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Reproductive Health Package CSR PFI Section II Child Health

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Reproductive Health Package CSR PFI Section II Child Health

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Section II

Child Health

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Section II

CHILD HEALTH

Neonatal Care

Immunization

Child Nutrition

Acute Respiratory Infection

Diarrhoea

Fever

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chapter 7

NEONATAL CARE

A neonate is an infant less than four weeks old. Neonatal mortality rate (NMR) is the ratio of deaths

in the first 28 days of life to 1000 live births occurring in a given population in a given period of

time. Three-fourths of newborn deaths occur in the first week of life.

Nearly 5 million neonates die each year world wide, 98 per cent of them in developing countries.

NMR varies from 5 in developed countries to 53 in the least developed countries. While infant

mortality has been decreasing steadily all over the world, changes in neonatal mortality have been

much slower. Immunization, oral rehydration, and control of acute respiratory infections have reduced

the post-neonatal component of infant mortality rate (IMR). Hence, neonatal mortality now constitutes

61 per cent of infant mortality and nearly half of child mortality in developing countries.

India contributes 2.4 million of the global burden of 10.8 million under-5 child deaths, which is the

highest for any nation in the world. Nearly 26 million infants are born each year, of whom 1.2 million

die as neonates and 1.7 million before reaching the first birthday. Over three-fourths of neonatal

deaths occur among low-birth-weight infants (weighing less that 2500 gm at birth). In India, one-third

of neonates are low birth weight (LBW).

Neonatal mortality has declined significantly in India since the 1970s largely due to maternal tetanus

toxoid (TT) immunization leading to near elimination of neonatal tetanus and also due to the gradual

increase in deliveries at institutions and by skilled attendants. There is a clear relationship between

the proportion of non-institutional deliveries and NMR.

Currently, only 40.7 per cent births in India occur in institutions. The proportion of home births in

rural areas is 75 per cent and among the poor families is 80 per cent. This aspect brings into focus,

once again, the need for education and increase the awareness of communities about the importance

of institutional delivery. At the same time, healthcare facilities for neonates are inaccessible for people

in remote areas. The quality of care offered in many hospitals is also below standard.

Cultural distance also matters. Some beliefs and practices with regard to neonates and their ailments

can cause neonatal deaths at home. In India, the estimated cost of hospital-based neonatal care is high

relative to the household income. As a result, people prefer to have another baby to paying the high

cost of hospital treatment. It is seen from available statistics that there is a wide variation in neonatal

mortality and child mortality in different Indian states. Some of the statistics for NMR are: Kerala

10/1000; Tamil Nadu 36/1000; West Bengal 31/1000; Maharashtra 33/1000; Gujarat 41/1000; Bihar

42/1000; Rajasthan 49/1000; Madhya Pradesh 59/1000. This wide variation could be an indicator of

cultural practices of new-born healthcare prevailing in different regions. This also points to the need

to document the cultural practices and to study if there is any relation between cultural practices and

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neonatal mortality. As a corollary to acknowledging cultural distances, to reduce neonatal mortality,

ways to provide neonatal care at home must be developed.

Prominent Causes of Neonate Mortality

The causes of neonatal mortality in India are: bacterial infections (52 per cent), asphyxia (20 per cent),

premature birth (15 per cent), and other causes including neonatal tetanus (13 per cent).

Neonate deaths in the first week are predominantly caused by birth asphyxia and premature birth,

whereas those after the first week are mostly due to bacterial infections.

The higher the home delivery rate, the higher is the neonatal mortality rate. Thus, the challenge of

improving new-born health is really in the home setting.

Asphyxia is lack of exchange of oxygen and carbon dioxide due to respiratory failure or disturbance,

resulting in insufficient brain oxygen, which leads to unconsciousness or death. During delivery the

neonate suffocates inside the reproductive tract and cannot breathe after birth. This can lead to serious

brain damage and can be fatal. In asphyxia the care-giver needs to blow little puffs of air into the

neonate’s throat.

Hypoxia generally refers to lack of oxygen in any part

of the body. This disorder of breathing in the new-

born period arises because of failure of normal cardio-

pulmonary adaptation.

Hypothermia, a potentially fatal condition occurs when

body temperature falls below 95°F (35°C). Premature

deliveries and low-birth-weight infants generally suffer

from hypothermia. The infant should be wrapped in a

blanket and breast-fed till she/he gains weight.

Table 7.1 presents the indications for early diagnosis of neonatal illness. Table 7.2 lists neonatal

ailments and their treatment. Table 7.3 lists essential neonate interventions.

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Table 7.3. Essential New-born Interventions

Basic Care of New-born born Well

Equipped to Survive

• Wrap in a cloth

• Prevent infections due to uncleanliness

at birth and later

• Exclusive and frequent breast-feeding

• Do not give bath for a week

• Avoid applying kohl/kajal into the

eyes; do not apply vermilion/ash/oil

on the wound of cord. Do not apply

oil in ears

Special Care for Premature or Low-birth-

weight Infants

• Early recognition and management of

new-born diseases

• Management of hypothermia

• Eye care: prevention and management of

ophthalmia neonatorum

• Initiation of breathing by resuscitation

when needed

New Trends in Thinking

Maternal and new-born health are linked. A pregnant woman who receives good antenatal care is more

likely to deliver a healthy baby. Besides nutrition and consumption of iron-folic acid tablets, antenatal

care includes awareness about institutional delivery, referral and transport services, emergency obstetric

care, etc. The new trend in maternal and new-born health has been developed into three major

sections, as follows: (i) in home deliveries, home-based neonatal care should be provided; (ii) in

institutional deliveries, referral and transport services should be available; (iii) family-based new-born

care.

What the Corporate Sector Can Do

New-born deaths cannot be reduced substantially without efforts to reduce maternal deaths and

improve maternal health. Maternal and neonatal health models can be developed to show the linkages

between the two. However, care during pregnancy and delivery must be accompanied by appropriate

care of new-borns and measures to reduce new-born deaths due to post-natal causes such as infections

(tetanus, sepsis), hypothermia and asphyxia.

Additionally, programmes need to focus on:

• Providing antenatal care with stress on nutrition, intake of IFA, regular check-ups;

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• increasing the number of quality institutional deliveries by creating awareness in the community

and accountability in the health system;

• providing necessary health facilities in all the health centres free of cost;

• making women aware about the need for trained birth attendants in home deliveries;

• making referral facility and transport available in case of emergency;

• making women aware about new-born care after understanding their cultural values attached to

neonatal care

• developing neonatal care services at community/village level.

References

Bang, A. et al., 1990. “Reduction in pneumonia mortality and total childhood mortality by means

of community based intervention trial in Gadchiroli, India”, The Lancet, vol. 336.

Bang, A. et al., 1994. “Management of childhood pneumonia by traditional birth attendants”, WHO

Bulletin OMS, Vol. 72.

Ministry of Health and Family Welfare, Government of India, “RCH-Phase II: National Programme

Implementation Plan”.

VHAI, 2001. “Where Women Have No Doctor : A Resource Guide for Women’s Health”,

Chapter 6. Pregnancy and Childbirth, New Delhi : Voluntary Health Association of India.

WHO, Geneva, “Safe Motherhood, Maternal Health and Safe Motherhood Programme, Division of

Family Health”.

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chapter 8

IMMUNIZATION

Immunization is a cost-effective health intervention which ensures child survival, prevents disability,

and helps reduce poverty and improve economic development. Immunization can save more lives for

the money invested than any other health intervention available today for the child. Immunization is

carried out against six vaccine-preventable diseases (VPDs) in India (tuberculosis, poliomyelitis, diphtheria,

pertussis, tetanus and measles) under the Universal Immunization Programme (UIP). Hepatitis-B is

also incorporated in some selected areas. Immunization is often the only healthcare intervention

carried out in the infant’s first year of life.

In India vaccine has been used since the mid-1900s for smallpox. Smallpox eradication in the 1970s

brought increased interest in the possibility of vaccination on a large scale to eradicate, control or

eliminate certain diseases. The foundation was thereby laid for the Expanded Programme on

Immunization (EPI) in 1978. EPI vaccines (DPT, OPV, BCG) were to be given by the first birthday.

TT for pregnant women was introduced in 1983. EPI gave way to UIP in 1985, with measles vaccine

added in the programme. Vitamin A was added as a supplement in 1990. UIP achieved national

coverage in 1990. Currently, a child is considered to be fully immunized if BCG, three doses of OPV

and DPT and measles are provided before the child reaches its first birthday.

Management of Vaccine-preventable Diseases

The following vaccine-preventable diseases require reporting to the government machinery at the

earliest, so as to prevent large-scale epidemics.

Poliomyelitis: The child develops sudden flaccid, asymmetric, paralysis of one or more limbs which

is not accompanied by any sensory loss. The clinical syndrome is called acute flaccid paralysis (AFP).

The mother is advised not to take any more intra-muscular injections and the child must be taken to

the hospital. A surveillance form needs to be filled and district-level staff in the government is

informed. Stool sample from the patient is collected. Polio immunization is arranged in the area

immediately surrounding the case.

Measles: There is usually three to five days of fever, red eyes, cough and cold, followed by rash that

starts on the face and spreads downwards. The rash usually disappears in three to four days, leaving

a brownish desquamation of skin. A case of measles is to be reported. Measles immunization for all

under-5 children in the area is to be organized.

Diphtheria occurs fairly rarely. It is characterized by a chronic cough and breathing difficulty. Examination

reveals a membrane-like structure in the throat. This can even cause obstruction and death. Diphtheria

is a medical emergency and requires immediate referral.

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Pertussis is typically present with a hacking cough, which finally ends with a whoop, therefore it is

also called whooping-cough.

Tetanus results when the tetanus bacteria infect a wound or cut. Neonatal tetanus occurs after an

unclean delivery. The neonate initially will present with poor feeding and umbilical infection but later

will develop the characteristic spasms and arching of the back. Adult tetanus is characterized by severe

spasm of the muscles of the face, limbs and back. The slightest movement triggers the spasm.

Hepatitis is characterized by fever, jaundice, nausea and vomiting. Hepatitis A spreads through

drinking contaminated water and is self-limiting. Hepatitis B is a dangerous variety of jaundice that

spreads through transfusion of infected blood, from infected mother to the child, contaminated

needles and syringes and through unprotected sex. Hepatitis B is diagnosed by testing the blood.

Tuberculosis presents one or more of the following symptoms for more than two weeks: (a) cough

with expectoration; (b) evening rise of fever; (c) loss of weight; (d) loss of appetite; (e) coughing out

blood (hemoptysis). Diagnosis is confirmed by examination of sputum for the tuberculosis germs.

Immunization Schedule

The immunization schedule followed in the country is

given in Table 8.1.

• Among adolescents tetanus toxoid is given at 10

and 16 years. A girl who has received the entire

schedule needs only one TT injection during her

pregnancy

• Measles need not be given if MMR (measles,

mumps, rubella) is available but if there is a

chance of the child getting measles before giving

MMR, the child must be given measles

vaccination and later on MMR.

• Haemophilus Influenzae type B (HIB) can be given along with Hepatitis B and DPT vaccines.

Some other vaccinations that can also be carried out are :

• The first dose of Varicella should be administered at 12–18 months and the second dose at age

4–6 years.

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• Two doses of Hep A six months apart are recommended for all children aged one year.

• All children aged 6–59 months and close contacts of all children aged 0–59 months are

recommended to receive influenzae vaccine.

• Administer PCV (pneumococcal conjugate vaccine) at ages 24–59 months in certain high-risk

groups.

Cold Chain Management

Cold chain is the process by which vaccines are

transported from the manufacturer to the point of

delivery at a constant recommended temperature.

Breakdown in the temperature at any point in

between compromises the potency of the vaccine.

The main components of the cold chain management

are:

Ice-lined Refrigerator. It maintains the temperature

at +2 to +8 degrees Celsius. It has several rows of

ice packs and a thermostat. It requires regular defrosting. All UIP vaccines are stored in this refrigerator.

Deep Freezer maintains a temperature of –18 to –20 degrees Celsius. Deep freezers are used for

making ice packs to be used in transportation of vaccine from the point of storage to the point of

use. During pulse polio immunization campaigns, OPV is stored in deep freezers.

Vaccine Carriers have two or four packs of ice. They are used for transporting vaccines from the point

of storage to the point of use. The “conditioned” ice packs provide for maintenance of the cold chain

for approximately six to eight hours, depending upon the surrounding temperature and opening of the

lid of the vaccine carrier.

Equipment for the delivery of Immunization Services

It was assessed in light of experience that since the sterilization equipment was not used according

to the norms, there were many cases of injection abscesses and blood-borne diseases, mostly under-

reported. These were hampering the progress of the immunization programme. Even after disposable

syringes replaced glass syringes, the issue was not addressed, primarily due to pilferage and reuse. A

study by IPEN found that 62.9 per cent of the injections given in India were unsafe, with 31.6 per

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cent carrying the chance of transmitting blood-borne infections. These issues became global. Thereafter,

a joint WHO-UNFPA-UNICEF statement in 2001 recommended that all immunization activities be

carried out with auto disable (AD) syringes universally by 2003. AD syringes lock after delivering the

required dose of vaccine. The immunization programme in India started converting to AD syringes

from 2005.

Waste Management

Most injuries, and thereby transmission of diseases, occur at the point of use, handling and disposal.

Lack of correct materials for collection of sharps could result in unsafe injections. Mishandling of used

sharps could lead to major disasters in healthcare settings. The AD syringe, for example, needs to be

cut at the point of generation, using the hub cutter. The cut sharps need to be disposed according

to the norms laid down by the Central Pollution Control Board.

Immunization waste management requires both expertise and professional integrity. The following

guidelines need to be followed in waste disposal:

• Use proper equipment.

• Correct faulty techniques by incorporating new and advanced knowledge.

• Keep abreast of new findings by regular training of healthcare workers.

• IEC/BCC materials to change the attitude of the beneficiaries.

• Proper waste management.

• Regular review of all guidelines, including waste management.

• Ensure adherence to such guidelines.

Monitoring the Programme

Monitoring is of utmost importance to maintain the quality of the vaccination programme. Some of

the monitoring indicators for quality include:

• Treating of beneficiaries with comfort and care.

• Availability of waste disposal mechanisms (hub cutters, sharps collectors) and proper disposal

according to the Central Pollution Control Board (CPCB) norms.

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• Availability and quality of personnel delivering the vaccination.

• Maintenance of the cold chain according to the norms.

• Availability of vaccines, AD syringes and reconstitution syringes according to the requirements.

• Ensuring vaccines available are in good quality.

• Adequate information, education, communication and behaviour change communication materials

and their delivery to the beneficiaries.

Profile of Deliverers of Immunization

To be acceptable to the community receiving the vaccinations, the immunization providers should:

• empathize with the beneficiaries;

• give four key messages: (a) what vaccine has been given, what are the possible reactions to it,

and what to do if reaction happens; (b) when is the next date of visit; (c) information on adverse

events following immunization; and (d) advice to bring the immunization card at the next visit;

• be in a position to address other healthcare requirements of the community;

• be a link between the needs and wants of the community and the delivery of such services by

the healthcare authorities;

• be in a position to track all beneficiaries and reach those who have dropped out of the

vaccination programme.

Several categories of personnel are available for the purpose in the public healthcare delivery:

• ANM (Auxiliary Nurse Midwife) is trained in various aspects of healthcare delivery, including

maternal and childcare and immunization.

• LHV (Lady Health Visitor) is an ANM who has been promoted based on her years of service.

She supervises the work of the ANM and also delivers immunization services.

• PHN (Public Health Nurse) is also a trained nurse who can deliver basic healthcare, including

maternal and child health.

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Points to note while Storing Vaccines and

Conducting an Immunization Session

• The vaccines need to be kept between +2°C and +8°C during transport from the depot to the

site.

• The refrigerator/deep freeze is to be kept between +2°C and +8°C.

• There should be a thermometer placed inside the refrigerator/deep freeze.

• A register/pad is kept with the refrigerator/deep freeze to monitor the temperature morning and

evening everyday.

• There should be a provision of power back-up (generator) to take care of power cuts.

• The vaccines need to be stored in the right racks of the refrigerator.

• The vaccines are always to be carried to the field in the vaccine carriers.

• Ice packs should be available to put in the vaccine carrier.

• Expired vaccines need to be removed from the refrigerator.

• Partly used vaccines are never to be kept in the refrigerator.

• Vaccines should not be stored for more than one month in the refrigerator.

• No food or drinks are to be kept in the vaccine refrigerator.

• There should be four ice-packs in each vaccine carrier when taken to the field.

• The list of the eligible children/women who need to be immunized during the next session is

to be drawn up well in advance.

• The list of number of doses of BCG, DPT, OPV, TT and measles needed for the next immunization

session should be ready well in advance.

• Parents/family members/women should be informed about the date, time and place where

immunization will be given.

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• There should be at least one set of sterile needle and syringes for each person and enough cotton

and saline.

• A needle-cutter should be there along with the containers to put the waste materials.

• A short (10 minutes) health education session (preferably on side-effects like fever, swelling,

etc., VPD, and their management or nutrition) can be organized before actually giving the

vaccine.

• The vaccine carrier is not to be opened till the team is ready to administer the vaccine.

• Vaccines are never to be kept outside the vaccine carrier.

For polio vaccine the vaccine vial monitor (VVM) is to be checked for colour change before administering.

In case of change of colour it is to be discarded.

The relevant information is to be entered in every client-retained card and the health workers’ register.

Reference

Material Adapted from Centre of Disease Control (CDC).

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chapter 9

CHILD NUTRITION

Malnutrition during early childhood can result in short- and long-term consequences such as poor

brain development, poor growth and muscle mass as well as chronic degenerative disorders in the later

part of adulthood. Undernutrition is implicated in 60 per cent of all under-5 deaths (see Figure 9.1).

Figure 9.1. Global Distribution of Cause-specific Mortality in Children under 5

India has a high prevalence – higher than even sub-Saharan Africa – of various forms of malnutrition,

namely, wasting (low weight for height – thinness), stunting (low height for age – shortness) and

underweight (low weight for age). India has more than 61 million stunted children, which accounts

for 34 per cent of the global total. While there has been a marginal reduction in stunting (6 per cent)

and underweight (3 per cent), an increase in wasting and underweight (3 per cent) has been observed

between 1999 and 2005.

India also has 79.2 per cent prevalence of various forms of anaemia. A decline of 5 per cent in various

forms has been observed during 1999–2005 while the prevalence of severe anaemia has increased by

1 per cent. Vitamin A deficiency continues to be a problem of public health significance among pre-

school children, with prevalence of Bitot spots (an objective sign of Vitamin A deficiency) being equal

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to or more than the WHO cut-off level of 0.5 per cent. Not even a single state/Union territory is free

of iodine deficiency disorders (IDD). Sample surveys conducted in 28 states and 7 Union territories

have revealed that out of 324 districts surveyed, 263 are IDD endemic. i.e., the prevalence of IDD

is above 10 per cent. India is among the nations with high risk for zinc deficiency for under-5

children. India alone has 0.6 million deaths and 24.6 disability adjusted life years (DALYs) attributed

to stunting, severe wasting and low birth weight. One DALY can be regarded as roughly one lost year

of so-called healthy life. Among the deficiencies of vitamins and minerals the largest disease burden

was attributed to Vitamin A and zinc deficiency.

Nutrients are of two kinds. Macro-nutrients refer to carbohydrate, fat and protein. Micro-nutrients

primarily refer to the fat-soluble vitamins (A, D, E and K), water-soluble vitamins (B complex and C)

and minerals that are required in small quantities but have important functions to perform. See Table

9.1 for some important micro-nutrients.

Table 9.1. Some Important Micro-nutrients

Nutrient

Functions

Vitamin A

anti-oxidant (protects cell membrane), growth, vision

Vitamin D

calcification of bones

Vitamin E

anti-oxidant and anti-ageing factor

Vitamin K

coagulation of blood

Vitamin B complex release of energy from carbohydrates, normal nerve functioning

Vitamin C

healthy and strong blood vessels, gums, anti-oxidant

Calcium

strength to bones and teeth, coagulation of blood

Iron

carrier of oxygen to each cell, part of enzymes in brain

Iodine

normal functioning of thyroid, which controls energy metabolism and

cognitive development during the pre-natal stage

Zinc

immunity, foetal growth, neuro-motor development

Food security refers both to (i) availability of food and (ii) access to it. Increase in food production

alone cannot address the problem of chronic micro-nutrient deficiency, also known as hidden hunger.

Nutrition security requires food diversification in order to meet the requirements of micro-nutrients

such as vitamins, minerals, and health-promoting phytochemicals.

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The risk of mortality from all causes (pneumonia, diarrhoea, malaria and measles) increases with

increase in the severity of various forms of under-nutrition. Vitamin A deficiency, besides causing

disability, is also associated with morbidity and mortality. Stunting is one of the clinical manifestations

of zinc deficiency, along with an increased risk of morbidities such as diarrhoea, pneumonia and

malaria. Mild or sub-clinical maternal iodine deficiency during pregnancy impairs motor and mental

development of the foetus. The resulting inter-generational effects are also observed. The population

with chronic iodine deficiency has a 13.5 point reduction in IQ. Other micro-nutrients of significance

are iron, folic acid, and vitamin B12, the lack of which is associated with stunting and poor neuro-

cognitive functions.

Deficiency of macro-nutrients leads to underweight, wasting (thinness) and stunting. Anthropometry

(measurement of body parts) is the simplest method to assess the nutritional status of an individual.

The most commonly used parameters are weight and height and indices using a combination of the

two. The height and weight of the healthy population is used as the reference standard (generally 50th

percentile of NCHS standards) and the subjects are classified into various grades of malnutrition using

a designated percentage of the median value of the reference standard. A deficit in weight for age

denotes wasting, which is short-term malnutrition. A deficit in height for age denotes stunting, which

is long-term malnutrition. A deficit in weight for height denotes wasting and stunting. Table 9.2

presents the modes of managing various grades of malnutrition.

Breast-feeding and Complementary Feeding

Exclusive breast-feeding for the first six months can

cut down about 15 per cent of all child deaths (Lancet

2003). Ensuring initiation of breast-feeding within one

hour could cut 22 per cent of neonatal mortality. This

effect was seen independent of exclusivity of breast-

feeding. Which means that in India, if all mothers

were enabled to initiate breast-feeding within the first

hour, about 250,000 neonate deaths could be saved.

Early initiation of breast-feeding ensures:

• colostrum feeding, which is full of

immunoglobulins and provides immunity to the neonate, and

• prevents the undesirable practice of giving pre-lacteals like ghutti and honey water, which can

cause infection.

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Table 9.2. Management of Various Grades of Malnutrition

Grade of

malnutrition or

Nutritional

Grade

Normal

Grade I

Grade II

Grade III

Grade IV

% of Median

Value of

NCHS

Management

< 80%

70–80%

60–70%

50–60%

<50%

Growth monitoring

Growth monitoring, advise frequent feeding with safe

nutritious food

Growth monitoring, advise frequent feeding with safe

nutritious food, attend to minor illnesses promptly

Admit into a nutrition rehabilitation centre or hospital as

hypothermia, hypoglycaemia and septic shock are common

and may require close monitoring of electrolyte levels,

intravenous drip, nasogastric tube feeding. Gradually give

nutrient-rich foods (75 kcal/100g and 1–1.5 gm protein per

kg body weight) every two hours. Appropriate dose of vitamin

A orally or intramuscularly, zinc, folic acid. As weight gain

commences and in absence of diarrhoea, 3 mg iron per kg

of body weight per day. If good weight gain occurs (10g/kg/

day), continue with the treatment. Discharge if absence of

infection, eating well, normal weight gain and no oedema.

Appropriate advice on nutrition and immunization to be

given to the care-givers.

After the age of six months complementary foods need

to be introduced along with sustained breast-feeding.

The important points to remember in complementary

feeding are:

• Frequency of feeding – an infant needs to be fed

five to six times in a day.

• Energy density of complementary foods – cereal-

based porridge has high starch content, which is

unsuitable for child feeding. Adding water to it

dilutes its energy density, which also is

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undesirable. A solution is to incorporate fats and oils or sugar and jaggery which are energy-

dense. Alternatively, adding a small quantity (2–4 gm) of germinated cereal flour called amylase

rich food (ARF) liquefies the thick porridge by breaking down the starch present.

• Active feeding – A caring attitude while feeding the child ensures good appetite and development.

• Safety of complementary foods – The complementary foods should be prepared, handled and

stored hygienically to prevent infection and diarrhoeal morbidity.

The foods that can be given to an infant are:

• Staple of the family, namely rice and wheat as

porridge, soft cooked dal and rice, mashed

chapati and dal/milk, soft cooked khichdi, etc.

with added sugar/jaggery and oil/ghee.

• Modified family food – the dal and vegetable

cooked for the family can be separated before

adding spices.

• Instant home-made infant foods – ready-to-reconstitute foods like sattu or roasted/malted mix

prepared from cereal, dal and nuts/oilseeds like til/groundnut.

Feeding a Sick Child

A sick child may be too weak to eat, have trouble swallowing, or find it difficult to breast-feed

because of a cough or blocked nose. Inefficient absorption of nutrients, loss of energy stores, and

dehydration due to vomiting or diarrhoea must be overcome. Even during a short illness, child growth

often falters.

During illness, continue feeding and increase the fluids. For a child under 6 months old, breast-feed

more frequently and longer at each feed. For a child 6–24 months old, (a) breast-feed more frequently

and longer at each feed, increase fluid intake, and offer food; (b) give frequent, small feeds; (c) give

nutrient-dense foods that are soft, varied, and the child’s favourite foods; (d) give mashed or soft foods

if the child has trouble swallowing (do not dilute foods or milk); (e) feed the child slowly and

patiently; encourage to eat but do not force.

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During recovery: (a) increase the amount of food until the child regains weight and is growing well;

(b) continue to feed frequently: give an extra meal every day or snacks; be responsive to the recovering

child’s increased hunger.

Micro-nutrient supplements also play a key role in nutrition during and after illness. Health providers

should follow the protocols for integrated management of childhood illnesses.

Key Messages

• Effective interventions are available to reduce stunting, micro-nutrient deficiencies and child

deaths. Effective implementation can reduce DALYs by a quarter in the short term.

• Counselling on exclusive breast-feeding for six months and fortification or supplementation with

Vitamin A and zinc has the greatest potential to reduce the burden of child morbidity and

mortality.

• Counselling is required to ensure timely introduction of appropriate, low cost, nutrient-dense

(home-available) complementary foods at six months. Improvement of complementary feeding

through counselling for food-secure populations and supplementation, fortification, dietary

diversification in food-insecure populations could substantially reduce the burden of stunting.

• Elimination of stunting will require long-term efforts and long-term investments to improve

education, economic status and empowerment of women.

Gaps

India has adequate infrastructure in the form of Integrated Child Development Services (ICDS) programme

and the school Mid Day Meal (MDM) programme. However, there are gaps in the existing nutrition-

related interventions, some of which are:

• There is no national system of nutrition monitoring, mapping and surveillance.

• Nutritional concerns are not adequately reflected in the policies and programmes of the government.

• Intersectoral coordination mechanism, crucial for nutrition promotion, is inadequate.

• ICDS coverage is not universal.

• Tribal areas, food-scarce districts, chronically drought-prone rural and tribal hamlets have

inadequate access to nutrition and health services.

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• Nutrition education and awareness generation is weak.

• Coverage of children under three years in Vitamin A prophylaxis programme is low.

• Iron-folic acid supplementation for pre-school children, adolescent girls, pregnant women and

lactating mothers is inadequate.

• Availability of iodized salt at household level has declined after the lifting of the ban on sale

of non-iodized salt in October 2000.

• Food fortification programmes are negligible. Supplementation, dietary diversification and

horticultural interventions are inadequate.

• Nutrition Programme for Adolescent Girls (NPAG) is only in fifty-one districts.

• Optimal infant and young child feeding practices (breast-feeding and complementary feeding)

need aggressive promotion.

Action Plan Required

• Repositioning of nutrition to make it an integral part of all the health and development programmes.

• Training programmes for health personnel should equip the trainees to address the problem of

malnutrition, low birth weight, nutritional deficiency disorders and issues concerning breast-

feeding, complementary feeding, nutrition and health education, etc.

• Convergence between implementing agencies, programmes and functionaries who have overlapping

objectives and target groups will amplify the impact of current programmes. For example, the

Department of Women and Child Development (DWCD) and the Department of Health and

Family Welfare (DHFW) have overlapping goals. Convergence at the village level appears integral

to the functions of both programmes. This can be achieved through the clarification of critical

objectives, detailing effective operational approaches, laying down clear roles and outcomes and

clear mechanisms for joint planning and monitoring, including common monitoring indicators.

• The National Rural Health Mission (NRHM) aims that preventive and promotive interventions

reach the vulnerable and marginalized through expanding outreach and linking with local

governance institutions. The key to the success of NRHM is inter-sectoral convergence, community

ownership steered through village health committees at the level of the Gram Panchayat, and

a strong public sector health system with support from the private sector. Intersectoral convergence

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in NRHM is visualized with drinking water, sanitation, hygiene and nutrition. An accredited

social health activist (ASHA) is expected to work with communities for social mobilization and

improve access to services. The anganwadi worker (AWW), schoolteacher, members of local

community-based organizations such as self-help groups (SHGs) and the village health committee

are expected to support the ASHA in her work. The district media officers under NRHM need

to be sensitized towards the problem of malnutrition, including micro-nutrient malnutrition, and

equipped to undertake nutrition orientation, awareness generation and IEC activities on various

nutritional issues.

• Primary healthcare to include nutrition as important service and include beds for severely

malnourished children.

• Establishing Nutrition Information System to reveal the current status of under-nutrition, micro-

nutrient malnutrition and diet-related chronic diseases among the people in the country.

• Provision of easy-to-use weighing balances for growth monitoring and use of growth charts to

educate mothers to take care of the malnourished child.

• Strengthening of existing iron-folic acid and Vitamin A supplementation programme. Include

deworming and nutrition health education for improved impact.

• Development of infrastructure for storage and cooking of food under MDM programme.

• Implementation and monitoring of sanitary practices for storage and cooking of food under

MDM programme.

• Convergence of NRHM school health programme (iron-folic acid, Vitamin A and deworming)

with MDM.

Adoption of New and Novel Approaches

• Introduction of national nutrition education programme to sensitize policymakers, orient programme

managers and for capacity building of functionaries.

• Promotion of double-fortified salt, fortified wheat flour, oil and ready-to-eat foods.

• Translation of infant and young child feeding (IYCF) guidelines and dietary guidelines into local

language.

• Nutrition-oriented horticultural interventions to increase the production of fruits and vegetables

at household/community level.

Table 9.3 represents a programme for effective Nutrition Intervention

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Table 9.3. Effective Nutrition Interventions

Intervention

Food and nutrition security

Promotion of early and

exclusive breast-feeding

Complementary feeding

(foods given after the age

of six months in addition

to breast milk)

Micro-nutrient interventions

Strategy

Food for work, dietary

diversification, nutrition education

Individual and group counselling

Behaviour change communication

and food supplements

Observed Outcomes

Increased intake of fruits and

vegetables

Reduced risk of morbidity, mortality

and improved linear growth/height

Improved linear growth/height

Supplementation and fortification;

dietary diversification including

home and community gardening,

livestock and dietary modifications

Reduction in morbidity and

mortality

Supplementary feeding

Food supplements

Improved linear growth

What the Corporate Sector Can Do

As a signatory to the Millennium Development Goals (MDG), India is committed to fulfil them by

2015. Out of the eight goals, MDG1 (eradication of extreme hunger and poverty) and MDG4 (reduce

child mortality) target children’s health. MDG1 aims at reducing by half (i) the prevalence of

underweight in children under-5 and (ii) the proportion of population below the minimum level of

dietary energy consumption. MDG4 aims at reducing by two-thirds under-5 mortality rate (U5MR)

between 1990 and 2015.

Corporate houses can accelerate the development process and help in attaining the MDG aspirations

for India by forming strategic alliances with government agencies and NGOs. This can be achieved

through the following:

• Set up grain banks and facilitate employment generation in rural and tribal areas to ensure food

security.

• Infrastructure development for post-harvest processing of fruits and vegetables to ensure nutrition

security.

• Adoption of ICDS and MDM programme centres. With the recent announcement by DWCD to

bring ICDS under mission mode and to provide anganwadi workers to a state on demand the

scope of the corporate world widens.

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• Provide infrastructure for nutrition and health programmes, e.g. kitchen and storage for MDM,

installation of solar driers at community level for drying of green leafy vegetables for incorporation

into MDM meals and a means of livelihood.

• Improving the access to and quality of health and nutrition services delivered through existing

public programmes.

• Explore strategies to facilitate community participation in the design and delivery of health and

nutrition programmes and improve mechanisms of training, data collection and supervision of

primary health and nutrition workers.

• Promote strengthening and convergence of nutrition component in various programmes.

• Help in developing infrastructure on the lines of “Akshayapatra” for centralized, nutritious, safe

and hygienic food preparation for schoolchildren. Box 9.1 presents an outline of the Akshayapatra

model.

• Promote self-help groups and provide micro-finance for livelihood.

• Help in capacity building through functional literacy and nutrition education programmes.

Box 9.1. Akshayapatra: A Successful Corporate Enterprise

Directed at Child Nutrition

The Akshayapatra Foundation was started by Madhu Pandit Dasa, an alumnus of IIT Mumbai,

in Bangalore in 2000.

Akshayapatra is the largest NGO-run school meal programme catering for 830,000 school

children. It operates in Karnataka, Rajasthan, Uttar Pradesh, Orissa and Gujarat (Ahmedabad and

Gandhinagar). The food is cooked in a centralized kitchen facility which consists of steam-heated

cauldrons. The method optimizes nutrient retention and minimizes contamination due to

automation. The food is then hygienically packed and distributed to schools in custom-built

vehicles.

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References

Deodhar S.Y., S. Mahandiratta, K.V. Ramani, D. Mavalankar, S. Ghosh and V. Braganza, 2007. “Mid

Day Meal Scheme: Understanding Critical Issues with Reference to Ahmedabad City”. Working

Paper No 2007-03-03, IIM Ahmedabad.

GOI, 2006. 11th five year plan (2007–2012), “Report of the Working Group on integrating Nutrition

with Health”, New Delhi: Ministry of Women and Child Development, November.

GOI, 2007. “Intersectoral Convergence”, New Delhi: Department of Women and Child Development

and Department of Health and Family Welfare.

Lancet, 2008. “Maternal and Child Under-nutrition”, Series 1–5. Lancet 373: 1–260. Published online,

17 January.

NFHS 3 (National Family Health Survey 3) 2005-2006. “National Fact Sheet”, Provisional data.

Radhakrishnan, R. and K. Venkata Reddy, “Vision 2020: Food Security and Nutrition”, paper prepared

for the Planning Commission.

UNICEF 2007. “The State of the World’s Children 2008”. UNICEF, New York, December 2007.

3.9 Page 29

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chapter 10

ACUTE RESPIRATORY INFECTION

Most under-5 children are susceptible to acute respiratory infection. If not treated in time it can turn

into fatal pneumonia. Symptoms of acute respiratory infection are: cough; running nose; fever; difficulty

in breathing. Taking care of the child with cough and cold at home involves some of these steps:

• Keep the child warm.

• Give plenty of fluids and continue breast-feeding.

• Give home remedies – ginger, honey, lemon,

kadha, etc.

• Ensure sufficient rest.

• Increase feeds after the child recovers.

• Immunizing children in time for vaccine-

preventable diseases also helps.

• Timely administration of vitamin A.

• Provide good nutrition and avoid exposure to cold, dust and smoke.

Figure : 10.1 presents the management of acute respiratory infection at the community level.

Figure 10.1. Management of Acute Respiratory Infection at Community Level

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What the Corporate Sector Can Do

• Advise about feeding the child: the feeding should

be continued during the illness and the frequency

of feeding increased after illness and adequate

fluids need to be given.

• Advise on control of fever using Paracetamol.

• Advise on keeping the infant warm.

• Advise referral to the nearest health facility if

the child has any of these danger signals: rapid

breathing; difficulty in breathing; unable to drink;

lethargy.

Reference

Adapted from the “Reading Material for ASHA”, Book No. 2, (Ministry of Health and Family Welfare,

Government of India) September 2005.

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chapter 11

DIARRHOEA

Diarrhoeal diseases are a major cause of disease and death among under-5 children. The majority

of fatalities are due to dehydration (loss of water and minerals). Diarrhoea is defined as passage of

liquid or watery stools. Passage of even one large watery motion among children can be diarrhoea.

Diarrhoea may be one of three kinds:

• Acute watery diarrhoea starts suddenly and may continue for up to fourteen days. Most of these

are self-limiting and will last for three to seven days.

• Persistent diarrhoea begins acutely and may last more than fourteen days.

• Dysentery is diarrhoea with visible blood in stools.

Figure 11.1 is a flowchart on management of diarrhoea.

Figure 11.1. Management of Diarrhoea

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Danger signs in diarrhoea are:

• The child becomes lethargic

• Not able to drink or breast-feed

• Blood appears in the stool

• Does not pass urine for eight hours

Golden Rules to Observe if a Child has

Diarrhoea

• Give ORS (oral redydration solution)

• Guide the mothers for preparing ORS. Take one

litre of clean drinking water in a clean container

after washing your hands with soap and water.

Add one packet of ORS in it and stir well.

Cover the vessel. One teaspoon of ORS should

be given every one-two minutes to infants as per

the table below:

Up to 2 months

Breast-feeding only

2 months up to 2 years

¼–½ cup

Give more if the child wants more

2 years and more

½–1 cup

Advise the mothers to give home-available fluids (HAF), e.g. plain clean water, lassi, shikanji.

• If the child is breast-fed, continue breast-feeding more frequently.

• If the child has started consuming other foods, continue feeding small quantities of these items.

• After the child recovers and normal appetite reappears, the child may be given more food than

normal to regain lost weight.

• Give extra fluids.

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The incidence of diarrhoea can be minimized by:

• exclusive breast-feeding for the first six months

• thorough hand washing before cooking food and

feeding the child

• keeping containers clean for preparing the food

and for feeding the child

• keeping the food covered

• keeping drinking water covered

• consuming freshly prepared food within one hour

• keeping the house and neighbouring area clean and proper disposal of waste so that houseflies

do not breed

• advising the families about getting sanitary latrines constructed in the household.

What the Corporate Sector Can Do

• Advise the families about chlorination of water in case of floods, etc.

• Advise families on the preparation and value of ORS.

• Assure ORS supplies.

• Refer in case of danger signs.

• Advise the family to take infants to the first referral unit immediately if the danger signs appear.

Reference

Adapted from the “Reading Material for ASHA”, Book No. I, (Ministry of Health and Family Welfare,

Government of India) September 2005.

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chapter 12

FEVER

After an attack by germs, the body works rapidly to generate more heat to kill the germs. Fever is

a common symptom of many diseases, which may be simple or serious. Some mild fevers subside

without any treatment or with treatment at home. Among these are fevers with no cough, running

nose, ear discharge, rash, diarrhoea, or any obvious infection. However, in children it may be a

symptom of an acute severe illness. For fever in children a blood smear examination should be done.

Several serious illnesses may be connected with fever – malaria, pneumonia, typhoid, TB, kala azar,

filariasis, brain fever, HIV/AIDS, etc.

It is prudent to take a sick person’s temperature even if she/he does not mention about having fever.

A simple way to find out if someone has fever is to touch your own forehead and the affected person’s

forehead with both sides of your hand. If the person’s forehead is warmer than yours, she/he may have

fever. Temperature by thermometer is taken orally or in the armpit. Temperature of 37–39 deg. C is

mild fever; 39–40 deg. C is moderate fever. Above 40 deg. C. is high fever. Thermometers

have mercury inside which is toxic and hence adequate care should be taken when used on children.

Figure 12.1 presents steps in management of fever.

General Treatment of Fever

• Mild fever generally needs no treatment.

• For moderate fever Paracetamol tablet is the best

treatment. One tablet thrice a day is enough for

adults. Give tablet Paracetamol for two days.

• For high fever, tepid water sponging is good first

aid, with Paracetamol tablets. If fever does not

come down within two days, refer to the nearest

health facility. Sponge the whole body with tepid

water. Do not use cold water as it causes shivers.

Do not give a blanket. Keep the windows open.

• Give enough water and fluids to drink.

• Light meals like khichdi, daal-rice, curds, dalia are soft and easily digested.

• Fever is the symptom of a disease: it is not a disease in itself. Paracetamol tablet or syrup only

brings down the temperature. It is not a fever cure since it does not kill the causative germs.

Remember several serious illnesses may be connected with fever, e.g. malaria, pneumonia, pus

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Figure 12.1. Steps in the Management of Fever

(anywhere), typhoid, TB, kala azar, filariasis, brain fever, HIV/AIDS, etc As a thumb rule, do

not wait for more than two days for cure.

Some Home Remedies for Fever

Home remedies soothe the effects of fever. Give:

Gulvel kadha – Take a thumb-thick piece of Gulvel. Add two-teaspoonful powder of dry ginger. Add

10 –12 glasses of water. Boil on slow fire. When three glass full decoction remains, cool it. Give

half a glass of freshly made decoction.

China grass tea – Tea prepared with china grass is a refreshing decoction for simple fever.

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Specific Treatment for Illness

For illnesses due to various germs we need to give specific medicines. Malaria, pneumonia, TB, etc.

need specific medicines other than Paracetamol. However, viral illnesses have no specific remedies.

Virus is a very small germ causing many fever-illnesses. Common cold, flu, dengue, jaundice, etc.

are viral illnesses.

What the Corporate Sector Can Do

In case of fever, advise the family to approach the PHC immediately if the patient :

• is less than two months old;

• is unconscious or drowsy;

• has convulsions;

• is not able to drink;

• has had fever for more than five days.

The corporate sector, in the long tem, can also

• Help malaria workers in getting blood samples from fever cases in the area.

• Keep seasonal information on the type of fever.

• Assure a depot holder in villages of chloroquine supply.

Reference

Adapted from the “Reading Material for ASHA, Book No. 2” Ministry of Health and Family Welfare),

Government of India, September 2005.

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POPULATION FOUNDATION OF INDIA

B-28, Qutab Institutional Area, Tara Crescent, New Delhi 110 016

Tel. No : 42899770, Fax : 42899795

Website : www.popfound.org, E-mail : popfound@sify.com