said to be healthy.  Medical historians admit that there was free exchange of thought and experience between the Hindu, Arab, Persian, Greek and Jewish scholars. The Samhitas of Charaka and Susruta were translated into Persian and Arabic in about 800 A.D. 

Hygiene was given an important place in ancient Indian medicine. The laws of Manu were a code of personal hygiene. Archaeological excavations at Mohenjo-daro and Harappa in the Indus valley uncovered cities of over two thousand years old which revealed rather advanced knowledge of sanitation, water supply and engineering. The golden age of Indian medicine was between 800 B.C. and 600 A.D. During the Moghul period and subsequent years, Ayurveda declined due to lack of State support. 

Mention must be made of the other indigenous systems medicine namely Unani-Tibb and Homoeopathy, which are not of Indian origin. The Unani-Tibb system of medicin whose origin is traced to the ancient Greek medicine, was introduced into India by the Muslim rulers about the 10 Century A.D. By the 13th Century, the Unani system medicine was firmly entrenched in certain towns and citi notably Delhi, Aligarh. Lucknow and Hyderabad. Homoeopathy was propounded by Samu Hahnemann (1755-1843) of Germany and gained foothold India during 1810 and 1839. It is a system of pharmaco dynamics based on "treatment of disease by the use of small amounts of a drug that, in healthy persons, produce symptoms similar to those of the disease being treated". Homoeopathy is practised in several countries, but India claims to have the largest number of practitioners of the system in the world. 

The Indian systems of medicine including Unani-Tibb and Homoeopathy are very much alive in India even today and in fact, have become part of the Indian culture.

Chinese medicine 

Chinese medicine claims to be the world's first organized body of medical knowledge dating back to 2700 B.C. It based on two principles - the yang and the yin. The yang believed to be an active masculine principle and the yin negative feminine principle. The balance of these two opposite forces meant good health. Hygiene, dietetics, hydro-therapy, massage, drugs were all used by the Chinese physicians. 

The Chinese were early pioneers of immunization. They practised variolation to prevent smallpox. To a Chinese, "the great doctor is one who treats not someone who is already sick but someone not yet ill". The Chinese have great faith in the traditional medicine, which is fully integrated with modern medicine. The Chinese system of "bare-foot doctors" and accupuncture have attracted worldwide attention in recent years.

Egyptian medicine 

Egypt has one of the oldest civilizations. In Egyptian times, the art of medicine was mingled with religion. Egyptian physicians were co-equals of priest trained in schools within the temples. They often helped priests care for the sick who were brought to the temples for treatment. Egyptian medicine reached its peak in the days of Imhotep (2800 B.C.) who was famous as a statesman, architect, builder of the step pyramid at Saqqarah and physician. The Egyptians worshipped many gods. Specializatic prevailed in Egyptian times. There were eye doctors, tooth doctors etc. All these doctors were officials payed by the State. Homer speaking of the doctors of the a world considered the Egyptians to be the "the best of all".

Egyptians believe that disease was due to absorption from the intestine of harmful substances which gave rise to putrefaction of blood and formation of pus. They believed that the pulse was "the speech of the heart". Diseases were treated with cathartics, enema, blood-letting and a wide range of drugs. The best known medical manuscripts belonging to the Egyptian times are the Edwin Smith papyrus (3000-2500 B.C.), and the Ebers papyrus (1150 B.C.). Castor oil, tannic acid, opium, turpentine, gentian, senna, minerals and root drugs were all used by the Egyptian physicians. A great number of diseases are reported in the papyri such as worms, eye diseases, diabetes, rheumatism, polio and schistosomiasis.

Mesopotamian medicine 

Contemporary with ancient Egyptian civilization, there existed another civilization in the land which lies between the Euphrates and Tigris rivers called Mesopotamia (now part of Iraq), often called the "Cradle of Civilization", as long as 6000 years ago. 

Mesopotamia was the cradle of magic and necromancy. Medical students were busy in classifying "demons", the causes of diseases. Geomancy, the interpretation of dreams, and hepatoscopic divination (the liver was considered the seat of life) are characteristic of their medical lore. Sumerians, Babylonians and Assyrians were the authors of a medical astrology which flourished in the whole of Eurasia. Prescriptions were written on tablets, in cuneiform writing. One of the oldest medical prescription comes from Mesopotamia, dating back to 2100 B.C. 

Hammurabi, a great king of Babylon formulated a set of drastic laws known as the Code of Hammurabi that governed the conduct of physicians and provided for health practices. Doctors whose proposed therapy proved wrong ran the risk of being killed. Laws relating to medical practice, including fees payable to physicians and penalties for harmful therapy are mentioned in the Babylonian Code of Hammurabi.

Greek medicine 

The Greeks enjoyed the reputation as the civilizers of the ancient world. An early leader in Greek medicine was Aesculapius. He bore two daughters - Hygiea and  Panacea. Panacea and Hygiea gave rise to dynasties of healers (curative medicine) and hygienists (preventive medicine) with different philosophies. Hygiea (prevention) is at present fashionable among the intellectuals; but Panacea (cure) gets the cash. Aesculapius is still cherished in medical circles - his staff, entwined by a serpent, continues to be the symbol of medicine. 

By far the greatest physician in Greek medicine was Hippocrates (460-370 B.C.) who is often called the "Father of Medicine". He was born on the little island of Cos, in the Aegean sea, about 460 B.C. He studied and classified diseases based on observation and reasoning. He challenged the tradition of magic in medicine, and initiated a radically new approach to medicine i.e., application of clinical methods in medicine. Hippocrate's lectures and writings, as compiled later by Alexandrian scholars into the "Corpus Hippocraticum", encompassed all branches of medicine. This 72-volume work contains the first scientific clinical case histories. Some of the sayings of Hippocrates later became favourites with physicians, such as "Life is short, the art (of medicine) long, opportunity fleeting, experience treacherous and judgement difficult", and "where there is love for mankind, there is love for the art of healing". His famous oath, the "Hippocratic oath" has become the keystone of medical ethics. It sets a high moral standard for the medical profession and demands absolute integrity of doctors. Hippocrates will always be regarded as one of the masters of the medical art. Hippocrates was also an epidemiologist. Since he distinguished between diseases which were epidemic and those which were endemic, he was, in fact, the first true epidemiologist. 

In short, the Greeks gave a new direction to medical thought. The Greeks believed that matter was made up of four elements - earth, air, fire and water. These elements had the corresponding qualities of being cold, dry, hot and moist and were represented in the body by the four humors - phlegm, yellow bile, blood and black bile - similar to the "tridosha theory" in Ayurveda. The Greeks postulated that health prevailed when the four humors were in equilibrium and when the balance was disturbed, disease was the result. The human body was assumed to have powers of restoration of humoral equilibrium, and it was the physician's primary role to assist in this healing process. Outstanding amongst post-Hippocratic medical centres was Alexandria's huge museum, the first University in the world which sheltered a library containing over 70,000 books. To this house of learning came eminent men. Between 300 B.C. and 30 B.C., thousands of pupils matriculated in the school of Alexandria, which replaced Athens as the world's centre of learning. In short, the Hippocratic school inspired in turn the Alexandria school, and the Arabo-Persian medicine. The Hippocratic school changed the destiny of medicine by separating it from magic and raising it to the status of a science. 

Roman medicine 

By the first Century B.C., the centre of civilization shifted to Rome. The Romans borrowed their medicine largely from the Greeks whom they had conquered. While the politics of the world became Roman, medicine remained Greek. 

The Romans were a more practical-minded people than the Greeks. They had a keen sense of sanitation. Public health was born in Rome with the development of baths, sewers and aqueducts. The Romans made fine roads throughout their empire, brought pure water to all their cities through aqueducts, drained marshes to combat malaria, built sewerage systems and established hospitals for the sick. An outstanding figure among Roman medical teachers was Galen (130-205 A.D.) who was born in the Greek city of Pergamon in Asia Minor (now Turkey). He was physician to the Roman emperor, Marcus Aurelius. His important contributions were in the field of comparative anatomy and experimental physiology. Galen was far ahead of his time in his views about health and disease. About health he stated: "Since both in importance and in time, health precedes disease, so we ought to consider first how health may be preserved, and then how one may best cure disease". About disease, Galen observed that disease is due to three factors - predisposing, exciting and environmental factors, a truly modern idea. The doctrines of Hippocrates and Galen were often in conflict since their approaches were so different - one is synthetic, the other analytic. The author of some 500 treatises on medical subjects, Galen was literally a "medical dictator" in his time, and also for a long time thereafter. His writings influenced European medicine. They were accepted as standard textbooks in medicine for 14 centuries, till his teachings and views were challenged by the anatomist, Vesalius in 1543, and the physiologist, William Harvey in 1628, almost 1500 years after his death!


Middle ages 

The period between 500 and 1500 A.D. is generally known as "Middle Ages". With the fall of the Roman empire, the medical schools established in Roman times also disappeared. Europe was ravaged by disease and pestilence: plague, smallpox, leprosy and tuberculosis. The practice of medicine reverted back to primitive medicine dominated by superstition and dogma. Rejection of the body and glorification of the spirit became the accepted pattern of behaviour. It was regarded as immoral to see one's body; consequently, people seldom bathed. Dissection of the human body was prohibited. Consequently there was no progress of medicine. The medieval period is therefore called the "Dark Ages of Medicine". 

When Europe was passing through the Dark Ages, the Arabs stole a march over the rest of the civilization. They translated the Graeco-Roman medical literature into Arabic and helped preserve the ancient knowledge. Borrowing largely from the Greeks and Romans, they developed their own system of medicine known as the Unani system of medicine. They founded schools of medicine and hospitals in Baghdad, Damascus, Cairo and other Muslim capitals. Leaders in Arabic medicine were the Persians, Abu Beer (865-925) also called Rhazes and Ibn Sina (980-1037) known as Avicenna to the western world. Rhazes was a director of a large hospital in Baghdad and a court physician as well. Noted for keen observation and inventiveness, he was the first to observe pupillary reaction to light; to use mercurial purgatives; and to publish the first known book on Children's diseases. However, the work most highly regarded today is his book on smallpox and measles which he distinguished clinically. Avicenna was an intellectual prodigy. He compiled a 21-volume encyclopedia, the "Canon of Medicine", which was to leave its mark on medical theory and practice. He was responsible for elevating Islamic medicine to its zenith in the middle ages. The greatest contribution of Arabs, in general, was in the field of pharmacology. Seeking the "elixir of life", they developed pharmaceutical chemistry, introducing a large number of drugs, herbal and chemical. They invented the art of writing prescriptions, an art inherited by our modern pharmacists. They introduced a wide range of syrups, oils, poultices, plasters, pills, powders, alcoholates and aromatic waters. The words drug, alcohol, syrup and sugar are all Arabian. The golden age of Arabic medicine was between 800-1300 A.D.

During the turbulent middle ages, Christianity exerted a wholesome influence. The spread of Christianity led to the establishment of hospitals. Early medieval hospitals rarely specialized in treatment of the sick. Usually the sick were received for the purpose of supplying their bodily wants and catering to their spiritual needs. The first hospital on record in England was built in York in 937 A.D. With the growth of medicine, a chain of hospitals sprang up from Persia to Spain -there were more than 60 in Baghdad and 33 in Cairo. Some hospitals, like Cairo's Al Mansur had separate departments for various diseases, wards for both sexes, fountains to cool fever patients, libraries, musicians and story tellers for the sleepless. 

During the middle ages, religious institutions known as "monasteries" headed by monks, saints and abbotts also came up. These monasteries admitted men and women from all ranks including kings and queens. They not only helped preserve the ancient knowledge but also rendered active medical and nursing care to the sick.

Medicine and Society

From time immemorial man has been interested in trying to control disease. The medicine man, the priest, the herbalist and the magician, all undertook in various ways to cure man's disease and/or to bring relief to the sick. Medical knowledge in fact has been derived, to a very great degree, from the intuitive and observational propositions and cumulative experiences gleaned from others.


 A history of medicine thus contributes a review of accomplishments and errors, false theories and misinformation and mistaken interpretations. In the course of its evolution, which proceeded by stages, with advances and halts, medicine has drawn richly from the traditional cultures of which it is a part, and later from biological and natural sciences and more recently from social and behavioural sciences. 


Medicine is built on the best of the past. 


The "explosion" of knowledge during the 20th century has made medicine more complex, and treatment more costly, but the benefits of modern medicine have not yet penetrated the social periphery in many countries. The glaring contrasts in the state of health between the developed and developing countries, between the rural and urban areas, and between the rich and poor have attracted worldwide criticism as "social injustice". 


Currently, the commitment of all countries, under the banner of the World Health Organization, is to wipe out the inequalities in the distribution of health resources and services, and attain the Millenium Development Goals. 


The goal of modern medicine is no longer merely treatment of sickness. The other and more important goals which have emerged are prevention of disease, promotion of health and improvement of the quality of life of individuals and groups or communities. In other words, the scope of medicine has considerably broadened during recent years. It is also regarded as an essential component of socio-economic development.

Malaria Life Cycle

Malaria Life Cycle
Follow the Plasmodium parasite's intricate and, occasionally bizarre, 13 steps to transmitting malaria:


Step 1
With her recent blood meal, the female Anopheles mosquito consumed dozens of stowaways: gametocytes male and female forms of the parasite Plasmodium falciparum.


Step 2
In the mosquito’s midgut, male gametocytes produce sperm-like microgametes. The female macrogametes soon are fertilized by the males, transform into zygotes and lengthen into sausage-shaped ookinetes.


Step 3
A few ookinetes pass through the midgut wall and form oocysts.


Step 4
For 8 to 15 days, the oocysts produce thousands of thread-like sporozoites. Perhaps 20 percent of them reach the mosquito’s salivary glands.


Step 5
As the mosquito bites another person, about 100 sporozoites swim with the saliva into the victim.


Step 6
The sporozoites ride the bloodstream. Only one or two reach their target: the liver. The human victim isn’t yet aware of the enemy within.


Step 7
After infiltrating a liver cell, each sporozoite transforms into a schizont that produces thousands of merozoites, which will invade red blood cells.


Step 8
After 5 to 7 days, the merozoites burst from the infected liver cell, enter the bloodstream and invade red blood cells. The infected person still doesn’t feel any symptoms.


Step 9
The parasite first takes on a signet-ring shape inside the red blood cell and later makes knobs on the red blood cell's surface, causing it to adhere to blood vessel lining and impede blood flow.


Step 10
The rings and the later form—trophozoites—feast on the red blood cell’s cytoplasm and hemoglobin. This stage ends with the formation of a schizont that produces up to 32 new merozoites. These exit and in a burst, invade still more red blood cells.


Step 11
The parasite’s numbers increase tenfold every 48 hours. From the one or two sporozoites that entered the liver, trillions of parasites may teem in the body. Two weeks after the mosquito’s bite, the patient experiences fever, headache, malaise and nausea.


Step 12
The knobby red blood cells stick like Velcro to the endothelial cells lining the blood vessels of the brain, heart and lung—and, in pregnant women, the placenta—which often leads to death.


Step 13
During the blood stage, some merozoites develop into yet another form of the parasite: the infective male and female gametocytes—seeds of destruction for malaria’s next victims.

-(http://magazine.jhsph.edu/2011/malaria/online_extras/galleries/malaria_life_cycle/index.html)

Malaria: The Forever War

Malaria—the disease that for millennia has filled cemeteries, killed kings, wrecked empires and thwarted human attempts to quash it—begins modestly enough. About 100 parasites swim in the saliva of a female mosquito.

That humble start spawns personal and global misery. The few parasites that invade a person can quickly expand to trillions, overwhelming the human body. The effect manifests in the dulled eyes of blinded children, the paroxysms of fever and chills racking the victim, the deaths of children and pregnant women, and the hobbled productivity of entire nations. Each year, malaria causes nearly 800,000 deaths and 225 million clinical cases.

Were it not such a horror, the Plasmodium parasite would be one of the wonders of the world. The resilient shape-shifter constantly adapts to its surroundings, masters sexual and asexual reproduction, slips past the immunological defenses of the Anopheles mosquito and human beings, rides in the belly of its arthropod ally to new victims…. A testament to evolutionary engineering, the parasite has a solution to every barrier it meets.

And so, Plasmodium has been virtually unstoppable. Humanity’s last global attempt at malaria’s eradication in the 1950s ended in shambles. Bright hopes were extinguished by the parasite’s resilience (and the mosquito’s growing resistance to insecticides).

However, the malaria story does not end there.

We Homo sapiens have our own brand of resilience, innovation and tricks for survival. Breakthroughs in genetics, parasitology, entomology, drug development, satellite technology and other areas have summoned new hopes against our old enemy.

Analyzing Disease Transmission at the Community Level

Researchers at the Johns Hopkins Bloomberg School of Public Health have found evidence of a role for neighborhood immunity in determining risk of dengue infection. While it is established that immunity can be an important factor in the large-scale distribution of disease, this study demonstrates that local variation at spatial scales of just a few hundred meters can significantly alter the risk of infection, even in a highly mobile and dense urban population with significant immunity. The study is published in May 28 edition of the journal PNAS.

Dengue is a mosquito-borne disease that infects nearly 50 million people worldwide each year, resulting in more than 19,000 deaths. There are four serotypes of dengue virus (DENV1–4) circulating in Bangkok, Thailand, where the study was conducted. Infection with dengue provides lifelong immunity to the infecting serotype and there is evidence infection temporarily protects from infection by other serotypes. When susceptibility to other serotypes returns there is an increased risk for severe disease. For the study, the research team used the household location of 1,912 confirmed dengue cases in Bangkok that were admitted to a local children’s hospital between 1995 and 2000. The available data enabled the researchers to pair dengue serotype infections with specific households.

Observations indicated that immunological memory of dengue serotypes occurs at the neighborhood level in this large urban setting. The researchers developed methods that have broad application to studying the spatiotemporal structure of disease risk where pathogen serotype or genetic information is known.

“We observe patterns of spatiotemporal dependence consistent with the expected impacts of lifelong and short-term immunity, and immune enhancement of disease at distances of under one kilometer,” said Henrik Salje, lead author of the study and doctoral candidate in the Bloomberg School’s Department of Epidemiology.

“By providing insight into the potential spatial scales that immunity in a population is correlated and distances over which the disease is dispersed, these findings can help us further understand how dengue is being maintained in endemic populations,” said the study’s senior author, Derek Cummings, PhD, assistant professor with the Bloomberg School’s departments of Epidemiology and International Health.

The authors of “Revealing the microscale spatial signature of dengue transmission and immunity in an urban population” are Henrik Salje, Justin Lessler, Timothy P. Endy, Frank Curriero, Robert V. Gibbons, Ananda Nisalak, Suchitira Nimmannitya, Siripen Kalayanarooj, Richard G. Jarman, Stephen J. Thomas, Donald S. Burke and Derek A. T. Cummings.

The research was funded by grants from the Gates Foundation Vaccine Modeling Initiative, the National Institutes of Health, the Burroughs Wellcome Fund Career Award, and the Research and Policy for Infectious Disease Dynamics initiative of the NIH and Department of Homeland Security.

-(http://www.jhsph.edu/publichealthnews/press_releases/2012/cummings_dengue.html)

Assessment of nutritional status from birth upto 18 years of age

Assessment of nutritional status from birth upto 18 years of age

By

Dr. Pallab Kanti Nath

MBBS, MD

Assessment of nutritional status from birth to 18 years of age

Introduction

The science of Human Nutrition can be defined as “the science of diet and its interactions with growth, development, physiology, metabolism, and composition of the human body . It involves the role of nutrition in normal and abnormal individuals, the impact of nutrition on health and disease, and the interactions between diet, host, and environment .” (1)

Nutrition plays a major role in health, prevention of disease, and recovery from illness. Therefore, we should have an understanding and awareness about nutrition in order to optimally promote health maintenance, prevent diseases, facilitate recovery from illness, and augment the treatment of medical and surgical diseased states. Awareness and application of nutrition in medical practice has a major impact on the health care in our society.

Malnutrition problems, like other health problems, can affect individuals, families and often communities as a whole. This is not surprising, considering that the roots of malnutrition related problems lie in socioeconomic status and cultural practices that are usually shared by many individuals in a given community. Thus communities afflicted by poverty and adverse living conditions may have a great majority of children and mothers showing signs of undernutrition, whereas affluent communities may have substantial number of individuals with diet-related problems like that of being overweight and obese.

Through centuries food has been recognized as important for human beings, in health and disease. The history of man to a large extent has been a struggle to obtain food. Until the turn of the nineteenth century the science of nutrition had a limited range. Protein, carbohydrate and fat had been recognized early in the 19th century as energy-yielding foods and much attention was paid to their metabolism and contribution to energy requirements (2).

The discovery of vitamins “rediscovered” the science of nutrition. Between the two World Wars, research on protein gained momentum. By about 1950, all the presently known vitamins and essential amino acids had been discovered (2).

Nutrition gained recognition as a scientific discipline, with roots in physiology and biochemistry. In fact, nutrition was regarded as a branch of physiology and taught as such to medical students (2).

Many advances were made during the past 50 years regarding the knowledge of nutrition and in the practical application of that knowledge. Specific nutritional diseases were identified and technologies developed to control them.( eg. Protein Energy Malnutrition, Endemic Goitre, Nutritional Anaemia, Nutritional Blindness and Diarrhoeal Diseases (2).

While attention was concentrated on nutrition deficiency diseases during the first decades of the 20^th century, the science of nutrition was extending its influence into other fields as well like agriculture, animal husbandry, economics and sociology. This led to "green revolution" and "white revolution" in India and increased food production (2). However, studies on diet and state of nutrition of people in India showed that poorer sections of the population continued to suffer from malnutrition despite increased food production. The result was that, for the first time the problem of nutrition began to attract international attention as a cause of social problems (3).

But, to have a qualitative as well as quantitative understanding of the magnitude of health problems related to nutrition, a method for assessment of the nutritional status in the human population was required. A major development in this regard took place in 1932 in Berlin when The health Organization of the League of Nations (HOLN) held its first conference to discuss the physical, clinical, and physiological aspects of nutrition assessment. This conference motivated the publication of procedures needed for conducting nutrition surveys (4). Subsequently, the monograph published by the Technical Commission of Nutrition of the Health Organization (TCNHO) became the first organized work on dietary standards (4). Around the same period, Bigwood's Guiding Principles for Studies on the Nutrition of Populations provided detailed procedures for conducting nutrition surveys which became a classic reference for conducting nutrition surveys (5). Although the initial methods have been revised but, the basic principles behind nutritional assessment have remained same over the past years (6).

 In the 1940s under the auspices of the United Nations the Food and Agriculture Organization (FAO) and the World Health Organization (WHO) were established. Representatives from each of the organizations were selected to form a Joint Expert Committee on Nutrition. In 1949, these representatives compiled information on nutritional status, dietary patterns, food supplies and the economics of particular populations and recommended the establishment of nutrition policies for each nation. In 1951, the Joint Commission of the WHO published a report that emphasized on anthropometric, clinical, and dietary data, but it did not make recommendations or set standards (5) (6).

Significant advances have since been made. The association of nutrition with infection, immunity, fertility, maternal and child health and family health have engaged scientific attention. More recently, a great deal of interest has been focused on the role of dietary factors in the pathogenesis of non-communicable diseases like coronary heart disease, diabetes and cancer etc.

One of the significant developments during the recent years is that the science of nutrition has linked itself to epidemiology. This association has given birth to newer concepts in nutrition such as epidemiological assessment of nutritional status of communities, nutritional and dietary surveys, nutritional surveillance, nutritional and growth monitoring, nutritional rehabilitation, nutritional indicators and nutritional interventions — all parts of what is broadly known as nutritional epidemiology (2). 

Assessment of Nutritional Status

To understand and correlate between the various factors that affect the nutritional status of a population and its implications on the development of the society as a whole, the foremost important step is assessment of the nutritional status of the population. The assessment of nutrition therefore is one of the 1^st steps in formulation of any public health strategy to combat malnutrition.

The various Methods of Nutritional Assessment from birth upto 18 years of age

The nutritional status of an individual is often the result of many interrelated factors. It is influenced by the adequacy of food intake both in terms of quantity and quality and also by the physical health of the individual (2). The assessment of nutritional status therefore involves various techniques with a multi-angled approach aimed at covering all the different stages in the natural history of nutritional diseases including the prepathogenesis phase as shown in the figure below.

The sequence of nutritional deficiency and specificity of assessment of the nutritional status can be also described using the following flow chart (7):-

Nutritional Status can be therefore, assessed by the following methods:-

Direct methods	Indirect methods
Clinical examination	Assessment of dietary Intake
Anthropometry	Vital Statistics
Biochemical evaluation	Ecological studies
Functional Assessment
Biophysical & Radiological examination

Methods of Nutritional Assessment (2,7)

The various methods used for appraisal of nutritional status are not mutually exclusive; on the contrary, they are complementary to each other as discussed below:-

DIRECT METHODS

1.     Clinical methods

Clinical examination assesses the level of health of an individual in relation to the food they consume. When two or more clinical signs characteristic of a deficiency disease are present simultaneously, their diagnostic significance is greatly enhanced (7). It is also the simplest and the most practical method of ascertaining the nutritional status of a group of individuals(2). A WHO Expert Committee (8) classified signs used in nutritional surveys into three categories as those:

a.      not related to nutrition, e.g., alopecia, pterygium

b.     that need further investigation, e .g. , malar pigmentation, corneal vascularisation, geographic tongue

c.      known to be of value, e.g., angular stomatitis, Bitot's spots, calf tenderness, absence of knee or ankle jerks (beri-beri), enlargement of the thyroid gland (endemic goitre), etc.

The following are some of the signs and symptoms which are found to be associated with nutritional inadequacy (9) in our study population:-

Site	Sign	Deficiency
General appearance	Loss of subcutaneous fat	Calories
	Sunken or hollow cheeks	Calories, fluid
Hair	Easily plucked hair, alopecia	Protein
	Dry, brittle hair	Protein,Biotin
	Corkscrew hairs	Vit C
Nails	Spooning	Iron
	Transverse depigmentation	Protein
Skin	Dry and scaly flaky paint	Vitamin A, zinc
	Nasolabial seborrhea	Essential fatty acid, riboflavin
	Psoriasiform rash	Vitamin A, zinc
	Pallor	Iron, vitamin B12, folate
	Follicular hyperkeratosis	Vitamin A, essential fatty acid
	Perifollicular hemorrhage	Vitamin C
	Easy bruising	Vitamin K or C
	Hyperpigmentation	Niacin
Eyes	Night blindness	Vitamin A, zinc
	Photophobia, xerosis	Vitamin A
	Conjunctival inflammation	Riboflavin, vitamin A
	Retinal field defect	Vitamin E
Mouth	Glossitis	Riboflavin, pyridoxine, niacin, folic acid, vitamin B12, iron
	Bleeding gums	Vitamin C, riboflavin
	Angular stomatitis	Riboflavin, pyridoxine, niacin
	Cheilosis	Riboflavin, pyridoxine, niacin
	Decreased taste or smell	Zinc
	Tongue fissuring	Niacin
	Tongue atrophy	Riboflavin, niacin, iron
	Loss of tooth enamel	Calcium
Neck	Goitre	Iodine
	Parotid enlargement	Protein
Heart	High output failure	Thiamin
Chest	Respiratory muscle weakness	Protein, phosphorus
Abdomen	Ascites	Protein
	Hepatomegaly	Protein, fat
Extremities	Edema	Protein
	Bone tenderness	Vitamin D
	Bone/joint pain	Vitamin A or C
	Muscle pain	Thiamin
	Joint swelling	Vitamin C
Muscle	Atrophic muscles, Decreased grip strength	Protein
Neurological	Dementia	Thiamin, vitamin B12, folate, niacin
	Acute disorientation	Phosphorus, niacin
	Nystagmus	Thiamin
	Ophthalmoplegia	Thiamin
	Wide-based gait	Thiamin
	Peripheral neuropathy	Thiamin, pyridoxine, vitamin E
	Loss of vibratory sense	Vitamin B12
	Loss of position sense	Vitamin B12
	Tetany	Calcium, magnesium
	Paresthesias	Thiamin, vitamin B12
	Wrist or foot drop	Thiamin
	Diminished reflexes	Iodine

Clinical examination for assessment of nutritional status has got many advantages as well as certain disadvantages also.

Advantages include the following (7):-

·        For clinical examination cooperation of the subject can be achieved easily because the procedure is noninvasive and the symptoms are observed externally.

·        This method is reliable and easy to organise.

·         Exact Age of the subject need not be ascertained always.

·        Symptoms are specific to a particular nutrient.

·    This method is not very expensive. It does not require elaborate apparatus and reagents.

However, clinical signs also have some disadvantages as well (2):-

·        Malnutrition cannot be quantified on the basis of clinical signs only.

·        Many deficiencies are unaccompanied by physical signs.

·        There is lack of specificity and most of the physical signs are subjective in nature.

To minimize subjective and errors in clinical examination, standard survey forms or schedules have been devised covering all areas of the body (2).

2.     Anthropometry

Anthropometric measurements can reflect changes in morphological variation due to inappropriate food intake or malnutrition. A variety of anthropometric measurements can be made either involving the whole body or parts of the body. In anthropometric measurements, there is no single permanent standard as because uniform growth pattern is not seen to occur equally all over the world and also in subsequent generations. Therefore, Local standards have to be developed for various ethnic groups and populations (7). The assessment of growth may be longitudinal or cross-sectional. Longitudinal assessment of growth entails measuring the same child at regular intervals. This provides valuable data about a child's progress. Cross-sectional studies are also essential to compare a child's growth with that of his peers. Cross-sectional comparisons involve large number of children of the same age. These children are measured and the range of their measurements (e.g., weight, height) is plotted, usually on percentile charts (2).

Components of Anthropometric Assessment:

a)   Weight-for-age

Body weight is the most widely used and simplest anthropometric measurement for evaluation of nutritional status. It indicates the body mass and is a composite of all body constituents like water, mineral, fat, protein and bone. It reflects more recent nutritional status than does height. Serial measurements of weight, as in growth monitoring are more sensitive indicators of changes in nutritional status than a single measurement at a point of time. In clinical practice however, the use of whole body indices may sometimes be limited as in cases when a child has ascites, fluid retention, or a large solid tumor which can confound the weight-based indices.

For measuring body weight, beam or lever actuated scales, with an accuracy of 50-100g can be used. Beam balances have been used in ICDS programme. Periodically scales have to be calibrated for accuracy using known weights. The zero error of the weighing scale should be checked before taking the weight and corrected as and when required (7). According to WHO(10), children should be weighed using a scale with the following features:

·        Solidly built and durable

·        Electronic (digital reading)

·        Measures up to 150 kg

·        Measures to a precision of 0.1 kg (100g)

·        Allows tared weighing

“Tared weighing” means that the scale can be re-set to zero (“tared”) with the person just weighed still on it.  Thus, a mother can stand on the scale, be weighed, and the scale tared. While remaining on the scale, if she is given her child to hold, the child’s weight alone appears on the scale.  Tared weighing has two advantages (10):

·        There is no need to subtract weights to determine the child’s weight alone (reducing the risk of error).

·        The child is likely to remain calm when held in the mother’s arms for weighing.

There are many types of scales currently in use like:-

Bathroom scales may give errors upto 1.5kg (7). Bathroom scales are therefore not recommended. WHO recommends the use of UNISCALE (made by UNICEF) (10). It has the recommended features of a weight scale as mentioned before.  It is powered by a lithium battery that is good for a million measurement sessions. The scale has a solar on-switch, so it requires adequate lighting to function. Footprints may be marked on the scale to show where a person should stand.

Procedure for measuring weight

1. If the child is less than 2 years old or is unable to stand, tared weighing should be done:

The scale is placed on a flat, hard, even surface.

Since the scale is solar powered, there must be enough light to operate the scale. To turn on the scale, the solar panel has to be covered for a second. When the number 0.0 appears, the scale is ready for use.The mother has to remove her shoes and step on the scale to be weighed alone first. After the mother’s weight appears on the display, she is made to remain standing on the scale. The reading is reset to zero by covering the solar panel of the scale (thus blocking out the light). Then the child is given to the mother to hold. The child’s weight now appears on the scale which can be recorded (10). 

2. If the child is 2 years or older:

If the child stands still, then he/she can be measured alone. The child should be Undressed in order to obtain an accurate weight. A wet diaper, or shoes and jeans, can weigh more than 0.5 kg. Babies should be weighed naked. They should be wrapped in a blanket to keep them warm until weighing. Older children should remove all but minimal clothing, such as their underclothes.

If it is too cold to undress a child, or if the child resists being undressed and becomes agitated, then clothed child should be weighed, but a note in the Growth Record that the child was clothed has to be kept.If it is socially unacceptable to undress the child, removal of as much of the clothing as possible should be tried (10).

Birth-weight measurement:

The birth—weight should be taken preferably within the first hour of life, before significant post—natal weight loss has occurred. The naked baby should be placed on a clean towel on the scale pan (2).

In home delivery, weight can be taken by placing the baby in a sling bag using a Salter weighing scale. The child is weighed to the nearest 100 g (2).

Nutritional status assessment from weight

Measurement of weight and rate of gain in weight  are the best single parameters for assessing physical growth. A single weight record only indicates the child's size at the moment, it does not give any information about whether a child’s weight is increasing, stationary or declining. This is because, normal variation in weight at a given age is wide. Ideally what is important is careful measurements at repeated intervals:-

·        Every month, from birth to 1 year

·        Every 2 months during the second year

·        Every 3 months  thereafter upto 5 years of age.

This has been recommended because this age group is at the geatest risk from growth faltering. By comparing the measurements with reference standards of weight of children of the same age, the trend of growth becomes obvious. This is best done on growth chart. Serial weighing is also useful to interpret the progress of growth when the age of the child is not known. Thus, without the aid of a growth chart, it is virtually impossible to detect changes in the rate of growth, such as sudden loss of weight or halt in gain. Each baby should have its own growth chart (2).

In different parts of India, the average birth weight of a child ranges between 2.7 and 2.9 kg. The term ‘Low birth weight’ has been defined as a birth weight of less than 2.5 kg (up to and including 2499 g), the measurement being taken preferably within the first hour of life, before significant postnatal weight loss has occurred. Low birth weight babies are further classified into 2 groups (2):-

                               I.            Pre-term Babies: These are babies born before 37 weeks of gestation. Their intrauterine growth may be normal. That is, their weight, length and development may be within normal limits for the duration of gestation. Given good neonatal care, these babies can catch up growth and by 2 to 3 years of age will be of normal size and performance.

                            II.            Small-For-Date (SFD) Babies : These may be born at term or pre-term. They weigh less than the 10th percentile for the gestational age. These babies are the result of retarded intrauterine foetal growth.  

A baby should gain at least 500 gram wt. per month in the first three months of life. The children who gain less weight are malnourished. It is usual for babies to gain about 1 kg a month, especially in the first 3 months.

Healthy babies on an average double their birth wt. by 5 months; treble it by the end of first year and quadruple it by the age of two years (2).

During the first year, wt. increases by about 7 kg. After that, the increase in weight is not so fast -- only about 2.5 kg during the second year and from then until puberty wt increases by about 2 kg per year (2).

b)   Height(Length)-for-age

The height of an individual is influenced both by genetic and environmental factors. The maximum growth potential of an individual is decided by hereditary factors, while among the environmental factors, the most important being nutrition and morbidity, determine the extent of exploitation of that genetic potential. Height is affected only by long-term nutritional deprivation, it is considered an index of chronic or long duration malnutrition (7).

Depending on a child’s age and ability to stand, the method of measurement is decided. A child’s length is measured lying down (recumbent) whereas, Height is measured standing upright. Decision as regards the selection of the method of measurement is decided by the following criteria (10):-

·        If a child is less than 2 years old, recumbent length is measured.

·        If the child is aged 2 years or older and able to stand, standing height is measured.

In general, standing height is about 0.7 cm less than recumbent length. This difference was taken into account in developing the WHO growth standards used to make the charts in the Growth Record. Therefore, it is important to adjust the measurements if length is taken instead of height, and vice versa (10):-

·        If a child less than 2 years old does not lie down for measurement of length, then standing height can be measured but, 0.7 cm must be added to convert it to length.

·        If a child aged 2 years or older cannot stand, then recumbent length can be measured but 0.7 cm should be subtracted to convert it to height.

Procedure for measuring height

Equipment needed to measure length is a Length Board (also called an Infantometer). It should be placed on a flat, stable surface such as a table. To measure height, a

Height Board is used(also called a Stadiometer). It is mounted at a right angle between a level floor and against a straight, vertical surface such as a wall or pillar.

Before the measurement shoes, socks and hair ornaments (if any) should be removed. If braids interfere with the measurement of length/height, they should be undone. When measurement is to be done on a young child the mother is needed to help with measurement and to

soothe and comfort the child. She should be explained the reasons for the measurement and the steps in the procedure for ensuring proper help. 

Measurement of length:

The 1^st measurement of length should be done within 3 days of life (2). The length board is covered with a thin cloth or soft paper for hygiene and for the baby’s comfort. Explanation should be given to the mother that she will need to place the baby on the length board herself and then

help to hold the baby's head in place while the measurement is being taken. She should be showed where to stand when placing the baby down (i.e. opposite to the person doing the measurement) on the side of the length board away from the tape. Also placement of the baby’s head should be showed to her (against the fixed headboard) so that she can move quickly and surely without distressing the baby.

When the mother understands the instructions and is ready to assist:

·        She is asked to lay the child on its back with its head against the fixed headboard, compressing the hair.

·        Quickly the head should be positioned so that an imaginary vertical line from the ear canal to the lower border of the eye socket is perpendicular to the board. (The child’s eyes should be looking straight up.) The mother is asked to move behind the headboard and hold the head in this position. Standing on the side of the length board from where the measuring tape can be seen footboard is moved:-

·        It must be checked that the child lies straight along the board and does not change position. Shoulders should touch the board, and the spine should not be arched. The mother  should be asked to inform if the child arches the back or moves out of position.

·        Now the child’s legs are held down with one hand and the footboard is moved with the other. Gentle pressure is applied to the knees to straighten the legs as far as they can go without causing injury. (Note: it is not possible to straighten the knees of newborns to the same degree as older children. Their knees are fragile and could be injured easily, minimum pressure should be applied.)

If a child is extremely agitated and both legs cannot be held in position, measurement with one leg in position is done.

·        While holding the knees, the footboard is pulled  against the child’s feet. The soles of the feet

should be flat against the footboard, toes pointing upwards. If the child bends the toes and

prevents the footboard from touching the soles, the soles can be scratched slightly and when the child straightens the toes the footboard is to be slid in quickly.

·        The measurement is Read and recorded in centimetres to the last completed 0.1 cm.

Measurement of height:

Check that shoes, socks and hair ornaments have been removed.

In case of a small child working with the mother, kneel down in order to get down to the level of the child:

·        Help the child to stand on the baseboard with feet slightly apart. The back of the head, shoulder blades, buttocks, calves, and heels should all touch the vertical board. This alignment may be impossible for an obese child, in which case, help the child to stand on the board with one or more contact points touching the board. The trunk should be balanced over the waist, i.e., not leaning back or forward.

·        Ask the mother to hold the child’s knees and ankles to help keep the legs straight and feet flat, with heels and calves touching the vertical board. Ask her to focus the child’s attention, soothe the child as needed, and inform you if the child moves out of position.

·        Position the child’s head so that a horizontal line from the ear canal to the lower border of the eye socket runs parallel to the baseboard. To keep the head in this position, hold the bridge between your thumb and forefinger over the child’s chin.

·        If necessary, push gently on the tummy to help the child stand to full height.

·        Still keeping the head in position, the other hand is to be used to pull down the headboard to rest firmly on top of the head and compress the hair.

·        Read the measurement and record the child’s height in centimetres to the last completed 0.1 cm.

The length of a baby at birth is about 50 cm. It increases by about 25 cm during the first year and by another 12 cm during the second year. During growth spurt, boys add something like 20 cm in their height, and girls gain about 16 cm. The spurt is followed by a rapid slowing of growth. Indian girls reach 98 per cent of their final height on an average by the age of 16.5 years, and boys reach the same stage by the age of 17.75 years (2).

Height is a stable measurement of growth and nutritional status, as opposed to body weight. Whereas weight reflects only the present health status of the child, height indicates the events in the past also (2).

c)    Weight-for-height

Weight-for-height is now considered more important than weight alone. It helps to determine whether a child is within range of "normal" weight for his height (2).

For example, a child on the 75th centile of both his height and weight is neither over—weight nor under—weight, but a child on the 75th centile of his weight chart and the 25th centile of his height chart is clearly overweight.

d)   Mid-arm Circumference

Arm circumference yields a relatively reliable estimation of the body's muscle mass, the reduction of which is one of the most striking mechanisms by which the body adjusts to inadequate energy intakes (2).

 Arm circumference cannot be used before the age of one year; between ages one and five years, it hardly varies (2).

An arm circumference exceeding 13.5 cm is a sign of a satisfactory nutritional status, between 12.5 and 13.5 cm it indicates mild—moderate malnutrition and below 12.5 cm, severe malnutrition (2).

Procedure to locate mid-point of upper arm:

On the left hand, the mid-point between the tip of the acromion of scapula and tip of the olecranon of the fore-arm bone, ulna is located with the arm flexed at the elbow and marked with a marker pen (7).

Classifications for assessment of Nutritional Status using  the aforementioned parameters:

1)   Gomez' classification (2):

Gomez' classification is based on weight retardation. It locates the child on the basis of his or her weight in comparison with a normal child of the same age. In this system, the "normal" reference child is in the 50th centile of the Boston standards. The cut—off values were set during a study of risk of death based on weight for age at admission to a hospital unit. This classification therefore, has a prognostic value for hospitalized children with PEM.

Grade	Weight-for-age
Normal nutritional status	Between 90 & 110%
1st*,mild malnutrition	Between 75 and 89%
2nd*,moderate malnutrition	Between 60 and 74%
3rd*,severe malnutrition	Under 60%

The disadvantages are :

·        A cut-off-point of 90 per cent of reference is high and thus some normal children may be classified as 1st degree malnourished.

·        By measuring only weight for age it is difficult to know if the low weight is due to a sudden acute episode of malnutrition or to long-standing chronic undernutrition (2).

2)   Waterlow's classification (2):

When a child's age is known, measurement of weight enables almost instant monitoring of growth & measurement of height shows the effect of nutritional status on long-term growth.

Waterlow's classification defines two groups for protein energy malnutrition:

·        malnutrition with retarded growth, in which a drop in the height/age ratio points to a chronic condition— shortness, or stunting.

·        malnutrition with a low weight for a normal height, in which the weight for height ratio is indicative of an acute condition of rapid weight loss, or wasting.

This combination of indicators makes it possible to label and classify individuals with reference to two poles:

·        Children with insufficient but well-proportioned growth.

·        Those with a normal height, but who are wasted.

Nutritional status	Stunting       (% of height/age)	Wasting (% of weight/height)
Normal	>95	>90
Mildly impaired	87.5 - 95	80 – 90
Moderately impaired	80 - 87.5	70 – 80
Severely impaired	<80	<70

3)   Indian Academy of Pediatrics (IAP) Classification(based on weight-for-age) (11):

IAP designates a weight of more than 80 percent of expected for age as normal. Grades of malnutrition are :

·        Grade I (71-80%)

·        Grade II (61-70%)

·        Grade III (51-60%)

·        Grade IV (£50%)

of expected weight(50^th percentile of reference standard) for that age.

Alphabet K is postfixed in presence of edema.

IAP classification is simple and the cut offs are suitable for Indian population. However, the disadvantage is that it does not take in account the child's height. The weight is also dependent on height besides the built; thus children who are short statured (not necessarily because of nutritional deprivation) are also misclassified as PEM by this classification (11).

4)   Welcome trust Classification (11):

This is also based on deficit in body weight for age and presence or absence of edema.

·        Children weighing between 60-80 per cent of their expected weight for age with edema are classified as kwashiorkor.

·        Those weighing between 60-80 per cent of expected without edema are known as having undernutrition.

·        Those without edema and weighing less than 60 per cent of their expected weight for age are considered to be having marasmus.

·        Marasmic kwashiorkor is applied to children with edema and body weight less than 60  percent of expected.

5)   Age Independent Anthropometric Indeces (11):

THE GROWTH CHARTS

The growth chart  or "road-to-health" chart was first designed by David Morley and was later modified by WHO. It  is a visible display of the child's physical growth and development. It is designed primarily for the longitudinal follow-up (i.e. growth monitoring) of a child, so that changes over time can be interpreted (2).

WHO has developed growth standards based on a sample of children from six countries: Brazil, Ghana, India, Norway, Oman, and the United States of America. The data was obtained from WHO Multicentre Growth Reference Study (MGRS). The study followed term babies from birth to 2 years of age, with frequent observations in the first weeks of life. Another group of children, age 18 to 71 months, were measured once, and data from the two samples were combined to create the growth standards for birth to 5 years of age (12).

By including children from many countries who were receiving recommended feeding and care, the MGRS resulted in prescriptive standards for normal growth, as opposed to simply descriptive references. The new standards show what growth can be achieved with recommended feeding and health care (e.g. immunizations, care during illness). The standards can be used anywhere in the world, since the study also showed that children everywhere grow in similar patterns when their nutrition, health, and care needs are met (12).

The nutritional status can be therefore easily assessed for any child using these standardized charts. For the assessment WHO has provided charts for both boys and girls based on:

o   length/height-for-age

o   weight-for-age

o   weight-for-length/height

o   BMI (body mass index)-for-age

Each of the graphs have got the following features (10):

o   x-axis – the horizontal reference line at the bottom of the graph. In the Growth Record graphs, some x-axes show age and some show length/height. Plot points on vertical lines corresponding to completed age (in weeks, months, or years and months), or to length or height rounded to the nearest whole centimetre.

o   y-axis – the vertical reference line at the far left of the graph. In the Growth Record graphs, the y-axes show length/height, weight, or BMI. Plot points on or between horizontal lines corresponding to length/height, weight or BMI as precisely as possible.

o   Plotted point – the point on a graph where a line extended from a measurement on the x-axis (e.g. age) intersects with a line extended from a measurement on the y-axis (e.g. weight)

Further details explained with an example as follows (13):-

Shown above is a Growth Chart for boys showing Weight-for-length from Birth to 2 years of age. The line labeled 0 on the chart represents the median value or the average value. The other curved lines are z-score lines, which indicate distance from the average. [ Z-scores may also be called standard deviation (SD) scores.] 

Z-score lines on the growth charts are numbered positively (1, 2, 3) or negatively (-1, -2,-3).  In general, a plotted point that is far from the median in either direction may represent a growth problem, although other factors must be considered, such as the growth trend, the health condition of the child and the height of the parents.

The points on the Growth chart are read as follows (13):

o   A point between the z-score lines -2 and -3 is “below -2.”

o   A point between the z-score lines 2 and 3 is “above 2.”

o   If point is exactly on the z-score line, it is considered in the less severe category.

Interpretation of the charts is easy and is done based on the following table provided by WHO (13):

Trends on growth charts

“Normally” growing children follow trends that are, in general, parallel to the median and z-score lines.  Most children will grow in a “track,” that is, on or between z-score lines and roughly parallel to the median; the track may be below or above the median. Children who are growing and developing normally will generally be on or between -2 and 2 z-scores of a given indicator (13).

When interpreting  growth charts, one should be alert for the following situations, which may indicate a problem or suggest risk (13):

o   There is a sharp incline or decline in the child’s growth line.

o   The child’s growth line remains flat (stagnant); i.e. there is no gain in weight or length/height.

(note- Whether or not the above situations actually represent a problem or risk depends on where the change in the growth trend began and where it is headed.  For example, if a child has been ill and lost weight, a rapid gain (shown by a sharp incline on the graph) can be good and indicate “catch-up growth.” Similarly, for an overweight child a slightly declining or flat weight growth trend towards the median may indicate desirable “catch-down.”  It is very important to consider the child’s whole situation when interpreting trends on growth charts.)

Growth chart used in India

India has adopted the new WHO Child Growth Standards (2006) in February 2009, for monitoring the young child growth and development within the National Rural Health Mission and the ICDS. These standards are available for both boys and girls below 5 years of age (2).

A joint "Mother and Child Protection Card" has been developed which provides space for recording (2):

ü family identification and registration

ü birth record

ü pregnancy record

ü institutional identification

ü care during pregnancy

ü preparation for delivery

ü registration under Janani Suraksha Yojana

ü details about immunization procedures

ü breast-feeding and introduction of supplementary food

ü milestones of the baby

ü birth spacing and reasons for special care.

The chart is easily understood by the health workers and the mother, with a visual record of the health and nutritional status of the child. It it kept by the mother and brought to the health centre at each visit (2).

The growth chart shows:

ü normal zone of weight for age

ü undernutrition (below — 2 SD)

ü severely underweight zone (below — 3 SD).

It is the direction of growth that is more important than the position of dots on the line. The importance of the direction of growth is illustrated at the left hand, upper corner of the chart. Flattening or falling of the child's weight curve signals growth failure, which is the earliest sign of the protein- energy malnutrition and may precede clinical signs by weeks and months (2).

BMI measurement in Pediatric Population

WHO has published BMI charts as a part of growth chart in upto 5 years of age for both boys and girls. Interpretation is similar to the interpretation of WHO growth charts as mentioned above.

Center for Disease Control and Prevention has published BMI charts to measure BMI from 2-20 years of age group (14).

For eg:

This chart shows the Body Mass Index (BMI) percentiles for boys from 2 to 20 years old. The curved lines show BMI percentiles. For example, the top curved line shows the 95% percentile, which means that 95% of children are at or under that value.The bottom of the chart shows ages, from 2 to 20 years. The left and right sides of the chart show BMI values.The chart shows that at age 2 years 95% of boys have a BMI less than 19.4 and 5% have one less than 14.6. At 20 years 95% of boys have a BMI less than 30.6, and 5% have one less than 19 (14).

The formula for calculation of BMI is same as that of adults:-

BMI =             Weight in Kilograms             
            (height in meter)(height in meter)

However, it is interpreted differently from adults.

The CDC weight status classifications for use with the above table are as follows (14):

Percentile	Weight Status
>95th	Overweight
85th-95th	At Risk of Overweight
5th-85th	Normal
5th or less	Underweight

e)    Head and chest circumference

At birth Head Circumference is about 34cm. It is about 2cm more than Chest Circumference. By 6-9 months, the two measurements become equal, after which the chest circumference overtakes the head circumference (2).

In severely malnourished children, this overtaking may be delayed by 3-4 years due to poor development of the thoracic cage (2).

For measurement Flexible fibre glass tape is used. The chest circumference is taken at the nipple level preferably in mid inspiration. The head circumference is measured by passing the tape round the head over the supra-orbital ridges of the frontal bone in front and the most protruding point of the occiput on the back of the head (7).

f)      Skinfold thickness (at Triceps,Biceps,Subscapular and Suprailiac region)

A large proportion of total body fat is located just under the skin. Since it is most accessible, the method used is the measurement of skinfold thickness. It is a rapid and "non-invasive" method for assessing body fat. Several varieties of callipers (e.g., Harpenden skin callipers) are available for the purpose. The measurement is taken at all the four sites:

                                                       I.            Mid-Triceps

                                                    II.            Biceps,

                                                 III.            Subscapular Region

                                                 IV.            Suprailiac Region.

The sum of the measurements should be less than 40 mm in boys and 50 mm in girls. Unfortunately standards for subcutaneous fat do not exist for comparison. Further, in extreme obesity, measurements may be impossible. The main drawback of skinfold measurements for nutritional status assessment  is their poor repeatability (2).

3.     Biochemical evaluation

a.      LABORATORY TESTS:

                   I.            Haemoglobin estimation : It is the most important laboratory test that is carried out in nutrition surveys. Haemoglobin level is a useful index of the overall state of nutrition irrespective of its significance in anaemia. An RBC count and a haematocrit determination are also valuable (11,2,7).

                II.            Stool and urine : Stool should be examined for intestinal parasites. History of parasitic infestation, chronic dysentery and diarrhoea provides useful background information about the nutritional status of persons. Urine should also be examined for albumin and sugar (2) (7).

b.     BIOCHEMICAL TESTS:

With increasing knowledge of the metabolic functions of vitamins and minerals, assessment of nutritional status by clinical signs has given way to more precise biochemical tests which may be applied to measure individual nutrient concentration in body fluids (e.g., serum retinol, serum iron) or detection of abnormal amounts of metabolites in urine (e.g., urinary iodine) frequently after a loading dose, or measurement of enzymes in which the vitamin is a known co-factor (for example in riboflavin deficiency) to help establish malnutrition in its preclinical stages. However, Biochemical tests are time-consuming and expensive. They cannot be applied on a large scale, as for example in the nutritional assessment of a whole community. They are often carried out on a subsample of the population. Most biochemical tests reveal only current nutritional status; they are useful to quantify mild deficiencies. If the clinical examination has raised a question, then the biochemical tests may be invoked to prove or disprove the question raised (2).

Some biochemical tests used in nutrition surveys (2):

Nutrient	Method	Normal value
Vitamin A	Serum retinol	20 mcg/dl
Thiamine	Thiamine pyrophosphate (TPP) stimulation of RBC transketolase activity	1.00-1.23 (ratio)
Riboflavin	RBC glutathione reductase activity stimulated by flavine adenine dinucleotide	1.0-1.2 (ratio)
Folate	Serum folate	6.0mcg/ml
	Red-cell folate	160mcgml
Vitamin B 12	Serum Vitamin B-12 concentration	160mg/L
Vitamin C	Leucocyte ascorbic acid	15 mcg/108 cells
Vitamin K	Prothrombin time	11-16 seconds
Protein	Serum albumin (g/L)	35
	Transferrin (g/L)	20
	Thyroid-binding pre-albumin  (mg/L)	250

4.     Functional Assessment

Functional indicators of nutritional status are diagnostic tests to determine the sufficiency of host nutritional status to permit cells, tissues, organs, anatomical systems or the host him/herself to perform optimally the intended nutrient dependent biological function (7).

Functional indices of nutritional status include cognitive ability, disease response, reproductive competence, physical activity, work performance and social and behavioural performance (7).

·       Increased severity of malnutrition is associated with an increased heart rate response to the same submaximal work rate.

·  Lactation performance is another functional index of individual nutriture. Milk volume is reduced in malnourished women as is fat and total energy content of the milk.

·     Growth velocity also represents a functional index. Growth rates are suboptimal in PEM, zinc deficiency and iodine deficiency. The use of this index requires serial, accurate anthropometric measurements. Severe deficiencies of several nutrients will delay the onset of menarche.

·      Social performance, the ability of an individual to interact with his or her peers and environment, is an index for functional nutritional status.

· Prenatally undernourished infants show several behavioural impairments that could negatively affect the development of social competence including reduced activity and less interaction with caretakers.

Functional indices have several potential advantages over static indices with respect to the validity of the information about nutritional status. A defective function may be uncovered despite an apparently "adequate" circulating or tissue level of a nutrient. Conversely, functional competence may be preserved even though the static index has fallen below the level of adequacy. Moreover, functional performance can to some extent be normalised on an individual basis rather than on a population standard, especially where performance can be assessed serially and a maximum output after nutritional supplement defined (7).

5.     Biophysical and Radiological examination

These tests are used in specific studies where additional information regarding change in the bone or muscular performance is required. For example, Radiological methods are used in studying the change of bones in rickets, osteomalacia, osteoporosis and scurvy (7).

When clinical examination is suggestive, radiographic examinations are done as a part of nutritional assessment. Some examples of radiographic findings for nutritional assessment are (7):

·        In rickets, there is healed concave line of increased density at distal ends of long bones usually the radius and ulna.

·        In infantile scurvy there is ground glass appearance of long bones with loss of density.

·        In beriberi there is increased cardiac size as visible through X-rays.

The main drawback of this method is that many sophisticated and expensive equipments along with technical knowledge are required in the interpreting data. It is also difficult to transport the equipments to interior parts of a village for organizing a nutritional assessment surveys (7).

Indirect methods

1.     Assessment of dietary Intake (Diet Survey)

  A diet survey provides information about dietary intake patterns of specific foods consumed and estimated nutrient intakes. It can help to indentify relative dietary inadequacies resulting in nutritional problems. Most of the time, the surveys are carried out for 7-10 days (7). Sometimes four season surveys are also done to increase the accuracy of the assessment.

Commonly utilized methods for Assessment of dietary Intake are:

·          Inventory Method:

This method is often employed in institutions like hostels, army barracks, orphanages etc, where homogenous groups of people take their meals from a common kitchen. In this method, the amounts of food stuffs issued to kitchen as per the records maintained by the warden are taken into consideration. No direct measurement or weighing is done. A reference period of one week is desirable (7).

·        Weighment Method:

                   I.            WEIGHMENT OF RAW FOODS: The survey team visits the households, and weighs all food that is going to be cooked and eaten as well as that which is wasted or discarded. The duration of the survey may vary from 1 to 21 days, but commonly 7 days which is called "one dietary cycle" (2).

                II.            WEIGHMENT OF COOKED FOODS: Foods should preferably be analyzed in the state in which they are normally consumed, but this method is not easily acceptable among people (2).

·        Expenditure Pattern Method (hostels, army barracks, orphanages etc.):

In this method, money spent on food as well as non-food items is assessed by administering a specially designed questionnaire. The reference period can be either a previous month or week.

This method, apparently is less cumbersome as it avoids actual weighing of foods. The reference period too is usually longer. In trained hands, both the methods, weighment and expenditure pattern method yield comparable results (7).

·        Diet History:

This method is useful for obtaining qualitative details of diet and studying patterns of food consumption by the study group. The procedure includes assessment of the frequency or consumption of different foods daily or number of times in a week or fortnight or occasionally (7).

This method has been used to study meal pattern, dietary habits, food preferences and avoidances during physiopathological conditions like pregnancy, lactation, sickness etc. Infant weaning and breast feeding practices and the associated cultural constraints which are often prevalent in the community can also be studied by this method (7).

At times, information on approximate quantities of foods  consumed like half a litre of milk per day required for a child in the family can also be collected (7).

·        Oral Questionnaire (24 hour recall):

In this recall method of oral questionnaire diet survey, a set of standardised cups suited to local conditions are used. Information on the total cooked amount of each preparation is noted in terms of standardised cups. The intake of each food item by the specific individual in the family such as the preschool child, adolescent girl etc is assessed by using the cups. The cups are used mainly to aid the respondent recall the quantities prepared and fed to the individual members (2) (7).

·        Chemical Analysis:

In this method, the individual is required to save a duplicate sample of each type of food eaten by him during the day. These samples are then collected and sent to the laboratory for chemical analysis.

It is the most accurate method but is costly and needs a good laboratory support (7).

·        Dietary score:

This method is useful when one is trying to assess the dietary intake of specific nutrient e.g., iron content of diet. Depending on the content of iron, a food item is given a score. The frequency of intake of those foods is noted by questionnaire method. The frequency of consumption of foods, the total score and percentages are then calculated (7).

Even the best of diet surveys, give only an approximate estimate of foods and nutrients consumed by an individual under study. The methods do not give any idea about the  amount food absorbed or utilized by his/her body.

The errors which occur generally in diet surveys are :

Ø memory lapses.

Ø long reporting period may give rise to a lot of errors.

Ø prestige and other considerations influencing the responses.

Ø non-response due to non-cooperation.

Ø conversion factors for the various crude local measures (inventory method).

Ø inaccurate weighing of food stuffs (weighment method).

Ø housewife deviating from the normal pattern of food consumption during the survey period (response errors).

Ø seasonal variations and improper selection of the reporting period.

Ø problems in the use of tables on nutritive value of foods.

Therefore, a combination of dietary, clinical and biochemical assessment is desirable for proper assessment of nutritional status of an individual or a community (7).

2.     Vital Statistics

An analysis of vital statistics — mortality and morbidity data — will identify groups at high risk:

·        Mortality in the age group 1 to 4 years is particularly related to malnutrition. In developing countries, it may be as much as 20 times than that in countries such as Australia, Denmark or France (2).

·        The other rates commonly used for this purpose are :     

§  Infant Mortality Rate

§  Second-Year Mortality Rate

§  Rate Of Low Birth-Weight Babies

§  Life Expectancy.

These rates are influenced by nutritional status and may thus be indices of nutritional status (2) (7).

·        Data on morbidity like:

o   Hospital Data

o   Data from Community Health And Morbidity Surveys

particularly in relation to Protein Energy Malnutrition, Anaemia,  Xerophthalmia and Other Vitamin Deficiencies, Endemic Goitre, Diarrhoea, Measles And Parasitic Infestations can be of value in providing additional information contributing to the nutritional status of the community especially in the children (2)

3.     Ecological studies

Malnutrition is the end result of many interacting ecological factors. Therefore in any type of nutritional assessment, it is useful to collect ecological information of the given subject, population group or community in order to make the nutrition assessment complete.

 A study of the ecological factors comprise the following :

o   FOOD BALANCE SHEET :

This is an indirect method of assessing food consumption, in which supplies are related to census population to derive levels of food consumption in terms of per capita supply availability (2) (7).

However, the estimate refers to the country as a whole, and so conceals differences which may exist between regions, and among economic, age and sex groups. The great advantage of this method is that it is cheaper and probably simpler than any method of direct assessment. Used properly, this method does give an indication of the general pattern of food consumption in the country (2).

o   SOCIO­ECONOMIC  FACTORS :

Food consumption patterns are likely to vary among various socioeconomic groups. Family size, occupation; income, education, customs, cultural patterns in relation to feeding practices of children and mothers, all influence food consumption patterns (2).

o   HEALTH AND EDUCATIONAL SERVICES :

Primary health care services, feeding and immunization programmes should also be taken into consideration (2).

o   CONDITIONING INFLUENCES :

These include parasitic, bacterial and viral infections which precipitate malnutrition. It is necessary to make an "ecological diagnosis" of the various factors influencing nutrition in the community before it is possible to put into effect measures for the prevention and control of malnutrition (2).

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