Swagata Chatterjee

Adequate nutrition is fundamental to childhood survival, growth, development and quality of life. It is also a recognised right of every child. Article 24 of the United Nations Convention on the Rights of the Child recognises the right of children to the highest attainable standard of health and explicitly calls upon States to combat disease and malnutrition through, among other measures, the provision of adequate nutritious food and clean drinking water. Yet, despite improvements in India’s child nutrition indicators over the past decade, undernutrition and micronutrient deficiencies remain widespread. According to the National Family Health Survey-5 (NFHS-5, 2019–21), 35.5% of children under five years were stunted, 19.3% were wasted and 32.1% were underweight. Childhood anaemia, meanwhile, increased from 58.6% in NFHS-4 to 67.1% in NFHS-5.

For children living with life-threatening and life-limiting illnesses, nutritional vulnerability can be substantially greater. Conditions such as HIV, thalassemia, cancer and other haematological disorders may affect appetite, nutrient intake, absorption, metabolism, growth and physical functioning, while treatment-related symptoms and repeated hospitalisation can further compromise nutritional status. Indian studies demonstrate high levels of undernutrition among children living with HIV, β-thalassemia major and cancer. In a study of 248 HIV-positive children in South India, 55% were underweight, 46% were stunted and 66% were anaemic. A study of 328 children with β-thalassemia major found that 48.2% were malnourished and that malnutrition was associated with poorer quality-of-life scores. Among 690 children with cancer studied at an Indian tertiary cancer centre, approximately one-third were undernourished depending on the anthropometric measure used. More recent evidence from Tata Memorial Centre further demonstrates the importance of nutritional status during childhood cancer treatment.

This article argues that nutrition must therefore be understood not as an ancillary welfare intervention, but as an integral component of holistic paediatric care. For children with serious illnesses, ensuring adequate nutrition is simultaneously an investment in physical health, growth, dignity, participation and quality of life. The experience of Happy Feet Home Foundation illustrates how nutritional support can be embedded within a broader model of paediatric palliative and supportive care, particularly for children whose medical vulnerability intersects with socioeconomic disadvantage.

Every Child Has the Right to Nutrition

Nutrition is often discussed as though it were one component of a child’s wellbeing among many competing priorities. In reality, nutrition underpins many of the processes that make childhood possible: physical growth, immune function, cognitive development, energy, recovery from illness and participation in everyday life.

A child requires adequate nutrition not simply to avoid hunger, but to grow.

This is why nutrition is fundamentally a rights issue.

The United Nations Convention on the Rights of the Child (UNCRC), adopted in 1989, recognises the child’s right to the highest attainable standard of health. Article 24 specifically requires States to take measures to combat disease and malnutrition and refers to the provision of adequate nutritious food and clean drinking water. The Convention also recognises the importance of ensuring that parents and children have access to knowledge concerning child health and nutrition.

This framing is important.

Adequate food is not something a child should receive only when a family can afford it, when an organisation has resources available, or when a child is considered sufficiently healthy to benefit from it. Nutrition is part of the conditions necessary for a child to exercise their broader rights to health, development and dignity.

The implications become particularly profound when the child is living with a life-threatening or life-limiting illness.

Such a child is simultaneously experiencing two realities: they are a child with the same developmental and nutritional requirements as any other child, and they are a child whose body may be coping with chronic disease, recurrent infection, treatment toxicity, inflammation, anaemia, pain, fatigue or other physiological stresses.

The nutritional needs of the child therefore do not disappear because of illness.

In many circumstances, they become more important.

India’s Nutrition Landscape: Progress alongside Persistent Inequality

India’s nutritional trajectory over the last decade presents a complex picture.

There has been measurable progress. Between NFHS-4 (2015–16) and NFHS-5 (2019–21), the prevalence of stunting among children under five declined from 38.4% to 35.5%; wasting declined from 21.0% to 19.3%; and underweight declined from 35.8% to 32.1%.

These improvements matter. They demonstrate that nutritional outcomes can change and that public policy and nutrition programmes can make a difference.

However, the remaining burden is considerable.

According to NFHS-5:

In other words, more than one in three young children in India were affected by stunting, while almost one in five experienced wasting.

The Government of India itself recognises that malnutrition increases children’s vulnerability to morbidity and mortality by reducing resistance to infections.

The burden of anaemia

The situation becomes even more concerning when micronutrient-related malnutrition is considered.

NFHS-5 reported that 67.1% of children aged 6–59 months were anaemic, compared with 58.6% in NFHS-4.

This represents an increase rather than an improvement.

Anaemia is especially significant in the context of children living with haematological conditions. A child who already experiences impaired haemoglobin production, repeated blood loss or chronic disease-related fatigue may have nutritional vulnerabilities that compound their existing physiological burden.

Nutrition therefore has to be understood in terms broader than calories alone.

The World Health Organization defines malnutrition as encompassing undernutrition—including wasting, stunting and underweight—as well as micronutrient-related malnutrition and overnutrition.

A child can therefore be eating regularly and still be nutritionally vulnerable.

The quality, diversity, quantity and bioavailability of food matter.

Nutrition Is More Than the Absence of Hunger

One of the most important distinctions in understanding child nutrition is the difference between being fed and being adequately nourished.

Food provides energy, but children also require protein, essential fatty acids, vitamins and minerals for tissue formation, immune function, neurological development and physiological regulation.

The World Health Organization identifies stunting as a marker of the cumulative effects of undernutrition and infections, while wasting generally reflects more acute nutritional deprivation and/or illness.

Consequently, nutrition must be assessed over time.

For a growing child, inadequate nutrition may manifest as:

These consequences are significant for any child.

For a child living with serious illness, they may be considerably more consequential.

When Illness and Malnutrition Intersect

Serious childhood illness does not exist independently of nutrition.

The relationship between disease and nutrition is often bidirectional.

Illness can increase nutritional vulnerability, while poor nutritional status can reduce the child’s physiological resilience.

The pathways differ according to the disease, but can include:

Disease → altered metabolism → increased nutritional requirements

Treatment → nausea, vomiting, mucositis, appetite changes or gastrointestinal symptoms → reduced intake

Repeated infection → increased physiological stress → nutritional depletion

Hospitalisation → disruption of routines and feeding → reduced intake

Poverty → food insecurity → inadequate dietary quality

These pathways can overlap.

A child with a life-limiting illness may therefore experience nutritional vulnerability through both biological mechanisms and social circumstances.

This is why the nutritional needs of these children cannot be addressed simply through a generic recommendation to “eat a balanced diet.”

The child may require nutritional assessment, monitoring, supplementation or additional food support depending on their individual circumstances.

HIV and Nutrition: A Particularly Strong Relationship

The relationship between HIV and nutrition is one of the clearest examples of the interaction between serious illness and nutritional status.

WHO states that weight loss and undernutrition are common among people living with HIV and can accelerate disease progression, increase morbidity and reduce survival. In children living with HIV, growth impairment may occur even before opportunistic infections or other obvious symptoms become apparent.

WHO therefore recommends that nutritional assessment and support be integrated into the routine care of children living with HIV, with attention to food security, food quantity, food quality, digestion and absorption.

The Indian evidence reinforces this concern.

A study of 248 HIV-infected children aged 1–12 years attending three outpatient clinics in South India found:

Importantly, anaemia was significantly associated with poor growth and advanced HIV disease. Children with stunting were also more likely to have anaemia.

Another Indian study involving 77 HIV-positive children found even broader nutritional vulnerability:

The researchers concluded that acute and chronic malnutrition and micronutrient deficiencies were common and recommended integrating nutritional care into HIV care strategies.

These findings illustrate an important principle:

For children living with HIV, nutrition is not separate from treatment. It is part of comprehensive treatment and care.

WHO’s guidance similarly emphasises that food security, food quantity, food quality, digestion and absorption all need to be considered when developing a nutritional care plan.

Thalassemia: Supporting a Child Through a Lifelong Disease

Thalassemia provides another compelling example.

Unlike an acute illness, thalassemia major can require lifelong medical management, including regular blood transfusions and iron chelation. The child’s nutritional needs must therefore be considered over years rather than only during periods of acute illness.

An Indian hospital-based study of 328 children with β-thalassemia major found that 48.2% were malnourished. All children classified as malnourished were underweight.

The study also identified several factors associated with malnutrition, including age, blood-transfusion frequency, spleen size, caste and maternal education.

Most importantly, malnutrition was not merely a number on a growth chart.

It was associated with poorer quality of life, including differences in physical and emotional domains.

This is an important shift in how nutritional status should be understood.

The objective is not simply to ensure that the child’s weight reaches an expected range.

The objective is to enable the child to live better.

For children living with chronic illnesses, growth, strength, mobility, energy and participation are themselves meaningful outcomes.

Childhood Cancer: Nutrition During Treatment

Cancer introduces another set of nutritional challenges.

The disease itself can alter metabolism, while treatment may produce nausea, vomiting, mucositis, changes in taste, gastrointestinal problems, appetite loss and fatigue. These symptoms can interfere directly with food intake.

Indian evidence demonstrates that nutritional vulnerability is already substantial at diagnosis.

A study of 690 children with cancer at an Indian tertiary cancer centre found:

The authors concluded that approximately one-third of children with cancer were malnourished, with particularly high wasting among children under five.

Another Indian study involving 1,187 children with cancer with complete anthropometric measurements found malnutrition prevalence ranging from approximately 38% to 81%, depending on the anthropometric measure used. The researchers argued for nutritional screening at diagnosis so that nutritional intervention could be initiated early.

New evidence from Mumbai

More recent evidence makes this argument even stronger.

A 2026 real-world study from Tata Memorial Centre, Mumbai, examined nutritional status among more than 2,000 children with cancer. At diagnosis, 65.3% were classified as undernourished using the study’s nutritional criteria. At six months, 52.2% remained undernourished.

The study also found that nutritional status changed during treatment: 45.5% of children gained weight, while 11.6% lost weight. Importantly, children who gained weight during follow-up had better two-year event-free survival than those who did not gain weight.

This study does not, by itself, prove that nutritional intervention causes improved survival. However, it adds important evidence to the growing understanding that nutritional trajectory during cancer treatment matters.

The implication for care is therefore clear:

Nutritional status should not be measured once at diagnosis and forgotten.

It needs to be monitored throughout the child’s treatment journey.

Nutrition, Haematological Illness and the Problem of Compounding Vulnerability

HIV, thalassemia and cancer are different diseases. Their nutritional pathways are not identical, and it would be scientifically inappropriate to treat them as though they were.

What they share, however, is the possibility of compounding vulnerability.

A child may already be experiencing:

When inadequate nutrition is added to this picture, the child faces another potential barrier to health and participation.

This is particularly important in low-income households.

For a family living on irregular or daily wages, caring for a seriously ill child may involve a combination of lost income, transport expenses, hospital-related expenditure and additional caregiving responsibilities.

Food is then competing with other essential household expenses.

The nutritional vulnerability of the child is consequently not always the result of caregivers failing to understand what the child needs.

Sometimes the family simply cannot afford what the child needs.

This distinction is essential.

Nutritional insecurity must not be framed as an individual failure of parents or caregivers. It can be a structural consequence of poverty, illness and unequal access to resources.

Why Nutrition Belongs Within Paediatric Palliative Care

Paediatric palliative care is fundamentally concerned with improving the quality of life of children living with serious illnesses and supporting their families.

This requires a holistic understanding of the child.

The child is not only a diagnosis.

They are a growing human being with physical, emotional, social and developmental needs.

Nutrition sits at the intersection of all of these dimensions.

Physically, adequate nutrition supports growth and strength.

Psychologically, food can provide comfort, pleasure and routine.

Socially, eating is an important part of family and community life.

Developmentally, adequate nutrition supports the child’s capacity to learn, play and participate.

In palliative care, the goal is therefore not necessarily to “correct” every nutritional abnormality at any cost. Nutritional care should remain individualised and aligned with the child’s clinical condition, goals and comfort.

This distinction is important.

Nutrition in palliative care is not about forcing a child to eat.

It is about asking:

What does this child need nutritionally, what is possible for them to consume, what gives them comfort and dignity, and how can we reduce avoidable nutritional suffering?

From Food Provision to Nutritional Care

This understanding changes how organisations working with vulnerable children should approach nutrition.

Providing a meal is valuable.

But nutritional care goes further.

It involves asking:

Such an approach recognises that food security and healthcare are interconnected.

WHO’s guidance for children living with HIV explicitly reflects this broader approach by recommending assessment of food security, food quantity and food quality alongside clinical nutritional status.

This principle has relevance beyond HIV.

For children with serious illnesses more broadly, nutritional care should be responsive to both the child’s body and the child’s circumstances.

Happy Feet Home Foundation: Making Nutrition Part of Care

It is within this evidence base that the approach of Happy Feet Home Foundation (HFH) can be understood.

HFH works with children and young people living with life-threatening and life-limiting illnesses, including HIV, thalassemia, cancer and other haematological conditions. Its model recognises that the consequences of serious childhood illness extend beyond medical symptoms and hospital treatment.

Nutrition is consequently incorporated as an active component of care.

At the Day Care Centre, children receive regular meals designed to provide nutritional value rather than merely calories. The food provided includes fruits, milk, eggs and salad, alongside protein-rich foods such as chicken and fish, according to the programme’s nutritional approach.

This is significant because the intervention is not based on the assumption that all children arrive with the same nutritional needs.

Children come from different households, with different medical conditions, different treatment histories and different levels of food security.

Nutrition therefore needs to remain responsive and need-based.

HFH also extends nutritional support beyond the Day Care Centre through need-based ration support for children receiving home-based care. This recognises an important reality: a child does not stop being nutritionally vulnerable when they leave a hospital or programme centre.

For families experiencing economic hardship, a nutritional intervention can help bridge the gap between the child’s nutritional requirements and the household’s capacity to consistently provide them.

Nutrition as a Matter of Dignity

There is another dimension of nutritional support that is difficult to capture through anthropometric measurements alone.

A seriously ill child already experiences a childhood shaped by uncertainty.

There may be hospital appointments instead of school.

Medical procedures instead of play.

Medication instead of routine.

Pain instead of physical freedom.

For such a child, food can be one of the ordinary experiences of childhood that remains possible.

A nutritious meal can nourish the body, but it can also provide routine, pleasure and a sense of normalcy.

This does not mean romanticising food or suggesting that nutrition can compensate for the profound difficulties associated with serious illness. Rather, it means recognising that quality of life is made up of ordinary experiences as well as clinical outcomes.

A child’s care should therefore ask not only:

How do we treat the disease?

but also:

How do we help this child live as well as possible while living with the disease?

Nutrition is part of that answer.

The Larger Argument: Nutrition Is Not an Add-On

The evidence across child nutrition, HIV, thalassemia and childhood cancer points towards a common conclusion.

Nutrition is foundational to childhood.

For the general population, India continues to face a substantial burden of undernutrition and anaemia despite measurable progress. For children living with serious illnesses, disease and treatment can create additional nutritional vulnerabilities. Indian studies demonstrate high levels of malnutrition among children with HIV, thalassemia and cancer, while emerging evidence suggests that nutritional status and changes in nutritional status may be associated with important clinical outcomes.

This does not mean that nutrition alone determines whether a child recovers, survives or experiences a particular clinical outcome.

It means something more fundamental:

Nutrition is one of the conditions that makes health, growth and quality of life possible.

Consequently, nutritional support should not be positioned as a charitable addition to medical care.

It should be positioned as part of holistic child care.

For children living with life-threatening and life-limiting illnesses, this becomes particularly urgent.

The child’s illness may be unavoidable.

The child’s medical vulnerability may be unavoidable.

But nutritional deprivation should not automatically become another unavoidable consequence.

Conclusion

Every child has the right to adequate nutrition.

This right does not become less important when a child becomes seriously ill. If anything, the evidence suggests that nutritional care may become more complex and more consequential.

India has made progress. Stunting, wasting and underweight have declined since NFHS-4. Yet the persistence of high levels of undernutrition and the increase in childhood anaemia demonstrate that nutritional insecurity remains a significant public health challenge.

For children living with serious illnesses, the challenge is compounded.

Indian research has documented high levels of underweight, stunting and anaemia among children living with HIV; almost half of children with β-thalassemia major in one Indian study were malnourished; and substantial nutritional vulnerability has been documented among children with cancer. Recent evidence from Tata Memorial Centre further highlights the importance of monitoring nutritional status throughout cancer treatment.

These findings make a compelling case for moving away from a narrow understanding of nutrition as food distribution.

Nutrition is care.

It is preventive care.

It is supportive care.

It is, in many circumstances, palliative care.

And it is a matter of children’s rights and dignity.

The experience of Happy Feet Home Foundation demonstrates how this principle can be translated into practice: by making nutritious food available at the Day Care Centre, responding to nutritional needs within home-based care, and recognising that a child’s health cannot be separated from the family’s social and economic circumstances.

Ultimately, caring for a child living with a life-threatening or life-limiting illness means caring for more than the disease.

It means caring for the child.

And caring for the child means ensuring that, for as long as possible, they have the nourishment, strength, comfort and dignity required to experience childhood—not merely survive illness.

References/ Core Evidence Base