As India tries to wriggle out of the mayhem caused by the second wave of COVID-19, a sense of anxiety hangs in the air. People are speculating, and shuddering as they speculate, that an impending third wave could hit children and adolescents more than the other age groups. Scientists and experts have been quashing such speculation, highlighting that there is hardly any data or evidence to support these conjectures. But whether or not the third wave is impending, and regardless of what its precise nature will be, India must squarely place its onus on one thing: improving the diet quality and nutrition of its children. This is non-negotiable. Food nutrition, safe food and positive lifestyles, after all, are the cornerstones of great immune function.
It is common knowledge that malnutrition is pervasive among India’s poor children. But in a real sense, nutritional deficiency also cuts across class. You see the twin problems of under-nutrition or excess weight/obesity coexisting with deficiencies of micronutrients like iron, zinc, calcium and several vitamins. Even among the relatively well-to-do, it’s a pincer grip. India has a huge task not to be a contributor to globesity—the global obesity epidemic—with all the associated health issues. This was the state of affairs even before Covid—for how the pandemic might have impacted the nutrition landscape of India’s children, we must await objective data from national-level surveys in the future.
Childhood and adolescence are two conjoined periods of continuous growth and development—a seamless duration, but one marked by various changes. For instance, between 2 and 10 years of age, children tend to grow at an average of 6-7 cm in height and 1.5 to 3 kg in weight every year. The adolescent period is spread almost over a decade—10-19 years—and it’s characterised by rapid increase in height and weight, hormonal changes, sexual maturation and wide swings in emotion; ‘environmental’ factors have an impact. But specifically, when the growth spurt happens at about 10-12 years in girls and two years later in boys, their nutritional needs are vastly increased, and for girls their nutritional status impacts not only their health, but that of generations to come.
Nutrition and Immunity
Malnutrition in any form can put children and adolescents at risk of compromised immune function, thus making them vulnerable to infections. So our focus should be not just on meeting their minimum calorie requirements, but to ensure adequate diversity in order to ensure the required balance of all necessary nutrients. The availability, accessibility and affordability of foods for some sections got impacted due to the economic upheavals caused by the pandemic, making many children vulnerable to under-nutrition and compromised immunity. On the other hand, physical activity has reduced tremendously for many urban children, screen time has gone up considerably (due to online classes, games or networking), eating schedules have gone awry, and consumption of high fat, sugar and salt foods may have increased. This again is likely to make them vulnerable to infections. It is our collective responsibility to see that India’s children are nurtured, nourished and safeguarded. We urgently need an aware, vigilant society here. In such a situation, what should be our approach to ensure our children/adolescents are healthy? Here are some guidelines:
For Infants and Young Children
Breast milk is the best source of nutrition for most infants, and it provides protection against many illnesses. Even during Covid infection, WHO recommends breastfeeding. Mothers should practise respiratory hygiene during feeding. If they have respiratory symptoms such as being short of breath, mothers should use a medical mask when near the child. Wash hands thoroughly with soap or sanitiser before and after contact with the child. If mothers are severely ill with Covid or suffer from other complications that prevent them from direct breastfeeding, breast milk can be expressed and fed to the child. In case of inability even to do that, wet nursing (another woman breastfeeding the child) or using donor human milk can be options.
From six months onwards, breast milk alone is not adequate for the infant to sustain optimal growth. Introduction of adequate and appropriate complementary foods is necessary for infants soon after completion of six months of age—and breastfeeding should be continued at least up to 2 years to prevent malnutrition and susceptibility to infection. Complementary foods should be adequately diversified and include cereal, pulses, nuts, milk, vegetables and fruits. Since infants cannot consume bulky complementary food in sufficient quantities, energy-rich foods like nuts, oilseeds and small amounts of fats/oils can be included. Gradually, they can be introduced to thoroughly cooked whole eggs, fish and meat in small quantities. Alternatively, adequate amounts of beans, legumes and pulses can be added.
Children of about one year of age should be introduced to the family diet. Additional nutritious foods—milk, fruits, small amounts of nuts, oilseeds—are needed to enhance the nutrient density of the family diet. Sugar and salt must be kept to the bare minimum, as the very young are likely to develop a taste for these, a pattern that will run far into the food habits even in their adult life. The minimum number of meals needed for the child, apart from breastfeeding, varies depending on the age of the child and on whether the child is being breastfed. During 6-8 months of age, a breastfed child needs to be given complementary feeds at least twice a day. During 9-24 months, this frequency needs to be at least 3-4 times a day. Importantly, all the routine immunisation measures suggested for children should be continued to keep other infections and diseases at bay.
There are many ways in which the disruptive social environment is affecting diet quality seriously. On the one hand, many children are at serious risk of under-nutrition—owing either to factors like displacement/migration or even familial sharing of rations meant to meet about a third of the child’s daily requirement. So safety net programmes and supplementary nutrition programmes—being kept afloat through take-home rations or home delivery of rations for those enrolled in ICDS or mid-day meals schemes—may not suffice. On the other hand, in cities, towns as well as among middle-class and affluent communities, restricted movement, constrained socialisation, curbs on outdoor games and even dwindling physical contact have become normal. School closures are not only preventing children from access to learning, but also limiting their interactions with peers. All this naturally has an impact on their psychosocial well-being—confusion, anxiety and frustration are the norm, with overexposure to mass media and social media often the only reprieve. This state of generalised stress naturally leads to cravings and binge eating. If you add to these diets lacking in diversity, consumption of high-carbohydrate and high-sugar foods, what you get is a long-term impact on child health.
In fact, as per the CNNS 2019 report, while 29 per cent of adolescents aged 10-19 years were anaemic and about 25-30 per cent were deficient in micronutrients such as B12 and vitamin D, ironically, a sizeable proportion also had metabolic biomarkers showing early signs of risk of non-communicable diseases (NCD) such as diabetes and hypertension. About 56 per cent of children had at least one of the biomarkers with an abnormal value. One tends to believe these are indicative of over-nutrition/obesity. However, micronutrient deficiencies associated with unhealthy diets lacking in legumes, beans, vegetables, fruits, nuts, seeds and milk might also be contributing to disrupted metabolism. This less-than-ideal situation is what may be getting exacerbated in the unprecedented situation we have now.
What can you do? Certainly do not sit back. Promote regular and healthy eating habits, lifestyle patterns and regular exercise within the confines of home. Empower children to check the nutrient contents printed on the food labels before they choose their foods—parents doing so themselves would help. We cannot do without social interventions at a bio-psychosocial level and let things drift.
Does Micronutrient Supplementation Work?
There is not enough evidence to come up with any guidance on micronutrient supplementation for prevention of Covid in healthy individuals or for its treatment. Nevertheless, micronutrients, if consumed from food sources like fruits, vegetables, nuts and whole grains and nuts, can play a key role in a well-functioning immune system. For a nation, people are its capital. We must pivot on children’s nutrition, using the pandemic to better understand the nutritional brick and mortar that holds up the body fortress. Plugging those gaps will build our future.
For children and adolescents
- Micronutrients (vitamins and minerals) and phytonutrients that are primarily available in fruits, vegetables, greens, nuts and whole grains play a crucial role in several metabolic pathways that aid in optimal immune function. They enhance both native and adaptive immune function and prevent infection. They also aid ‘immune memory’ formation. A substantial serving of fresh fruits and vegetables, as much as 300-500 gm per day per child depending on the age group, is suggested to enhance their micronutrient intake.
- Fruits, vegetables, curd, yogurt and nuts increase beneficial probiotic bacteria in the intestine, regulate gut microbiota, maintain intestinal integrity and thereby reduce transmission of toxins from the intestine to the blood. Better to prefer fresh fruits to fresh fruit juices.
- Consuming meat, poultry and eggs is not risky. Thoroughly cooked meat/ poultry may be included in moderation. Sea fish are very good sources of some essential fatty acids and nutrients.
- Milk and milk products like curd supply good quality protein and other nutrients. Ideally, about 300 to 400 ml is recommended.
- Indulgence in frequent munching of high-calorie and empty-nutrient-value snacks such as salty snacks, biscuits, bakery products, noodles, ice creams, cookies and cakes, fried snacks and sweetened beverages should be avoided.
- Consumption of highly processed foods, juices and carbonated drinks should be discouraged. These are high in fat, salt and sugar, and poor in nutrients (vitamins, minerals, phytonutrients).
- Consumption of fat, salt and sugar should be monitored. Fat—no more than 25-50g/day—and preferably more than two varieties of oils.
- Children must maintain ideal body weight for their age and height. Being underweight or overweight/obese impairs immunity and increases inflammation. Therefore, moderate physical activity/yoga should be promoted. This also reduces stress and helps burn calories. It is possible to engage in this activity in the confines of home.
- Adequate water intake should be encouraged.
- Screen time should be reduced. Children must be engaged in conversations, household chores and cooking activities.
- Adequate sleep must be ensured.
Dr SubbaRao, a senior scientist, heads the Nutrition Communication, Information & Health Education (NICHE) division at ICMR-NIN
Dr Hemalatha is Director, ICMR-National Institute of Nutrition