The 14-month-old who lives on tea and biscuits
Sunita, an anganwadi worker in a village near Muzaffarpur, visits Rekha's home. Rekha's son Arjun is 14 months old and weighs 7.4 kg; his upper-arm band reads yellow. He is breastfed on demand but refuses dal-rice, kheer and mashed banana, and is mostly given tea with a glucose biscuit three or four times a day because 'he cries otherwise'. His palms and eyelids look pale, the skin on his legs is dry and flaky, and he has had three loose stools this week but no fever or blood. Rekha's husband earns about ₹9,000 a month as a daily-wage mason; the family eats rice, potato, some dal and seasonal greens, and buys milk only when there is extra money. The mother-in-law insists that 'mother's milk is complete food until two years' and that stopping tea will make the child weak. Rekha asks Sunita whether she should buy a tin of formula or start buffalo milk.
1. From the details given, name the two most probable nutrition-related problems and list the specific evidence supporting each. Separate firm evidence from what still needs measurement.
Read the worked answer
1. Moderate undernutrition with faltering growth.
- Weight 7.4 kg at 14 months is far below the expected 9–10 kg range.
- MUAC tape reading yellow = moderate acute malnutrition band, not red (severe).
- Diet is energy-thin: tea and a biscuit several times a day replacing thick, energy-dense food.
- Dry flaky skin fits poor fat and vitamin intake, but skin alone never proves a deficiency.
2. Probable iron-deficiency anaemia.
- Pallor of palms and eyelids.
- Almost no iron-rich food in the household diet.
- Tea several times a day: tannins bind iron and block absorption.
- No mention of iron syrup or supplementation. Pallor is a screening sign only, so the answer must say probable and ask for haemoglobin estimation.
What the case does not prove. Three loose stools without fever or blood point to dietary/dilutional diarrhoea or teething stools, not dysentery; do not label it infection on this evidence. Refusal of solids is a feeding-behaviour problem, not illness by itself. A good answer therefore states which conclusions are firm (weight, MUAC, diet pattern) and which need a test (Hb) or a second visit (stool, weight gain).
2. Build a low-cost one-day feeding plan for Arjun using foods the family already buys, and explain how you would deal with the tea habit and its effect on iron.
Read the worked answer
Principle: the child needs small, thick, frequent feeds of family food plus continued breastfeeding - not a shop product. Aim for about five feeds a day, each the consistency of thick porridge so a small stomach gets energy.
| Time | Feed | Reason |
|---|---|---|
| Early morning | Breastfeed | Keeps breastfeeding, gives comfort |
| 8 a.m. | Mashed banana or boiled potato mashed with a teaspoon of oil/ghee | Cheap, energy-dense, soft |
| 11 a.m. | Thick dal-rice mash with a little oil, hand-mashed | Uses food already cooked at home; oil raises energy without volume |
| 2 p.m. | Same family sabzi mashed with rice; add chopped green leaves finely | Iron and vitamin A at no extra cost |
| 5 p.m. | Sattu or roasted gram flour mixed with water and a pinch of salt, or curd | Local Bihari protein food, cheap |
| 8 p.m. | Khichdi with dal and seasonal vegetable | Complete protein, soft |
| Night | Breastfeed on demand | Continue to two years |
Handling the tea. Do not fight it head-on: reduce gradually, from four cups to two, then to one. Replace the biscuit with roasted chana or a piece of guava. Most important, move tea away from meals - at least one hour between tea and food - because tannins taken with a meal cut iron absorption sharply. Give lemon or amla with the dal-rice: vitamin C in the same meal increases absorption of the iron that is there. Never give tea in the bottle or as a substitute for a feed.
3. Evaluate the grandmother's claim and the two options Rekha put forward (formula or buffalo milk). State what you would actually advise and why.
Read the worked answer
The grandmother is half right. Breast milk should continue up to two years and beyond - that part is correct. But 'complete food until two years' is wrong: after six months, breast milk alone cannot supply enough energy, iron, zinc and vitamin A, so family food is compulsory alongside it. The claim that stopping tea will weaken the child has no basis; tea supplies sugar and tannins, not strength.
Formula (₹400–700 a tin, recurring monthly): nutritionally sound but expensive for a ₹9,000 income, and risky in this home because dilution to stretch the tin, unboiled water and unsterilised bottles cause infection. It is not the first choice here.
Buffalo milk: cheaper and available, but it has far more protein, fat and minerals than an infant kidney can handle and almost no iron, so it must be diluted and boiled. Large volumes of milk also displace solid food and can cause occult blood loss from the gut, worsening anaemia.
What to advise: continue breastfeeding on demand, stop the tea, and give thick family foods five times a day with a little oil. If animal milk is used at all, boil it, dilute buffalo milk with an equal part of water for now, and cap total milk near 500 ml a day so it does not replace food. Add lemon or guava with meals for iron, and refer for haemoglobin testing and iron supplementation through the anganwadi or sub-centre. Weigh him again in a month: weight gain, not argument, is the test of the advice.