Recent studies have revealed a decline in the prevalence of severe and moderate malnutrition in several regions of the world. (1) However high rates of mild malnutrition still persist which have a higher risk of mortality in developing countries. (2) In developing countries, taking into account diarrhea, pneumonia, measles and all of these together as causes of death, the risk of death for preschoolers with a mild deficit of the weight-for-age indicator (Z-score -2.0 to <-1.0) is 1.73-2.32 times higher than for children with adequate weight-for-age. Whereas it is 3.01 to 5.39 times if the child is moderately malnourished (Z-score -3.0 to <-2.0) and 5.22 to 12.50 times in those severely malnourished (Z-score <-3.0) (3). Pelletier et al have found that mild-to-moderate malnutrition contributes to 50-75% of deaths in the first years of life. He also noted that 83% of deaths in developing countries could be avoided if the mild and moderate forms were included in actions to reduce malnutrition. (3)

Micronutrient malnutrition is a term used to refer to diseases caused by a dietary deficiency of vitamins or minerals. Vitamin A deficiency, iron deficiency anaemia and iodine deficiency disorders are the most common forms of Micronutrient malnutrition. (17)

A high proportion of children in developing countries are already nutritionally depleted when they become preschoolers. Many are born low birth weight or preterm, poor maternal micronutrient status during pregnancy contributes to lower infant nutrient deposition in utero, poor maternal micronutrient status during lactation leading to nutritional deficiency in infancy and thus later in life. (4) At the time of weaning, complementary feeds should be adequately energy dense to meet the growing needs of the child. However it has been found that these children eat much less due to their small gastric capacity, have poor intake of micronutrients. (5) In most developing countries, the intake of animal source foods (ASF) is too low to provide the population with sufficient amounts of nutrients such as vitamin B12, bioavailable iron and zinc, riboflavin and calcium. (4) A variety of economic and social factors contribute towards malnutrition (6,7). Indian children's diets are predominantly vegetarian, based on cereals and legumes and are deficient in milk and milk products. (8)

India has 1/3rd of global 2 billion people suffering from vitamin and micronutrient deficit. The reported prevalence of nutritional anemia in children varies from 44% to 74%. The prevalence rates are also high in preschool children which are 63%, and, 44% between 3 to 5 years. (9,10). India has the largest number of Vitamin A deficient children in the world with 330,000 children dying directly or indirectly every year, due to this deficiency. (11) Micronutrient malnutrition is a persistent problem in India and as the recent data suggest some of micronutrient malnutrition has increased in the last 2 decades. (12) Iodine deficiency disorders prevalence is present in over 71 million people with insufficient iodine intake. (13) Balasubramaniam et al documented calcium deficiency rickets among toddlers attending an urban hospital in Lucknow. The mean daily calcium intake in this group of children belonging primarily to low and lower middle socio-economic group was 282 + 114 mg. (14) The peak age at which rickets is most prevalent is 3-18 months. (15) Agrawal et al found that 43% of non-walking in children is attributable to rickets due to vitamin D deficiency. (15)

The overt effects of micronutrient malnutrition, such as blindness, anemia and goiter, have been known for many centuries. (16) Vast preschoolers with micronutrient deficiencies are unable to achieve their full mental and physical potential due to stunted growth, low physical work capacity, reduced IQ and lower resistance to infection. (16)

Interventions should thus be directed to prevent malnutrition in preschoolers. Food fortification could be a method to provide micronutrients on a long term basis to these children.

1.		World Health Organization (WHO). Global Database on Child Growth and Malnutrition. Geneva: WHO, 1997
2.		World Health Organization (WHO). Reducing Risks, Promoting Health Life. Supporting Material for the Word Health Report. Geneva: WHO, 2002.
3.		Pelletier, DL. The relationship between child anthropometry and mortality in developing countries: implications for policy, programs and future research. Journal of Nutrition 1994; 124(Suppl. 1): 2047S-2081S
4.		Allen LH. Causes of nutrition-related public health problems of preschool children: available diet. J Pediatr Gastroenterol Nutr. 2006; 43 Suppl 3: S8-12.
5.		Brown K, Peerson J, Kimmons J, et al. Options for achieving adequate intake from home-prepared complementary foods in low income countries. In: Black R, Michaelsen K, editors. Public Health Issues in Infant and Child Nutrition. Philadelphia: Lippincott Williams & Wilkins; 2002. pp. 239-256
6.		Oliveira Assis AM, Barreto ML, Magalhaes de Oliveira LP, de Oliveira VA, da Silva Prado M, da Silva Gomes GS, et al. Determinants of mild-to-moderate malnutrition in preschoolers in an urban area of Northeastern Brazil: a hierarchical approach. Public Health Nutr. 2008;11: 387-394
7.		UNICEF. State of the world children 2008: Child Survival: UNICEF; New York: 2008.
8.		Ekbote VH, Khadilkar AV, Chiplonkar SA, Hanumante NM, Khadilkar VV, Mughal MZ. A pilot randomized controlled trial of oral calcium and vitamin D supplementation using fortified laddoos in underprivileged Indian toddlers. Eur J Clin Nutr. 2011 Jan 19. [Epub ahead of print]
9.		WHO/UNU/UNICEF -Master protocol: population study of relative effectiveness of weekly and daily supplementation in pregnant women "adolescent girls and pre school children". 1993 -Revised July 28
10.		Mehta MN. Draft report on effectiveness of Daily and Weekly iron & folic Acid supplementation in Anemic, Adolescent Girls based on UNICEF research project submitted to UNICEF. 1998
11.		Kotecha PV, Lahariya C. Micronutrient supplementation and child survival in India. Indian J Pediatr. 2010; 77: 419-424
12.		International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India: Volume I. Mumbai: IIPS 2007.
13.		Bohac L, Gulati D. Integrating small salt producers in Rajasthan into India's universal salt iodization strategy; ICCIDD News Letter No 33; 2009.
14.		Bhatia V. Dietary calcium intake - a critical reappraisal. Indian J Med Res. 2008 Mar;127(3):269-73.
15.		Agarwal A, Gulati D, Rath S, Walia M. Rickets: a cause of delayed walking in toddlers. Indian J Pediatr. 2009; 76: 269-272
16.		Food fortification for reducing micronutrient deficiency. Available at URL: http://www.ifm.net/industry/food_fortification.htm. Accessed on 5th February 2010
17.		Preventing micronutrient malnutrition a guide to food based approaches. Available at URL: http://www.fao.org/docrep/x0245e/x0245e01.htm. Accessed on 5th February 2010