Child malnutrition remains one of the main public health challenges of the 21st
century. Recent global estimates suggest that stunting, wasting, and intrauterine growth retardation are responsible for 2.2 million deaths and 21% of disability-adjusted life-years lost among children under 5
]. Results from the third National Nutrition Survey in Bhutan show that while there has been a major decrease in the prevalence of stunting among children 6 months to 5 years (from 60.9% in 1986-88 to 34.9% in 2008), linear growth retardation remains a significant public health problem that poses a threat to the healthy growth and development of Bhutanese children. Compared to other countries, current stunting rates in Bhutan are categorized as high (range 30-39.9%)
The problem of stunting starts early. As shown in Figure
, the critical period for stunting in Bhutanese children is the first 2 years of life. This is consistent with child growth patterns worldwide
] and confirms the importance of the first two years of life as a critical period when linear growth is most sensitive to environmentally modifiable factors. It also highlights the need for prenatal and early life interventions to avert the growth failure that occurs during this sensitive period and decrease the risk of maternal mortality and disability due to obstructed labour.
However, stunting often goes unrecognized, especially in communities where short stature is so common that it seems normal. Even among health workers, stunting generally does not receive the same attention as underweight or wasting, especially if height is not routinely measured as part of community health programs. Thus, in Bhutan as elsewhere, early identification of linear growth faltering is essential for improving the effectiveness of public health programs in preventing stunting. Likewise, the regional differences in the distribution of childhood stunting shown in Figure
need to be taken into consideration when planning interventions to tackle this problem. A separate survey should be carried out on a sub-regional level, like district, constituency or gewogs, with more sectors involved to provide information on all major factors related to undernutrition and investigate the underlying causes for the regional differences.
Rates of childhood underweight have dropped more than two-thirds since the first national survey (34% in 1986-88 versus 10.4% in 2008). Underweight is evenly distributed across geographical regions, with a national rate categorized as of moderate public health significance when compared with the overall estimate for Asia (19.5% in 2010)
]. Of greater concern, however, is the prevalence of wasting (4.7% based on the 2008 NNS and 5.9% based on the MICS 2010
]), with prevalence rates up to 7% or more in the 6 to 24 month age group and the Western region (Table
). These wasting rates indicate that acute undernutrition remains a matter of concern in early childhood, especially as severely malnourished children have 900 times higher risk of death
]. Growth monitoring in Bhutan is carried out by health workers in the Basic Health Units (BHUs); however, children living in remote areas have little contact with BHUs, mainly at the time of immunization (at weeks 6, 10 and 14, and 9 and 24 months). An approach to identify these children in need of immediate attention will be to establish a system for identifying children with severe malnutrition in the community so that they can be referred to the BHUs for treatment. The screening for severely malnourished children could be done by village health workers using MUAC (assessments to be done on a monthly basis during the first year of life and every 3 months thereafter). MUAC should be assessed using a coloured tape (easy to interpret) following the WHO/UNICEF guidelines on the assessment of severe malnutrition
]. Children identified as severely malnourished on the basis of low MUAC should be immediately referred to the BHUs where their weight-for-height should be assessed. It is important to note that the two indicators (MUAC and weight-for-height) do not always coincide
], and therefore all children screened as severely malnourished on the basis of MUAC should be accepted and referred to the nearest hospital even if their weight-for-height is not below -3SD.
The high rate of stunting coupled with the moderate level of underweight indicates that childhood overweight is likely becoming a condition of concern in Bhutan. Although the rates are still low (4.4% of children aged 6-59 months were above +2SD of the WHO standards' weight-for-height), a slight but steady increase is observed across time (Figure
Using the indicator BMI-for-age (an alternate indicator to assess childhood overweight) the national prevalence was 6.9%, with rates as high as 11% in the Eastern region
]. These levels of childhood overweight are similar to the overall estimate for Asia in 2010
]. The high prevalence of both stunting and severe wasting, coupled with increasing rates of overweight, highlight the fact that monitoring weight-for-age alone is insufficient; it is also necessary to include the measurement of length/height to be able to monitor low height-for-age (stunting) as well as low and high weight-for-height (wasting and overweight) at both individual and population levels. Bhutan’s Maternal & Child Health (MCH) handbook is being revised to include sex-specific length/height-for-age charts based on the WHO Child Growth Standards.
Various factors are responsible for the decline in growth indicators, among them inadequate quantity and/or quality of complementary feeding relative to children’s energy and nutrient needs, or that serves as a channel for infectious agents and toxins. There is a large body of scientific evidence on what constitutes appropriate infant and young child feeding, from exclusive breastfeeding during the first 6 months of life
] to guiding principles on complementary feeding
]. More importantly, there is ample evidence that appropriate infant feeding practices result in better growth for infants and young children in poor environments. A recent analysis of Demographic and Health Survey data from 46 countries found that countries with low rates of exclusive breastfeeding and inadequate dietary diversity consistently had a high prevalence of undernutrition
Bhutan’s Ministry of Health recommends exclusive breastfeeding from birth to 6 months of age. According to the 2008 survey, initiation of breastfeeding within the first hour after birth is high (81.5%) and the median duration of breastfeeding is 23 months. However, 14% of mothers introduce other foods (usually butter) by the first month, and by 6 months only 10% are exclusively breastfeeding their babies. Exclusive breastfeeding for 6 months is also challenging for mothers working in the public sector since they are granted only 3 months maternity leave while workers in the private sector have only 2 months.
The National Assembly has begun to discuss these issues, including proposals for a maternity support fund to provide minimum wages for 6 months to enable mothers to breastfeed. In addition to actions aimed at protecting and promoting exclusive breastfeeding for the first 6 months of life, it will be important to revise the feeding recommendations in the MCH handbook to include more specific information regarding both types and amounts of food and feeding frequency appropriate for each age group. The inclusion of Infant and Young Child Feeding indicators
] in the Health Management Information System will strengthen the nutrition surveillance system and help monitor the adequacy of feeding practices for Bhutanese children. Similarly, future nutrition surveys should incorporate questions about childhood illnesses – especially diarrhoeal diseases and respiratory infections – given their impact on child growth trajectories.