IN THIS warren of narrow streets and alleys that is Sitio Bato, Barangay Ermita, vendors line the paths with their wares—rice, chocolate porridge and popular viands that residents can just snap up for their daily meals—proliferating like the coin-operated machines dispensing mineral water every three meters.
But the plethora of food stalls masks a harsh reality.
Nearly one in five children under five years old in Barangay Ermita, Cebu City is malnourished.
This was the result of the 2018 Operation Timbang (OPT) Plus, the weighing and height measurement of children 0-59 months old conducted in the first quarter of the year by health center officials in the communities.
Emma Seville, nutrition program coordinator of Cebu City’s Department of Social Welfare Services (DSWS), said 18.9 percent of under-five children in Barangay Ermita were underweight or too light for their age.
Cebu City is the fifth richest city in the Philippines by net assets/equity, according to the Commission on Audit. Yet, the level of child mlanutrition revealed in its annual OPT Plus shows much still has to be done to ensure that its prosperity translates to better health for a wider swath of the population.
Ermita leads the barangays in Cebu City with the highest malnutrition prevalence, said Seville.
The other barangays in the top 10 in terms of underweight children are Toong, with a 14.3 percent prevalence; Lorega San Miguel, 14.2 percent; Sudlon 1, 10.5 percent; Pahina Central, 10.3 percent; Sambag 2, 10.2 percent; Malubog and Inayawan, both with 9.9 percent; and Lusaran and Pasil, both with 9.5 percent.
Signs and risks
The indicators for malnutrition are underweight (low weight for age), wasting (low weight for height), and stunting (low height for age).
According to Save the Children Philippines, underweight indicates undernutrition that incorporates stunting, small stature, wasting and severe malnutrition.
Studies show that children already stunted in the first three years of life have poorer cognitive performance and lower grade level attainment, said the group, which added that stunting’s cognitive impact is irreversible by age five.
To help arrest malnutrition, the Cebu City Health Department provides medical intervention, while the DSWS comes in with supplemental feeding after the OPT Plus identifies the malnourished children.
Dr. Maria Theresa Tipgos, Cebu City Health Department field program division chief handling all the health centers and the programs implemented by the Department of Health (DOH), said that by another measure of malnutrition, which is weight for height, eight children under six years old in the city were found this year to be suffering from severe acute malnutrition (SAM), seven of whom were below five years old.
The figures for those suffering from moderate acute malnutrition (MAM) had yet to be consolidated.
In children 6-59 months old, SAM is defined by having a very low weight for height (wasting), or clinical signs of bilateral pitting edema, or a mid-upper arm circumference (MUAC) of just 11.4 centimeters or below. A child with MAM would have a MUAC of 11.5 to 12.5 centimeters.
Numbers
Tipgos cautioned against reading too much into the high malnutrition figures, saying there had been discrepancies in the encoding of the OPT results, possibly bloating the numbers of the malnourished, because the electronic reporting system was so sensitive that if the barangay health worker (BHW) rounded off the age of the child to, say, two years old, from the actual child’s age of one year old and 11 months, the system’s automatic computation based on the child’s weight for age would indicate the child to be too light for his age and thus severely underweight, even if the BHW’s own classification of the child was just underweight.
“In 2018, our target was to measure 154,036 children 0-59 months old, but we covered only 92,837,” said Tipgos.
In 2017, the target was 148,315 children under five years old. But only 55.25 percent, or 81,938 children, were weighed. The low coverage resulted in the finding of only one child with SAM and 240 with MAM.
Tipgos said the BHWs are given three months to conduct the OPT house to house in their assigned sitios, during which they also update the family profile, listing the senior citizens down to the youngest family members, and those who are sick and pregnant. Sometimes, they cannot cover all the children estimated to be living in the area because they also have activities in the health center to attend to.
Other times, the BHWs are also removed, or replaced, with the replacement not being familiar with the sitio, making it difficult for the worker to cover everyone in the area.
Oversupply
Under the Philippine Integrated Management of Acute Malnutrition program to help children 6-59 months suffering from acute malnutrition, the DOH 7 began last year the distribution in Cebu of ready-to-use therapeutic food (RUTF) for the outpatient treatment of SAM, and F-75 and F-100 therapeutic milk for the inpatient treatment of SAM.
For the whole province, commodities were made available for an estimated 5,000 children with SAM, of which the allocation for 1,000 children was delivered to Cebu City.
But since only a few children with SAM were identified in the city, most of the RUTFs have not been used and just expired.
Tipgos said they had tried to return the stocks, but with the DOH 7 still having enough, they were instead given the verbal advice to just use the stocks for the children with MAM.
“We advised them to use the RUTF for the borderline SAM instead,” DOH 7 nutritionist-dietician IV Juliet Tutor confirmed.
But Tipgos said that without written advice from the DOH 7, “we cannot just give the RUTF to a child to whom that is not indicated because that is high protein. That would destroy the kidneys. The indicator for the RUTF is for SAM. For MAM, there are no guidelines yet, so it is purely advice on the proper complementary food for feeding.”
Monitoring
Tipgos said once the undernourished are identified, the Cebu City Health Department monitors them monthly.
“We have the Garantisadong Pambata every six months, where we give deworming (tablet) and Vitamin A supplementation (drops). Vitamin A is for children 0-12 months. From one year old onward, it’s Vitamin A and deworming every six months.
“Plus, we have the Pabasa sa Nutrisyon, where we teach the mothers the variety of food to be cooked for the family. When it comes to feeding the child, you are supposed to see if the food is balanced and how much to give the child. And you should give it three times a day. Aside from that, there should be dessert, like fruits,” she said emphatically.
The department also promotes exclusive breastfeeding of the child for the first six months of life, and then from six months to one year old, breastfeeding and complementary feeding with the proper amount and type of food.
“Exclusive breastfeeding means no water, not even vitamins, unless the doctor recommends it,” she said.
But sometimes, because they have to work, mothers stop breastfeeding, and that’s one of the reasons the child becomes malnourished.
But other mothers, especially teenagers, don’t breastfeed because of the fear that it will cause their breasts to sag. Tipgos said this was a myth. Still others think they don’t have enough milk when in fact, Tipgos said, the milk will come out when the baby suckles, if the baby is positioned properly.
Breastfeeding exclusively for six months has another benefit: lactation amenorrhea, which protects the mother from getting pregnant and bringing another child into the world that the family cannot afford to feed.
Bottle woes
“When you start bottle feeding, that’s when the diarrhea begins. The child can get pneumonia and otitis media,” an ear problem that occurs when mothers leave the bottle in the baby’s mouth even when it is no longer hungry, causing the milk to run into the baby’s ear, said Tipgos.
In bottle feeding, the water or food could also back out into the nasal passage, and that’s how coughing begins, which will later progress to pneumonia, she said.
“Aside from pneumonia, if the child is already suffering from colds, then you just bottle-feed, he can choke to death, or the milk will go to the lungs and he gets aspiration pneumonia,” she said.
Tipgos went on with the sins of bottle-feeding mothers, saying that instead of boiling the water for the milk, mothers today just go to ATMs (Automatic Tubig Machines) to buy water for P1 that’s already good for one bottle.
“You’re supposed to boil the water,” she said. “But they think that water from the ATM is clean. But not all mineral or bottled water is safe for babies. Or probably they want to save on the cooking gas.”
“They think this is much cheaper, much easier to do, without thinking that this is not safe for the baby,” she said.
Starting a child on solid food before six months, when his intestines have not yet matured, also causes indigestion and diarrhea. This makes the child vulnerable to infection, which his little body must use up calories to fight, leading to malnutrition.
In Sitio Bato, Ermita, a mother cradling her four-month-old baby, told SunStar Cebu that when not breastfeeding the baby, she gives the infant instant cereal, which she mixes with hot water she buys from vendors for P2 a glass.
On their own
Tipgos said the causes of the hardship of mothers varied. Some had husbands in jail. Others couldn’t work because they had to watch the children. Or if the husband was employed, his earnings were not enough to meet the needs of the whole family.
But Ermita barangay nutrition scholar Rowena Dilao said poverty was not the main reason for child malnutrition in her village.
“It’s not that they don’t have money, because the residents sell goods at the Carbon Market,” she said in Cebuano.
What happens, she said, is that mothers leave their homes at 3 or 4 a.m. daily to sell their products at the Carbon Market in the village, leaving their oldest children, some only 10 years old, with money to feed the younger children.
“They don’t cook anymore. They just buy food at the many food stalls in the area,” she said.
The result is that the children indulge themselves in “tuslob-buwa,” which involves dipping hanging, shaped rice in a frying pan containing pig brains and oil, or spend the money on junk food instead of more nutritious food.
“Nutritious food is not supposed to be a problem because with the market here, there are lots of vegetables,” Dilao said. “But rather than cook, it is easier to just buy food from the stalls.”
She also cited vice as a major driver of malnutrition, saying many of the malnourished children had parents who gambled and did illegal drugs.
“The parents just say, ‘Here’s P20.’ They don’t check if their children eat the different kinds of food, like meat, fruits,” Dilao said.
From the start
But the sins of mothers start way before that.
While pregnant, the mothers are already given enough supply of iron to take until after they deliver their babies.
“The mother needs iron during pregnancy, because if she is anemic, there’s a tendency she’ll bleed during pregnancy, and the baby in the womb also needs iron. Some mothers say they took the iron. But actually, they did not. That’s why some still look pale. If the mother’s condition is not good, she’ll be malnourished. So some babies also come out malnourished,” Tipgos said.
She said the City Health’s Pabasa sa Nutrisyon program was aimed at mothers that needed help.
“We call in especially those mothers not breastfeeding. They are taught about nutrition. We inculcate the (idea that) at least, they should have plants or gardening at home, where they can get vegetables. The BHW identifies those with malnourished children based on the OPT and the mothers who don’t breastfeed,” she said.
But the Pabasa is done by a health center only twice a year. Each run is five days. And at each run, only 20-25 mothers in the barangay get to join. And participation is voluntary.
Some mothers don’t even finish the five-day run, which consists only of two-three-hour afternoon sessions.
In 2017, some 93 percent of mothers in the city breastfed within the first hour of delivery, while only 72 percent exclusively breastfed for the first six months.
Worldwide, according to the World Health Organization (WHO), only 40 percent of infants 0–6 months old are exclusively breastfed, which means the city has fared better.
But the WHO also said that globally, 5.6 million children under five years old died in 2016, with undernutrition linked to 45 percent of the child deaths.
This means if the parents’ unsafe early feeding practices are not corrected, babies could still lose all their gains from exclusive breastfeeding, and later just add to the city’s statistics on child malnutrition and mortality.
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