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Children in Tibet

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    “They are small but otherwise healthy”. “We need local growth charts because American and European charts are not relevant to these children”. These are things that are said about stunted children in developing countries. But they are wrong. There is good evidence that well nourished children, wherever they live, grow in accord with international growth standards. A report from Tibet (Nancy S Harris and colleagues.New England Journal of Medicine2001;344:341–7) has shown that stunted children there are not healthy.  Over 2000 Tibetan children aged up to 7 years were examined in 1994–95. It was estimated that 13.2% of the children born to the mothers in the survey had died. Half of the children (1067 out of 2078) had a z score for height of −2.0 or lower. Mean z score was −0.5 in the first 6 months of life, −1.6 by 12 months, and around −2.0 to −2.4 at later ages. Fifty six per cent of children aged over 24 months were stunted (z score −2.0 or lower) and 24% were severely stunted (z score −3.0 or lower). Stunting was found in 35% of urban and 60% of non-urban children. Two thirds of all the children examined had clinical rickets and 85% of 130 children tested had low serum concentrations of 25-hydroxyvitamin D. Fifty five per cent had abdominal distention, 43% hair depigmentation, and 40% dental caries. Three per cent had a goitre. Children living outside towns were less healthy than urban children.  Although many of the children had stunted growth, they were not wasted, their weight-for-height scores being normal. Nevertheless, 14% of those less than 24 months old had a mid-upper-arm circumference of less than 11.5 cm (a value previously shown to be associated with increased mortality) and 75 % of those in their second year had a chest-to-head circumference ratio of less than 1.0, indicative of undernutrition. There was evidence that the average height of 3 year olds had decreased between 1986 and 1995. There was no consistent relationship between the height of these children and the altitude at which they lived.  Many children in Tibet are small for their age and this stunting is due to malnutrition and is associated with considerable morbidity. The writers of an accompanying editorial (Ibid: 373–4) refer to “a silent calamity” and call for “the political and economic commitment to say that enough is enough; it is time to make things better”.

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