Newborn

Child Health
Services and
Supplementary Module for Programmes
Community Health Officers-

Child Health Division, MoHFW GOI

1
 Table of Contents

List of Abbreviations ........................................................................................................... 3

Chapter 1: Introduction to Newborn and Child Health Programmes............................ 6
i. Key newborn and child intervention ................................................................................... 6
ii. Roles and responsibilities of CHO in Newborn, Child Health and Nutrition Programmes
.............................................................................................................................................. 10
iii. Referral linkages from Ayushman Bharat-Health and Wellness Centres (AB-HWC) to
higher facility for newborn and child health programmes ................................................... 12
Chapter 2: Services at different levels of newborn care and Care during birth and
counselling during discharge ............................................................................................ 15
Chapter 3: Community Based Programmes for Children ............................................ 21
Chapter 4: Assessment and care of sick young infant (0-2 months of age) .................. 38
Chapter 5: Assessment and care of sick child (2-59 months of age) ............................. 53
Chapter 6: Infant and Young Child Feeding (IYCF) ..................................................... 73
Chapter 7: Iron and Folic Acid Supplementation .......................................................... 85
Chapter 8: Early Detection and Management of children with growth failure ........... 92
Chapter 9: Immunization for Children ........................................................................... 99
Chapter 10: Early Childhood Development .................................................................. 107
Chapter 11: Child Health Screening and Early Intervention Services ....................... 111
ANNEXURES ....................................................................................................................... 1
Annexure 1- Roles and Responsibilities of ASHA and MPW (Female and Male) in
delivery of neonatal, infant and childhood services............................................................... 1
Annexure 2- Counselling regarding Feeding Problem, important messages for
breastfeeding, correct positioning and attachment for breastfeeding .................................... 5
Annexure 3- Preparation of ORS using an ORS packet ........................................................ 8
Annexure 4 - Zinc Supplementation for 14 days for a child having diarrhoea ............... 9
Annexure 5- Method of administration of IFA syrup .......................................................... 11
Annexure 6- Counselling regarding safe WASH practices ................................................. 12
Annexure 7- Importance of Nutrition in Childhood ............................................................ 15
Annexure 8 - Common Items Required For Early Childhood Screening ............................ 17
Annexure 9 - Learning Tool for Milestone Assessment ...................................................... 17

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 List of Abbreviations

AB-HWC Ayushman Bharat- Health and Wellness Centre

ACT Artemisinin-based Combination Therapy
AEFI Adverse Events Following Immunization
AMB Anemia Mukt Bharat
ANM Auxillary Nurse Midwife
ARI Acute Respiratory Infection
AWH Anganwadi Helper
AWW Anganwadi Worker
BCG Bacillus Calmette Guerin
BMI Body Mass Index
BMO Block Medical Officer
CAS Common Application Software
CHC Community Health Centre
CHO Community Health Officer
CLMC Comprehensive Lactation Management Centres
CNNS Comprehensive National Nutrition Survey
CPHC Comprehensive Primary Health Care
DEIC District Early Intervention Centre
DH District Hospital
DPT Diphtheria, Pertussis and Tetanus
EBM Expressed Breast Milk
ECD Early Childhood Development
ETAT Emergency Triage Assessment and Treatment
FBNC Facility Based Newborn Care
F-IMNCI Facility-based Integrated Management of Neonatal and Childhood Illnesses
FRU First Referral Unit
HBNC Home Based Newborn Care
HBYC Home Based Care for Young Child
HMIS Health Management Information System
HRA High- risk area
ICDS Integrated Child Development Services Scheme
ICT Information and Communication Technologies
IDCF Intensified Diarrhoea Control Fortnight
IEC Information, Education and Communication
IFA Iron and Folic Acid
IMI Intensified Mission Indradhanush
IMNCI Integrated Management of Neonatal and Childhood Illnesses
IMR Infant Mortality Rate
IPV Inactivated Polio Vaccine
IT Information Technology
ITN Insecticide-Treated Net
IU International Unit
IUCD Intrauterine Contraceptive Device

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IYCF Infant and Young Child Feeding
JE Japanese encephalitis
JSSK Janani Shishu Suraksha Karyakram
JSY Janani Suraksha Yojana
KMC Kangaroo Mother Care
LBW Low-birth weight
LMC Lactation Management Centre
MAA Mother’s Absolute Affection
MCP Card Mother and Child Protection Card
MNCU Mother Newborn Care Unit
MO Medical Officer
MoHFW Ministry of Health and Family Welfare
MPW Multi-Purpose Worker
MR Measles Rubella
MUD Mop Up Day
MWCD Ministry of Women and Child Development
NAMP National Anti Malaria Program
NBCC New Born Care Corner
NBSU Newborn Stabilization Unit
NDD National Deworming Day
NFHS National Family Health Survey
NHM National Health Mission
NHP National Health Policy
NICU Neonatal Intensive Care Unit
NIDDCP National Iodine Deficiency Disorders Control Programme
NIS National Immunization Schedule
NMR Neonatal Mortality Rate
NPP National Population Policy
NRC Nutrition Rehabilitation Centre
NRHM National Rural Health Mission
NRLM National Rural Livelihood Mission
NSSK Navjaat Shishsu Suraksha Karyakarm
OPV Oral Polio Vaccine
ORS Oral Rehydration Solution
PAIUCD Post-Abortion Intrauterine Contraceptive Device
PCV Pneumococcal Conjugate Vaccine
PHC Primary Health Centre
PMMVY Pradhan Mantri Matri Vandana Yojana
POSHAN The Prime Minister's Overarching Scheme for Holistic Nutrition
PPIUCD Postpartum Intrauterine Contraceptive Device
PSBI Possible Serious Bacterial Infection
RBSK Rashtriya Bal Suraksha Karyakram
RCH Reproductive and Child Health
RDT Rapid Diagnostic Test
RI Routine Immunization
RMNCAH+N Reproductive, Maternal, Newborn, Child, Adolescent Health Plus Nutrition
RVV Rotavirus Vaccine
SAANS Social Awareness & Action to Neutralize Pneumonia Successfully

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SAM Severe Acute Malnutrition
SD Standard Deviation
SDG Sustainable Development Goal
SDH Sub-District Hospital
SHC Sub-Health Centre
SNCU Special Newborn Care Unit
SRS Sample Registration System
Td Tetanus & adult Diphtheria
THR Take Home Ration
U5MR Under 5 Mortality Rate
UIP Universal Immunization Programme
VHSNC Village Health, Nutrition and Sanitation Committee
VHSND Village Health Sanitation and Nutrition Day
WASH Water, Sanitation and Hygiene
WHO World Health Organization

5
 Chapter 1: Introduction to Newborn and Child
Health Programmes

i. Key newborn and child intervention

The Child Health Programme under the Reproductive, Maternal, Newborn, Child , Adolescent Health
Plus Nutrition (RMNCAH+N) Strategy of the National Health Mission (NHM) comprehensively
integrates interventions that improve child health and nutrition status and addresses factors
contributing to neonatal, infant, under-five mortality and malnutrition. The National Population
Policy (NPP) 2000, the National Health Policy (NHP) 2002, Twelfth Five Year Plan (2007-12),
National Health Mission (NRHM - 2005 – 2017), Sustainable Development Goals (SDG) (2016-
2030) and National Health Policy, 2017 have laid down the goals for child health.

Under the National Health Mission, wide range of efforts are being taken for health systems
strengthening to improve service delivery. The RMNCAH+N strategy is being implemented to
ensure continuum of care from facility to community, across life stages.

Child Health Goals under NHP-2025 and SDG-2030

Child Health Indicator Current status (SRS* NHP 2025 SDG 2030
2018)
Neonatal Mortality rate 23 16 by 2025 <10
Infant Mortality Rate 32 28 by 2019 -
Under 5 Mortality Rate 36 23 by 2025 ≤25
*-Sample Registration System

• Progress on Child Health (As per SRS 2018)

Indicators • Definition • Progress

Neonatal Mortality• Number of deaths of children during the • Decline from 37 per 1000 live births in
Rate (NMR) period of 0-28 days per 1000 live births in a 2005 to 23 per 1000 live births (2018).
given year or other period.
Infant Mortality • Number of deaths of children in the age 0-• Decline from 58/1000 live births (2005) to
Rate (IMR) 1 year per 1000 live births in a given time 32 per 1000 live births (2018).
period and for a given region.

Under 5 Mortality • Number of deaths of children in the age • Decline from 68/1000 live births (2008) to
Rate (U5MR) group of 0-5 years per 1,000 live births in 36 per 1000 live births (2018).
a given time period and for a given region .

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Highlights • Decline in rural IMR more than urban;
• Decline in rural U5MR more than urban;
• Decline in female U5MR more than male;
• Early Neonatal deaths a matter of concern (4.9 lakhs newborns die within the first
week of birth)

Causes of Child Mortality in India

The major causes of child mortality in India as per the SRS reports (2010-13) are:
prematurity & low birth weight (29.8%), pneumonia (17.1%), diarrhoeal diseases (8.6%), other non-
communicable diseases (8.3%), birth asphyxia & birth trauma (8.2%), injuries (4.6%), congenital
anomalies (4.4%), ill-defined or cause unknown (4.4%), acute bacterial sepsis and severe infections
(3.6%), fever of unknown origin (2.5%) and all other remaining causes (8.4%). Besides these,
malnutrition is a contributory factor in 45% of under-five child deaths.

Interventions under Child Health

Based on the identified causes of mortality, five major strategic areas have been identified to improve
child health outcomes. These are:

Following initiatives are being implemented under National Health Mission to deliver key
interventions to improve the newborn and child health in your area:

Key newborn and child Schemes/Programmes under NHM

intervention
Financial incentives / Janani Suraksha Yojana (JSY)
entitlements for free transport (https://nhm.gov.in/WriteReadData/l892s/97827133331523438951.pdf) and
and treatment of newborns and Janani Shishu Suraksha Karyakaram (JSSK)
infants (up to 1 year of age) in (https://nhm.gov.in/images/pdf/programmes/jssk/guidelines/guidelines_for_jssk
health facilities .pdf)

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Key newborn and child Schemes/Programmes under NHM
intervention
Care at birth, including Newborn Care Corners, Navjaat Shishsu Suraksha Karyakarm (NSSK)
resuscitation, at delivery (https://nhm.gov.in/images/pdf/programmes/child-
points health/guidelines/manual.zip)

Facility based newborn care Newborn Stabilization Unit (NBSU), Special Newborn Care Unit
(SNCU) (https://nhm.gov.in/images/pdf/programmes/child-
health/guidelines/fbnc_operational_guide.zip)

Home based care by Home based newborn care (HBNC)

community health workers (https://nhm.gov.in/images/pdf/programmes/child-
health/guidelines/Revised_Home_Based_New_Born_Care_Operational_Guidel
ines_2014.pdf),
Home based care for Young Child (HBYC)
(https://www.nhm.gov.in/images/pdf/programmes/RBSK/Operational_Guidelin
es/HBYC_Guidelines.pdf)

Ensuring immunization Universal Immunization Programme (UIP),

Intensified Mission Indradhanush (IMI)
Screening and management of Rashtriya Bal Suraksha Karyakram (RBSK)
4Ds-developmental delays, (https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Rastriya-
defects, disease and deficiency Bal-Swasthya-Karyakram(RBSK).pdf) and resource document
disorders (https://nhm.gov.in/index1.php?lang=1&level=5&sublinkid=1197&lid=371)

Facility based management of Nutrition Rehabilitation Centres (NRCs)

Severe Acute Malnutrition (https://www.nhm.gov.in/images/pdf/programmes/child-
health/guidelines/operational_guidelines_on_fbmc_with_sam.pdf)
Mother’s Absolute Affection Infant and Young Child Feeding (IYCF)
(MAA) programme (https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Enhancing-
optimal-IYCF-practices.pdf) and Lactation Management Centres (LMCs)
(https://nhm.gov.in/images/pdf/programmes/IYCF/National_Guidelines_Lactati
on_Management_Centres.pdf)
Micronutrient supplementation Anemia Mukt Bharat (https://anemiamuktbharat.info/resources/#operational-
(Iron, Folic acid, Vitamin A) guideline), Vitamin A supplementation
(https://nhm.gov.in/images/pdf/programmes/child-
health/guidelines/goi_vit_a.pdf)
Deworming National Deworming Day (NDD)
(https://nhm.gov.in/images/pdf/programmes/child-
health/guidelines/deworming_guidelines.zip)

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Key newborn and child Schemes/Programmes under NHM
intervention
In-patient and Out-patient Integrated management of newborn and childhood illnesses in
management of common community (IMNCI) & Facility (F-IMNCI)
childhood illnesses including (https://nhm.gov.in/images/pdf/programmes/child-
pneumonia, diarrhea,
health/guidelines/operational_guidelines_for_fimnci.pdf), Social Awareness
malnutrition etc.
& Action to Neutralize Pneumonia Successfully (SAANS)
(https://nhm.gov.in/New_Updates_2018/SAANS/Childhood_Pneumonia
_Management_Guidelines.zip), Intensified Diarrhoea Control Fortnight
(IDCF)
(https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/
CH/Schemes/IDCF/IDCF_2019/IDCF_2019_Guideline.docx),
Strengthening Pediatric Care at District Hospital
(https://nhm.gov.in/images/pdf/programmes/child-
health/guidelines/Strenghtening_Facility_Based_Paediatric_Care-
Operational_Guidelines.pdf)
Other National Programmes National Iodine Deficiency Disorders Control Programme (NIDDCP)-
related to Nutrition https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1054&lid=2
30

It is important to understand that interventions in other stages of woman’s life, including adolescence,
pre-pregnancy, pregnancy and lactation also make a significant difference to the health and survival
of children.Interventions related to care around birth, family planning and appropriate nutrition
practices linked contribute to positive newborn and child health outcomes. Hence a life cycle
approach has been adopted under the national programme.

Under Ayushman Bharat – Health and Wellness Centres, the existing SHC and PHCs are being
upgraded as HWCs with the objective of strengthening existing services related to RMNCAH+N and
communicable diseases and expansion of services by adding new services such as NCDs, Oral health,
Mental Health, Eye and ENT care, elderly and palliative care and emergency care. As Sub-Health
Centre-Health and Wellness Centres (SHC-HWCs), are the first point of contact, strengthening of
these services at SHC-HWCs level will help in ensuring optimum coverage and reducing neonatal
and child morbidity and mortality.

This module will help you to develop an overall understanding of important newborn and child
health interventions being implemented as part of the various programmes to facilitate effective
delivery of these initiatives. Various neonatal, infant and child health care services are delivered
across different levels of care ranging from household and outreach sites in the community level
(ASHAs and MPWs), to primary care facilities (SHCs and PHCs) and secondary level facilities
(CHC and DH).
Annexure-1 enlists the specific roles and responsibilities of the ASHA and MPW (Female and Male)
in delivery of neonatal, infant and childhood services.

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Given below are the role and responsibilities that you are expected to perform at SHC- HWCs in
coordination with your team of MPWs and ASHAs and Medical Officers at PHC- HWC.

ii. Roles and responsibilities of CHO in Newborn, Child Health and Nutrition
Interventions-
A. Clinical Functions for Ambulatory care and management

a. Newborn Care Services

▪ At SHC-HWC-delivery point, provide essential newborn care which includes establishment of
respiration, delayed cord clamping, vitamin-K injection, immunization, immediate drying and skin
to skin contact, prevention of hypothermia, early initiation of breastfeeding (within an
hour),exclusive breastfeeding, prevention of infection, identification and recording of birth
defect/congenital anomalies and appropriate referral, identification, of danger signs and early and
appropriate referral.
▪ Assess newborn referred by ASHAs under HBNC for any danger signs/symptoms as per IMNCI
protocol and perform pre-referral stabilization and facilitate referral to nearest
NBSU/SNCU.Maintain high- risk newborn list for NBSU/SNCU discharged babies and low birth
weight babies in SHC-HWC catchment area and facilitate their regular facility and community
follow-up care
▪ Counselling support to mothers/caregivers in the postnatal period during each contact at the health
facility or during visit to community on danger signs in newborn, keeping the newborn warm,
responsive feeding, play and communication and importance of immunization

b. Infant and Childhood Health Services

▪ Outpatient management of sick young infants and children for all illnesses as per IMNCI protocol
including assessment, classification and management.
▪ Ensure referral linkages to nearest appropriate health facility for appropriate management of sick
young infants and children maintaining time to care.
▪ Ensure provision of Provide follow-up care of children discharged from higher health facilities.
▪ Measurement of weight of all children for ensuring appropriate dosages of medicines.
▪ Ensure completion of age appropriate immunization of children. Reporting of Adverse Events
Following Immunization (AEFI) events and providing follow-up care to children with AEFI.
▪ Ensure age appropriate Vitamin-A supplementation, de- worming, Zinc/ Oral Rehydration Solution
(ORS) and iron supplementation of children.
▪ Support screening of children in catchment area for 4Ds by the RBSK Mobile Health Team and
facilitate timely referral of child to District Early Intervention Centre (DEIC). Counsel and follow-
up caregivers of identified children for secondary tertiary care supported under National Health
Mission.
▪ Screening, early management, timely referral and follow-up care for nutritional disorders including
childhood nutritional deficiencies, overweight and obesity related problems in children.
Examine sick SAM child referred by Anganwadi Worker (AWW)/MPW/ASHA for confirmation of
sickness and necessary management through appropriate referral and follow up care, as per
protocols. Ensure follow-up care of NRC discharged SAM children through ASHAs, MPWs and
AWWs to prevent relapse.
Maintain and share the list of sick SAM children referred to NRCs/paediatric facility with Block
Medical Officer (BMO), who will liaison with NRC in-charge/Paediatrician of the First Referral
Unit (FRU)/Sub-District Hospital (SDH)/District Hospital (DH) for further care provision.

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 Coordinate with BMO to get an updated list of NRC children for ensuring follow up care as per
schedule
▪ Ensure use of MCP card by primary healthcare team (ASHA, MPW) to explain concept of early
childhood development to parents/ caregivers, responsive parenting/parenting tips, developmental
milestones and warning signs.
▪ Assess children with any warning sign referred by ASHA/AWW/MPW for timely referral and
management.
▪ Counselling support to mothers/caregivers at the health facility or during visit to community on
promotion of IYCF practices, key hygiene practices, importance of immunization, age-appropriate
play and communication activities. Facilitate teleconsultation services with PHC-MO to seek
advice/clarifications on treatment, pre-referral stabilization, referral advice, appropriate care
during follow-up, etc.
-B. Public Health Functions for Health Promotion, Prevention and Disease Surveillance
▪ Support and supervise the collection of data related to children in your service area by primary
health care team for understanding status of sick newborns/low-birth weight (LBW) babies,
neonatal deaths, childhood diseases/deaths, coverage of child immunization and developing local
plans for taking appropriate action, with a particular focus on vulnerable/marginalized population.
▪ Ensuring line listing and tracking health and nutritional status of all children in your service area
with the help of ASHAs/AWWs/MPWs for seeking healthcare services and for updating status in
MCP card.
▪ Surveillance for unusually high incidence of childhood cases of diarrhoea, dysentery, fever,
jaundice, diphtheria, whooping cough, tetanus, polio and other diseases with immediate notification
to PHC-MO and other authorities.
▪ Ensure supervision of activities related to availability of health services in AWC to children aged 6
months-6 years.
▪ Facilitate multi-sectoral convergence for community level action on health promotion and
prevention with support of ASHA, MPW, AWW, Village Health, Nutrition and Sanitation
Committee (VHSNC), Panchayat/tribal groups and Village Health Sanitation and Nutrition Day
(VHSND) sessions-Organize health camps/special health education drives/health promotion
campaigns/activities/ to improve community awareness about different health and nutrition related
initiatives like The Prime Minister's Overarching Scheme for Holistic Nutrition (POSHAN) Maah,
National Deworming Day (NDD), National Newborn Week and SAANS campaign etc and improve
uptake of services.
▪ Encourage mother/caregivers to utilize healthcare services available at SHC-HWC, services
available under national health programmes
▪ Mentor ASHAs and MPWs to ensure equitable delivery of child care services with special
focus on marginalized/ vulnerable household
C. Managerial Functions for efficient functioning of HWCs
▪ Provide mentoring and supportive supervision to the primary health care team for effectively
conducting community and outreach and facility-level activities. Provide regular feedback to the
team.
▪ Supervise that records of newborn, infants and children, are maintained in reporting formats,
integrated RCH register/RCH Portal, Health Management Information System (HMIS), and
updated regularly.
▪ Ensure ASHA/MPW maintain line list of all newborns (delivered at home and institution both),
infants, children especially those vulnerable newborns – NBSU/SNCU/NRC discharged, children
identified under RBSK, children with malnutrition etc.

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 ▪ Ensure regular filling and validate records of children in the Mother and Child Protection (MCP)
card with focus on nutritional status and growth monitoring.
▪ Submission of monthly performance report of SHC-HWC to PHC-MO for disbursement of
performance linked payments to SHC-HWC team.
▪ Ensure monthly HBNC and HBYC reports are collated and submitted for onward transmission.
▪ Ensure child health related medicines, consumables, reagents and logistics are in adequate stock at
the SHC-HWC.
▪ Support ASHA, ASHA Facilitators and MPW for maintaining functional items as per guidelines
and proper use of HBNC kit and HBYC kit (wherever available) during each home visit.
▪ Conducting monthly HWC meetings with MPW and ASHAs at the SHC-HWC for assessing
progress on child health outcomes, identifying and addressing gaps, discussing common issues and
planning for necessary actions, capacity building.
▪ Support and supervise ASHA/ASHA Facilitators and MPWs in mentoring role by undertaking joint
home visits every month to at least 2-3 identified vulnerable newborns/children or resistant families
for motivating families to adopt healthy behaviours, utilize services at HWCs, access referral,
ensuring treatment compliance, etc.
▪ Support ANM/MPWs in undertaking routine immunization sessions and provide supportive
supervision to ensure immunization coverage as per due list.
▪ Support ASHAs to undertake regular home visits for early identification of danger signs in newborn
and young child for prompt referral and management
▪ Facilitate participation of all stakeholders during VHSND sessions and monitoring of atleast two
sessions/month using the VHSND monitoring checklist to record/observe quality of services and
availability of medicines and diagnostics
▪ Participate in the community/village level meetings of VHSNC and discuss about new health services
available at SHC-HWC and current health programmes with the community.
▪
-

The CHOs are expected to work under the overall supervision of the PHC- Medical Officer. The PHC
Medical Officer will monitor, support and supervise the delivery of comprehensive primary health care
through the network of SHC-HWCs. PHC-MO will provide support to the Primary Health Care team at
HWC-SHC undertaking through monthly visits and holding PHC review meetings for- technical
handholding capacity building, assessing progress on coverage of beneficiaries under various services,
identifying and addressing gaps/problem solving.

ii. Referral linkages from Ayushman Bharat-Health and Wellness

Centres (AB-HWC) to higher facility for newborn and child health
programmes

Early and appropriate referral plays vital role in reducing newborn and child mortality. You should
follow the referral protocols and ensure pre-referral treatment while referring newborn and child to

12
higher centres. The list of referral centres needs to be identified in advanced and information about it
should be displayed at each SHC-HWC. The list of referral conditions along with indicative referral
facility is mentioned in the table below.
S. No. Referral Conditions Referral Health Facility

1. Danger signs/symptoms in newborn and young Nearest health facility with

infant (0-2 months): NBSU/SNCU services.
▪ Low Birth Weight (<1800 NBSU are at Community Health Centres
gms)* (CHC)/ First Referral Unit.
▪ Baby cold (Axillary
temperature less than 35.5oC)/hot to touch
(Axillary temperature 37.5oC or above)
(*Direct referral to SNCU at DH/SDH.
▪ Inability/ difficulty in
In case, there is refusal to referral or
feeding
SNCU travel time is more than one hour
▪ Difficulty in breathing/ fast
breathing (60 breaths per minute or more) then pre-referral stabilization of all cases
▪ Severe chest indrawing* with danger signs should be done at
▪ Abnormal movements NBSU and managed accordingly).
(Convulsions/Fits)*
▪ Severe dehydration*(less
movement, sunken eyes, skin pinch goes back Nutritional Rehabilitation
very slowly) Centre/Paediatric Facility – for
▪ Appearance of jaundice management of severe acute and
within 24 hours of age/ yellow staining of palms moderate malnutrition with
or soles*
complications.
▪ Malnutrition- Severe acute and moderate acute
cases - with medical complication
▪ -
▪ Persistent diarrhoea (>14
days)

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 2. Danger signs/symptoms in children (2-59 Nearest health facility- CHC/SDH/DH
months): wherever paediatrician or paediatric care
services are available.
▪ Unable to drink or
breastfeed
▪ Vomits everything
▪ Convulsions during the
present illness
▪ Unconscious or lethargic
▪ Fast Breathing (2-11
months 50 breaths per minute or more; 12-59
months 40 breaths per minute or more)
▪ Chest indrawing Nutritional Rehabilitation
▪ Severe dehydration (less Centre/Paediatric Facility – for
movement, sunken eyes, skin pinch goes back management of severe acute and
very slowly)
moderate malnutrition with
▪ Persistent diarrhoea (>14
complications.
days)
▪ Very severe febrile
disease/Malaria
▪ Malnutrition- Severe
acute and moderate acute cases - with
medical complication; Severe Anemia
(Hb<7 gm/dl) for children 6-59 months of age
and (Hb<8 gm/dl) for children 5-11 years of age
▪ Childhood overweight and
obesity

3. Adverse Events Following Immunization (AEFI) PHC where Medical Officer is

posted/Nearest AEFI management
centres

4. For selected health conditions-Defects at birth, Link to RBSK mobile health team/
Disease, Deficiency and Development Delays as per District Early Intervention Centre
RBSK guidelines (DEIC) at DH and/or the DEIC
manager.

Remember- To ensure continuum of care, you as a CHO at SHC-HWC will facilitate referral
appointment based on the health condition of the child i.e, refer directly to a District Hospital to a
specialist in case of danger signs or refer to PHC for management of acute simple illness like fever . You
must undertake the mapping of referral facilities to ensure continuum of care and obtain details from
your PHC- Medical Officer of the secondary care facilities where referral would need to be undertaken
for emergency situations.

14
Chapter 2: Services at different levels of newborn
care and Care during birth and counselling during
discharge

The neonatal period (the first 28 days of life) carries the highest risk of death than any other period
during the childhood. Therefore, this period is crucial for child survival. A healthy neonate will lay
the foundation of healthy adults who can thrive and contribute to their communities and societies.

India reports maximum number of neonatal deaths in the world despite the fact that the neonatal
mortality rate (NMR) has declined from 44 per 1000 live births in 2000 to 23 per 1000 live births in
2018 (SRS, 2018). Commitments under India Newborn Action Plan and SDG for attaining single
digit NMR per 1000 live births by 2030 will require concerted efforts by all the stakeholders
including families and communities.

Why is it important to prioritize care for the newborns?

It is estimated that around 40% of all neonatal deaths take place during labour and on the day of birth
(approximately within 48 hours around birth). About three- fourths of the total neonatal deaths occurs
in the first week of life. Around 80% of the newborn deaths are due to preventable causes. Low cost,
effective interventions like exclusive breast feeding, maintaining temperature and prevention of
sepsis can save most of the newborn. Access to care during sickness by early detection of danger
signs and prompt referral to equipped facilities further helps the improving newborn survival.

Continuum of newborn care

Facility Based Newborn Care (FBNC) along with Home Based Newborn Care (HBNC) establishes a
continuum of care to ensure that every newborn receives essential services right from the time of
birth and first 48 hours at the health facility and then at home during the first 42 days of life.
Monitoring in first 48 hours after birth is important to detect any danger sign at the earliest. If a
woman stays in the health facility for mandatory 48 hours after birth, monitor daily both mother and
newborn. If the woman returns home within a few hours after delivery before 48 hours period, ASHA
must make a visit within 24 hours of woman reaching home. She will continue to provide care to the
neonate at home as per the scheduled visits up to the 42nd day of life. You will read in detail about
HBNC programme in the next chapter.

1. Facility Based Newborn Care Program

▪ New Born Care Corners (NBCCs) are spaces within the labour rooms and operation theatres
of all public health facilities consisting of an earmarked area equipped for providing essential
newborn care including resuscitation.
▪ Special New Born Care Units (SNCUs) are established at District Hospitals while Newborn

15
 Stabilization Unit (NBSU) are at Community Health Centres (CHC)/ First Referral Unit1
(FRU).Both these units are established for provision of care to sick and small newborns. They
provide care for newborns in first month of life. Now, Mother Newborn Care Unit (MNCU)
along with SNCU are being developed where mother and baby can be cared together ensuring
zero separation.
▪ There are referral linkages between these units, so that all newborns receive appropriate level
of care after birth.

The details of these units are given below-

1.1. Newborn Care Corner (NBCC)

Newborn Care Corner (NBCC) is a designated space in the labour room and obstetric Operation
Theatre which is situated in draught free area, with equipments like radiant warmers, suction
machines, self-inflating bag/AMBU bag including masks of size 0 &1, oxygen availability etc.
NBCC is established to provide support to newborns required essential newborn care and
resuscitation services and/or assistance at the time of birth by Navjat Sishu Suraksha Karyakaram
(NSSK) trained staff.
1.2. Newborn Stabilization Unit (NBSU)
Newborn Stabilization Units (NBSU) is 4-6 bedded unit established at the sub district level for
managing sick and small newborns who are not so seriously ill and therefore can be managed at first
level of newborn care facility. Pre-referral stabilizing of sick and small newborn at NBSUs before
transfer to SNCU/ Neonatal Intensive Care Unit (NICU) essentially improves the outcome of these
babies.
1.3. Special Newborn Care Unit (SNCU)
SNCU is a 12 bedded or larger unit located at District/Sub- district hospitals and Medical Colleges
with dedicated and adequately trained doctors, staff nurses and support staff to provide 24*7
comprehensive secondary level of newborn care to small and sick neonates.

1.4. Mother Newborn Care Unit (MNCU) – This is a new concept where the aim is ‘no separation’
of mother and baby including small and sick babies who require newborn care. The mother and
newborn dyad/pair are to be cared for together while mother is empowered to participate in
developmentally supportive care to her own newborn.

1
First Referral Unit (FRU) provides comprehensive obstetric care services including like caesarean section,
newborn care, emergency care of sick children, full range of family planning services, safe abortion services
treatment of STI/RTI availability of blood storage unit and referral transport services.

16
 2. Overview of services at different levels of newborn care

Newborn care corner Newborn Stabilization Special Newborn Care Unit

(at all Delivery units (FRUs/CHCs) (Sub- District/District)
Points)
Resuscitation, Resuscitation, provision of Resuscitation, provision of
provision of warmth, warmth, warmth, prevention of
prevention of prevention of infection, infection, early initiation of
Care at birth
infection, early initiation of breastfeeding and weighing
early initiation of breastfeeding, the newborn
breastfeeding, weighing the newborn
weighing the newborn

Care of normal Ensure breastfeeding/ Ensure breastfeeding/ Ensure breastfeeding/

newborn lactation support lactation support lactation support

Care of sick Identification and Management of low birth Managing of low birth
newborn prompt referral of ‘at weight infants ≥1800 weight infants <1800grams,
risk’ and ‘sick’ grams with no other managing all sick newborns
newborn complication, (except those requiring
phototherapy for newborns mechanical ventilation and
with hyper-bilirubinemia, major surgical interventions),
management of newborn follow-up of all babies
sepsis, discharged from the unit and
stabilization and referral of high- risk newborns,
sick newborns and those lactation support services
with very low birth weight including breastfeeding,
(rooming in), expressed breastmilk feeding
lactation support services and feeding of donor human
including breastfeeding, milk, if comprehensive
expressed breastmilk lactation management
feeding, referral services centres (CLMCs) are
functional, referral services

3. Strengthening Facility- Based Paediatric Care in District Hospital

Facility- based care for sick children is complementary to primary care and provides a continuum of
care for severely ill children referred to FRU and District Hospital. Good quality in-patient care for
children is required at health facilities to increase the impact of appropriate primary care
interventions on child survival. District Hospitals serve as the hub for secondary inpatient care in the
districts and in certain states the FRU/ CHCs also cater to the need for in-patient care.
The operational guideline for Strengthening Facility Based Paediatric Care in District Hospital was
launched in year 2015 which provisioned to set comprehensive paediatric care service units at
District Hospital. These units are-
1. Paeadiatric Outpatient Facility (including immunization and counselling services),
2. Emergency Triage Assessment and Treatment (ETAT) Facility,

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3. Paediatric Inpatient Facility (High Dependency Unit, Paediatric Ward, Diarrhoea Treatment Unit
and Isolation Room),
4. Ancillary (eg; laboratory, imaging, pharmacy) & Auxilliary Facilities (eg; play area, hospital
kitchen).
The general paediatric care facility will function in close coordination with specialized units such as
Special Newborn Care Unit (SNCU), Nutrition Rehabilitation Centre (NRC) and District Early
Intervention Centre (DEIC).

4. Care to be provided at birth and counselling before discharge from SHC-HWC

If SHC-HWC is a designated delivery point, you must have a skilled birth attendant 24*7 to provide
essential newborn care following birth which includes the following:

▪ Establishment of respiration
▪ Delayed cord clamping
▪ Immediate drying and skin to skin contact
▪ Prevention of hypothermia (child’s body temperature is below normal)
▪ Early initiation of breastfeeding, exclusive breastfeeding and lactation support
▪ Prevention of infection
▪ Detection of danger signs

You must maintain a functional newborn care corner with all the standard, clean and functional
equipment in place. Mother/caregiver to be counseled before discharge for the following in the post-
natal ward of the SHC-HWC-

1. Maintenance of body temperature

Newborns if left wet and naked lose up to 2 to 4 degree celsius within 10-20 minutes. Large surface
area (head big in size compared to its body) and less subcutaneous fat adds to further decrease in
temperature. Increased risk of death especially in LBW and pre-term babies, if hypothermia
continues. It decreases ability to suckle at the breast, leading to poor feeding and weakness and more
prone to increased susceptibility to infections. So, baby should be kept dry and well covered at all
times.

Do remember to ask/check for passage of meconium (early stool passed by a newborn soon after birth)
within 24 hours or urine within 48 hours of any neonate who is born at the SHC-HWC. In case there
are any congenital anomalies/birth defects, report to District RBSK Mobile Health Team/ DEIC at
District Hospital and/or DEIC Manager.

2. Initiation of Breast Feeding and sustaining it

Breastfeeding must be initiated as early as possible, definitely within 1 hour of birth. The time of
initiation should be documented. Skilled birth attendant should assist the mother in helping breastfeed
the baby. The mother should be advised for demand feeding, both during day and night, at least 8-12
times a day. During each feed, one breast should be completely emptied before the baby is put to the
other breast. There is no need for additional water or other fluids except under medical supervision.

18
3. Care of the umbilical stump
The cord must be left open without any dressing. Check for redness and discharge. Do not apply any
medication on the cord. The cord usually falls after 4 to 10 days.

4. Skin care/ Bathing

It is preferable to bathe the baby when cord dries off. Healthy newborn can be given a bath after 48
hours but wait for seven days in case of LBW babies. Special precautions must be taken during
bathing to prevent draught and chilling. During the winter months, instead of bathing, the baby can be
sponged daily to avoid unnecessary exposure and risk of hypothermia. To keep a small baby clean,
advice mother to give a light oil massage followed by warm water sponging to clean the oil but
making sure that the room is warm, and the baby is not left uncovered for more than 10 minutes.
Mother/caregiver should not pour oil into any orifice, like the nose or ears at any time.

5. Weight Recording
All the infants should be weighed after stabilization and birth weight recorded. Mother/caregiver
should ensure regular recording of weight. A single-use paper towel or a sterile cloth towel should be
placed on the weighing scale beneath the infant. The weighing scale must be periodically (at least
weekly) calibrated.

6. Vitamin K
CHO will ensure administration of Vitamin K injection. Vitamin K should be administered
intramuscularly on the antero-lateral aspect of the thigh using a 26-gauge needle and one ml syringe.
Dose to be used is 0.5 mg for babies weighing less than 1000 g and 1.0 mg for those weighing above
a 1000 gms at birth.

7. Care of the eyes

Routine application of antiseptic or ointment for prevention of ophthalmianeonatorum is not
recommended. Some neonates may develop persistent epiphora (watering) due to blockage of
nasolacrimal duct by epithelial debris. The mother/caregiver should be advised to massage the
nasolacrimal duct area (by massaging the either side of the nose adjacent to the medial canthus) 5 to 8
times daily, each time before she feeds the baby. The use of kajal must be avoided as it may transmit
infections, cause injury or even cause lead poisoning.

8. Immunization
It is recommended to give BCG, zero dose of oral polio vaccine and birth dose of Hepatitis B
vaccine. Refer to the section on immunization for details.

9. Danger Signs in the baby should be explained to the mother/caregiver before discharge and she
should be advised to bring the baby to the facility if any of the following danger sign is observed.

▪ Baby cold/hot to touch

▪ Inability/ difficulty in feeding
▪ Difficulty in breathing/ fast breathing
▪ Abnormal movements
▪ Less movement
▪ Appearance of jaundice within 24 hours of age/ yellow staining of palms or

19
 soles

Caregivers/Family members may also be counselled to seek care in case of persistent vomiting,
excessive crying, drooling of saliva or choking during feeding, bleeding from any site, superficial
infections such as conjunctivitis, pustules, umbilical sepsis, (redness at base of the stump and
discharge), oral thrush, etc.

Before discharge from the SHC-HWC, you must ensure that-

▪ Infant has been immunized, no signs of illness including significant jaundice and is being
breastfed adequately.
▪ Mother is free from any significant illness and confident to take care of her infant, advised
regarding danger signs and care seeking.
▪ Next follow up visit is scheduled and informed to the mother/caregiver.

Key messages to remember for care of the newborn

▪ Keep the mother and newborn together
▪ Lactating mother to continue with a nutritious diet
▪ Breast feed the baby exclusively
▪ Practice handwashing to prevent infection
▪ Mother/caregiver must be aware of the danger signs and seek care promptly, after
discharge
▪ If the baby is born before term or is low birth weight baby, the mother/caregiver should
provide Kangaroo Mother Care (KMC) or continue assisted breast feeding if required.
▪ If the baby has been discharged from NBSU/SNCU then continue the follow up as
advised.

In this chapter, you have gained an understanding regarding the Facility Based Newborn Care
(FBNC), health services available at different levels of newborn care and care to be provided at birth
and counselling before discharge from SHC-HWC. In the next chapter, you will learn about the
various community-based programmes for children.

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Chapter 3: Community Based Programmes for
Children

Multiple interventions at community and facility level are needed to enable optimal growth and
development of children. As a CHO, you should be aware of the key initiatives that are targeted for
children. The details are as follows-
1. Mothers Absolute Affection (MAA) programme for appropriate Infant and Young Child
feeding (IYCF)
▪ Early initiation of breastfeeding (colostrum feeding) within one hour
▪ Exclusive breastfeeding for six months
▪ Appropriate complementary feeding on completion of 6 months of age
▪ Counselling for continued breastfeeding up to 2 years and beyond
▪ Active feeding for children during and after illness

2. Micronutrient Supplementation and Deworming

▪ Iron and Folic Acid (IFA) supplementation (from 6month-59 month and 5-9 years)
▪ Vitamin A prophylaxis programme (9 month – 59 month)
▪ Deworming in children and adolescent (1-19 years)

3. Support for Development care (to ensure Early Childhood Development)

▪ Identify the interaction between a child and a parent
▪ Counsel mothers/families on play and communication activities
▪ Discuss age- appropriate activities for the child

4. Early detection, prevention and management of common childhood illnesses (IMNCI)

▪ Prevention and early detection of malnutrition
▪ Promoting healthy practices for Infant and Young Child Feeding
▪ Enabling Early Childhood Development
▪ Ensuring Immunization
▪ Prevention and management of common childhood illnesses (fever, jaundice, diarrhoea,
pneumonia, etc.)

5. Coordinating for screening and management of 4Ds-Developmental delays, Defects, Disease

and Deficiency Disorders under RBSK, covering children at birth to 18 years of age.

6. Other National Programmes related to Nutrition -

▪ Integrated Child Development Services (ICDS) Scheme

21
▪ National Programme of Mid-Day Meal in Schools (MDMS)
▪ National Iodine Deficiency Disorders Control Programme (NIDDCP)

3.1 Need for community-based programmes for children

National Health Policy (2017) and Sustainable Development Goal- 3 (Good Health and Well-being
for people) lays emphasis on improving the health of both mother and children by reducing some of
the preventable causes associated with maternal and child mortality. Even with significant decline in
child mortality over the last decade, there continues to be challenges related to child health and
nutrition indicators that need our targeted attention.

According to National Family Health Survey (NFHS-4, 2015-16)-

▪ 41.6% children under 3 years are breastfed within one hour of birth.
▪ 54.9% children under age 6 months are exclusively breastfed.
▪ 9.6% of total children aged 6-23 months receive an adequate diet (adequate diet means-feeding several times a
day as per the age recommendation and giving a diverse variety of foods to meet the requirement for optimal
growth and development).
▪ 42.7% of children aged 6-8 months receiving solid or semi-solid food and breast milk.
▪ 35.7% of children under 5 years are underweight (weight-for-age).
▪ 38.4% of children under 5 years are stunted (height-for-age).
▪ 21% of children under 5 years are wasted (weight-for-height).
▪ 7.5% of children under 5 years are severely wasted (weight-for-height).
▪ 62% of children aged 12-23 months are fully immunized (BCG, measles, and 3 doses each of polio and DPT).
▪ 60.2% of children age 9-59 months who received a vitamin A dose in last 6 months.
▪ 50.6% children with diarrhoea in the last 2 weeks received oral rehydration solution (ORS).
▪ 73.2% children with fever or symptoms of Acute respiratory Infection (ARI) sought treatment/advise in the
health facility in last 2 weeks.
▪ 58.4% children between 6-59 months of age are anaemic (haemoglobin level less than 11.0 g/dl).

According to the Comprehensive National Nutrition Survey (CNNS), 2016-18 from 30 states in India-
Children aged 5-9 Years-

Variables Male Female Urban Rural Total

Children aged 5-9 years who are stunted (height-for- 21.6 22.1 17.8 23.1 21.9
age) (%) (Below -2 standard deviations (SD), based
on WHO standards)

Children aged 5-9 years who are severely stunted 5.8 5.3 3.7 6.1 5.5
(height-for-age) (%) (Below -3 standard deviations,
based on WHO standards)

Children aged 5-9 years who are moderate or 25.7 20.3 19.8 24.0 23.0
severely thin (BMI for age) (%) (z-score < -2 SD,

22
 based on WHO standards)

Children aged 5-9 years who are severely thin (BMI 5.9 3.9 4.7 4.9 4.9
for age) (%) (z-score < -3 SD, based on WHO
standards)

The above indicators reflect sub-optimal infant and young child feeding practices, low immunization
coverage, common childhood infections, undernutrition in children, etc. which are chiefly
attributable to poor awareness and knowledge regarding nutritious diet during pregnancy and
lactation period, child feeding practices (low rates of breast feeding), dietary diversification
(consuming foods from all four food groups2), food fortification, health-care seeking behaviour in
case of maternal, post-natal illness, growth monitoring, hygiene and sanitation practices, integrated
management of neonatal and childhood illness (IMNCI), immunisation, etc. Even in the school-age
children (5–9 years), poor nutritional status in both rural and urban areas is observed and thus this
age group also requires focussed interventions.
It is also observed that around 3 months of age and beyond, problems such as lack of breastfeeding
or faltering in exclusive breastfeeding plays as one important risk factor of undernutrition and
sickness during this first two years of life. Also, delay in initiation or inadequate complementary
feeding beyond six months results in the child becoming undernourished. In addition, poor hygiene
and sanitation and poor child caring practices in the home during this period may also lead to
recurrent infections leading to sickness which results in sub-optimal physical growth and
development of the child. Home visits by primary health care team can help reduce the adverse
impact of these factors by counselling, preventive actions and early identification of health issues.
Considering the influence of diarrhoea, pneumonia, undernutrition and the importance of WASH
related interventions on overall child survival and development, addressing this gap in health system
contact is crucial.

One such flagship programme, aimed at improving nutritional outcomes among children by 2022 is
POSHAN Abhiyaan or the National Nutrition Mission.

3.2 POSHAN Abhiyaan

In 2018, Government of India launched POSHAN (Prime Minister Overarching Scheme for Holistic
Nourishment) Abhiyaan, to address malnutrition challenges in India. POSHAN Abhiyaan is a multi-
ministerial convergence mission with the vision to ensure attainment of malnutrition free India by
2022 (“kuposhan-mukt” India). The Ministry of Women and Child Development (MWCD) is
implementing POSHAN Abhiyaan in collaboration with various key Ministries and Departments.
The goal of POSHAN Abhiyaan is to achieve improvement in nutritional status of children 0-6 years,
adolescent girls, pregnant women and lactating mothers in a time bound manner. The Ministry of
Women and Child Development (MWCD) is implementing POSHAN Abhiyaan in convergence with

2
Four food groups- a. Cereals & Millets; Pulses (dals) & Legumes, b. Vegetables & Fruits, c. Milk
and Animal products and d. Fats/Oils, Sugar & Nuts.

23
other ministries, with Ministry of Health and Family Welfare (MoHFW) being an important
stakeholder in implementation of POSHAN Abhiyaan. Anemia Mukt Bharat (AMB) strategy,
Intensified Diarrhoea Control Fortnight (IDCF), Mother’s Absolute Affection Programme (MAA),
Immunization, Home Based Newborn Care (HBNC) and Home-Based Care of Young Children
(HBYC) are the important components of the POSHAN Abhiyaan implemented by MoHFW.
The goals of POSHAN Abhiyaan related to children are to:
Targets of POSHAN Abhiyaan
Prevent and reduce stunting in children (0- 6 years) By 6% @ 2% per year
Prevent and reduce undernutrition (underweight prevalence) in By 6% @ 2% per year
children (0-6 years)
Reduce the prevalence of anaemia among young Children (6-59 By 9% @ 3% per year
months)
Reduce Low Birth Weight (LBW) By 6% @ 2% per year

Pillars of POSHAN Abhiyaan

▪ Ensuring access to quality services across the continuum of care to every woman and child,
particularly during the first 1000 days of the child’s life
▪ Convergence- Ensuring convergence of multiple programmes and schemes: ICDS, Pradhan
Mantri Matri Vandana Yojana (PMMVY), NHM (with its sub components such as JSY, MCP
card, Anemia Mukt Bharat, RBSK, IDCF, HBNC, HBYC, Take Home Rations), Swachh Bharat
Mission, National Drinking Water Mission, NRLM, etc.
▪ Use of Information and Communication Technologies (ICT) Based Real Time Monitoring
system - ICDS- Common Application Software (ICDS-CAS)- to empower the AWW with near
real time information to ensure prompt and preventive action, rather than reactive one.
▪ Training and Capacity building- Incremental Learning Approach to be adopted to teach 21
thematic modules.
▪ Jan Andolan- Engaging the community in this Mission to ensure that it transcends the contours of
being a mere Government programme into a peoples’ movement inducing large scale behaviour
change with the ownership of the efforts being vested in the community rather than government
delivery mechanisms, to create awareness about health.

3.2.1 Some of the key community-based programmes being implemented for children are as
follows

1. Mother’s Absolute Affection (MAA) Programme

Promotion of breastfeeding and counselling support are important to improve the rates of exclusive
breastfeeding and child feeding practices. Policy and programmes are in place from various
Ministries to promote, protect and support breastfeeding and this includes provision of paid
maternity leave in all factories & Government institutions. Infant Milk Substitutes, Feeding Bottles,
and Infant Foods (Regulation of Production, Supply and Distribution) Act, 1993, and amendment
Act 2003 has been enacted by Government of India in the country to protect and promote

24
breastfeeding and ensure proper use of infant foods. This act provides for the regulation and
irrational promotion of production, supply and distribution of infant milk substitutes, feeding
bottles and infant foods.

“MAA-Mother’s Absolute Affection'’ is a nationwide programme launched in the month of

August 2016 to bring focus on promotion of breastfeeding and provision of counselling services for
supporting breastfeeding through health systems. ‘MAA’ signifies the support a lactating mother
requires from family members and at health facilities to breastfeed successfully. The main
components of the MAA Programme are as below-

a) Community awareness generation- through mass media and mid media focusing on main
barriers of breastfeeding namely the myth of ‘Not enough milk’, issues related to correct
technique of breastfeeding, issues related to breastfeeding of a first time/working mother

b) Strengthening inter personal communication through ASHA- by conducting mothers’

meetings for all pregnant & lactating mothers for advocacy on breastfeeding and appropriate
complementary feeding

c) Skilled support for breastfeeding at delivery points in public health facilities- to equip
them to protect breastfeeding, handle various breastfeeding challenges, complementary
feeding, growth monitoring etc. with special focus on high case load facilities using dedicated
training packages including one day sensitization module, 4-days IYCF training package for
ANM/MPW-F along with a counseling guide and the trainer’s guide are available.

d) Monitoring and Award/recognition- Team awards of the amount Rs. 10,000 would be given
to facilities showing good performance on breastfeeding as per pre-decided criterion and
evaluation by expert teams.

2. Micronutrient Supplementation

2.1 Anaemia Mukt Bharat (AMB) Strategy

The Anemia Mukt Bharat Strategy aims to reduce anemia prevalence in the six target age groups via
six interventions based on six robust institutional mechanisms.The six target age groups are- pre-
school children (6-59 months), children (5-9 years), adolescents (10-19 years), women of
reproductive age group (15-49), pregnant women and lactating mothers, thereby breaking the inter-
generational chain of anaemia and subsequently reducing its overall prevalence. The six
interventions under Anemia Mukt Bharat strategy are as follows:
▪ Prophylactic Iron Folic Acid (IFA) Supplementation
▪ Deworming
▪ Intensified year-round Behaviour Change Communication
Campaign including delayed cord clamping
▪ Testing and Treatment of anemia using digital methods and
point of care treatment
▪ Mandatory provision of Iron Folic Acid fortified foods in public health programmes

25
▪ Addressing non-nutritional causes of anaemia in endemic pockets, with special focus on
Malaria, Hemoglobinopathies and Fluorosis

Early detection of anaemia especially severe anaemia in children by RBSK mobile health team with
corrective measures should be taken.
The primary healthcare team at SHC-HWC should educate and create awareness generation amongst
mother/caregiver especially among the vulnerable section of the population attending the SHC-
HWC, VHSND session, VHSNC meeting, anganwadi centres, home visits and campaigns about the
prevalence of childhood anaemia, its ill effects, and its prevention by promoting consumption of iron
and vitamin C rich foods, avoiding consumption of inhibitors in the diet like tea, coffee with meals
or IFA syrup. There should be a minimum gap of at least for one hour before and after meals or IFA
syrup for consumption of tea/coffee.

Provision of Fortified foods in government-funded health programmes-

Food fortification refers to the addition of micronutrients (vitamins and minerals required in small
amounts for development) in a food so as to improve the nutritional quality of food at very reasonable
cost and to provide public health benefit with minimal risk to health. Fortified food is a food which has
undergone the process of fortification as per regulations. The Government of India has mandated the use
of fortified salt, wheat flour and oil in foods served under Integrated Child Development Services
(ICDS) and Mid-day Meal (MDM) schemes to address micronutrient deficiencies. In addition, all health
facility-based programmes where food is being provided are mandated to provide fortified wheat, rice
(with iron, folic acid and vitamin B12), and double fortified salt (with iodine and iron), and oil (with
vitamin A and D) as per standards for fortification of staple foods (salt, wheat, rice, milk and oil)
prescribed and notified by the Food Safety and Standards Authority of India (FSSAI, 2016).
As a CHO, you should ensure that fortified foods with +F logo is provided in all government-funded
health programmes where food is being provided such as Anganwadi centres under Integrated Child
Development Services (ICDS) and in schools under Mid-day Meal (MDM) schemes; fair price shops
through public-distribution system, local ration shops, kendriya bhandars, any other state-specific
government scheme, etc. VHSNC members along with primary healthcare team members, support
groups, self-help groups, etc. can provide support in helping generate public demand for availability of
+F fortified foods.

2.2 Vitamin A Prophylaxis Programme

Vitamin A deficiency is one of the simplest preventable nutritional disorders. Deficiency of Vitamin
A in children can cause blindness. Vitamin A is essential for maintenance of healthy epithelium,

26
skeletal growth, protection of body against infection and normal vision. Early detection of Vitamin A
deficiency in children by RBSK mobile health team with corrective measures should be taken.
The different strategies under the programme are-
1. Periodic dosing (supplementation) of Vitamin A/ Prophylactic Vitamin A Supplementation-
The National Programme for Prevention and Control of Vitamin A Deficiency Disorder is in
operation since 1970. There is a provision for administering mega doses of vitamin A. It
recommends for at least nine doses of vitamin A to be given to all children aged 9 to 59 months.
The first dose of 100,000 International Unit (IU) is administered with measles vaccination at 9
months and subsequent doses of 200,000 IU each, every six months till 5 years of age. Some states
also conduct biannual rounds of Vitamin A supplementation in campaign mode.
2. Fortification of commonly consumed foods- Fortification of suitable, universally consumed
foods is considered a cost- effective public health intervention in the control of many micronutrient
deficiencies. Food items like oil and milk are fortified with Vitamin A and Vitamin D as prescribed
and notified by FSSAI. However, there is no national public health programme for fortification for
eradication of vitamin A deficiency as yet.

3. Dietary modification for production and consumption of vitamin A/ beta carotene rich
foods- Regular consumption of vitamin A and beta carotene rich foods by children such as milk and
milk products, butter, ghee; eggs, liver, meat, chicken, fish, dark green leafy vegetables like cholai
(amaranthus), drum-stick leaves, methi (fenugreek), spinach (palak), sarson saag (mustard), turnip
leaves, coriander, radish leaves, bathua leaves; yellow and orange vegetables and fruits like carrots,
tomatoes, pumpkin, jackfruit (kathal), sweet potato (shakarkandi), papaya, mango, apricots
(khoomani), cabbage, etc. and appropriate breastfeeding (colostrum is rich in Vitamin A). Home
garden/Community garden to grow vitamin rich vegetables and fruits should be encouraged,
wherever applicable.
4. Nutrition Education- Create awareness and knowledge in the community regarding the
importance of vitamin A rich foods and thereby improve their consumption.

The primary healthcare team at SHC-HWC should educate and create awareness generation amongst
mother/caregiver especially among the vulnerable section of the population attending the SHC-
HWC, VHSND session, VHSNC meeting, anganwadi centres, home visits and during health
campaigns about deficiency diseases of vitamin A in children, its ill effects, and prevention by
consumption of locally available, seasonal Vitamin A rich foods and encouraging breastfeeding
focusing on colostrum feeding and Vitamin A supplementation.
2.3 National Deworming Day (NDD)
To combat parasitic worm infections among preschool (anganwadi) and school-age children,
Government of India has adopted a single- fixed day strategy called National Deworming Day,
during which, albendazole 400 mg chewable tablets is administered to all children from 1-19 years of
age through the platform of schools and anganwadi centres on 10th February and 10th August every
year. NDD is followed by MUD (Mop Up Day) after 7 days of NDD for missed children.
3. Home Based Newborn Care (HBNC) Programme
Under this programme, all newborns are visited as per the at home by ASHAs in her area to provide
essential newborn care, prevention of neonatal complications, early identification of neonatal

27
illnesses and provision of appropriate care and referral and support the mother/caregiver to adopt
healthy practices. She conducts six visits in case of institutional delivery and seven visits in case of
home delivery in the first 42 days of life.

The structured schedule of home visits undertaken by ASHAs for providing essential newborn care
are given below.

Newborn- Institutional 6 Home-Visits- 3rd day, 7th day, 14th day, 21st day, 28th day and 42nd day.
delivery
(born in health facility)
Newborn- Home 7 Home-Visits- ASHA should be there at birth or at least visit within the first
Delivery hour on day of birth (1st day), 3rd day, 7th day, 14th day, 21st day, 28th day and
42nd day.
High-risk babies- Pre- Additional visits are needed for high-risk babies- a daily visit, if possible, for the first
term babies, low-birth week and once every three days until the baby is 28 days old.
weight babies, small For babies discharged from Special Newborn Care Unit (SNCU)/ Newborn
babies, sick babies, Stabilisation Unit (NBSU)/ Nutrition Rehabilitation Centre (NRC)- ASHAs would
malnourished babies, make the first home visit within 24 hours of discharge (Day of discharge is counted
babies discharged from as day 1 of home visit schedule) and the six remaining home visits will be completed
SNCU/ NBSU/NRC as per HBNC visit schedule i.e. 3rd day, 7th day, 14th day, 21st day, 28th day and 42nd
day from the day of discharge. In case the newborn gets admitted after few days of
birth, ASHA will complete the remaining visits after discharge.

The aim is providing essential care for newborn in the first six weeks of life when maximum
mortality takes place. The HBNC visits enabled continuity of care and ensured survival of the new
born. ASHA is provided with a kit with essential medicines and equipment required to conduct these
visits. She identifies newborn who are sick and refers them to the SHC-HWC for further
management. During the home-visits, the ASHA fills the Mother-Newborn Home Visit Card (HBNC
card/form) which captures information regarding post-natal care of mother and newborn care and
help identify danger signs in both mother and child. The filled HBNC card/form is verified/checked
by MPW-F/ASHA Facilitator for ensuring quality of home visits and for any further management.

The ASHA receives an incentive of INR 250 for competing all the 6/7 visits. The conditionality for
incentive includes: registration of birth, recording of weight and completion 1st dose of OPV and
DPT vaccination and recording in Mother Child Protection (MCP) card.

As the CHO, you must ensure that the ASHA identifies high risk newborns and helps you to keep
track of their health and wellbeing in the neonatal period and first year of life.

HIGH RISK NEWBORN BABIES

1. Babies born before full term (preterm)
2. Birth weight less than 2.5 kg (low birth weight babies)
3. Sick babies discharged from SNCU after treatment
4. Newborns with congenital anomalies/birth defects
5. Newborn whose mother is either sick/dead or cannot take care

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4. Home-Based Care for Young Child (HBYC)
Under NHM, MoHFW has launched Home Based Care for the Young Child (HBYC) programme
under POSHAN Abhiyaan as convergent action with the Ministry of Women and Child
Development to strengthen health and nutrition status of young children.
The objective of Home-Based Care for Young Child is to:
▪ Reduce child deaths and illnesses;
▪ Improve nutritional status of young children; and
▪ Ensure proper growth and early childhood development of young children.

As part of HBYC initiative, ASHA undertakes five additional home visits after the 42nd day, in
addition to the 6/7 visits for HBNC. ASHA will visit the child on completion of 3 months, 6
months, 9 months, 12 months and 15 months. In addition, the quarterly follow-up home visits
schedule starting from 3rd month onwards till one year of life for low birth weight babies, SNCU
and NRC discharged children that ASHAs are already making will be integrated into this HBYC
schedule.
Home visits will allow ASHAs to increase contacts with the child and parents/caregivers during the
first fifteen months of life. This will help to identify problems early and support families in taking
the appropriate action, whether through improved home care practices or through referral to
appropriate health facilities. .
The additional home visits by ASHAs deliver interventions in four key domains namely nutrition,
health, child development and WASH (water, sanitation and hygiene, including safe faeces
disposal). ASHA receives an incentive of INR Rs. 250/- for five additional home visits for each
young child (Rs. 50 per visit/child). In case of more than one child like twins/triplets, the amount of
incentive will be provided per child. ASHA fills the HBYC card after completion of specified
activities and get them validated by ASHA Facilitator or the ANM/MPW-F.
Area specific actions under HBYC

KEY DOMAINS SPECIFIC ACTIONS

NUTRITION ▪ Exclusive breastfeeding for six months
▪ Adequate complementary feeding from six months and continued breast
feeding up to two years of age
▪ Iron and folic acid (IFA) supplementation
▪ Promote use of fortified food
HEALTH ▪ Full immunization for children
▪ Regular growth monitoring
▪ Appropriate use of Oral Rehydration Solution (ORS) during diarrhoea
episodes
▪ Early care seeking during sickness
CHILD
▪ Age appropriate play and communication for children
DEVELOPMENT
WASH ▪ Appropriate hand washing practices

The additional home visits will provide opportunities for the following:

29
 ▪ Promote exclusive breastfeeding for the first 6 months of life.
▪ Emphasize timely, adequate and appropriate complementary feeding for children on
completion of six months and beyond.
▪ Counsel parents/ caregivers regarding age appropriate play and communication for children
(development support care).
▪ Build the capacity of mothers/caregivers through counselling and support to identify and
manage problems related to nutrition and health in their child.
▪ Allow for early identification of delay in growth and development of children by using the
MCP card.
▪ Enable prevention and management of common childhood illnesses.
▪ Ensure prompt referral of sick children to health facilities for management of complications.
▪ Follow-up for compliance to medication and care of sick children discharged from health
facilities.

As a CHO, you need to be familiar with all the key tasks that are to be undertaken at the community
level by ASHA and AWW to ensure care for the young child. You will coordinate with these two
functionaries, support and supervise so that they are able to undertake all the tasks listed below.

Key Tasks that will be undertaken by ASHA and AWW at community level to provide care for
the young child
Home visits ASHA AWW*

At 3rd ▪ Support for exclusive ▪ Weigh infants monthly

Month breastfeeding
▪ Record weight of the child and plotting
▪ Ensure recording/plotting of on growth chart (weight-for age)
growth chart-weight-for-age and
▪ Record length/height of the child and
weight-for-length/height by
plotting on growth chart (weight-for
AWW; identify growth faltering
length/height)
▪ Check immunization status
▪ Identify underweight and wasting in
▪ Counsel for the following- children and take appropriate action
a) Exclusive breast feeding (birth to ▪ Counsel regarding growth monitoring
6 months)
▪ Counsel mothers for exclusive
b) Hand washing practices breastfeeding from birth to 6 months of
age
c) Family Planning
▪ Distribute ‘Take Home Ration’ to
d) Parenting-ensuring appropriate
lactating mothers and counsel for
play and communication
nutrition of their child
▪ If the child is sick, has
▪ Check for developmental delays
development delay or danger
signs, provide counselling, first
contact care and refer if required.

30
At 6th, 9th, All above activities PLUS- All above activities PLUS-
12th and 15th
▪ Ensure that age-appropriate ▪ Distribute ‘Take Home Ration’ to
Months
complementary food is given on children (with additional THR to
completion of 6 months malnourished children) and provide
nutrition-specific counseling to
▪ Ensure measles vaccine and
mothers/caregivers for their children
Vitamin A dose is given as per
schedule ▪ Counsel regarding age-appropriate
complementary feeding on completion of
▪ Counsel for age-appropriate
6 months of age
complementary feeding on
completion of 6 months ▪ Counsel for deworming of children above
1 year of age
▪ Provide Oral Rehydration Salt
packet at home; demonstrate how
to prepare ORS and give to the
child when required
▪ Provide IFA syrup at home
▪ Teach mother/caregiver
regarding IFA syrup
administration; ensure that IFA
syrup is given to the child by the
mother/caregiver on a bi-weekly
basis
▪ Provide first contact care and
referral for illness

AWW*- Adapted from Operational Guidelines on Home-Based Care for Young Child, 2018.
In addition, you need to support and supervise the activities undertaken by ASHA, ASHA Facilitator
and MPW under HBYC. The specific role of ASHA Facilitator and MPW to support ASHA in
improving HBNC and HBYC activities listed below.

Role of ASHA Facilitator and MPW to support ASHA in improving HBNC and
HBYC activities
S. Activity ASHA Facilitator MPW
No.
1 Household visit ▪ Focus on equity and coverage of ▪ Focus on improving
services provided by ASHAs. technical skills and
knowledge of ASHAs to
▪ Ensure that all houses specifically
ensure quality of visits.
from marginalized communities
receive services from ASHAs. ▪ Review and give feedback
about the accuracy of
▪ Identify the gaps where ASHAs need
identification of illness and
additional hand holding and provide
referral decisions taken by
on the job mentoring support to
ASHAs.
ASHAs.
▪ Provide care to the children

31
 at home in cases where
families are not willing to
seek care at the health
facilities.

2 Ensure Logistics ▪ Collect and submit information about ▪ Support the replenishment
– Supply of availability of equipment and process by providing
Medicines and medicines with ASHAs to the next medicines from SHC,
Equipment level. whenever feasible.
▪ Support the process of replenishment ▪ Support the process of
through PHC. replenishment through PHC.

3 Support the ▪ Review and verify the payment ▪ Review and verify the
payment process vouchers and submit on a timely payment vouchers and
basis as per the defined process in submit on a timely basis as
the district/ state. per the defined process in
the district/ state.
▪ Keeping record of service
delivered and keeps health
events to be matched with
MCP card.
▪ Signing of forms for
payments of ASHA and
submit then timely at PHC
for timely payment.

4 Grievance ▪ Address the grievance immediately ▪ Discuss the issue and

Redressal and facilitate for quick redressal as provide technical support
per guideline. immediately.

5 Death reporting ▪ Collect death reports from ASHA, ▪ Collect information and
find out causes of death, visiting conduct joint visit to
household by using format 11 & 12, families, support ASHA for
support ASHA for preventing any addressing such issues to
such death further, share information reduce death.
with MPW & MO.

6 VHSNC/VHSND / ▪ See regularity of meeting, fund ▪ Inform and deliver services

MAS utilization and involvement of on VHSND to women and
community for developing health children when ASHA &
plan. Support ASHA to conduct AWW mobilizes them.
meetings.

7 Referral Services ▪ Motivate ASHA to identify seek ▪ Conducting joint visit to

child and refer to health facility. If family, do check up to seek
families are rigid, you should child and refer to facility
accompany ASHA to convince them after basic treatment.
and can take the support from
VHSNC member.

8 Monthly cluster ▪ Conduct meeting for review, ▪ Discuss the issue and its
meeting with

32
 ASHA planning and to solve issues. solution for benefit of all
Highlight issues for PHC meeting, ASHAs.
obtaining data from ASHA and bring
solidarity among ASHAs.

9 PHC/CHC level ▪ Attend meeting to facilitate for ▪ Provide technical input in

meeting with MO proper incentive payment to ASHA monthly training refresher
under various program. on HBYC.

10 Selection, training ▪ Select new ASHA if position vacant ▪ Provide hand holding
and support to or she is non-performing, ensure knowledge to ASHA to gain
ASHA ASHA attended rounds of training, her knowledge, confidence
support ASHA trainer for conducting for better service delivery.
effective training, support ASHA to
improve their effective functionality,
mentoring ASHA to conduct
VHSND and other village meetings.

Roles and responsibilities of CHO towards ensuring newborn and child care services under
HBNC and HBYC
1. As the in-charge of the SHC-HWC, your foremost role is to keep your staff updated, motivated
and supervised so that the staff can perform their duties effectively. In case the SHC-HWC is a
delivery point it is important to provide supervision to see the care around birth.
2. Ensure and validate the records of newborn in the MCP card at the time of institutional delivery
and arrange for the birth certificate to be issued.
3. In case of the danger signs in young infant and child, perform pre-referral stabilization and
facilitate referral. If there are no danger signs manage as per IMNCI protocols and follow up. You
will read about it in subsequent chapters.
4. Support and supervise the MPW or ASHA Facilitators in undertaking joint home visits with
ASHAs in resolving challenges faced by ASHAs in providing care under HBNC and HBYC
programme, with special focus on marginalized and vulnerable population and resistant families.
You will also accompany the ASHA and MPWs to beneficiary households where additional support
is required for motivating families to adopt healthy child practices.
5. An updated line list of all newborns and children till 15 months of age in your catchment area
should be available with ASHAs, MPWs and yourself. Amongst these, identify and pay extra
attention to newborns, young infants or children who are high-risk as described above, refer to
appropriate health facility for further management and follow-up/constantly track them to ensure
adherence to treatment plan and ensuring recovery.
6. During your interaction with mothers/caregivers counsel them regarding her physical well-being,
nutritional support during lactation, use of modern method of contraception, keeping the new born
warm, eye/cord care, promotion of exclusive breastfeeding for the first six months of a child’s life,
age-appropriate complementary feeding practices for all children aged 6–24 months, responsive
feeding, continuation of feeding during illness, importance of hand-washing, using clean drinking
water and its storage, safe sanitation and hygiene practices, age-specific immunization, appropriate
play and communication with the child, etc. for proper growth and development.

33
7. Mobilize the lactating mothers and their children for registration at the nearby AWC to receive
‘Take Home Ration’ (THR) for themselves and their children beyond 6 months of age and additional
THR to malnourished children.
8. Update the records of new born and children in RCH Portal and other IT applications/registers that
have been developed for tracking of HBNC and HBYC.
9. As a CHO, you also need to be familiar with all the key tasks that are to be undertaken at the
community level by ASHA, MPW and AWW to ensure care for the newborn and child.

Details regarding Early Childhood Development and RBSK programme have been covered in detail
in Chapters 10 and 11, respectively.

5. Early detection, prevention and management of common childhood illnesses (IMNCI)

5.1 Intensified Diarrhoea Control Fortnight (IDCF)

In order to increase awareness about the use of ORS and Zinc during diarrhoea, an Intensified
Diarrhoea Control Fortnight (IDCF) is being observed in the monsoon season every year since 2014,
with the ultimate aim of ‘zero child deaths due to childhood diarrhoea’. During fortnight health
workers visit the households of under five children, conduct community level awareness generation
activities and distribute ORS packets to the families with children under five years of age.

5.2 SAANS (Social Awareness and Actions to Neutralize Pneumonia Successfully) Initiative
This was launched on 16th November 2019 to accelerate action to reduce deaths due to Childhood
Pneumonia. The SAANS initiative encompasses a three-tiered strategy:
i) National Childhood Pneumonia Management Guideline on treatment and management of
Childhood Pneumonia;
ii) Skill building and training of service providers for identification and standardized management of
Pneumonia; and
iii) 360-degree communication SAANS Campaign to ensure greater awareness on Childhood
Pneumonia among families and parents in order to trigger behaviour change and improve care
seeking.

One of the key outcomes of all the community-based programs is early detection of sick children.
Counselling on key rearing practices also include making the family aware of the danger signs and
importance of early care seeking. Free referral of infant up to one year of age is entitled under JSSK.

GOI released a guideline on Strengthening of pediatric care at District hospital for facility-based
care of sick children. RMNCAH+N matrix for essential commodities ensured nebulizers and
essential pediatric drugs even at PHC level.

The training packages Integrated Management of Childhood Illnesses (IMNCI & F-IMNCI) trains
the health providers in both outpatient and inpatient treatment of sick child

Pre-referral stabilization of sick child, prior information to the referring unit and ensuring complete
details on referral slip adds a lot in improving the outcome of sick child.

Remember timely access to the facility-based care by a sick child reduces both mortality and
morbidities.

34
6. Other National Programmes related to Nutrition)
In India many nutritional programmes are being implemented to improve the nutritional status of the
people with emphasis on women and children. Nutrition education plays an important role in
prevention and control of nutritional deficiency diseases.

Given below are some of the important nutritional programmes for children. You have already
learned about these programmes in the six-month course in Certificate Programme in Community
Health.

6.1 Integrated Child Development Services (ICDS) Scheme

ICDS Scheme launched on 2nd October, 1975, is one of the flagship programmes of the Government
of India and represents one of the world’s largest and unique programmes for early childhood care
and development. The beneficiaries under the Scheme are children in the age group of 0–6 years,
pregnant women and lactating mothers. This scheme provides a platform in the form of Anganwadi
Centres for providing all services under the Scheme.

Services under ICDS- The ICDS Scheme offers a package of six services-
▪ Supplementary Nutrition- Children in the age group of six months to 6 years (including those
suffering from malnutrition (undernutrition), pregnant and lactating mothers till six months after
child birth. This entails the following for children-

S. No. Categories Type of meal or food as per the nutritional standards

1 Children (between 6 Take Home Ration as per Anganwadi Services- in form of premixes/
to 36 months) ready-to-eat food
2 Malnourished children Take Home Ration as per Anganwadi Services- in form of premixes/
(between 6 to 36 ready-to-eat food with extra calories and proteins
months)
3 Children (between 3 Morning snacks in the form of milk/banana/egg/seasonal fruits/micro-
to 6 years) nutrient fortified food followed by a hot cooked meal
4 Malnourished children Additional calories and protein in addition to the meal or food provided
(between 3 to 6 years) to children between three to six years

▪ Pre-school non-formal education- Children for 3-6 years of age

▪ Nutrition and health education- Women (15-45 years) nursing and expectant mothers
▪ Immunisation- Children below 6 years, pregnant and lactating mothers
▪ Health check-up- Children below 6 years, pregnant and lactating mothers
▪ Referral services- Children below 6 years, pregnant and lactating mothers

6.2 National Programme of Mid Day Meal in Schools

In order to combat malnutrition and improve the health of school children, school meal provides best
opportunity for nutrition education for removing prejudices and imparting good dietary habits. This
scheme of Ministry of Education aims at enhancing enrollment, retention and attendance and
simultaneously improving nutritional levels among children studying in Government, Local Body
and Government aided primary (classes I to V) and upper primary schools (VI-VIII class) and the

35
Centres run under Education Guarantee Scheme/Alternative & Innovative Education and National
Children Labour Project schools of all areas across the country. The primary aim of the programme
is to provide at least one nourishing meal to the school going children per day free of charge every
day except on school holidays.

The objectives are to:

i) serve as an incentive for the children to attend school on all working days
ii) reduce dropouts from school
iii) improve the nutritional status of the child
It also serves as an opportunity to impart basic health /nutritional education to children. This
programme provides a supplement to the children, and not a substitute to the food eaten at home. The
meal provides one third the total daily energy requirement and half the need of proteins to the child.

6.3 National Iodine Deficiency Disorders Control Programme (NIDDCP)

Goitre and cretinism (severe hypothyroidism in an infant or child) are the two outstanding clinical
manifestations of endemic iodine deficiency. Iodine deficiency is one of the main causes of impaired
cognitive development in children. The characteristic features of cretinism include deaf, mutism,
squint, mental retardation, and spastic neuro–motor disorders. Early detection of goitre in children by
RBSK mobile health team with corrective measures should be taken.

Strategies for preventing Iodine Deficiency Disorders are-

1. Fortification- Availability of iodized salt for nation-wide consumption to combat this nutritional
disorder. It is the most economical convenient and effective means of mass prophylaxis.
Salt is usually fortified with potassium iodate. Daily consumption of 10 gm of iodized salt (25 ppm)
of potassium iodate provides about 150 micro gm of iodine at the consumer level. There is also
double fortified salt (iodised salt with iron) now available as per FSSAI. However, However, there is
no national public health programme for double fortification of salt (with both iodine and iron) for
eradication of IDD as yet.
2. Communication campaign- A mass communication campaign is needed to create awareness in
the community about the consequences of IDD and the benefits of iodized salt. Education of the
community regarding intake of iodised salt for kitchen and table use and simple measures such as
keeping common salt in closed bottles having a tight lid so as to minimise iodine loss during storage,
by not putting salt in boiling vegetables but sprinkling after cooking to preserve iodine, etc,
organising special health education campaign in the schools, SHC-HWC, AWCs, VHSND session,
regarding the disease and the ways to control IDD are effective measures.

The primary healthcare team at SHC-HWC should educate and create awareness generation amongst
mother/caregiver especially among the vulnerable section of the population attending the SHC-
HWC, VHSND session, VHSNC meeting, anganwadi centres, home visits and campaigns about
iodine deficiency disorders in children, its ill effects, and its prevention by promoting consumption
of iodized salt/ double fortified salt (wherever available) and encourage shopkeepers on selling
iodised salt.7. Community Platform- Village Health Sanitation and Nutrition Day (VHSND)

VHSND is a joint initiative of the Ministry of Health and Family Welfare and the Ministry of
Woman and Child Development for addressing the nutrition concerns in children, adolescent girls,
pregnant women and lactating mothers. It is a common platform for allowing the beneficiaries
(pregnant women, lactating women, children 0-6 years old, children for immunization, undernourished

36
children including SAM children (0-59 months) and adolescent girls (10-19 years) to access the services
of the MPWs, CHO, ASHA, Anganwadi Worker (AWW) and Anganwadi Helper (AWH). It is to be
organized in every village once a month at the Anganwadi Centre (it can also be held more than once
depending on the local context e.g. high population villages) or in any other government building
that is conveniently located, easily accessible and has adequate space for the different activities. It
serves as a platform to provide health, nutrition, early childhood development, and sanitation
services to all the beneficiaries especially to marginalized and vulnerable communities.
▪ The health component includes basic health services and counselling for reproductive, maternal,
newborn, child and adolescent health, communicable diseases, and non-communicable diseases
(NCDs).
▪ The nutrition component includes services as well as counselling related to growth monitoring,
promotion of infant and young child nutrition including breast feeding and complementary
feeding, maternal nutrition, micronutrients and dietary diversity.
▪ Early childhood development emphasizes age appropriate play and communication for children.
▪ The focus of sanitation is on promoting hygiene, hand washing, safe drinking water and use of
toilets.
ASHA, MPW-F/ANM and AWW in addition to providing routine services and interpersonal
counselling to beneficiaries, will jointly conduct group counselling sessions with all beneficiaries
including pregnant women, adolescents and caregivers of children for awareness generation and
behaviour change as per month-wise theme. Group counselling on topics related to immunization,
Vitamin A supplementation, food fortification, importance of micronutrients, deworming, early
initiation of breastfeeding, early childhood care and education, diarrhoea prevention and
management, anaemia prevention in children, optimal breastfeeding practices and IYCF, nutrition
activities (Poshan Maah) including promotion of kitchen garden, hygiene, sanitation and safe
drinking water, growth monitoring and child development, acute respiratory infections (ARIs) and
Pneumonia, appropriate complementary feeding, responsive feeding, etc. can be taken.
Role of CHO for a successful VHSND
▪ Provide supportive supervision and monitor the VHSND session (you are required to monitor at
least two VHSNDs in a month) by filling VHSND Site Monitoring Checklist. The checklist
includes observations and record review. Submit the filled monitoring checklist to the Block
level nodal officer (Health) along with feedback for improvement.
▪ Ensure that the ASHA/AWW mobilizes the targeted beneficiaries for attending the VHSND
session. Representatives of Panchayat and the VHSNC will help Anganwadi workers and ASHAs
to publicize VHSND and display them at appropriate public places. They may also help AWWs
and ASHAs in community mobilization especially for the hard to reach and resistant families
as well as in logistics arrangements for VHSND session.
▪ Ensure presence of ASHA, MPW, Anganwadi Worker and Anganwadi Helper during the entire
session.
▪ Ensure that community level workers (ASHA, MPW, AWW, AWH and PRI representative)
organize and manage the VHSND session- adequate space/corners for carrying the activities,
availability of adequate supplies including MCP card, contraceptives, medicines, vaccines and
functional equipment at the site and undertake their roles and responsibilities for providing the
routine services and jointly provide nutrition and health education and conduct group counselling
sessions as per monthly theme.

For more details on VHSND please visit -

https://nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/CH/Guidelines/National_Gui
delines_on_VHSND_English_Low_Res.pdf

37
Chapter 4: Assessment and care of sick young infant
(0-2 months of age)
In children under five years of age, pneumonia, diarrhoea, malaria and neonatal infections are the
most important causes of death. Malnutrition, especially undernutrition, increases the risk of
death. Low birth weight and poor feeding are the major reasons for malnutrition in infants and
children. Many children and infants suffer from more than one illness at a time.

Outpatient Management of Children is an integrated approach that includes the assessment,

classification and management of the major problems as infant or a child aged less than 5 years may
have. It also includes assessment of nutritional and immunization status of all sick infants and
childre
n.
In this chapter you will learn the following:
✓ Assess young infants (0-59 days) for possible bacterial infection, jaundice and
diarrhoea
✓ Check if infant has difficulty in feeding & Very
Low Weight (<1800 gms)
✓ Check the young infant’s immunization status
✓ Provide pre-referral treatment and refer when required
✓ Address breastfeeding problems
✓ Advise the mother on home care for the sick young infant

ASSESS AND CLASSIFY THE SICK YOUNG INFANT

Sick young infants are somewhat different from older children. Sick young infants frequently have
only general signs like lethargy, low body temperature or fever. They can become sick very quickly
and may die within a few hours or days. These are some of the reasons why young infants have to be
managed differently.

Tips for effective communication

▪ Greet the mother/caregiver and listen carefully to what they tell you.
▪ Ask the questions in a way which the mother/caregiver understands.
▪ Give the mother/caregiver time to answer the questions; ask additional questions when the
mother/caregiver is not sure about the answer.
▪ Ask mother/caregiver additional questions to help give clearer answers. Nod, Hmmm…. when
mother/caregiver is saying something.
▪ Do not appear to be in a hurry.

History taking in a newborn is complex as the presenting complaints are the observations of the
mother/care giver and therefore need to be reviewed critically.

38
The details of antenatal period and events at/ around the time of delivery (place of delivery, type of
delivery and did the newborn required any assistance) and the postnatal period are very relevant.
Check MCP Card for entry in date/time of birth/status of the mother and newborn at discharge,
breastfeeding and immunization status.

As a CHO, you will undertake the following activities for the management of common health
problems in the young infant.

1. ASSESS EVERY YOUNG INFANT FOR POSSIBLE BACTERIAL INFECTION AND

JAUNDICE

If one or more than one sign is present, do pre-referral stabilization and arrange for 108 ambulance
for referral to the appropriate health facility (NBSU at CHC/FRU or SNCU at SDH/District
Hospital).

ASK: LOOK, LISTEN & FEEL:

Count the breaths in one minute.

Is the infant having
difficulty in feeding?
Repeat the count if elevated.
Look for severe chest indrawing. } Young infant
must be calm
Look at the umbilicus. Is it red or draining pus?
Has the infant had
convulsions? Look for skin pustules.
Measure axillary/armpit temperature (if not possible feel for fever or low
body temperature).
Look at the young infant’s movements.

If infant is sleeping, ask the mother/caregiver to wake him/her.

- Does the infant move on his/her own?

If the infant is not moving, gently stimulate him/her.

- Does the infant not move at all?

-Look for jaundice?

Are the palms and soles yellow?

ASK: Is the infant having difficulty in feeding?

Any difficulty mentioned by the mother/caregiver is important. A young infant who was feeding well
earlier but is not feeding well now may have a serious infection and should be referred urgently to
appropriate health facility (NBSU at CHC/FRU or SNCU at SDH/District Hospital). The
mother/caregiver may also mention difficulties like related to breastfeeding which will be discussed
during breastfeeding assessment. Has the infant had convulsions/fits? Use the local term for
convulsions/fits.

LOOK for Severe chest indrawing

39
Ask the mother/caregiver to lift young the infant's shirt to look when the young infant breathes at the
lower chest wall (lower ribs). The young infant has chest indrawing if the lower chest wall goes IN,
when the infant breathes IN. In normal breathing, the whole chest wall (upper and lower) and the
abdomen move OUT when the young infant breathes IN. If you only see chest indrawing when the
young infant is crying or feeding, the young infant does not have chest indrawing. Mild chest
indrawing is normal in a young infant because the chest wall is soft. Severe chest indrawing is
serious, easily seen and is a sign of pneumonia in a young infant.

EXAMINE skin for pustules are red spots or blisters, which contain pus.

LOOK at the young infant's movements. Does the young infant move only when stimulated? Are
there no movements even after the young infant is stimulated?

An awake young infant will normally move his arms or legs or turn his head several times in a minute
if you watch him closely. Observe the infant's movements while you do the assessment. If the infant
moves only when stimulated and then stops moving, or does not move even when stimulated, it is a
sign of severe disease.

LISTEN & FEEL:

Counting of Respiratory rate: Tell the mother/caregiver you are going to count the infant's
breathing for a full one minute and during this time try to keep the infant calm. Use a watch with a
second hand or a digital watch. Glance at the second hand as you count the breathing movement
anywhere on the infant's chest or abdomen. (Ask the mother/caregiver to lift the infant's -clothing if
breathing movements not visible). Repeat the count if the count if elevated (60 breaths per minute or
more) OR you are not sure about the number of breaths you counted. The second count is accepted as
the final count. If the young infant has fast breath, the young infant may have pneumonia. This is
considered serious in a young infant.
FEEL: Measure axillary/armpit temperature (if not possible feel for fever or low body temperature).
Fever (axillary temperature of 37.50C (99.50 F) or above 37.5 0C) is uncommon in the first two
months of life. If a young infant has fever, this may mean the infant has a serious bacterial infection.
When the temperature is 37.50C- 390C, undressing and exposing the young infant to room
temperature is usually all that is necessary.
Young infants can also respond to infection by dropping their axillary temperature to below 35.50C
(95.90 F). This is known as Hypothermia and the young infant feels cold to touch.
Keep the thermometer in the axilla (armpit) and then hold the young infant’s arm against his body for
5 minutes before reading the temperature. If you do not have a thermometer, feel the infant's
abdomen or armpit and determine if it feels hot or cold to touch.
The normal temperature in a child is 36.5-37.40C (97.70-99.320 F).
CLASSIFY THE YOUNG INFANT FOR POSSIBLE SERIOUS BACTERIAL
INFECTION (PSBI)

The classification table for Possible Bacterial Infection is given below.

Signs Classify as Action to be taken by CHO

40
 ▪ Not able to feed OR ▪ Give first dose of oral amoxicillin and
▪ Convulsions/Fits OR intramuscular gentamicin.
POSSIBLE ▪ Treat to prevent low blood sugar.
▪ Fast breathing (60 breaths per SERIOUS ▪ Warm the young infant by Skin to Skin
minute or more) OR BACTERIAL contact if temperature less than 36.50C
▪ Severe chest indrawing OR INFECTION (or feels cold to touch) while arranging
referral.
▪ Axillary temperature 37.5oC or
above (or feels hot to touch) or ▪ Advise mother/caregiver how to keep
▪ Axillary temperature less than the young infant warm on the way to
35.5oC (or feels cold to touch) OR the health facility.
▪ Movement only when stimulated or
no movement at all ▪ Refer urgently to NBSU at CHC/FRU
or SNCU at SDH/District Hospital.

▪ Give oral amoxicillin for 5 days.

▪ Umbilicus red or draining pus LOCAL
OR ▪ Teach mother/caregiver to treat local
BACTERIAL infections at home.
▪ Skin pustules INFECTION
▪ Follow up in 2 days.

IDENTIFY TREATMENT AND TREAT THE YOUNG INFANT

IF REFERRAL IS REQUIRED FOR PSBI

Explain to the mother/caregiver the need for referral and get their agreement to take the young
infant. If she appears reluctant then try to find out the reasons for this and find solutions.
Prepare a referral slip and give pre-referral treatment and provide any instructions that the
mother/caregiver should follow while on her way to the -health facility. Advise the mother to
continue to breastfeed the baby while on the way to the health facility. If the young infant has severe
dehydration and the infant can feed then the mother must continue to give sips of ORS once every
minute or two minutes throughout when she is travelling to the referral facility.

If antibiotic is to be given, then make sure you give the first dose of antibiotic. Give an extra dose of
this medicine if it is going to take a long time before the infant reaches the health facility.
Administer injection Gentamicin along with oral Amoxicillin to young infants suspected with sepsis
under the following situations-

• Pre-referral dose - Give the first dose of each antibiotic before referral to a health facility.

• Completion of antibiotic treatment - If the infant has not completed a course of either of the
antibiotic following discharge from a health facility, complete the course of the treatment as
prescribed by the PHC-Medical Officer.

• Referral not possible or refused - Under this special situation where referral is not possible or is
refused, continue to give treatment for 7 days.

41
The doses are given in the table below.

Doses of antibiotics for young infant

Gentamicin Oral Amoxicillin

Weight Intramuscular*
80 mg in 2ml vial 125 mg in 5ml syrup Tablet (250mg)

1.5 upto 2.0Kg 0.2 ml 2.0 ml ¼

2.0 upto3.0Kg 0.3 ml 2.5 ml ½

3.0 upto 4.0Kg 0.4 ml 3.0 ml ½

4.0 upto 5.0Kg 0.5 ml 4.0 ml ½

*Avoid using undiluted 40 mg/ml gentamicin.

➢ ORAL AMOXYCILLIN FOR LOCAL BACTERIAL INFECTION

You as the CHO, will give the full course of amoxicillin (for 5 days) to infants with LOCAL
BACTERIAL INFECTION at home. Give amoxicillin by mouth every morning and every night for
five days.

➢ ORAL AMOXICILLIN AND INTRAMUSCULAR GENTAMICIN FOR PSBI

You as the CHO, will give one dose (pre-referral) for Possible Serious Bacterial Infection in doses
given above and REFER urgently to NBSU at CHC/FRU or SNCU at SDH/District Hospital.
Inform the PHC-MO, regarding the referral made to the higher health facility.

Giving injectable Gentamicin- Dosage: 5 mg/kg body weight once a day.

▪ Route of administration: Intramuscular

▪ Site of Injection: Antero-Lateral aspect of the thigh
▪ Preparation: Injection Gentamicin is available in two preparations – 20 mg/2 ml and 80 mg/2 ml.
Use only 80 mg/2 ml preparation in young infants. This provides 40 mg Gentamicin per 1 ml. This
preparation ensures that the volume of injection Gentamicin fluid for young infants does not exceed
the safe limit of 1ml.There is no need for refrigerator/cold chain maintenance for the storage of the
injection.
▪ Syringe and needle: 1 ml disposable syringe with 23-gauge needle should be used.
▪ Alternatively, Insulin syringe could be used. Auto disposable syringes provided for immunization
should not be used because of varying dosage marking.
▪ Duration of treatment: Total duration of treatment is 7 days. In cases of follow up treatment, follow
the advice as per the discharge slip/ medical doctor’s prescription.

Preventing low blood sugar as a pre-referral management-A sick young infant who are unable to breastfeed
adequately, have the danger of developing low blood sugar which is a serious condition. Thus, it is important to
prevent low blood sugar in young infants.

Your treatment and instructions to the mother/caregiver will depend if the infant is able to feed and swallow. If the
42
infant is:
1. ABLE TO BREASTFEED, ask the mother to breastfeed;
2. UNABLE TO BREASTFEED, BUT ABLE TO SWALLOW
Steps in teaching the mother/caregiver to give oral medicines at home
▪ Determine the medicine and dosage and explain the mother/caregiver the need of the
medicine.
▪ Demonstrate the correct dose and ask mother/caregiver to measure the first dose and give it in
front of you.
▪ Label it and ask the mother/caregiver to follow the schedule as described even if the infant
gets well. Do confirm whether they have understood.

TO TREAT SKIN PUSTULES OR UMBILICAL INFECTIONS

The mother/caregiver should: Wash hands. Gently wash off pus and crusts with soap and water. Dry
the area. Paint with gentian violet 0.5%. Wash hands. Tell the mother/caregiver to do the treatment
twice daily.

2. CLASSIFY THE YOUNG INFANT FOR JAUNDICE

LOOK for Jaundice- Press the infant’s skin over the forehead with your fingers to blanch, remove
your fingers and look for yellow discolouration under natural light. If there is yellow discoloration,
the infant has jaundice. To assess for severity, repeat the process over the palms and soles too.

Almost all neonates may have ‘physiological jaundice’ during the first week of life due to several
physiological changes taking place after birth. Physiological jaundice does not extend to palms and
soles and does not need any treatment. However, if jaundice appears on first day, persists for 14 days
or more and extends to palms and soles it is severe jaundice and requires urgent attention.

The classification table for Jaundice is given below.

Signs Classify as Action to be taken by CHO

▪ Any jaundice in the infant SEVERE JAUNDICE ▪ Treat to prevent low blood sugar.
less than 24 hours of age ▪ Warm the young infant by Skin to Skin
contact if temperature less than 36.5oC
OR (or feels cold to touch) while arranging
referral.
▪ Yellow palms and soles at ▪ Advise mother/caregiver how to keep
any age the young infant warm on the way to
OR the health facility.
▪ Refer URGENTLY to NBSU at
▪ Jaundice for 14 days or more CHC/FRU or SNCU at
SDH/District Hospital.

43
 ▪ Jaundice appearing after 24 JAUNDICE ▪ Advise mother/caregiver to give home
hours of age AND care.
▪ Palms and soles not yellow ▪ Ask the mother/caregiver to return
immediately if the palms and soles turn
yellow.
▪ Follow up in 1 day.
▪ If the young infant is older than 14
days , refer to NBSU at CHC/FRU or
SNCU at SDH/District Hospital for
assessment.

3. ASSESS YOUNG INFANT FOR DIARRHOEA

Ask: Does the young infant have diarrhoea

If the stools have changed from the usual pattern and are many and watery, the young infant has
diarrhoea. Breastfed babies normally have frequent loose stools.
Look at the young infant’s general condition: Look for the Infant's movements- does the infant
move on his/her own, does the infant move only when stimulated but then stops, does the infant not
move at all?, is the infant "restless and irritable".
A child is classified as restless and irritable if s/he is restless and irritable all the time or every time
s/he is touched and handled. If an infant or child is calm when breastfeeding but again restless and
irritable when he stops breastfeeding, s/he has the sign restless and irritable.
Signs of Dehydration
▪ Sunken eyes: If you think that the eyes are sunken, ask the mother/caregiver if they think infant's
eyes look unusual. Their opinion helps you confirm that the young infant's eyes are sunken.

▪ Pinch the skin of the abdomen: Ask the mother/caregiver to hold the young infant in her lap so
that the infant is lying flat on its back. Locate an area half way between the infant’s navel and the
side of the tummy. Now pinch the skin with the thumb and the first finger by lifting it for one
second and then releasing it. Do not pinch with the tip of the finger or the thumb since this will
cause pain to the infant. After leaving the skin, check to see how soon the skin returns to normal.
A very short tenting of the skin lasting less than 2 seconds is considered as slow skin pinch. If the
skin returns to normal immediately after being pinched, the skin pinch is normal.

The classification table for the type of diarrhoea is shown below.

Signs Classify as Action to be taken by CHO

44
Two of the following signs: ▪ Give first dose of oral amoxicillin
▪ Movement only when and intramuscular gentamicin.
stimulated or no movement atSEVERE ▪ Refer URGENTLY to NBSU at
all DEHYDRATION CHC/FRU or SNCU at
▪ Sunken eyes, SDH/District Hospital with
▪ Skin pinch goes back very mother/caregiver giving frequent
slowly sips of ORS on the way.
▪ Not able to drink or drinking ▪ Advise mother to continue
poorly breastfeeding.
▪ ▪ Advise mother/caregiver on
keeping the young infant warm on
the way to the health facility.
Two of the following signs: SOME DEHYDRATION
▪ Restless or irritable
▪ Sunken eyes
▪ Skin pinch goes back slowly
▪ Drinks eagerly, thirsty
▪ Not enough signs to classify ▪ Give fluids (breast milk, ORS) to
as dehydration NO DEHYDRATION treat diarrhoea at home (Plan A).
▪ Follow-up in 2 days if not
improving.

TREATMENT OF DIARRHOEA

Plan A: Treat Diarrhoea at Home

The best way to give a young infant extra fluid and continue feeding is to breastfeed more often and
for longer at each breastfeed. If an infant is exclusively breastfed, it is important not to introduce a
food-based fluid.
Additional fluids that may be given to a young infant are ORS solution and clean, preferably boiled,
water. If a young infant will be given ORS solution at home, tell the mother to give 5 teaspoons of
ORS followed by 2 teaspoons of clean, preferably boiled water to the infant after each watery stool.
She should first offer a breastfeed, then give the ORS solution. Remind the mother/caregiver to stop
giving ORS solution after the diarrhoea has stopped.

REFERRAL FOR SICK YOUNG INFANT

▪ Referral urgently (to NBSU at CHC/FRU or SNCU at SDH/District Hospital) is the best
option for a young infant classification with SEVERE DEHYDRATION AND SOME
DEHYDRATION with low weight.
▪ Give one dose (pre-referral) of Oral Amoxicillin and Intramuscular Gentamicin using the
same dosage as given above (in the section on PSBI) and refer to the appropriate health facility.

IF REFERRAL IS NOT POSSIBLE, give oral amoxicillin every 12 hours and intramuscular
gentamicin once daily for 7 days.

FOLLOW UP-A young infant with diarrhoea should be seen after 2 days.

45
To summarise-

Assessment Findings Treatment

If young infant has some or severe dehydration Refer urgently to NBSU at CHC/FRU or
or blood in stool or any sign of possible serious SNCU at SDH/District Hospital
bacterial infection or if duration of diarrhoea is
for14 days or more
If duration of diarrhoea less than 14 days, no
blood in the stool and young infant has no Continue breastfeeding and give ORS
dehydration prepared with clean drinking water

4. CHECK FOR VERY LOW WEIGHT and FEEDING PROBLEM

All young infants are weighed. Young infants whose weight is <1800 gms should be referred to a
health facility (NBSU at CHC/FRU or SNCU at SDH/District Hospital). The young infant should be
breastfed as often and for as long as the infant wants, both during day and night. This should be 8 or
more times in 24 hours. A young infant should be exclusively breastfed. Pain while breastfeeding
may indicate sore nipples, breast engorgement or breast abscess. The four signs of good attachment to
the breast are chin touching breast (or very close), mouth wide open, lower lip turned outward and
more areola visible above than below the mouth. If all of these four signs are present, the infant has
good attachment. The infant is suckling effectively if he suckles with slow deep sucks and sometimes
pauses. A satisfied infant appears relaxed, sleepy, and loses interest in the breast.

ASSESSMENT OF FEEDING IN YOUNG INFANTS HAS TWO PARTS-

Asking the mother: Is the young infant breastfed? If yes, how many times in 24 hours? You also ask
questions to determine if she is having difficulty feeding the infant, what the young infant is fed and
how often. Does the infant usually receive any other foods or drinks? If yes, how often? Find out if
the young infant is receiving any other foods or drinks such as other milk, juice, tea, thin porridge,
dilute cereal, or even water. Ask how often he/she receives it and the amount. What do you use to
feed the infant? (to know whether infant takes other foods or drinks, find out if the mother uses a
feeding bottle, cup or any other device). Does the mother have pain while breastfeeding?
Assess Breastfeeding: If an infant: Has no indications to refer urgently to health facility: If the infant
has not fed in the previous hour, as the mother to put her infant to the breast and observe the
breastfeed for at least for 4 minutes (if the infant was fed during the last hour, ask the mother if she
wait and inform you when the infant is willing to feed again).
LOOK: Is the infant able to attach? Is the infant suckling effectively? (attachment to the breast, slow
deep sucks, sometimes pausing, may see or hear the infant swallowing). Look for signs that the infant
is satisfied.
An infant who is not suckling at all is not able to suck breastmilk into his mouth and swallow. If a
blocked nose seems to interfere with breastfeeding, clear the infant's nose and check for effective
suckle by infant.

46
LOOK: Inside the mouth of the infant at the tongue and inside of the cheek for ulcers or white
patches in the mouth (thrush- milk curds on the inside of the cheek, or a thick white coating of the
tongue). Look for sore/cracked nipples, Engorged breasts or breast abscess in the mother.
Engorged breasts are swollen, hard and tender. Presence of a breast abscess is indicated additionally
by localized redness and warmth.

CLASSIFY FOR FEEDING PROBLEM: Reassure the mother that all mothers produce enough
milk for their baby and if she has twins then it will suffice for both. Encourage the mother to continue
breastfeeding more frequently when she complains of not enough milk.
The classification table for feeding is given below.
Signs Classify as Action to be taken by CHO
▪ Weight < 1800 gms VERY LOW ▪ Treat to prevent low blood sugar.
WEIGHT ▪ Warm the young infant by Skin to
Skin contact if temperature less than
36.50C (or feels cold to touch) while
facilitating referral.
▪ Refer URGENTLY to NBSU at
CHC/FRU or SNCU at SDH/District
Hospital.
▪ Advise mother/caregiver how to keep
the young infant warm on the way to
the health facility.
▪ Weight 1800-2500gm LOW WEIGHT OR ▪ Advise mother to give home care
OR (breastfeed infant exclusively, keep
infant warm, apply nothing to cord,
▪ Not well attached to FEEDING ask mother to wash hands and explain
breast /not suckling PROBLEM danger signs in the infant)
effectively ▪ Follow-up in 2 days.
OR ▪ Follow-up low weight in 14 days.
▪ Less than 8 breastfeeds ▪ Excessive weight loss (normal 8-10%
in 24 hours of birth weight by 3-4 days of age)
would indicate inadequate
OR
breastfeeding.
▪ If infant is not well attached or not
▪ Receives other foods or suckling effectively, teach correct
drinks positioning and attachment.
▪ Advise to increase frequency of
OR feeding. Counsel mother about
breastfeeding more, reducing other
▪ Thrush (ulcers or white foods or drinks, and using a cup and
patches in mouth). spoon. If not breastfeeding at all,
OR advise mother to feed with a cup and
spoon and teach the mother to feed
▪ Breast or nipple with a cup and spoon.
problems ▪ If thrush, teach
themother/caregiver to treat thrush

47
 at home- apply 0.25% gentian
violet paint twice daily.
▪ If low weight, teach the
mother/caregiver how to keep the
young infant with low weight
warm at home.
▪ If breast or nipple problem, teach
the mother to treat these problems.
▪ Weight >= 2500 gm NO FEEDING ▪ Advise mother to give home care for
and no other signs of PROBLEM the young infant.
inadequate feeding ▪ Praise the mother for feeding the
infant well.

Refer to Annexure-2 on how to counsel the mother of a young infant with feeding problem, correct
positioning and attachment for breastfeeding.

Teach the mother to treat breast and nipple problems

If nipple is sore, apply breast milk for soothing effect and ensure correct positioning and attachment
of the baby if mother continues to have discomfort, feed expressed breast milk (EBM) with
katori/cup and spoon or paladai.
If breasts are engorged, let the baby continue to suck if possible. If the baby cannot suckle
effectively, help the mother to express milk and then put the young infant to the breast. Putting a
warm compress on the breast may help. If breast abscess, advise mother to feed from the other
breast and refer to a surgeon at DH.

Teach the mother to express breast milk by hand and feed with a katori/cup and spoon or
paladai

1. The mother after washing her hands with soap and water is made to sit comfortably.
2. Warm compress on the breast may be placed for a few minutes if desired.
3. Mother may be asked to gently massage the breast starting from the chest moving toward the
nipple; in a circular motion (near the underarm, and then to the bottom of the breast etc.), so that all
parts of the breast are massaged.
4. She may hold a clean cup, glass or jug with a wide mouth near her breast with one hand. With the
other hand, the mother is asked to place her thumb above and her first finger below the nipple and
areola. Then she is asked to push her thumb and finger slightly inwards towards the chest wall (about
1-2 cm) and then press the areola between the thumb and finger (do not squeeze the nipple). This
repeated action would allow to milk to drip out.
5. She must repeat this action also from the sides of the areola to make sure that milk is expressed
from all quadrants. Collect the milk in a clean cup, glass or jug.
6. Milk may drip at the beginning and then spray out after it starts flowing. Expression must be
continued for 3-5 minutes until the milk flow slows down.
7. The mother must perform the expression from both breasts and it may take her about 15-20
minutes to express both breasts completely.

For feeding the baby, small amounts of the expressed breast milk are taken into the spoon or paladai
and directly poured from the angle of the mouth. One must wait for the baby to swallow the milk
before more milk is poured into the mouth.

48
Common breastfeeding problems and possible solutions

Breastfeeding problem Counsel the mother

Mother feels her milk is not You will first enquire about the signs of insufficient breastfeeding such
enough for the baby as baby seems lethargic, takes too little/too much time at the breast and
weight gain is not as expected.

The most common causes of insufficient milk is breastfeeding

mismanagement with inappropriate timing and duration of feedings,
unrelieved engorgement, inappropriate mother-infant separation,
improper positioning and latch-on.

You should counsel the mother to:

▪ Increase her food and fluid intake.
▪ Breastfeed in a relaxed environment free from any mental stress.
▪ Taking adequate rest during the day.
▪ Breastfeeding frequently including at night, at least 8-12 times
during 24 hours.
▪ Breastfeed at one breast until completely empty. Then feed from
the other breast.
Young infant is being fed with ▪ Mother/caregiver must be counseled regarding harmful effects of
a bottle, cotton or dropper bottle feeding.
▪ In case of expressed breast milk feeding, clean katori or cup with
spoon/paladai should be used.
▪ Mother/caregiver should be encouraged to continue exclusive
breastfeeding for 6 months.

Mother works outside home ▪ Breastfeed frequently before going to work and after returning
home, including at night.
▪ Express breast milk before leaving for work and ask the
caregiver to feed the young infant with a katori/cup and spoon
or paladai.

TO TREAT THRUSH (ULCERS OR WHITE PATCHES IN MOUTH)

The mother/caregiver should: Wash hands. Wash mouth with clean soft cloth wrapped around the
finger and wet with salt water. Paint the mouth with gentian violet 0.25%. Wash hands.

FOLLOW UP

When young infant returns for follow-up after 2 days reassess feeding-

49
Review with the mother/caregiver the changes that the mother/caregiver has been able to bring
about in the child’s feeding.

Have her attempts been successful? If successful, reassure the mother/caregiver and
ask her to continue
If the mother has not been able to follow the Find out the reasons and try to correct them.
advice Ask her/caregiver to come back after 2 days.

If you do not think that feeding will improve, refer the child to NBSU at CHC/FRU or SNCU at
SDH/District Hospital.

5. CHECK IMMUNIZATION STATUS

You as the CHO, should check the immunization status of all young infants in your service area. If
any immunization is due, advise the mother/caregiver to get the immunization at the earliest
opportunity.

IMMUNIZATION SCHEDULE AGE VACCINE

Birth Oral Polio Vaccine (OPV)-0, Bacillus
Calmette Guerin (BCG), Hepatitis B-0
6 weeks OPV-1, Pentavalent-1, Inactivated Polio
Vaccine (IPV)-1, Rotavirus-1,
Pneumococcal Conjugate Vaccine (PCV)*-
1

*PCV in selected states/districts: Bihar, Himachal Pradesh, Madhya Pradesh, Uttar Pradesh (selected districts)
and Rajasthan; in Haryana as state initiative.

6. ADVISE MOTHER/CAREGIVER TO GIVE HOME CARE

Advise the mother/caregiver on giving home care to the sick young infant-

1. EXCLUSIVELY BREASTFEED THE YOUNG INFANT (for breastfeeding mothers)

▪ Give only breast milk to the young infant.
▪ Breastfeed frequently, as often and for as long as the infant wants day and night, either sick or
healthy. Explain the mother/caregiver that sick young infants have higher nutritional needs than
normal children.
▪ Stroke on sides of the lips and the upper part of the chin to wake up a sleeping infant for feeding.
▪ Feed expressed breast milk (EBM) using a cup/katori with paladai or spoon in case they are
unable to feed directly from the breast.
▪ Put to breast to allow them to lick the nipple and try to suckle. Once the child is able to suckle,

50
 child should be put to the breast as often as possible to stimulate milk production.

2. MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES
▪ In cool weather, cover the infant’s head and feet, and add extra clothing.
▪ Use Kangaroo Mother Care (KMC) to prevent hypothermia; KMC provides skin-to-skin contact,
warmth and closeness to the mother’s breast. Caregivers/family members can also practice
Kangaroo Care.

3. KNOW WHEN TO RETURN AT SHC-HWC

Follow –up visits When to Return Immediately

If the infant has: Return for Advise the caretaker to return immediately if
first follow- the young infant has any of these signs:
up in:
➢Breastfeeding poorly
▪ JAUNDICE 1 day
▪ DIARRHOEA 2 days ➢Reduced activity
▪ FEEDING PROBLEM ➢Becomes sicker
▪ THRUSH
▪ LOCAL BACTERIAL INFECTION ➢Develops a fever

▪ PNEUMONIA 2 days ➢Feels unusually cold

▪ SEVERE PNEUMONIA when ➢Develops fast breathing
referral is refused or not feasible
➢Develops difficult breathing
LOW WEIGHT FOR AGE in an infant 7 days
➢Palms or soles appear yellow
not receiving breastmilk

LOW WEIGHT FOR AGE in breastfed 14 days

infant

4. HOME CARE ADVICE FOR THE MOTHER/CAREGIVER INCLUDES THE

FOLLOWING

▪ To breastfeed the infant frequently, as often and as long as the infant wants, day and night,
during sickness and health.
▪ To ensure that the infant is kept warm at all times.
▪ Advise mother/caregiver to wash hands with soap and water, after defecation and after
cleaning the bottom of the baby.
▪ Advise the mother/caregiver not to apply anything on the cord and keep the cord and
umbilicus dry.
▪ Also teach the mother/caregiver when to return immediately. The signs mentioned in the table
above are particularly important signs to watch for. Teach the mother/caregiver these signs.
Use local terms that the mother/caregiver can understand.
▪ Ask checking questions to be sure the mother/caregiver knows when to return immediately.

5. HOW TO KEEP THE YOUNG INFANT WITH LOW WEIGHT WARM AT HOME

51
Do not bathe low birth weight baby and if required use lukewarm water to clean. Provide skin to
skin contact to the baby as Kangaroo Mother Care (KMC) all through the day and if that is not
possible then:
▪ Keep the room warm with a home heating device.
▪ Clothe the baby in 3-4 layers; cover the head, hands and feet with cap, gloves and socks,
respectively.
▪ Let baby and mother/caregiver lie together on a soft, thick bedding.
▪ Cover the baby and the mother/caregiver with additional quilt, blanket or shawl, especially in
cold weather. The best way to maintain temperature warm a baby with low temperature is by
placing the baby in skin-to-skin contact with the mother (or any adult/caregiver). Skin to skin
contact can also be used to keep a baby warm during transport and at home.

Warm the young infant using Skin to Skin contact (Kangaroo Mother Care)

Provide Skin to Skin contact (Kangaroo mother care) as much as possible, day and night.
▪ Provide privacy to the mother/caregiver.
▪ Request the mother/caregiver to sit or recline comfortably.
▪ Undress the baby gently, except for cap, nappy and socks.
▪ Place the baby prone on mother’s/caregiver’s chest in an upright and extended posture,
between the breasts in skin to skin contact; turn baby’s head to one side to keep airways clear.
▪ Cover the baby with mother’s/caregiver’s blouse, pallu, gown or any cloth; wrap the baby-
mother/caregiver duo with an added blanket or shawl.
▪ Breastfeed the baby frequently.
▪ If possible, warm the room with a heating device.
▪ If mother is not available, skin to skin contact may be provided by the father or any other
adult/caregiver.

When Skin to Skin contact not possible:

▪ Keep the room warm with a home heating device.
▪ Clothe the baby in 1-2 layers (during summer).
▪ Clothe the baby in 3-4 layers (during winter) and cover the head, hands and feet with cap,
gloves and socks respectively.
▪ Let the baby and mother/caregiver lie together on a soft, thick bedding. Cover the baby and
the mother/caregiver with additional quilt, blanket or shawl in cold weather during winter, the
linen and clothes of the baby should be pre-warmed before dressing.
▪ Cover the baby adequately using cap, socks and mittens. Keep the room warm with the help of
a heater. During summer months, depending upon the environmental temperature, the baby
should be dressed in loose cotton clothes and kept indoors as far as possible. Exposure of the
baby to direct sunlight during the hot summer months can lead to serious hyperthermia.

Role of CHO in assessment and care of sick young infant (0-2 months)

1. Undertake assessment of common illnesses in sick young infants by recognizing the danger signs.
2. Timely and urgent referral of sick young infants to appropriate referral centres on the basis of
assessment with proper counselling to the mothers/ caregiver and provide pre-referral treatment as
per protocols explained above.
3. Provide appropriate treatment for the management of the common illnesses in sick young infant as
per protocol.

52
4. Teach the mother/caregivers regarding the danger signs in the young infant with immediate
reporting, administration of oral medicines, treatment of local infection at home and preventive
strategies of these diseases.
5. Support and supervise the primary healthcare team to ensure the following steps are undertaken
for sick young infants especially discharged from SNCU/NBSU -
▪ Early registration of the young infant at the nearest Anganwadi Centre for provision of
appropriate services as per age- immunization, growth monitoring, health check-up and referral
services.
▪ Follow-up care through home visits by ASHAs and MPWs for SNCU/NBSU discharged sick
young infants as per schedule.
▪ Medication being given to the infant by the mother/caregiver as per the prescribed treatment plan
on the discharge card.
▪ Ensure the mother/caregiver visits the health facility as per the next follow up date given on the
discharge card.
▪ Ascertain that weight is being regularly measured by ASHA during her home visits and recorded
in Mother-Newborn Home Visit Card (HBNC card/form). MPW will measure the weight of the
child and record in MCP card. Monitor progress in weight for age of the sick young infant.
▪ Ensure early detection for any congenital anomalies/birth defects by during home visits by
ASHA and 4Ds- defects at birth, development delays including disability, specific deficiencies
and diseases by RBSK mobile health teams in every block. Link identified young infant by
ASHA with available service provisions under RBSK. Timely follow-up of discharged infants to
ensure appropriate care.
▪ Ensure counselling of the mother/caregiver on early childhood development using the MCP card
by ASHA and MPW and timely reporting by mother/caregiver to ASHA, MPW or you in case of
any warning sign in the child.
▪ Inform ASHAs and MPWs to mobilize the mother/caregiver to bring the discharged young infant
to health facility in the first week of discharge to assess for development of any danger signs.
Initiate prompt referral using JSSK referral mechanism, if required.
▪ Counsel mother/caregiver regarding importance of extra care of sick young infants at home-
prevention of infection by maintaining hygiene, warm care, appropriate feeding support for
exclusive breastfeeding, solving breastfeeding problems, teaching correct position and
attachment for breastfeeding, age-specific immunization, etc.

Chapter 5: Assessment and care of sick child (2-59

months of age)
This chapter describes how to assess and classify sick child (2-59 months) so that signs of disease are
not overlooked.. The assessment procedure for this age group includes several important steps that
must be taken by the health care provider, including:
1. Asking the mother/caregiver about the child’s problem
2. Checking for general danger signs

53
3. Checking for main symptoms
4. Checking nutritional status
5. Assessing the child’s feeding
6. Checking immunization status; Vitamin-A, Iron folic acid syrup supplementation,
deworming status, and
7. Assessing other problems

ASKING THE MOTHER/CAREGIVER ABOUT THE CHILD’S PROBLEM

It is critical to communicate effectively with the child's mother or caregiver. Using good
communication helps to reassure the mother or caregiver that the child will receive appropriate care.

CHECKING FOR GENERAL DANGER SIGNS

You should ensure that the general danger signs are not overlooked as they indicate towards severity
of illness. The danger signs are:
▪ The child is unable to drink or breastfeed
▪ The child vomits everything
▪ The child has had convulsions/fits during the present illness
▪ The child is unconscious or lethargic

Presence of any danger sign mandates quick assessment, pre-referral treatment and urgent
referral to the CHC/DH wherever paediatrician or paediatric care services are available.
If a child has one or more of these signs, s/he must be considered seriously ill and will almost always
need referral. The child should be quickly assessed for the most important causes of serious illness -
acute respiratory infection (ARI), diarrhoea, and fever (especially associated with malaria and
measles). A rapid assessment of nutritional status is also essential, as malnutrition (undernutrition)
and anaemia could also affect health outcomes of the child.
CHECKING MAIN SYMPTOMS: After checking for general danger signs, you must check for main
symptoms:
➢ Cough or difficult breathing
➢ Chest indrawing
➢ Fast breathing
➢ Diarrhoea
➢ Fever

ASSESS AND CLASSIFY each of these symptoms to decide the treatment and follow up.
1. CASE MANAGEMENT OF A CHILD WITH COUGH OR DIFFICULT BREATHING

CLINICAL ASSESSMENT: Three key clinical signs are used to assess a sick child with cough or
difficult breathing:

➢ Respiratory rate, which distinguishes children who have pneumonia from those
who do not. Pneumonia is one of the most common form of acute respiratory infection that
affects the lungs. It is most commonly caused by viruses or bacteria. This infection is generally

54
 spread by air-borne droplets from a cough or sneeze of an infected person.
If the Child’s age is The child has fast breathing if you
2 months up to 12 months count:
50 breaths per minute or more
12 months up to 5years 40 breaths per minute or more

➢ Chest indrawing, which indicates severe pneumonia or very severe disease.

➢ Wheeze, a whistling sound that occurs during breathing, usually during expiration
(breathing air out of the lungs) through narrowed airways and indicates asthma or
hypersensitivity.

If pulse oximeter is available, it is an important tool to identify children with hypoxemia

(oxygen saturation <90%).

CLASSIFY AND TREAT CHILD WITH COUGH OR DIFFICULT BREATHING

Assess and classify children with cough and/or difficult breathing using the classification given
below. Measure oxygen saturation of the sick child using pulse oximeter. Listen for audible wheeze.
Wheezing is a high-pitched whistling sound made while child breathes. It is heard most clearly when
sick children exhale, but in severe cases, it can be heard when they inhale. It is caused by narrowed
airways or inflammation in the airways.
Signs Classify As - Action to be taken by CHO
Presence of any general danger SEVERE ▪ Refer urgently for hospitalization at CHC
signs- PNEUMONIA or DH after pre-referral dosage of Oral
▪ Not able to drink or OR Amoxicillin and IM Gentamicin.
breastfeed or VERY SEVERE ▪ Give oxygen if saturation < 90%, while
▪ Persistent vomiting DISEASE arranging referral.
(vomits everything) or
▪ Convulsions/fits or
▪ Lethargic/reduced level of
▪ consciousness

or
▪ Chest indrawing

Fast breathing: PNEUMONIA ▪ Give Oral Amoxicillin for 5 days in

(Respiratory rates: consultation with MO- PHC.
▪ 2-11 months – 50 or ▪ Treat wheeze if present.
more breaths per ▪ Advise home care for cough and cold.
▪ Advise mother/caregiver when to return
minute
immediately.
▪ 12-59 months– 40 or ▪ Follow up after 2 days.
more breaths per
minute)

▪ No signs of severe NO PNEUMONIA: ▪ Advise home care for cough -and cold*.
Pneumonia or Pneumonia COUGH OR COLD ▪ If coughing for more than 14 days, refer
for assessment to PHC-MO.
▪ Follow up after 5 days if not improving.

55
 If oxygen saturation is < 90%, refer as Severe Pneumonia or Very Severe Disease.

IDENTIFY TREATMENT AND TREAT THE CHILD

If the child has any general danger sign, REFER THE CHILD at CHC or DH wherever paediatrician
or paediatric care services are available after giving appropriate pre-referral treatment.
You as a CHO, will provide pre-referral dosage of antibiotics for Very Severe Disease/Severe
Pneumonia
Age or Weight Amount of Amount of Amount of
Gentamicin to be Amoxicillin to be Amoxicillin to be
given intramuscularly given per-orally given per-orally as
as Injection as Syrup dispersible tablet
(vial*contains 80 mg (contains 125 mg/ (contains 250 mg)
in 2 ml) 5 ml)
1
2 months up to 4 months 0.5 - 1.0 ml 5 ml /2
(4 - < 6 kg)
4 months up to 12 1.1 - 1.8 ml 10 ml 1
months (6 - < 10 kg)
12 months up to 3 years 1.9 - 2.7 ml 15 ml 11/2
(10 - < 14 kg)
3 years up to 5 years 2.8 - 3.5 ml - 2
(14 - < 20 kg)

You as a CHO, will Treat Pneumonia with Oral Amoxicillin

Dosage of Amoxicillin for Pneumonia
Age or Weight Amount of Amoxicillin to be Amount of Amoxicillin to be
given orally as Syrup (125 given as a dispersible tablet
mg per 5 ml) twice a day x 5 (250 mg) twice a day x 5 days
days
1
2 months up to 4 months 5 ml /2
(4 kg to< 6 kg)
4 months up to 12 months 10 ml 1
(6 kg to< 10 kg)
12 months up to 3 years 15 ml 11/2
(10 kg to< 14 kg)
3 years up to 5 years - 2
(14 kg to< 20 kg)

IF THE CHILD HAS WHEEZING, give 3 doses of nebulized salbutamol repeated every 20
minutes; or 2-4 puffs of Salbutamol MDI with spacer (at a gap of 2-3 minutes between each puff)
every 20 minutes and if there is improvement, continue use of bronchodilators under monitoring.

56
IF REFERRAL IS NOT FEASIBLE OR REFUSED in case of Severe Pneumonia or Very
Severe Disease, manage with oral amoxicillin twice a day and Injection Gentamicin once a day for 7
days in consultation with MO- PHC and daily assessment. Use the same doses as mentioned in the
tables above.

FOLLOW-UP CARE
After 2 days of treatment, review with the mother/caregiver if the treatment has been given as
advised. Then, assess the child by checking for general danger signs, chest indrawing and count the
breathing rate for one minute.
Assessment findings Treatment

If chest indrawing or general REFER URGENTLY at CHC or DH wherever

danger signs paediatrician or paediatric care services are
available.
If fast breathing persists and the Refer to a doctor at CHC or DH wherever
child has been given the medicines paediatrician or paediatric care services are
as advised available.
If breathing is slower and the Continue the antibiotic for 3 days.
child is feeding better

If the child has no Pneumonia (but has cough or cold) * - Advise for mother/caregiver on home
care are as follows-

▪ Keep the child warm and properly covered.

▪ An infant below 6 months who is exclusively breastfed should not be given any home
available fluids or home remedy.
▪ Continue breastfeeding the child. Breastfeed frequently and for longer period at each feed. Breast
milk is the best remedy for a child.
▪ Continue feeding the child during the illness. Child should continue to be given normal diet
during cough and cold (if child is above 6 months of age). This is important as this will prevent
malnutrition and also help the child to recover from illness.
▪ In case the child is not able to take the normal quantities of food, s/he should be given small
quantities of food frequently.
▪ Child can also be given foods of thicker consistency such as khichari, dalia, sooji or rice in milk,
idli, etc. Small quantities of oil/ghee should be added to the food to provide extra energy.
▪ After the illness, at least one extra meal should be given to the child for at least a week to help
the child in speedy recovery.
▪ Give extra home available fluids (as much as the child will take) such as rice or pulses-based
drink, daal soup, vegetable soup, green coconut water, milk, plain clean water or other locally
available fluids (if child is above 6 months of age). This would help in the relief of cough.
Always feed from a cup or spoon. Never use a bottle.
▪ If the child's nose is blocked and interferes with feeding, clear the nose. Keep the nose clean by
putting in nose drops (boiled and cooled water with salt mixed in it) and by cleaning the nose
with a soft cotton cloth. Saline nasal drops at home can also be prepared by adding ½ teaspoon of

57
 common salt (2.5 gm) to 250 ml (1 glass) of clean drinking water. Fresh solution should be
prepared daily.
▪ Avoid cough syrups.
▪ Advise mother/caregiver on how to give medicines at home.

Teach the mother/caregivers to watch for the following signs of illness and return quickly if
they occur:
▪ Child becomes sicker,
▪ Not able to drink or breastfeed,
▪ Fast breathing,
▪ Difficult breathing or
▪ Develops a fever

If any of these above signs appear, mother/caregiver should immediately contact you and visit
the SHC-HWC- for further referral to CHC or DH.

2. ASSESS AND CLASSIFY DIARRHOEA

If the mother/caregiver says the child has diarrhoea:
ASK: LOOK at the child's general condition.
For how long child has diarrhoea? ▪ Is the child lethargic or unconscious?
Is there blood in stools? ▪ Restless and irritable?

Look for sunken eyes.

Offer the child fluid to drink.

Is the child: not able to drink or drinking poorly? Drinking
eagerly, thirsty?

FEEL
PINCH the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Slowly?

The classification table for the type of diarrhoea in sick children is given below.

Signs Classify as Action to be taken by CHO

58
 Two of the following signs:
• Lethargic or unconscious • Refer URGENTLY to CHC or DH
SEVERE wherever paediatrician or
DEHYDRATION
• Sunken eyes paediatric care services are
• Not able to drink or drinking available with mother/caregiver
giving frequent sips of ORSfluids
poorly
on the way.
• Skin pinch goes back very slowly

Two of the following signs: • Treat Some Dehydration with

SOME ORS (as per Plan B of IDCF
•Restless, irritable
DEHYDRATION toolkit).
•Sunken eyes • Reassess after 4 hours and
•Drinks eagerly, thirsty classify for dehydration again
and decide as per Plan B.
•Skin pinch goes back slowly
• Follow-up in 2 days if not
improving.

• Not enough signs to classify as NO • Give fluids (home-available

some or severe dehydration Passing DEHYDRATION fluids/breast milk) and Food to
urine normally. treat diarrhoea at home (Plan A
of IDCF toolkit).
• Follow-up in 2 days if not
improving.
▪ Blood in stool DYSENTERY • REFER URGENTLY to CHC
or DH wherever paediatrician
or paediatric care services are
available with mother/caregiver
giving frequent sips of
ORS/fluids on the way.

Remember:

59
 ▪ Classify all cases of diarrhoea for dehydration. In addition, also classify dysentery if there is
blood in stool.
▪ If the diarrhea is of 14 days or more duration, the child has severe persistent diarrhoea. This
child should be referred to CHC or DH wherever paediatrician or paediatric care services are
available.
▪ Children with signs of severe dehydration should be referred to CHC or DH wherever paediatrician
or paediatric care services are available.
▪ Children with dysentery should be referred to CHC or DH wherever paediatrician or paediatric
care services are available.
▪ Children with some dehydration should be rehydrated with ORS.
▪ Children who are not dehydrated and have no blood in stools should be managed at home.

IDENTIFY TREATMENT AND TREAT THE CHILD

A. Home care for treatment of diarrhoea with no dehydration includes the following (Plan A)
1. ORS till the diarrhoea stops and Zinc daily for 14 days. Refer to Annexure-3, for teaching
mother/caregiver the steps involved in preparing ORS using ORS packet.
2. The child should be given extra fluids to drink as much as the child will take. Advise the
mother/caregiver to give home available fluids. Some examples of useful and harmful home
available fluids are given in the table below:
Useful Harmful

1. Breast Milk 1. Soft drinks/Cola drinks

2. Yoghurt drink 2. Fruit juices (sweetened)
3. Lemon drink (Sikanjavi) 3. Tea, Coffee
4. Rice Water
5. ‘Dal’(lentil)
6. Vegetable soup
7. Green coconut water
8. Fresh Fruit Juice(unsweetened)
9. Plain clean water or other locally available fluids

HOW MUCH EXTRA FLUID TO GIVE AFTER EACH LOOSE STOOL (Plan A)

60
 Age
Up to 2 months 2 months upto 2 years 2 years and more

5 tea spoons (1 teaspoon=5 ml) ¼ glass-1/2 glass (50-100 1/2-1 cup (100-200 ml)
ml)
Give more if the child wants.

Tips to help the mother/caregiver:

▪ Give frequent small sips from a cup.
▪ If the child vomits, wait for 10 minutes. Then continue but more slowly.
▪ Continue giving extra fluids until the diarrhoea stops.
▪ Continue breastfeeding whenever the child wants and for longer at each feed.

2. Give zinc supplement one time daily for 14 days.

Age Dose
2-6 months 10 mg (half tablet) in breast milk in spoon
6 months - 5 years 20 mg (one tablet) in clean water in spoon

Refer Annexure-4 on demonstration and administration of zinc supplementation to child by the

mother/caregiver.

3.Continue feeding. The child should continue to be fed as much as the child would take. If the child
is reluctant to eat, then feed more often than before smaller amounts of food. As soon as the child
recovers the child’s appetite would return and the mother should feed extra foods to make up for the
excessive losses during the disease. Advise on hand-washing to the mother/caregiver and toilet use.
4.Advise the mother/caregiver when to return. The signs that she must look for are:
▪ Child becomes sicker;
▪ N
ot able to drink or breastfeed or drinking poorly
▪ B
lood in stool
▪ Develops a fever

B. Treatment of Diarrhoea with some dehydration with ORS at Health Facility- SHC-HWC
(Plan B)

61
 The child with diarrhoea of less than 14 days duration who has signs of some dehydration should
be treated under your supervision at SHC-HWC with ORS for 4 hours. For this, keep the
mother/caregiver and child under observation, either at the sub-health centre or at the home of the
child.
Use the table to determine the amount of ORS that should be given to the child in 4 hours.

After about 4 hours of giving ORS, reassess the child for dehydration. If the child is no longer
dehydrated, tell the mother/caregiver to give home available fluids the same way as she gave ORS.
Begin feeding the child even if dehydration persists, continue ORS. If the child is still dehydrated,
refer to the nearest health facility / PHC. On the way, mother/caregiver should continue to give
ORS to the child.
Follow the same advice regarding zinc supplement, feeding and danger signs as given above.
FOLLOW UP CARE
A child with diarrhoea having some or no dehydration should be seen after 2 days. Assess the
child’s diarrhoea and review the feeding.
Assessment Findings Treatment
If very slow skin pinch or drinks poorly or ▪ Refer urgently at CHC or DH wherever
general danger sign paediatrician or paediatric care services
are available.
If child has some dehydration (slow skin pinch ▪ Treat with ORS.
and drinks eagerly) ▪ Reassess after 4 hours

62
 If child has no dehydration (skin pinch normal ▪ Continue home available fluids.
and drinks normally) ▪ Review feeding and solve
problems.

3. ASSESS AND CLASSIFY FEVER

Fever is a common problem among young children. A child with fever may have malaria or
another disease such as simple cough or cold or other viral infection.

DOES THE CHILD HAVE FEVER? (By history or feels hot or temperature 37.50C or above)
IF YES: LOOKANDFEEL:
THENASK: ▪ Look or feel for stiff neck
▪ Fever for how long?
▪ If more than 7 days, has fever been present
every day?

Test POSITIVE/NEGATIVE/NA
P. falciparum/P. vivax

Before classifying fever, check for other obvious causes of fever (e.g. cough, diarrhoea, skin
infection etc.). The National Anti Malaria Program (NAMP) in some areas has provided health
workers rapid diagnostic kits and anti-malarials including Artemisinin-based Combination Therapy
(ACT) for early diagnosis and treatment of P. falciparum cases. Before treating a child with fever,
therefore, you will determine whether the child has malaria by doing a rapid diagnostic test (RDT).
➢ If the fever has been present every day for more than7 days, refer this child for further
assessment.
➢ A child with fever and stiff neck may have meningitis. A child with meningitis needs
urgent treatment with injectable antibiotics and referral at CHC or DH wherever paediatrician
or paediatric care services are available.

CLASSIFY FEVER
Given below is the classification table for Fever.

Signs Classify as -Action to be taken by CHO

▪ Give first dose of oral amoxicillin and IM
▪ Any general danger VERY Gentamicin.
sign or SEVERE ▪ Treat the child to prevent low blood
▪ Stiff neck FEBRILE sugar.
DISEASE ▪ Give one dose of paracetamol for high
fever.
▪ Refer URGENTLY to CHC or DH
wherever paediatrician or paediatric
care services are available.

63
▪ Positive RDT
▪ Give antimalarials as per NAMP guidelines.
MALARIA ▪ Give one dose of paracetamol for high fever
(temperature 38.5 degree Celsius or 101.3
degree Fahrenheit or above).
▪ Advise mother/caregiver on home care for
fever.
▪ Advise mother/caregivers on use of
insecticide-treated nets (ITNs).

▪ Follow-up in 2 days if fever persists.

▪ If fever is present every day for more than 7
days, refer for assessment to CHC or DH
wherever paediatrician or paediatric
care services are available.

▪ Negative MALARIA ▪ Give one dose of paracetamol for high

RDT/N.A. UNLIKELY fever (temperature 38.5 degree Celsius
▪ Other causes or 101.3 degree Fahrenheit or above).
of fever ▪ Advise mother/caregiver on home care
present* for fever.
▪ Advise mother/caregiver when to return
immediately.
▪ Follow-up in 2 days if fever persists.
▪ If fever is present every day for more
than 7 days, refer for assessment to
CHC or DH wherever paediatrician or
paediatric care services are available.
* Other causes of fever include cough or cold, pneumonia, diarrhoea, dysentery and skin
infections.

▪ Do not assess for fever if the child does not have fever.
▪ If fever has been present every day for 7 days or more refer to CHC or DH wherever
paediatrician or paediatric care services are available.
▪ Remember to classify a child with fever who has a general danger sign as VERY SEVERE
FEBRILE DISEASE.

HOME CARE FOR CHILD WITH FEVER

For the child with fever who does not have severe disease, treat with home care advice to the
mother/caregiver.
1. Advise the mother/caregiver to continue feeding the child during the illness. Continue
breastfeeding. 2. Advise the mother/caregiver to continue giving home available fluids as much
as the child would take such as rice or pulses-based drink, dal/pulse soup, vegetable soup, green
coconut water, milk, plain clean water or other locally available fluids (if child is above 6 months
of age). Increase breastfeeding.
The sick child who has fever needs more fluids.

64
 3. Teach the mother/caregiver to look for signs of illness when to return to you immediately-

▪ Child becomes sicker,

▪ Not able to drink or breastfeed.

TREAT HIGH FEVER WITH PARACETAMOL

Fever whatever the cause should be treated with paracetamol. If the axillary temperature is 38.5oC
or above, give paracetamol. The dose of paracetamol is given in the table below. Paracetamol may
be repeated after 6 hours if fever is high. If fever persists for seven days or more refer the child to
the CHC or DH wherever paediatrician or paediatric care services are available.

Age of the Child Paracetamol (500mg tablet)

2 months up to 3years ¼
3 years up to 5years ½

GIVE ANTIMALARIALS AS PER NAMP GUIDELINES

Once a sick child is diagnosed positive by RDT or microscopy, treatment is started. The first dose
is always taken in the presence of the health worker. The blister pack with remaining tablets is
given to the mother/caregiver to take home with clear instructions for giving to the sick child.

Caution: If the patient is a child under 5 years, wait for 15 minutes after giving the first dose. If it
is vomited within this period, let the child rest for 15 minutes, and then give the first dose again i.e.
open a new blister-pack and discard what remains of the old. If the child vomits the first dose
again, it is considered a case of severe malaria, refer the child immediately to the nearest Block
PHC/ CHC/ District Hospital.
Explain to the mother/caregiver-
➢ That if the treatment is not completed as prescribed, the disease may manifest again with
more serious features and more difficult to treat.
➢ To come back immediately, if there is no improvement after24 hours, if the situation
gets worse or the fever comes back.
➢ That regular use of a mosquito net (preferably insecticide treated net) is the best way to
prevent malaria.

FOLLOW- UP CARE
Malaria/Malaria Unlikely
After 2 days of treatment review fever:

Assessment Findings Treatment

65
 Child with a general danger sign or stiff neck Refer urgently to CHC or DH wherever
paediatrician or paediatric care services are
available.
If the child has any obvious cause of fever Provide treatment or refer to CHC or DH
other than malaria wherever paediatrician or paediatric care
services.
If malaria is the only apparent cause of fever Continue antimalarial/start antimalarial
treatment if not given and see again in 2 days
till fever settles.
If fever has been present for 7 days Refer for assessment to CHC or DH wherever
paediatrician or paediatric care services are
available.

4. CHECK FOR MALNUTRITION

Check ALL sick children for signs suggesting malnutrition.

CHECK FOR MALNUTRITION

LOOK AND FEEL:
• Look for visible severe wasting (weight in relation to length/height)
• Look for oedema of both feet

You will learn how to identify children with visible severe wasting in Chapter- 8 on Early Detection
and Management of children with growth failure.

66
CLASSIFY MALNUTRITION
Given below is the classification table for malnutrition.
Signs Classify as Action to be taken by CHO
Weight-for- ▪ Prevent low blood sugar by
Height/Length < - 3 breastfeeding, other milk/water with
Standard Deviation SEVERE sugar (4 teaspoons of sugar per cup).1
AND Medical ACUTE
teaspoon=5 gms.
MALNUTRITION
complications* OR with Medical ▪ Keep the child warm.
Complication ▪ Refer URGENTLY to the Nutrition
poor appetite OR
Rehabilitation Centre (NRC)/ Paediatric
Bilateral pitting
care facility at CHC or DH.
oedema
SEVERE ▪ Referral to Anganwadi Centre
Weight for height <-
ACUTE (AWC) for nutritional management.
3 Standard Deviation MALNUTRITION
AND without Medical
complication
Good Appetite
AND
Clinically well and
alert

*Medical Complications: Severe bilateral pitting oedema, anorexia (as demonstrated by an

appetite test), intractable vomiting, convulsions/fits, lethargy or not alert, unconsciousness, lower
respiratory tract infection, high fever, severe dehydration, severe anaemia, hypoglycaemia,
hypothermia, signs of xerophthalmia (corneal xerosis, ulceration, cloudiness or keratomalacia).

67
 Remember:Always refer Infants less than 6 months to paediatric care facility /NRC- When
there is visible severe wasting, if length of child is < 45 cm or W/L<-3SD or are oedematous or are
too weak or feeble to suckle.

▪ A child with severe acute malnutrition with Medical complications has a serious
problem and should be urgently referred to the NRC/ Nearest paediatric facility at CHC
or DH.
▪ Children with very low weight should be assessed and counseled for feeding.
▪ All children less than 2 years of age should be assessed and counseled for feeding.

5. CHECK FOR ANAEMIA

Check all children aged 6-59 months for signs suggesting anaemia.

CHECK FOR A NAEMIA

LOOK AND FEEL:

Look for palmar pallor. Is it-
▪ Severe palmar pallor?
▪Some palmar pallor?

Pallor is unusual paleness of the skin. It is a sign of anaemia.

To see if the child has palmar pallor, look at the skin of the child's palm. Hold the child's palm
open by grasping it gently from the side. Do not stretch the fingers backwards. This may cause
pallor by blocking the blood supply.
Compare the colour of the child's palm with your own palm and with the palms of other children.
If the skin of the child's palm is pale, the child has some palmar pallor. If the skin of the palm is
very pale or so pale that it looks white, the child has severe palmar pallor.
CLASSIFY ANAEMIA
Given below is the classification table for anaemia.

Signs Classify as Action to be taken by CHO

▪ Severe SEVERE
palmar ANAEMIA
pallor ▪ Refer URGENTLY to CHC or SDH/DH wherever
(Hb< 7gm/dl) paediatrician or paediatric care services.

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▪ Some ANAEMIA In case of mild anaemia:
palmar
pallor (Mild: Hb 10-10.9
(to be ▪ Therapeutic IFA syrup has to be given to anaemic children
gm/dl;
tested 6-59 months of age with the help of auto-dispenser. Give
Moderate: Hb 7-
using 1 ml of iron folic acid syrup once daily preferably after
digital 9.9 gm/dl) meal for children 6-12 months for 2 months (follow up by
invasive ASHA after 1 month to check compliance).
haemogl
obinome
ter to ▪ For children 1-3 years of age, 1.5 ml iron folic acid syrup
decide once daily preferably after meal should be given to child
the level with the help of auto-dispenser for 2 months (follow up by
to ASHA after 1 month to check compliance).
anemia)
▪ Similarly, for children aged 3-5 years, 2 ml iron folic acid
syrup has to be given to child with the help of auto-
dispenser for 2 months (follow up by ASHA after 1 month
to check compliance).

▪ If there is no anemia after 2 months, prophylactic IFA

syrup should be initiated.

▪ If there is no increase/ drop in Hb level after 2 months of

therapeutic treatment, refer to higher center.

In case of moderate anemia:

▪ If the child is moderately anemic (Hb 7-9.9 gm/dl), then a

complete blood count (CBC) should be done to ascertain
the cause of anaemia.
▪ In case of iron deficiency anaemia, therapeutic dose of
IFA Syrup (as mentioned above) has to be provided to the
child for 2 months. Follow up after 1 month to check Hb
level and IFA syrup compliance of the child.
▪ In there is no increase/ drop in Hb level after 1 month of
therapeutic treatment, refer to higher health centre.
▪ If there is improvement in Hb level (i.e. moderate to mild
anemia) after 2 months, therapeutic IFA should be
continued for another month. Follow up should be done
every month to assess the Hb status and compliance to
IFA syrup.
▪ As soon as the Hb level < 11gm/dl is achieved,
prophylactic IFA syrup should be given.
▪ Assess the child’s feeding & development support care
and counsel the mother/caregiver.
▪ Follow-up in 14 days.

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 ▪ No NO ANAEMIA ▪ Give prophylactic biweekly 1ml iron folic acid syrup
palmar through auto-dispenser for child 6 months or older.
pallor (Hb>11 gm/dl)

TREAT ANAEMIA WITH IRON FOLIC ACID

Treat some palmar pallor (mild and moderate anemia) with iron and folic acid syrup therapy. The
dose and duration of iron is given in Chapter 7 on Iron and Folic Acid Supplementation.
▪ Inform mother/caregiver that the stools of the child may become black. This is not a cause of
worry.
▪ There should be a gap of at least two hours between iron folic acid supplementation and giving
milk to the child since this reduces the absorption of the medicine and makes it less effective.
Also advise mother/caregiver to feed the child according to the age- specific feeding
recommendations and to give citrus fruits to the child as it contains Vitamin C which increases
iron absorption. These are described in Chapter 7 on Iron and Folic Acid Supplementation.
▪ For therapeutic IFA supplementation, give iron folic acid syrup for14 days initially and ask
mother/caregiver to return for follow up at that time. If child is doing well give iron therapy
again till child consume iron for 60 days.
▪ Inform the mother/caregiver to revisit with the child immediately if the child develops any
danger signs such as unconsciousness, convulsions/fits, inability to eat or drink, diarrhoea,
stomach ache, etc.
Note: Do not give iron to a child receiving anti-malarial drugs. The child should be treated for
malaria if the risk of malaria is high.
FOLLOW UP-
Review whether the child is getting the iron folic acid syrup as advised. Is the child feeling better?
Is the child eating better?
➢ Give iron folic acid supplement for another 14 days for a total of 60 days. Advise return after 14
days.
➢ Assess pallor/haemoglobin estimation.
➢ Refer at CHC or SDH/ DH wherever paediatrician or paediatric care services are available if
the child is not improved after 2 months of treatment with iron.

6. PROMOTE THE HEALTH OF THE CHILD1. Update immunization as required according to

age
2. Give Vitamin A as per age
3. Give prophylactic IFA
4. Counsel for child’s feeding and development support care if child is very low weight for age or has
anaemia or if the child is less than 2 years of age.

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 6.1. CHECK THE CHILD'S IMMUNIZATION STATUS
The immunization status of all children, who are seen by CHO, should be checked (in the MCP
card). The National Immunization Schedule is given in Chapter 9 on Immunization for children.
A child who needs to be immunized, the mother/caregiver should be advised to go for vaccination on
the next immunization day at AWC/SHC-HWC/PHC.
6.2. CHECK THE CHILD’S PROPHYLACTIC VITAMIN A SUPPLEMENTATION
STATUS
In the national programme, vitamin A is given at the age of 9 months when the child is brought for
measles rubella (MR) immunization and subsequently with Diphtheria, Pertussis and Tetanus
(DPT) Booster at 16-24 months. After this, the child is given Vitamin A six monthly till 5 years of
age.

PROPHYLACTIC VITAMIN-A

Give a single dose of vitamin A:

▪ 100,000 IU/1ml at 9 months with measles rubella (MR) immunization,

▪ 200,000 IU/2ml at 16-18months with DPT Booster,
▪ 200,000 IU/2ml at 24 months, 30 months, 36 months, 42 months, 48 months,
54 months and 60 months.

Ask- has the child (> one year of age) received vitamin A. If not given in 6 months, give
Vitamin A supplementation.

Some States/UTs also conduct biannual round of Vitamin A supplementation six months apart and
provide Vitamin-A supplementation to children as per schedule and dose above.

6.3. PROPHYLACTIC IRON ANDFOLIC ACID SUPPLEMENTATION STATUS

Prophylactic supplementation of iron and folic acid syrup, twice in every week is recommended
under the Anemia Mukt Bharat (AMB) strategy for all children 6-59 months of age. You will
actively promote IFA syrup to all children and ensure a regular supply of IFA syrup for easy
administration to children. Refer Annexure- 5 on teaching mother/caregiver to provide IFA syrup to
the child.
PROPHYLACTIC IFA supplementation-

Give 1 ml iron folic acid syrup to a child preferably one hour after meals, two times in a week with an
auto dispenser, containing 20 mg elemental iron and 100 mcg folic acid (IFA syrup) if the child is 6
months of age or older. In case of children suffering from acute illness, IFA syrup can be given to
them after the child has recovered.

6.4. DEWORMING STATUS

Albendazole tablet is provided to children after one year of age. You should check the status of
deworming in the MCP card. In case the status is not mentioned in the MCP card for the last
deworming dose, the mother/caregiver should be asked regarding the same and to contact the

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ASHA/MPW for administering deworming tablet during the next round. If the child has any signs of
worm infestations (round worm/threadworm/pinworm), appropriate deworming dose for treatment
to be provided as given below.

Medicine Doses by age

Below 1 year 1-2 year 2 years onwards

Albendazole Not to be given (safety not Half tablet One tablet (biannual
established) (biannual dose) dose)
(400mg tablets)

Role of CHO in assessment and care of sick child (2-59 months)

1. Undertake assessment of common illnesses in sick child by recognizing the danger signs.
2. Timely and urgent referral of sick child to appropriate referral centres on the basis of assessment
with proper counselling to the mothers/ caregiver and provide pre-referral treatment as per protocols.
3. Provide appropriate treatment for the management of the common illnesses in sick child as per
protocol.
4. Teach the mother/caregivers regarding the danger signs in the sick child with immediate reporting,
administration of oral medicines, treatment of local infection at home and preventive strategies of
these diseases.
5. Ensure timely referral of SAM children by ASHA.
6. Support and supervise the primary healthcare team to ensure the following steps are undertaken
for sick children especially discharged from higher health facilities -
▪ Registration of the children at the nearest Anganwadi Centre to ensure uptake of services at
AWC.
▪ Follow-up care through home visits undertaken by ASHAs and MPW for sick children
discharged from health facilities.
▪ Medication being given to the child by the mother/caregiver as per the prescribed treatment plan
on the discharge card.
▪ Ensure the mother/caregiver visits the health facility as per the next follow up date given on the
discharge card.
▪ Ascertain that weight is being regularly of the child measured by ASHA during her home visits
and recorded in Mother-Newborn Home Visit Card (HBNC card/form). MPW will measure the
weight of the child and record in MCP card. Monitor progress in weight for age of the sick young
child.
▪ Ensure early detection for 4Ds- defects at birth, development delays including disability, specific
deficiencies and diseases by RBSK mobile health teams in every block with referral to DEIC for
further management. Timely follow-up of discharged children to ensure appropriate care.
▪ Ensure counselling of the mother/caregiver on early childhood development using the MCP card
by ASHA and MPW and timely reporting by mother/caregiver to ASHA, MPW or you in case of
any warning sign in the child.
▪ Inform ASHAs/MPWs to mobilize the mother/caregiver to bring the discharged child to HWC-
SHC in the first week of discharge to assess for development of any danger signs. Initiate prompt
referral, if required.
▪ Counselling of mother/caregiver regarding importance of extra care of such children at home-

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 prevention of infections by maintaining hygiene, warm care, appropriate feeding support for
breastfeeding, age-specific immunization, age-appropriate and adequate complementary feeding,
prevention of childhood illnesses like diarrhoea, fever, pneumonia, explain activities/parenting
tips for adequate stimulation for child’s growth, expression of breast milk and feeding,
micronutrient supplementation such as Vitamin A and IFA syrup, etc. as per guidelines.

Chapter 6: Infant and Young Child Feeding (IYCF)

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. In this chapter, the knowledge and skills on Infant and Young Child Feeding (IYCF) will be
refreshed for better coordination with ASHAs, MPWs andAWWs to ensure adequate nutrition for
newborn and children below 2 years of age.

We all know that nutrition plays an important role in maintaining our health. Adequate amounts of
different nutrients in appropriate proportions are required for a healthy body. When diet is not
balanced3 and is inadequate in terms of calories, proteins, fat, micronutrients and minerals, it results
in nutritional deficiency diseases especially in children.

Early childhood is the most rapid period of development in human life and ensuring care of the
mother and the child in the first 1000 days of life (begin from the day a woman conceives and
continues till the child turns two years of age. It is known as sum of 270 days of pregnancy, 365 days
of the 1st year of infant’s life and 365 days of the 2nd year of child’s life), lays the basis for healthy
mental, emotional and physical growth of children. This in turn ensures optimum health and
wellbeing in adult life.

Malnutrition (a state of deficiency or excess of nutrients) in the form of undernutrition and

overnutrition in children, has been found to have overarching effect on all components of RMNCAH
care and severely affects the overall development of children. Malnutrition results from several
causes e.g., poverty, large sized families, improper feeding habits, unhealthy dietary choices, taboos
and unhealthy beliefs related to feeding, poor breastfeeding, delayed or inadequate complementary
feeding, frequent childhood infections (acute respiratory tract infection, diarrhoea, etc.). Children
who are undernourished have an increased risk to infections, frequent episodes of illnesses such as
diarrhoea, pneumonia, etc. and take longer to recover.

Undernutrition in early childhood is associated with irreversible damage to children’s mental and
physical growth and increases their susceptibility to childhood infections. These factors in early
childhood result in poor academic performance, poor learning capacity and poor health and nutrition
status through childhood, adolescence and adulthood. Overnutrition, in the form of overweight
(excess body weight for a particular height) and obesity (excess body fat) commonly seen in
childhood due to lack of physical exercise, excess intake of calories in the diet and other
physiological factors is also harmful and may result in potential health problems such as heart
diseases, diabetes and hypertension later in life.

Age- appropriate responsive parenting advice and IYCF practices should be promoted by you during
each contact with the mother/caregivers whether at the health facility, outreach activities and home-
based care visits.

Age appropriate optimal Infant and Young Child Feeding practices to be promoted-

3
Balanced Diet- Wholesome diet which provides essential nutrients like carbohydrates, fats, proteins, vitamins, minerals,
and water from all food groups in the proper amounts to maintain good health. In addition, it also provides dietary fibre.

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Around delivery and during first six months:
1. Initiation of early breastfeeding (Colostrum feeding) immediately after birth, or definitely within
1 hour of birth.
2. Exclusive breastfeeding during the first six months of life (180 days).
3. Ensuring good nutrition and rest during lactation period for the mother and motivate her to be cheerful for
a successful motherhood.
4. Provide lactation support to mothers to ensure breastfeeding.
5. No pre-lacteals (no other foods or fluids, not even water) for the child.

At six months and beyond

1. Timely introduction of solid, semi- solid or soft complementary foods on completion of six months.
2. Age- appropriate and safe complementary feeding for children 6-24 months: Bringing dietary diversity in
complementary food (eating a variety of foods from each food groups in proper quantities). Gradually
increasing food consistency and variety as the infant grows older, adapting to the infant’s requirements and
abilities.
3. Continue breastfeeding along with the complementary feeding for two years or beyond
At all times
1. Practice active and responsive feeding at all times- during illness and healthy period.
2. Practice good hygiene and proper food handling.
3. Continue feeding the child during illness- increase fluid intake during illness, more frequent breastfeeding,
and soft foods. After illness, encourage the child to eat more.

In addition, regular growth monitoring for identification of early growth faltering, iron and
folic acid supplementation, immunization, appropriate use of ORS during diarrhoea, age-
appropriate play and communication with children and appropriate hand washing practices,
safe hygiene and sanitation practices, etc. are the other most effective interventions for overall
child survival - good nutritional status, growth, development, health, and ultimately the
survival of infants and young children.

Counselling the family members regarding safe WASH practices is listed in Annexure-6.

6.1 Important messages for Breastfeeding

You should reinforce the following key messages to promote breastfeeding amongst the mother/
caregivers:
▪ Counseling on the importance of early initiation of breastfeeding with colostrum feeding.
▪ A newborn baby can be breast feed on demand i.e. whenever the baby cries for feeds. The
usual time interval between each feed is about 2 to 3 hours. Mothers should be advised that
they should feed their babies at least 8-12 times in 24 hours, both day and night and
importantly they should not miss feeding in the night. Frequent feeding helps mothers to
produce more breastmilk.
▪
▪ Mother should continue breastfeeding at frequent intervals even during diarrhoea or any other
illnesses to help the child to get optimal nutrition and recover from the illness faster.

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▪ Discourage the mother/family from giving top feeds/pre-lacteal feeds (other than breast milk
like animal milk, powdered milk, etc.), additional food or fluid, herbal water, honey, glucose
water, ghutti water, plain water, animal or powdered milk, etc., using bottles and teats (a
plastic nipple used on top of the bottle) for feeding the child as they are harmful and are
likely to carry infections as well as problems in breastfeeding.
▪ Advise the mother/caregiver on breastfeeding sick young infants and children as learnt in the
Chapter- 4 and 5.
6.2 Counsel and support for Exclusive Breastfeeding

▪ In our country, only about half of the children under 6 months of age are being exclusively
breastfed. Exclusive breastfeeding means feeding the child ONLY breast milk for the first 6
months (180 days). Breast milk provides all nutrients and contains sufficient water to meet the
requirements of the child up to six months of age; the infants who are exclusively breastfed do
not require anything else.
▪ During the post-natal visits of mothers and newborn, you and the ASHA and MPW will
undertake the following actions for ensuring support for exclusive breastfeeding such as -
counselling of the mother/caregiver in dealing with breastfeeding problems by providing
support in management of common breastfeeding problems such as delay in initiation, no milk
secretion, incorrect position and attachment, short duration of breastfeeding, feeding of low
birth infants and insufficient milk production.

Refer Annexure-2 for information related to counselling regarding feeding problem, important
messages for breastfeeding, correct positioning and attachment for breastfeeding.

6.3 Complementary Feeding

Complementary feeding means complementing solid/semi-solid or soft foods with breast milk after
child attains age of six months i.e 180 days.

Need for starting complementary feeding on completion of six months of age-

▪ Breast milk alone is not sufficient to meet the nutritional requirements of the growing infant.
▪ 6 months to 24 months is a period of rapid growth and development in the young child and
demands extra nutrition.
▪ Breastfeeding should be continued for a minimum of 2 years or beyond because it is an
important source of nutrition, provides energy, other essential nutrients and protects infants
from infection, who are particularly vulnerable during the transition period when
complementary feeding begins.

Table - Requirements of Complementary Foods

Timely Introduced at completion of six months when requirement for energy and nutrients
exceeds that provided by breastmilk alone.
Dietary Should provide sufficient nutrients to meet the growing needs of the child- energy,
Diversification protein, vitamins and minerals from different food groups like:
Cereals such as wheat, wheat flour (atta/maida), rice, rice flakes (chirwa), maize/

76
 corn, barley, semolina (suji), vermicelli (sevian), puffed rice (murmura), etc,
Millets like bajra, ragi, jowar, kodo, sama, samva, etc. and
Pulses (daals like channa/moong/urad/arhar/besan/chana, sprouted pulses) and
legumes (rajma, lobia, soyabean), etc;
Vegetables (including green leafy vegetables,other coloured vegetables, starchy
roots and tubers like potatoes, sweet potato (shakarkandi), colocasia (arbi), yam
(jimikand) and other root vegetables and Fruits;
Milk and Milk Products like milk, curd, cottage cheese (paneer), etc.,
Animal products/non-vegetarian foods (meat, liver, fish, poultry, eggs (well-
cooked), etc.); and
Fats/oils, sugar and nuts like ghee/butter/vegetable cooking oils (groundnut oil,
mustard oil, soyabean oil, coconut oil) and sugar/jaggery (gur)/honey and nuts like
groundnuts, almonds, cashewnuts, etc. Nuts may be added only if child is not
allergic (especially groundnut). Nuts can be roasted, crushed and powdered and
then given to the child (till the child can chew properly). Whole nuts may cause
choking in the child.
Encourage the mother/caregiver on use of fortified foods, wherever available.

Active Feeding Encourage the child to eat more without forced feeding from a separate
method/Properly cup/katori/plate at recommended frequency.
Fed Children have small stomach therefore should be fed more frequently.
Safe Food should be hygienically prepared and stored. Mothers/caregivers should wash
their hands with soap and water before preparing food and feeding the child. Also
wash the child’s hands.

Table - Five Important Things To Remember About Complementary Feeding

Consistency Quantity Frequency Density Variety

• Depends on • Increase with • Increase • Add a spoon • Add fruits
age of the age of the with age of of some and
child and child. the child. edible oils vegetables- The
readiness to • Encourage for • Number of or fats/ rule is that the
chew and better intake feeds will ghee/butter; greener it is,
swallow. but not force increase sugar/ or the more
• Initially child to eat gradually with jaggery red and yellow
include soft more. increase in age (gur) is the feed,
and mashed • At one-year, of the child. to each feed, the more is
foods. child should to make the the protective
• Move receive half feed rich in quality.
gradually to the mother’s energy. • Meat, egg
foods with nutrition. (well-cooked),
appropriate poultry, fish,
thick etc. are liked
consistency. by children and
• Give Daal are also very
(and not nutritive and
Daal ka protective.
Paani)
• Feed
prepared

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should not
be too thin
and too
thick. Test:
stays on
spoon when
the spoon is
tilted (see
figure given
below)

78
 Different consistencies of Complementary Food

6.4 Assessing information on Complementary Feeding from the mother/caregiver

1. Start by asking if the mother/caregiver is breastfeeding the child?

▪ How many times in a day- both day and night
▪ Is the child breast fed at night? If yes, how many times is the child fed at night.

2. Does the child take any other food or fluids?

▪ What foods or fluids?
▪ How many times per day?
▪ Are the foods thick or thin?
▪ What do you use to feed the child?
▪ How large are the servings (cup/katori, teaspoon, tablespoon)?
▪ Does the child receive separate serving from the family members?
▪ Who feeds the child and how?
▪ What feeding difficulties does mother/caregiver experience, if any?

3. Ask if the child’s feeding has changed during the illness?

▪ If yes, how?
▪ The mother’s/caregiver’s answers to these questions will give you an idea whether the
child is receiving adequate amount of nutrition from breastfeeding and complementary
feeding.

As the supervisor of the primary healthcare team, you should ensure that the mother/caregivers are
counselled during home visits, visit to health facility, health campaigns, VHSND session or any
other contact by the primary health care team members regarding-
▪ Exclusive breastfeeding till 6 months of age of the child. Children who are breastfeeding, need
to be breastfed more often and for longer time even during illness.
▪ Timely initiation of complementary feeding along with responsive feeding for all healthy and
sick children.
▪ Support them in teaching right quantities for complementary feeds by using dietary
diversification and use of fortified foods, wherever available.
▪ . Maintaining age- appropriate feeding pattern by informing on what should be avoided.
Feeding during illness by providing small frequent meals and more fluids including
breastmilk. After an illness, children should be given more food and more often
than usual for at least 2 weeks to help recover from the weight lost during illness.

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6.5 Important messages for mothers and caregivers on Complementary Feeding

▪ Introduce only one food at a time and keep adding new foods one by one increase the variety. If the
child dislikes a particular food, remove it from the diet for some time and give again at a later
stage.
▪ Breastfeed as often as the child wants and continue breastfeeding if the child is sick.
▪ Combination of pulses (daals) and legumes with cereals and millets should be given. Example- daal
with rice or cracked wheat porridge (dalia) with daal, chappati/roti soaked in daal, bajra khichri
with daal, etc. Feed should be prepared from locally available pulses and cereals/millets.
▪ Oil/ghee/butter, sugar/jaggery (gur), roasted crushed and powdered/mashed groundnut (if the child
is not allergic) etc. can be added to the feed for making it rich, tasty and easy to swallow. Do not
add spices to the food of the child.
▪ Wash and cook locally available fresh and seasonal vegetables and fruits should be given to the
child. Mashed fruits and vegetables can be added to the feed.
▪ Cook all the food items thoroughly, use safe water, discard all leftovers on children’s plates and do
not save them for later
▪ Cereals/millets and pulses that are soaked, sprouted, dry roasted and powdered for cooking can be
given to the child as they are easily digested.
▪ Animal products/non-vegetarian foods (meat, liver, fish, poultry, eggs (well-cooked), etc.),
wherever culturally acceptable, can be started as early and given as often possible to the child.
▪ Plan for one to two healthy snacks which are like small meals to be given in between the main
meals but must NOT be a replacement of meals. Mashed fruits like banana, papaya, mango,
cheeku and other soft fruits; boiled and mashed potatoes, mashed vegetables, well-cooked eggs,
curd, panjeeri, laddoo, halwa, upma, idli, poha with crushed/mashed groundnuts (do not add
groundnuts if child is allergic), etc. are some of the examples of food items to be given as snack
to the child.
▪ Feed the child in a separate cup/katori/plate as it will help mother/caregivers to understand the
quantity of food eaten by the child.
▪ Show interest, smile or play games to encourage children to eat enough food.
▪ Continue complementary feeding during illness and increase the amount during the recovery
period.
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 ▪ Complementary foods should be prepared hygienically and use clean utensils to prepare and feed of
the child. Mothers/caregivers must wash their hands before preparing and before feeding the
child. The child’s hands should be washed also.
▪ Thoroughly rinse raw fruits and vegetables under running water before cooking
▪ Girls and boys have the same nutrition requirement to grow and develop and both should be given
the same amount and kind of food.
▪ Use only iodized salt for cooking asiodine improves intelligence in the child. Double fortified salt
(fortified with both iron and iodine), wherever available should be consumed.

6.6. Informing mothers and caregivers what should be avoided in Complementary Feeding
It is also important to explain mothers/caregivers to avoid:
▪ Ready-made or processed food available in the market such as toffees, sweets, chips, chocolates,
biscuits, namkeens; drinks such as tea, coffee, cola drinks, cold drinks, sweetened fruit juices,
sharbats, etc.
▪ Showing personal dislikes for any food item otherwise child will not learn to eat all types of foods.
▪ Food which can pose choking hazard such as whole nuts, grapes, raw carrot pieces, etc. initially.
These should be given only at a later stage when the chewing and swallowing ability has been fully
developed.

6.7 Complementary Feeding- Quantity and Frequency for the Child

At 6 months On completion of 6 months, start feeding 2-3 tablespoons at each meal of soft, well-
mashed foods, 2-3 times each day (1Tablespoon = 15 ml).

Continue breastfeeding, introduce one food at a time, such as a small amount of

vegetables, followed by fruits, dal and cereals and increase amount of the feed slowly.
From 6 months upto 9 2-3 tablespoons to be gradually increased to half (1/2) cup/katori at each meal of
months mashed food, 2-3 times each day and 1-2 snacks. 1 full cup/katori -250 ml (the volume
may vary).
Continue breastfeeding, introduce one new food at a time such as khichri, dalia,
include foods from food groups such as- 1) cereals, 2) green vegetables and fruits 3)
oil, ghee; 4) mashed dal/fish/egg (only hard boiled) and also give iron drops/syrup to
maintain the body’s iron stores.
From 9 months upto 12 At least, half (1/2) cup/katori at each meal of finely chopped or mashed food and foods
months- that the baby can pick up with her/his fingers, 3-4 times each day and 1-2 snacks.
Continue breastfeeding, give foods that require chewing, give Vitamin A syrup for
improving eyesight, give iron drops/syrup to maintain the body’s iron stores.
From 12 months upto 2 Introduce family foods, chopped or mashed, give ¾ to 1full cup/katori at each meal, 3-
years 4 times each day and 1-2 snacks.

2 years and older Diverse and an adequate diet- Give a variety of family foods to the child, at least 1 full
children cup/katori (250ml) at each meal, 3-4 meals each day with 1-2 nutritious snacks
between meals.

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6.8 Feeding the child responsively

Mothers/caregivers should recognize the signs of hunger and respond as soon as possible. Responsive feeding
means gently encouraging-not forcing-the child to eat.

Counsel the mothers/caregivers to:

1. Be patient in feeding the child and encourage them to eat. Do not force the child to eat.
2. Try different food combinations, tastes and methods to encourage feeding if children refuse many foods.
3. Play games to help the child to eat enough food and to encourage the child to try new foods.
4. Minimize any disturbances - during meals, if the child loses interest easily.
5. Smile and talk to children during feeding, with eye to eye contact as feeding times are periods of learning and
affection.
6. Do not express anger at children who refuse to eat. These actions usually result in children eating less.

Prevention of overweight and obesity in children

We have mostly learned and heard about only one aspect of malnutrition i.e. undernutrition in children. The other
aspect of malnutrition i.e. childhood obesity is also increasing resulting in burden of diet-related chronic non-
communicable diseases in the country.

According to the Comprehensive National Nutrition Survey (CNNS), 2016-18 from 30 states in India-
Children aged 5-9 Years-

Variables Male Female Urban Rural Total

Children aged 5-9 years who are overweight or obese 4.2 3.3 7.5 2.6 3.7
(BMI for age) (%) (z-score >+1 standard deviation,
based on WHO standards)

Children aged 5-9 years who are obese (BMI for age) 1.8 0.9 2.8 0.9 1.3
(%) (z -score >+2 SD, based on WHO standards)

We know that the quantity of foods needed to meet body requirements differ with age, gender, body composition
and physical activity. In the last few years, there have been changes in the lifestyle of people in both rural and urban
areas. There has been a shift from consuming traditional and fibre-rich foods like whole products - wheat (atta
products), jowar, bajra, maize, pulses and legumes, fruits and vegetables towards 'modern' foods such as eating
more processed foods and ready-to-eat foods, changing cooking practices, increased intake of processed and
intensive marketing of junk (unhealthy) foods. Consumption of energy-rich diets containing higher amount of fat,
salt and sugar pose a serious health risk to people, especially children. Such changes in the diet are applicable to
rural and urban areas alike as intake of processed foods has increased because they are easily available, cheaper and
easier to make when compared to healthy/fresh foods and low physical activity.

Over-feeding during infancy, childhood and adolescence predisposes to overweight/ obesity during adulthood. Also,
increased indoor activities- indoor games, watching television, using mobile phones, playing video games, using
computer, etc., influence of the advertisements of energy- rich foods and consuming unhealthy foods/junk food are
strongly associated with weight gain in childhood. In children, overweight and obesity can be controlled by

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increasing daily physical activity and developing right and healthy eating habits from infancy to keep the body
weight within the normal limits. You have already learnt regarding assessment, management and prevention of
obesity in children during your six-month course in Certificate Programme in Community Health.

Prevention of overweight and obesity in children

Family members and school must be a role model for healthy diet and physical activity for the children. The
following points will help you advise mother/caregivers for prevention of excessive weight gain in children.
▪ Creating an enabling environment at home for promoting consumption of a healthy diet and promoting regular
physical activity. Children who are overweight/obese need to lose weight and maintain a healthy weight.
▪ Encourage exclusive breastfeeding till 6 months after birth and inclusion of healthy foods from food groups in
appropriate amounts during complementary feeding.
▪ All meals to be taken at regular intervals.
▪ Eating a balanced diet/wholesome diet from all food groups in proper amounts as required children to maintain
good health.
▪ Inclusion of a variety of fresh, colourful, seasonal and locally available whole fruits and vegetables (including
green leafy vegetables).
▪ Increase consumption of whole cereals and pulses (with outer covering) as they are high in fibre or roughage
rather than eating refined cereals and pulses.
▪ Restrict eating processed foods or packaged foods - these have high amount of fat/oil (fried foods), salt and
sugar (chocolates, sweets, mithai, mathris, pastries, kachori, samosa, pakoras, papads, pickles,
namkeens/savouries, biscuits, chips, chowmein, noodles, tikki, momos, chutneys, sauces, etc.
▪ Healthy methods of cooking (boiling, steaming, roasting, cooking with minimal oil) should be used rather than
deep frying or using excess amount of oil.
▪ Use vegetables oils like mustard oil, groundnut oil, soyabean oil, etc. for cooking.
▪ Consumption of lean meats like chicken, fish rather than red meat like mutton, liver, brain, etc.
▪ Encourage good hydration - plenty of fluids like plain water, buttermilk (chaach), lemon water (nimbu paani),
coconut water, soups (dal, vegetable or chicken), lassi, milk, etc. Avoid consumption of carbonated and
sweetened beverages like cold drinks, sodas, sweetened fruit juices, etc.
▪ Restrict eating out and encourage the whole family to eat the same food as the child.
▪ Not use food as a reward or punishment.
▪ Encourage daily physical activity both outdoors and at home. Children must also be encouraged to do household
chores.
▪ Reduce TV viewing, playing video games/using computer/mobile phone to less than two hours a day.
▪ Schools must provide a supporting environment for promoting physical activity and healthy food practices
among the children. Encourage the children to participate in sports that they enjoy such as badminton, football,
tennis, football, kho-kho, walking, dancing, swimming, etc.
▪ Family members and school teachers must help bring positive changes in the child’s behaviour- build the child’s
self-confidence and esteem and help him deal with the peer pressure.

The information provided in this chapter is related with promotion of Infant and Young Child Feeding
practices till 2 years of age. Rapid growth occurring in foetal life and during infancy is followed by a long
period of gradual growth during childhood. Thus, good nutrition during childhood period is important as it
lays the base for healthy life.
Importance of nutrition during childhood period has been provided in Annexure- 7.

Role of a CHO in promoting breastfeeding and complementary feeding in for infants and young
children
▪ Alongwith the primary healthcare team, during home visits, VHSND sessions, routine/special
campaigns, immunization sessions, visit to SHC-HWC, or any other contact, counsel the
mother/caregivers on the following -
➢ Importance of early and exclusive breastfeeding from birth to 6 months with feeding of colostrum.
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➢ Timely introduction of age-appropriate complementary feeding to the child while continuing
breastfeeding on completion of six months of age, to both girl and boy children alike. Inclusion of
foods from all the four food groups.
➢ Continued breastfeeding for 2 years or beyond.
➢ Active feeding for children (breastfeeding and complementary feeding) during and after illness.
➢ Importance of regular hand-washing before and after preparing food, before feeding the child and
after using the toilet.
➢ Ensure support from family members husband, mother and father in-law, etc. for the mother to
provide her sufficient rest and adequate nutrition to breastfeed her child. Family support is required to
feed the child responsively.
➢ Ensure families having sick and malnourished children are counselled and following your advice.

▪ Ensure that ASHAs under HBNC and HBYC programme are undertaking age-specific activities
related to nutrition. Review the nutritional status of infants and young children in your service area
with support from MPWs, ASHAs and AWW to ascertain whether all children are being provided
with age appropriate and adequate complementary feeding. Monitor families especially having sick
and malnourished children.

▪ Undertake joint visits with ASHA/MPW to households where the primary healthcare team is unable
to convince the family for exclusive breastfeeding/complementary feeding or feeding during illness.
▪ Pay special attention and provide appropriate care to mothers with problems in breastfeeding and those
children who are unable to take breastfeed or complementary feed. Provide referral if required to health
facility and follow-up with them closely to ensure child is provided appropriate care and is growing well.
▪ Coordinate with AWW to ensure that –
➢ Early registration of lactating mothers and their children at the nearby AWC to avail the
services.
➢ ‘Take Home Ration’ from AWC to be provided to lactating mothers till six months after
child birth and children from 6 months of age, with extra THR to malnourished children.
➢ Nutrition-specific counselling provided regarding breastfeeding and age-appropriate
complementary feeding to all mothers/caregivers whose children who have competed six
months.
➢ During VHNSD sessions, health promotion and counselling activities related to nutrition
are undertaken.

▪ Organize special campaigns such as breastfeeding promotion week, group counselling sessions, growth
monitoring sessions, mothers support groups meetings, celebration of POSHAN Maah, POSHAN
Pakhwada, etc. in coordination with ASHA/MPW/AWW/VHSNC members/ other support groups to enable
health promotion related to IYCF in your catchment area. Such campaigns can also help you in overcoming
the harmful traditional practices and beliefs related to young child feeding and nutrition prevalent amongst
mother-in- law, fathers- in-law, husband and other family members.

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Chapter 7: Iron and Folic Acid Supplementation

You must be aware that IFA Supplementation prevents anaemia in children.

Anaemia is a condition when there is low haemoglobin level in the body resulting in less ability
to carry oxygen to all parts of the body. Anaemia in children causes poor learning ability, low
concentration, tiredness, poor school performance and poor coordination of language in
children. The child is unable to reach his/her full potential both physically and mentally.

Table - Haemoglobin levels in children to diagnose anaemia (g/dl)

Age group No Anaemia Mild Moderate Severe

Children 6–59 ≥11 10–10.9 7–9.9 <7

months of age
Children 5–11 ≥ 11.1 11–11.4 8–10.9 <8
years of age
Source: WHO- Nutritional Anemia: Tools for Effective Prevention and Control, 2017.

This chapter will refresh your knowledge on causes of anaemia in children, IFA
supplementation and provide an update on activities related to National Anemia Mukt Bharat
(AMB) strategy.

Remember

▪ Breast-milk is sufficient to meet the iron requirement of a breastfed child only until 6
months of age.
▪ Iron from breast milk is more easily available to the young child. The onset
of anaemia in young children is generally after 6 months of age and increases from 6–
8 months till the child is 1 year old.

7.1 Causes of Nutritional Anaemia in Children

The common causes of nutritional anaemia are:

▪ Low iron stores at birth due to anaemia in mother.

▪ Non-exclusive breastfeeding up to 6 months of age.
▪ Too early introduction of complementary food i.e. before completion of 6
months of age (resulting in diminished breast milk intake, insufficient iron intake,
and heightened risk of intestinal infections)
▪ Late introduction of appropriate (iron-rich and nutritious) complementary foods i.e.
later than completion of 6 months of age.
▪ Insufficient quantity of iron and iron enhancers in diet (foods rich in Vitamin C)
and low availability of dietary iron (especially from vegetarian diet).
▪ Iron loss due to parasite load (e.g. malaria, intestinal worms).
▪ Poor environmental sanitation, unsafe drinking water and inadequate personal
hygiene leading to frequent illnesses.
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 To overcome this problem, government has launched Anemia Mukt Bharat (AMB)
strategy recently to promote Iron and Folic Acid (IFA) supplementation in all children
and adolescents starting from 6 months to 19 years of age.

Table - Dose and regime for Iron and Folic Acid Supplementation for prevention of anaemia
Age group Dose and regime

Children 6–59 months of age* Biweekly, 1 ml Iron and Folic Acid syrup;
Each ml of Iron and Folic Acid syrup containing 20 mg
elemental Iron + 100 mcg of Folic Acid.
Bottle (50ml) to have an ‘auto-dispenser’ and
information leaflet as per MoHFW guidelines in the mono-
carton.

Children 5–9 years of age Weekly, 1 Iron and Folic Acid tablet;
Each tablet containing 45mg elemental Iron + 400 mcg Folic
Acid, sugar-coated, pink colour.

School-going adolescent girls Weekly, 1 Iron and Folic Acid tablet;

and boys, 10–19 years of age. Each tablet containing 60 mg elemental iron + 500 mcg
Out-of-school adolescent girls, Folic Acid, sugar-coated, blue colour.
10–19
years of age

Source: Operational Guidelines for Programme Managers. Anemia Mukt Bharat-Intensified National Iron Plus
Initiative (I-NIPI), Ministry of Health and Family Welfare, Government of India, 2018.
*IFA syrup should not be given in children suffering from acute illness (fever, diarrhoea, pneumonia, etc.).
Mother/caregivers should be advised to continue subsequent doses of IFA supplementation as soon as the child
recovers from these illnesses. It is also not to be provided in children suffering from thalassemia major and in those
with history of repeated blood transfusion. The IFA supplementation in severely acute malnourished (SAM) children,
should be continued as per management protocol for SAM management

7.2 Given below is the Service delivery strategy under Anemia Mukt Bharat

Service delivery strategy under Anaemia Mukt Bharat

Target Group Children 6-59 months
▪ Children 6-59 months should be given biweekly IFA syrup
Prophylactic administration of by ASHA through home visits and mothers/caregivers will
iron folic acid supplementation
be equipped with the skills to provide biweekly IFA dose at
the household level.
▪ IFA syrup bottles will be distributed to mothers/caregiver to
provide bi-weekly IFA dose at household level.
▪ ASHA will receive required number of IFA syrup bottles
with auto-dispenser from respective SHC/PHC. -
▪ ASHA will provide IFA supplementation (1ml) twice a week
for one week during home visits using the auto-dispenser.
▪ IFA syrup should be given to the child atleast one hour after
consumption of food (breastfeed, given semi-solid food/solid
food).
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 ▪ ASHA will teach the mother/caregiver to provide bi-weekly
IFA dose to their child.

▪ ASHA will record the compliance in the MCP card (page

no. 27) and also teach the mother/caregiver to mark the
compliance in MCP card.

▪ From second week to end of first month, ASHA will take

weekly visits and from second month onwards, she will
undertake fortnightly home visits to supervise IFA
supplementation provided by mother/caregiver.
▪ CHO and MPWs will monitor line list of target group,
ensure adequate supplies of IFA and provide support to
ASHAs to enable uptake of IFA supplementation and ensure
compliance and monitor entry in the MCP card.

Who will screen and place of

▪ MPW/CHO: VHSND/Sub-Health Centre/immunization
screening session site. CHO will refer to appropriate health facility for
Hb assessment.
▪ RSBK team: AWC/school. Screening for anemia in children
under-5 years will be done biannually and follow-up with
the children diagnosed with anemia in scheduled visits by
RBSK mobile health team as per protocol;
▪ Medical Officer: Health Facility.
/

Periodicity ▪ RBSK/MPW/CHO: as per scheduled microplan

▪ MO: opportunistic

Anaemia management protocol for children- Therapeutic Management of Anaemia of children

aged 6–59 months

If Hemoglobin is 7-10.9 g/dl (mild and moderate anemia)

First level of 3 mg of iron/Kg/day for 2 months
treatment (at all ▪ For children 6 months-12 months (6-10 kgs): 1 ml of IFA syrup, once a day
levels of care) ▪ For children 1-3 years (10-14 kg): 1.5 ml of IFA syrup, once a day
▪ For children 3-5 years (14-19 kg): 2 ml of IFA syrup, once a day
▪ Line listing of all anaemic children to be maintained by the
MPW/ASHA/AWW and reviewed by CHO
Follow- up ▪ Hb estimation after completing 2 months of therapeutic treatment to
document increase in Hb and follow up every month by MPW/CHO at
VHSND/SHC-HWC/immunization session site.
▪ Monitoring by ASHA for compliance of IFA syrup every 14 days during
home visits, for a period of 2 months.
▪ If haemoglobin levels have improved to normal level, discontinue the
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 treatment, but continue with the prophylactic IFA dose.

If no improvement, ▪ In case the child has not responded to the treatment of anaemia with daily
after first level of dose of iron folic acid syrup for 2 months, refer the child to the FRU/DH-
treatment Medical Officer/Paediatrician/Physician for further investigation
▪ Refer urgently to District Hospital/First Referral Unit
If Hemoglobin cut off ▪ Management of severe anaemia in children 6-59 months is to be done by the
is <7g/dl (severe Medical officer at First Referral Unit (FRU)/District Hospital (DH) based
anaemia) on investigation and subsequent diagnosis.

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Anaemia management protocol for children- Therapeutic Management of Anaemia of children aged 5–9
years
Target group Children 5–9 years
Who will screen and RSBK teams will screen in-school and out-of-school children for
place of screening anaemia. All children with clinical signs and symptoms of anaemia
will be referred to SHC/PHC for Hb estimation and further
management.

Periodicity ▪ Once a year

▪ Opportunistic screening, e.g., routine Hb assessment of sick
children presented to health facility
If If Haemoglobin is 8–11.4 g/dl (mild and moderate anaemia) o is 8–11.4 g/dl (mild and moderate anaemia)
First level of ▪ 3 mg of iron/kg/day for 2 months
treatment ▪ Line listing of all anaemic cases to be maintained in the school
(at all levels of register for Iron Folic Acid supplementation and given to the MPW/
care) LHV/CHO for designated area.

Follow-up ▪ Class teacher/ Nodal teacher at school to orient parents during

Parent Teacher Meeting (PTM) for compliance of treatment
▪ Parents to ensure follow-up of child after 30 days and 60 days at nearest
SHC/health facility
▪ Follow-up by LHV/MPW/CHO of designated area, as feasible.
▪ Hb estimation after completing 2 months of treatment to document
Hb>=11.5 g/dl
▪ If haemoglobin levels have improved to normal level, discontinue the
treatment, but continue with the prophylacticIFA dose
If no improvement
after first level of ▪ In case the child has not responded to the treatment of anaemia
treatment with daily dose of iron for 2 months, refer the child to the FRU/DH-
Medical Officer/paediatrician/physician for further investigation.

If Haemoglobin is <8 g/dl (severe anaemia)

Treatment ▪ Refer urgently to District Hospital/First Referral Unit
▪ Management of severe anemia in children of 5–9 years is to be done by the
Medical Officer at the First Referral Unit/District Hospital based on
investigation

7.3 Deworming

National Deworming Day (NDD): To combat parasitic worm infestation among pre-school and
school-age children, Ministry of Health & Family Welfare, Government of India has adopted a
single- fixed day strategy called National Deworming Day since 2015. During NDD,
albendazole chewable tablet is administered to all children from 1-19 years of age through the
platform of schools and Anganwadi Centres in the month of February and August every year.
NDD is followed by MUD (Mop Up Day) after 7 days of NDD for missed children.

Table - Dose and regime for deworming

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 Age group Dose and regime Administration

Children 12– Biannual dose of 400 mg Appropriate administration of tablets to children between
59 months of albendazole (½ tablet to the ages of 1 and 3 years is important.
age children 12–24 months and 1 The tablet should be broken and then crush the half tablet
tablet to children between two spoons, then add safe water to help
24–59 months) administer the medicine.

Children 5–9 Biannual dose of 400 mg The tablet can be chewed properly.
years of age albendazole (1 tablet) Albendazole tablets that are not chewed may have
significantly lower effectiveness.
Ensure drinking water is available.
Use a spoon to administer one full tablet to the child
yourself ad do not give it to parents to be taken home.
Source- Adapted from Operational Guidelines for Programme Managers. Anemia Mukt Bharat-Intensified National
Iron Plus Initiative (I-NIPI), Ministry of Health and Family Welfare, Government of India, 2018.

Refer Annexure- 5 regarding teaching mother/caregiver regarding administration of IFA supplementation to

children.

Role of CHO in Implementation of IFA Supplementation and Biannual Deworming for

Children

▪ Ensure that ASHA and MPW enumerates all children and prepares a line-listing of children in
the service area.

▪ Supervise ASHA and MPW for ensuring recording date of administering biweekly iron folic
acid supplementation and biannual deworming to children in page 27 of the MCP card
(Compliance Card).
▪ Monitor that mother/caregivers have received IFA syrup bottle by the ASHA and are able to administer the
IFA syrup to their child with recording of compliance in the MCP card (check for tick (√) marked in the
card).
▪ Assist the ASHA and MPW in regularly motivating families who refuse to provide IFA syrup and
albendazole tablets to their children. Undertake joint visits with ASHA and MPW to difficult households
where they are unable to convince the family for biweekly IFA supplementation and biannual deworming
for children.
▪ Undertake various health-promotion activities for behaviour change in the community regarding importance
of IFA supplementation, deworming and intake of iron, folic acid and Vitamin C rich foods and fortified
foods (wherever available). ASHA, MPW, AWW and VHSNC members may assist in carrying out these
activities.
▪ Assist the ASHA and MPW in counselling mother/caregivers regarding the following-
➢ Free availability of IFA syrup and deworming tablets at public health facilities and AWC.
➢ Benefit of IFA syrup for their child, improving iron and folate content of the diets and the importance of
sanitation and hygienic practices in order to prevent anaemia and worm infestation in the child.
➢ Importance of providing the IFA supplementation and biannual deworming in children; its positive impact
on physical and mental development of the child e.g. improvement in wellbeing, attentiveness in studies
and intelligence, etc.
➢ Minor side effects associated with IFA administration such as black discolouration of stools.
➢ Immediately contacting the primary healthcare team members in case of any problem after consumption of
iron folic acid syrup by the child.
➢ Increased intake of iron, folic acid and vitamin C-rich foods through dietary
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 diversification/quantity/frequency and food fortification in children to meet the nutritional requirements of
the child and reduce the risk of any anaemia.
➢ Iron-rich and folic acid-rich foods in the diet of the child-dark green leafy vegetables like mustard leaves
(sarson saag), drumstick, turnip leaves, fenugreek (methi), bathua, mint (pudina), amaranth (chaulai),
spinach (palak), spring onion, colocasia (arbi) leaves, etc.; ragi, whole wheat flour, whole grains, pumpkin,
raw banana (plantain banana), pulses (daals), legumes (rajmah, lobia, soyabean, black chickpeas (kala
chana), jaggery (gur), fresh peas, fresh beans, nuts, dry dates, raisins, sesame (til) seeds, animal foods/ non-
vegetarian sources like meat, liver, poultry, egg, fish, etc.
➢ Advice to include foods containing Vitamin C like cauliflower, cabbage, tomato, watermelon, guava,
orange, lemon, gooseberry (amla), sweet lime (mosambi), etc. and animal foods- meat, poultry, fish, liver,
egg, etc., fermented and sprouted foods (grains and pulses), etc. as these increase the absorption of iron.
Iron and folic acid fortified foods can also be included in the diet wherever available.
➢ Consumption of fortified food items (wherever available) like wheat flour, rice, iodized salt (double
fortified), oil and milk should be encouraged the child’s diet.

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Chapter 8: Early Detection and Management of children
with growth failure

The concept of early detection and management of children with growth failure is very important.
You should be well versed with the contents of MCP card for using it during counselling,
recording and monitoring of various health and nutrition events and be aware of children with
growth failure in your service area.
When a small baby gains weight, grows in height, begins to roll over, sits up and walks, we say
that the child is growing. In children, growth is most rapid at the younger age, particularly in the
first six months. In this age, they are more vulnerable to diseases and inadequate nutrition, which
affects their normal growth pattern. It is, therefore, essential to monitor growth of children in this
age more frequently.
Growth is measured in terms of changes in weight with respect to age, length or height of
children. Length is recorded for children less than 2 years of age and height for children above 2
years of age.
Regular growth monitoring or measuring growth is important helps in visualizing change in
weight over a period with respect to age, length/height of the child and helps to identify if the
child is growing properly or not. These changes are useful in giving advice to the
mother/caregiver about the growing pattern of the child. This process is called ‘GROWTH
MONITORING’.
Recording of child’s weight should be done once every month up to age of 3 years and at least
once in 3 months, thereafter. Length is to be recorded once in three months from birth to 2 years
of age and height once in 6 months (2 years to 5 years of age). This data should be entered in
CAS application and plotted on MCP card simultaneously by AWW.
Optimal growth and development of the child can be ensured only with adequate food,
preventing illness and a caring, nurturing and social environment. Maximum growth happens in
the first two years of life. A healthy child approximately doubles the birth weight at 5th month
and is three times the birth weight by the first birthday. By the end of second year, the weight is 4
times the birth weight. We must understand that weight gain is not the only way to assess a
child’s growth. Increase in length or height of the child is also included in the growth pattern of
the child. However, changes in child’s length are slower than the weight. At the time of birth, the
baby’s length is around 50 cm. Expected gain in length in the first year after birth is 25 cms and
in the second year is 12 cms, contributing to a total increase of 37 cms length/ height in the first
two years of life.
The AWW uses the growth chart for monitoring growth for every child, separately available for
girls and boys. Every child in your SHC-HWC area, should be weighed and her/his weight
plotted on the growth chart according to the age of the child. In addition, the length/height of the
child will also be recorded in the growth chart given for weight-for-length/height in the MCP
card. The AWW is responsible for recording weight and length/height of the child during at
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AWCs. ASHA as part of HBYC visits, needs to ensure that the weight and length/height of the
child is recorded by the AWW and details are made available to the mother/caregiver in MCP
card by the AWW in addition to nutritional counselling and other mechanisms as specified by
your district or state.
If the weight and/or length/height of the child is not recorded, ASHA will mobilise and
accompany the mother/caregiver to the nearest AWC for recording the weight and length/height
of the child for ensuring growth monitoring.
You will provide support to the ASHA, MPW, AWW and RBSK Mobile Health Team and
ensure all the activities related to growth monitoring are carried out effectively.
8.1 What is Growth Faltering?
Growth faltering is the slowing or stopping of growth. It is a sign that something is wrong with
the child and immediate action must be taken to restore growth. One can join the weight dots on
the growth chart, to plot growth curve. The direction of the growth curve indicates the progress
of the child and is helpful in providing appropriate counseling and initiating necessary actions
such as referral, etc. for malnourished children. Based on changes in growth pattern, one can
provide suitable advice the mother/caregiver on the nutritional requirement of the child.

8.2 Plotting of Growth Charts

The AWW uses a growth monitoring chart for every child. There are separate growth charts (as
per WHO child growth standards) for girls and boys up to the age of five years, as they have
different weights and lengths/heights beginning at birth and grow to different sizes according to
age. These are also available in the MCP card. The AWW also has growth charts available with
her up to the age of five years. Every child in your service area should be weighed and
length/height recorded. Their weight and length/height should be plotted on the growth chart.
There are also growth charts available for plotting height for age of the child. This is available
with the AWW.

There are three indicators commonly used to measure growth failure in the child. These
indicators are commonly used for detection of malnutrition and reporting purposes.

Measuring a child's weight and height tells us if the child is underweight, stunted or wasted.
These measurements are age and gender specific.

▪ Measuring a child's weight and mapping it against its age (as on the growth chart) tells us if the
child is underweight (or low weight for age). This, in general, tells us about the nutritional
progress and growth of a child. It is important to note also that a child may be underweight
either because of short length/height (stunting) or thinness or both.
▪ Measuring a child's height and mapping it against its age (as on the growth chart) tells us if the
child is stunted (or low height for age). This tells us that the child has chronic malnutrition,
which is likely a result of long-term suboptimal health and/or nutritional conditions and/or
that the child has suffered from repeated infections.
Measuring a child's weight and mapping it against its height (as on the growth chart) tells
us if the child is wasted (or low weight for height). This tells us that the child has acute
malnutrition due to a recent severe event, such as drastically reduced food intake resulting
in lack of adequate food and nutrients and/or illness.
How to plot weight for age to identify the child is underweight:

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 ▪ The left-hand vertical line is the measure of the child’s weight.
▪ The bottom line of the chart shows the child’s age in months.
▪ Find the point on the chart where the line for the child’s weight meets the line for the
child’s age.
Similar process will be used while plotting height for age and weight according to height in the
growth chart.

8.3 Decide where the point is in relation to the curves:

▪ If the point is below the bottom most (-3 Standard Deviation/SD) curve, the child is
severely malnourished (red/orange zone).
▪ If the point is between 2nd and 3rd SD curve or exactly on the 3rd curve, the child is
moderately malnourished (yellow zone).
▪ If the point is on or above the curve marked zero or between the curve zero and -2SD
(second curve) or exactly on the 2nd curve, then the child is normal (green zone).
In addition to AWW monitoring the growth in children at AWC, the Mobile health team under RBSK,
undertakes standard measurements of weight and length/height for preschool children in rural areas
and urban slum (6 weeks to 6 years) atleast twice a year and for school children enrolled in
Government and Government aided schools (6 years to 18 years) at least once a year. Age-appropriate
weighing machine and infantometer for measuring length in young infants (lying down) and
stadiometer for measuring height in children (standing) is used. Charts/tools such as age and sex
specific growth charts (weight-for-age, weight-for-height and height-for-age WHO growth charts from
birth to 5 years of age and Body Mass Index (BMI) -for-age WHO charts for undernutrition and
overnutrition for 6 to 18 years) are used to know whether measurements of a child are normal or are of
concern or require urgent referral (Normal, <-2SD, <-3SD or >+2SD, >+3SD).

8.4 Discussing the child’s growth and follow-up action needed.

Table – Interpretation of growth curve

Good - Upward curve Dangerous- Flat curve Very Dangerous-Downward

curve
The curve is moving upwards. The curve is flat, but has not gone The curve is moving down, into
Indicates- down to another colour band. another colour band. Indicates loss
▪ Adequate weight gain Indicates that the child is not of weight or their child's height is
for the age of the child; gaining weight or the child's height less for his age (growth is slow).
▪ Adequate height for the is less for his age (growth is slow) Talk to AWW/
age of the child and and is not growing adequately. This MPW/ASHA/DEIC Manager
▪ Adequate weight gain is called stagnation. The child immediately. Child may be
for the length/height of needs attention of the severely malnourished and she/he
the child. mother/caregiver. Also, the cause needs urgent specialised medical
94
 The child is growing needs to be investigated. care and immediate referral to
well and is healthy. Talk to AWW/MPW/ASHA/DEIC NRC or Hospital with paediatric
Manager immediately. Such facility/DEIC for medical
children treatment.
should be referred to DEIC or
higher facility for treatment.
Praise, and assess feeding to Review feeding, praise what Follow- up of discharged children
reinforce the good practices of she/caregiver is doing well and to ensure compliance.
the mother/ caregiver and ask identify feeding problems for
them to continue feeding the bringing about change. Follow- up
child well and ensure sanitation of discharged children to ensure
and hygiene. compliance.

Tell the mother/caregiver to pay greater attention to the following -

▪ Exclusive breastfeeding till six months of age.
▪ Adequate and age appropriate complementary feeding on completion of six months of age.
▪ Feed the child with diverse foods available at home (food from all four food groups).
▪ Give small frequent meals. Regularly feed the child by using separate bowl for feeding so that the
mother/caregiver could keep track of what and how much the child has been fed.
▪ For malnourished children above six month of age, mother/caregiver must feed the child as much as
she or he can eat, increase the frequency of feeding to 5- 6 times in a day, provide variety in the food
and give nutrient-rich foods and advise adding oil or ghee to the food.
▪ Following good sanitation and hygiene practices- washing hands with soap and water before
preparing the food, before feeding the child, after defecation and disposal of waste. Use clean water
for drinking and keep food covered and protected from flies.
▪ Counsel the mother/caregiver to regularly keep a track of the growth of their child.
▪ Regular follow up of the malnourished children who are being taken care at home or discharged
from health facility.

8.5 Identifying Visible Severe Wasting

▪ A child with visible severe wasting is very thin, has no fat, and looks like skin and bones.
Some children are thin but do
not have visible severe
wasting. This assessment step
helps you in identifying the
children with visible severe
wasting who need urgent
treatment and referral to a
NRC/DH/DEIC.
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▪ To look for visible severe wasting, remove the child’s clothes. Look for severe wasting of the
muscles of the shoulders, arms, buttocks and legs. Look at the child from the side to see if the
fat of the buttocks is missing. When wasting is extreme, there are many folds of skin on the
buttocks and thigh.
▪ The face of a child with visible severe wasting may still look normal. The child’s abdomen
may be large or distended.

▪ Look and feel to determine if the child has nutritional oedema (swelling of foot due to fluid
retention). Grasp the foot so that it rests in your hand with your
thumb on top of the foot. Press your thumb gently for a few
seconds on the upper surface of each foot. The child has oedema
if a pit (dent) remains in the foot when you lift your thumb. This
is one of the ways to detect children with severe malnutrition in
the community. Such children will require prompt hospitalization
in a centre which manages such children. This is often the
NRC/District Hospital.

Nutritional Rehabilitation Centres (NRC) are facility-based units providing medical and nutritional therapy to
children with Severe Acute Malnourished (SAM) under 5 years of age with medical complications. In
addition, there is special focus on improving the skills of mothers on child care and feeding practices so that
the child continues to receive adequate care at home. The mothers are imparted skills on child care and
feeding practices so that the child continues to receive adequate care at home.

8.6 Severe Acute Malnutrition (SAM)

Children with very low weight-for-height/length (below -3SD of the median WHO child growth
standards), or presence of nutritional oedema are said to have Severe Acute Malnutrition.

Children with SAM are at significantly higher the risk of death and are nine times more likely to die
than well-nourished children. It can be an indirect cause of child death by increasing the mortality in
children suffering from common illnesses such as diarrhoea and pneumonia.

You have already learnt about classification and management of SAM children with and without
medical complication in Chapter 5. Children with SAM with no complications can also be possibly
managed in the community but would require a very close supervision.

Role of CHO in Growth Monitoring, Early Detection of growth failure and Management of Children
with growth failure at community level

▪ Ensuring early registration of all children at the nearest AWC for availing the child
care services like supplementary nutritional support, growth monitoring and promotion,
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 immunization, early child care, health check-up and referral services.
▪ Ensure provision of THR for children from 6 months of age to 3 years and freshly
cooked hot food and a morning snack to pre-school children aged 3-6 years attending the AWC.
Ensure extra nutrition is provided to malnourished children as per norms.
▪ Ensuring line listing and tracking health and nutritional status of all children in your
service area with the help of ASHAs/AWWs/MPWs. Prioritize listing and undertaking joint
home visits with ASHA and MPW to malnourished children in your area for taking corrective
and timely action.
▪ Ensure regular growth monitoring of children under five at AWC, VHSND sessions and coordinate
with AWW for updating the growth status in MCP card. Regular growth monitoring at the AWC is an
opportunity for active case finding.
▪ Ensure mother/caregiver are mobilized for growth monitoring by RBSK Mobile Health Team for
children between 6 weeks to 18 years.
▪ Review and discuss with ASHAs/AWWs/MPWs regarding the growth charts of children during the
monthly SHC-HWC meeting to identify children showing signs of growth faltering and find possible
ways of ensuring nutritional adequacy and reasons for growth faltering.
▪ Utilization of untied funds of VHSNC to meet the special care needs of malnourished
children if required.
▪ Organize and supervise special campaigns such as breastfeeding promotion week,
group counseling sessions, mothers support groups meetings, community meetings, POSHAN
Maah, POSHAN Pakhwada, etc. in coordination with ASHA/MPW/AWW/VHSNC members to
enable health promotion related to IYCF, growth and development of children at your service
area or AWCs.
▪ Sensitization of ASHA, MPW and AWW for detection and timely referral of SAM children. Referring
all children who are SAM with Medical Complication to Nutrition Rehabilitation Centres
(NRCs)/Paediatric facility, coordinating to obtain instructions for follow up care to be undertaken by
ASHAs and ensuring follow up visits as per recommended schedule by ASHAs with support from
ASHA Facilitators/MPWs. These children should especially be monitored for relapse after discharge
from NRC. Other siblings of the child must also be kept under observation and all of them considered
as ‘high risk’ and followed up accordingly.
▪ Assist the ASHA/MPW/AWW in counselling the mother/caregiver for the following-
➢ Importance of weighing and measuring length/height of the child regularly.
➢ Discussing the trend of growth of the child during home visits, VHNSD session, visit
to SHC-HWC and counselling depending on the direction of the growth curve in the MCP
card.
➢ Promoting optimal infant and young child feeding and care practices- early and
exclusive breastfeeding for the first six months of a child’s life, age-appropriate
complementary feeding practices for all children aged on completion of 6 months (e.g.,
dietary diversity) together with continued breastfeeding to 2 years or beyond, , adequate care
and feeding of sick children to prevent malnutrition, age-specific immunization, appropriate
play and communication with the child, management of common childhood illnesses,
integration of key hygiene and sanitation practices (safe drinking water, hand-washing with
soap, safe disposal of excreta, food hygiene), ensure adequate intake of essential
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 micronutrients through supplementation, fortification and food consumption as per National
Programmes, etc. for proper growth and development.
➢ Follow-up with mother/caregiver to ensure adherence to treatment plan suggested by health
facilities for malnourished children.

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Chapter 9: Immunization for Children

Infectious diseases during childhood compound the effect of malnutrition by increasing the nutrient needs of
the body, and therefore may even prove fatal. It is, hence, important to protect the child again these diseases
through immunization. The immunization is given at different ages during the first year of life and helps to
develop lifelong immunity in the child against diseases. Needless to say, immunization is important not only
for children receiving less than optimum nutrition but for every child as a preventive measure against
infection.
A key task of the SHC-HWC is providing age- appropriate immunization to all children in the catchment area.
This includes all migrant populations, marginalized and vulnerable population staying in the catchment area
even if they are not in the list or records. All members of HWC team i.e. ASHAs, MPWs and CHOs have
specified role in ensuring 100% immunization coverage. Targeted approach of Intensified Mission
Indradhanush can be adapted along with routine immunization services to achieve 100% coverage. As a CHO,
you need to be well aware of the National Immunization Schedule under Universal Immunization Programme
(UIP). You will support the MPWs and ASHAs in conducting immunization sessions and ensure improvement
in immunization coverage.
You or the MPW will fill the details- date of vaccination and also write the next vaccination date in the MCP
card and will return the card to the mother/caregiver. You may refer to the MCP card, page 36-37 to check the
immunization status of the child during the household visits or their visits to SHC-HWC from birth to 16 years
of age.
A Routine Immunization Counterfoil, as given on Page 39 and 40 in the MCP card, enlists the date of
vaccination from birth to 16 years of age, which is to be kept at the SHC-HWC to maintain the child’s record.

To address the gaps in improving population coverage it is important to understand the possible reasons for
low immunization coverage. From your experience you will know that some of these possible reasons are-

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 Reason for low immunization coverage
▪ Low awareness of benefits of immunization- Families/caregivers are unaware regarding the benefits of
immunization
▪ Lack of information- Families/caregivers not aware about importance of immunization, due vaccination,
place and time of immunization session, etc.
▪ Drop-outs- Children who receive one or more vaccination, but do not return for subsequent doses;
children of migrant families miss out on due vaccination.
▪ Missed opportunities- failure to provide vaccines which are to be co-administered as per National
Immunization Schedule.
▪ Unreached population/ geographical barrier- Vulnerable or marginalized populations with limited
access to health services or face socio-economic barriers to utilize health services.
▪ Vaccine hesitant population and financial barriers- who do not have confidence in vaccination due to
misconceptions and myths, fear of Adverse Effects Following Immunization (AEFI), loss of wages, etc.
▪ Operational issues- session not organized on scheduled place and time due to various reasons,
unavailability of vaccine at session site, etc.
▪ Cultural or religious reasons- There is refusal of vaccination due to myths, rumours and
▪ misconceptions prevalent in few sections of the society.Gender barrier- Sometimes women are not
allowed to attend sessions by their family members.
Also, if it is a girl child, family members may not give importance to her vaccination.

The National Immunization Schedule (NIS) and detailed NIS for Infants, Children and Pregnant Women
(Vaccine-wise) are given below.

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 National Immunization Schedule (NIS)
Age Vaccines given

Birth Bacillus Calmette Guerin (BCG), Oral Polio Vaccine (OPV)-0 dose, Hepatitis B birth dose

OPV-1, Pentavalent-1, Rotavirus Vaccine (RVV)-1, Fractional dose of Inactivated Polio Vaccine
6 Weeks
(fIPV)-1, Pneumococcal Conjugate Vaccine (PCV) -1*

10 weeks OPV-2, Pentavalent-2, RVV-2

14 weeks OPV-3, Pentavalent-3, fIPV-2, RVV-3, PCV-2*

9-12 months Measles & Rubella (MR)-1, JE-1**, PCV-Booster*

16-24 months MR-2, JE-2**, Diphtheria, Pertussis & Tetanus (DPT)-Booster-1, OPV –Booster

5-6 years DPT-Booster-2

10 years Tetanus & adult Diphtheria (Td)

16 years Td

Pregnant
Td-1, Td-2 or Td-Booster***
Mother

* PCV in selected states/districts: Bihar, Himachal Pradesh, Madhya Pradesh, Uttar Pradesh (selected districts) and
Rajasthan; in Haryana as state initiative
** Japanese encephalitis (JE) in endemic districts only
*** One dose if previously vaccinated within 3 years

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National Immunization Schedule (NIS) for Infants, Children and Pregnant Women (Vaccine-wise)

Vaccine When to give Dose Route Site

For Pregnant Women

Tetanus & adult Early in pregnancy 0.5 ml Intra-muscular Upper Arm
Diphtheria (Td)-1

Td-2 4 weeks after Td-1 0.5 ml Intra-muscular Upper Arm

Td- Booster If received 2 TT/Td 0.5 ml Intra-muscular Upper Arm
doses in a pregnancy
within the last 3 years*
For Infants
Bacillus Calmette At birth or as early as 0.1ml Intra-dermal Left Upper Arm
Guerin (BCG) possible till one year of
(0.05ml until 1
age
month age)

Hepatitis B - Birth At birth or as early as 0.5 ml Intra-muscular Antero-lateral side

dose possible within 24 of mid-thigh
hours
Oral Polio Vaccine At birth or as early as 2 drops Oral Oral
(OPV)-0 possible within the
first 15 days
OPV 1, 2 & 3 At 6 weeks, 10 weeks 2 drops Oral Oral
& 14 weeks

(OPV can be given till

5 years of age)
Pentavalent At 6 weeks, 10 weeks 0.5 ml Intra-muscular Antero-lateral side
& 14 weeks of mid-thigh
1, 2 & 3
(can be given till one
year of age)
Pneumococcal Two primary doses at 0.5 ml Intra-muscular Antero-lateral side
Conjugate Vaccine 6 and 14 weeks of mid-thigh
(PCV) followed by Booster
dose at 9-12 months

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Vaccine When to give Dose Route Site

Rotavirus (RVV) At 6 weeks, 10 weeks 5 drops (liquid Oral Oral

& 14 weeks vaccine)

(can be given till one 2.5 ml (lyophilized

year of age) vaccine)
Inactivated Polio Two fractional dose at 0.1 ml Intra dermal two Intra-dermal: Right
Vaccine (IPV) 6 and 14 weeks of age fractional dose upper arm
Measles Rubella 9 completed months- 0.5 ml Sub-cutaneous Right upper Arm
(MR) 1 dose st
12 months.

(Measles can be given

till 5 years of age)

Japanese 9 completed months- 0.5 ml

Encephalitis (JE) - 1 12 months. Sub-cutaneous (Live Left upper Arm
attenuated vaccine) (Live attenuated
vaccine)

Anterolateral aspect
Intramuscular(Killed of mid thigh (Killed
vaccine) vaccine)

Vitamin A At 9 completed months 1 ml Oral Oral

with measles-Rubella
(1 dose)
st
(1
lakh International
Unit /IU)
For Children
Diphtheria, 16-24 months 0.5 ml Intra-muscular Antero-lateral side
Pertussis & Tetanus of mid-thigh
(DPT) booster-1

MR 2 dose
nd
16-24 months 0.5 ml Sub-cutaneous Right upper Arm
OPV Booster 16-24 months 2 drops Oral Oral

JE-2 16-24 months 0.5 ml

Sub-cutaneous (Live Left upper Arm
attenuated vaccine) (Live attenuated
vaccine)

Anterolateral aspect
Intramuscular (Killed of mid thigh (Killed
vaccine) vaccine)

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Vaccine When to give Dose Route Site

Vitamin A 16-18 months. Then 2 ml Oral Oral

one dose every 6
(2nd to 9th dose) months up to the age (2 lakh IU)
of 5 years.
DPT Booster-2 5-6 years 0.5 ml. Intra-muscular Upper Arm
Td 10 years & 16 years 0.5 ml Intra-muscular Upper Arm
*One dose if previously vaccinated within 3 years
Note:
▪ JE Vaccine is introduced in select endemic districts after the campaign.
▪ The 2 to 9 doses of Vitamin A can be administered to children 1-5 years old during biannual rounds, in
nd th

collaboration with ICDS.

▪ PCV in selected states/districts: Bihar, Himachal Pradesh, Madhya Pradesh, Rajasthan & Uttar Pradesh
(selected districts), and in Haryana as state initiative

Adverse events following immunization (AEFI)- AEFI is defined as any untoward medical occurrence which
follows immunization and which does not necessarily have a causal relationship with the usage of the vaccine. The
adverse event may be any unfavourable or unintended sign, abnormal laboratory finding, symptom or disease.
Majority of the adverse event are coincidental i.e. unrelated to vaccine or vaccination process but have to be reported
as the symptoms or signs have occurred after vaccination.

Role of CHO in undertaking following activities to improve immunization coverage-

Service provision:
▪ Ensure early registration of child at the nearest AWC to avail the immunization services.
▪ Give administrative and technical support to the SHC-HWC primary healthcare team under the overall
ambit of work defined in the Comprehensive and Primary Health Care (CPHC) operational guidelines.
▪ Ensure immunization services at Routine Immunization (RI) sessions ,VHSNDs, health campaigns, health
promotion events, etc.
▪ Ensure quality head count survey for immunization services by supportive supervision of activities of
MPW and ASHA.
▪ Ensure meticulous micro planning for routine immunization services, high- risk area (HRA) tagging,
mapping of areas under sub-health centre with areas demarcation for each ANM/MPW-F if more than 2
ANMs/MPW-F.

▪ Supportive supervision of activities of MPW and ASHAs in in preparation of line listing, regular updating
of list of eligible children, review of due list prepared and tracking drop outs and left out children. Ensure
reasons for drop-outs are entered in the routine immunization counterfoil in the MCP card by you or the
MPW.
▪ Ensure availability of vaccines and logistics at cold chain points and session sites in your SHC-HWC area.
▪ Ensure cold chain and equipment management.

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▪ Supportive supervision of immunization session site and High risk areas/populations (HRAs) form an
ensure availability of updated due list, proper vaccination important component of the master list of the areas
technique, vaccine management is undertaken. for preparing RI-Micro-plan.
▪ Ensure observance of standard precautions to prevent
HRAs are special sites/areas, which may be one or
infection and appropriate waste segregation and disposal. more of the following types of areas:
▪ Ensure MPW is providing four key messages after child
vaccination to their mother/caregivers- what vaccine was ▪ Hard-to-reach areas.
given and what disease it prevents, when and where to ▪ Unserved or underserved areas/areas with
shortage of health workers.
come for the next visit, what minor adverse events could ▪ Migratory populations including temporary
occur and how to deal with them and to keep the harvesters, brick kiln workers and construction
immunization card safe and bring it along for the next labourers in large construction sites.
visit. ▪ Security compromised areas.

▪ Submit monthly reports and ensure availability and

quality of records-MCP, RCH/Immunization register,
RCH Portal, etc.
▪ Ensuring early identification, classification, recording, reporting and referral for AEFI if any. Management
of minor AEFIs (like fever, pain etc.) symptomatically and establish linkages with nearby health facility
for management of serious AEFIs like to PHC-MO. Accompany the mother/caregiver of the child if
needed to the referral health facility.
▪ Report all AEFIs to the Medical Officer at PHC immediately. The process of finding out the reasons for the
AEFI will help the MO and you to understand why the event happened.
▪ Ensure all AEFIs details are entered in the AEFI block register maintained at the Block PHC.
▪ Regular review/follow-up of AEFI cases and take appropriate corrective action as per the guidance of the
Medical Officer at the PHC.
▪ Facilitation of any campaign/intensification activity including inter-sectoral coordination. Organize
inter-sectoral coordination meetings at with ICDS/ local village administration/ NGOs, etc. .
▪ Monitor surveillance activities undertaken by MPW and ASHAs to ensure all cases are reported from
health facility and community; regular review of sub-health centre surveillance reports for
completeness and accuracy [activities include surveillance for diphtheria, pertussis, neonatal tetanus,
Measles Rubella and Polio].

Demand generation:
▪ Organize meetings to discuss and orient ASHA/MPWs in their area for increasing demand for
immunization services, building vaccine confidence among care givers and mobilizing beneficiaries
for timely vaccination.
▪ Praise and encourage the family for ensuring their child’s immunization if all necessary vaccines have been
given.
▪ Counsel beneficiaries, handhold ASHAs and MPWs and partner with community to overcome social,
economic, geographic barriers in improving immunization coverage.
▪ Active mobilization of all beneficiaries by ASHAs and MPWs with focus on reaching the marginalized and
migrant population. Check the immunization status of the child from the MCP card whether child has
received age-appropriate vaccines.
▪ Inform when and where the family can take the child for the next vaccination, for a missed vaccine, or if a
vaccine is due soon.
▪ Allay fear of Adverse Event Following Immunization (AEFI).

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▪ Coordination with community/religious/local leaders, teachers and volunteers on regular basis;
encourage them to discuss immunization in their meetings.
▪ Ensure effective mobilization of children by ASHA, MPW and VHSNC members for immunization
sessions during VHSND session or at the health facilities. This can be achieved by-
➢ ASHA escorting the mother/caregiver and child to the session/SHC-HWC for immunization, if
required. This may be required for families living in remote areas or those having sick children,
malnourished children, girl child, etc.
➢ VHSNC members playing an important role to motivate resistant families for immunization.
➢ Religious group members and other support group members may also provide support in removing
myths and encouraging families for regular immunization of children.

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Chapter 10: Early Childhood Development
10.1 Importance of Focussing on Early Childhood Development (ECD)

Development of a child begins with the start of a woman’s pregnancy. The first 1000 days of
life spanning between conception and the second birthday provides a unique window of
opportunity to act at a time when the foundations of optimal neurodevelopment and health,
and growth are being established for rest of the life span. This foundation may also have
inter-generational effect.

By the age of 2 years, 80% of the brain is developed. During these formative years, presence
and absence of adequate healthcare, good nutrition, early learning and stimulation, quality
childcare practices and a clean safe environment have a definite influence in the future of the
child.

Children learn gradually in these early years of life to talk, walk, run, think and solve
problems thus becoming more capable and independent. These gradual changes indicate the
child’s development and are indicated as developmental milestones.
Both girl and boy child deserve same attention and care from the families to grow and
develop adequately. The environment, in which a child is growing up plays a role in the
cognitive and psychosocial development. Activities that involve playing, singing or reading
which stimulate the brain through all the senses can help improve a child’s ability to engage,
think and communicate. Parents/caregivers can engage with their young children by-

▪ Responding appropriately to what the child communicates for example, hunger, pain and
discomfort, interest in something or affection
▪ Communicating-talking and smiling
▪ Playing
▪ Story telling

Apart from the physical growth, a human baby’s brain development paves the way for her
future level of intelligence and quality of life. Much of this development starts before a baby
is even born. Active participation of all family members/caregivers like father, mother-in-
law, father-in-law, and other family members, besides the mother, is important for growth
and development of the child. Often these involvements result into a strong, healthy
relationship between family members/caregivers and the child while providing support to the
mother.

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10.2 Tracking Developmental Milestones
Developmental milestones are activities (physical skills and behaviours) that most infants and
children perform as they grow and develop. These milestones are age- dependent and follow
a pattern of an expected range.

You should refer to the MCP Card to understand the age-specific activities children of a
particular age generally do, follow the parenting tips appropriate to the age of the child which
the parents and the family members do to help their child achieve these milestones.

You must remember-

▪ That each child is unique.
▪ Not all children develop at the same rate.
▪ Timings of development milestone could vary from child to child.

As CHO, you should inform parents/caregivers-

▪ A child may reach each milestone at his or her own speed. Some children show an
interest or skills in an activity earlier than others or later than others. That is why
some children learn how to walk or talk much earlier than other children of the same
age.
▪ Explain them about the developmental pages of the MCP card (pages 12- 25) given
for 2-3 months child to 3 years of age and how to use the instructions especially the
‘warning’ signs.
▪ Low weight babies, malnourished children, sick children discharged from
NICU/SNCU/NBSU/NRC, etc. all need additional stimulation like play and
communication activities, to grow and develop well and catch up. Encourage families
of such children constantly and motivate them to avail the regular follow- ups at
District Early Intervention Centres (DEIC) and follow advice on ways to play and
communicate with their children.
▪ If the child seems ‘slow’ or ‘unable to respond’, encourage families to promptly avail
services from DEIC.
10.3 What are Developmental Delays?

Development is continuous and progressive. Over a period of time, simple skills are replaced
by finer and complex skills, through learning and practice. Child development is the period of
growth (physical, mental and social) that begins at birth and continues through early
adulthood. = -

Development in each child is unique and different from others due to his genes but
importantly by environmental experiences. The rate of development differs from one child to
another. There are individual differences in rate of development due to heredity &

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environment influences, e.g. one child may walk at the age of 9 months and the other may do
so at the age of 13 months. Both are normal.

Hence, there is a normal range. Once it is outside the normal range then, we say there is
developmental delay and requires further evaluation. Development delay is a term used when
a child’s development is delayed in one or more areas compared to other children. Parents
and others become aware of delay when the child does not achieve some or all of the
milestones at the expected age. Other children may present with behaviour problems, which
may be associated with delayed development. These delays if not addressed timely may lead
to permanent disabilities including cognitive, hearing or vision.

Under RBSK, quick identification of the developmental delays (assessing the child’s
development) including disability is undertaken for children till 18 years of age through use
of material (red ring, rattle, bell, crayons, etc) and developmental delay pictorial tools. You
will learn about this programme in the next chapter.

Knowing the pattern of child development and its characteristics helps to understand the process and
identify developmental delays early in children for early intervention.
10.3 Parenting Tips

You will support and supervise the primary healthcare team in providing ‘Parenting Tips’ to
the parent/caregiver to play and communicate with the child appropriately for the age. These
are provided in the MCP card from pages 12-25. The following counselling tips are required
to be given to the parent/caregiver to support child’s development-
➢ If the parents/caregivers do not play with the child, discuss ways to help child see,
hear, feel and move, appropriate for child’s age and ask caregiver to do play or
communication you need to provide the following counselling tips to the parent/caregiver
to support child’s development members to use non-sharp household objects that are
clean and safe for the child for playing, if the household does not have toys for the child
to play.
➢ If the parent/caregiver does not talk to child or talks harshly to child and child is less
than 6 months, ask caregiver to look into child’s eye and talk to the child. For older
children, give caregiver and child an activity to do together. Help caregiver understand
what child is doing and thinking and see if child responds and smiles. Help the caregiver
in understanding that talking before the child talks prepares the child for talking, as
children copy speech and actions of others around them.

➢ If the parent/caregiver tries to force smile or is not responsive to child, ask caregiver
make gestures and cooing sounds; copy child’s sounds and gestures and see child’s
responses. Inform them about ways to make the child smile- e.g. make a funny face, gently
rub the child’s tummy, clap their hands, play games with the child, etc.
➢ If the parent/caregiver shows anger at the child, help caregiver distract child from
unwanted actions by giving alternative toy or activity.
➢ If the parent/caregiver is not able to comfort child you need to provide the following
counselling tips to the parent/caregiver to support child’s development for comfort, help
caregiver look into child’s eye and gently talk to child and hold child.
➢ If the parent/caregiver says the child is slow to learn, encourage more activity with the
child, check hearing and seeing. Refer child with difficulties to the nearest health centre.

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10.4 Counsel on Child Safety Measures
Children need a clean, safe and protected physical environment safe from injuries and
accidents while they are playing and learning. Thus, it is also important to inform the
parents/caregivers during your interaction, on how to protect children from injuries and
accidents. Along with the primary healthcare team, advise parents/caregivers to-
▪ Keep playing objects of a child, clean and washed.
▪ Keep the child in clean surroundings by placing the child on a clean mat or clean
carpet (dari) or clean cloth while playing.
▪ Keep dangerous substances like medicines, poisons, insecticides, bleach, acids and
liquid fertilizers and fuels (kerosene) out of children’s reach. Store carefully in clearly
marked containers.
▪ Keep children away from fires, cooking stoves, hot liquids and foods, and exposed
electric wires to prevent burn injury.
▪ Never leave young children alone in or near water as they can drown in a very small
amount of water, even in a tub/bucket.
▪ Do not let young children play on or near the road; always have someone older
supervise them.
▪ Secure stairs, roofs and windows using barriers in order to protect children from
falling.
▪ Keep sharp and thin objects like knives, scissors, needles, etc. out of reach of
children.
▪ Keep small objects, such as coins, nuts and buttons, etc. out of reach as young
children like to put them in their mouth. This can lead to choking.

Role of CHO in enabling undertaking community level Milestone Assessment by

ASHAs/MPWs to track Early Childhood Development

The MCP card (page 12-25) provides details of milestones of children from 2-3 months of
age up to 3 years of age, which is divided in three sections. These are what most babies do,
parenting tips for children and “warning” signs. You will play an important role in
encouraging and explaining to the parents/caregivers of children regarding the importance of
Early Childhood Development and building appropriate communication with the child to
ensure proper growth and development and undertake the following activities- 1. Support and
supervise MPWs and ASHAs to help parents/caregivers in providing support for early
childhood development, providing parenting tips and identifying warning signs in child by
using the MCP card during their interaction with children.
2. Assist the primary healthcare team in using the MCP card for undertaking age-specific
milestone assessment, providing age- appropriate parenting tips to caregivers and identifying
warning signs at the community level.3. Support and supervise ASHAs/MPWs in effectively
undertaking their ECD activities during the home visits by helping mother/caregivers
understand-
a. What most babies do at a specific age- ASHAs and MPWs will use MCP card section on
‘What most babies do’ (page 12-25) to track progress on development milestones of the child
up to 3 years of age.
b. Teach the mothers/caregivers to undertake milestone assessment- ASHA and MPWs
trained as part of HBYC programme will teach the mothers/caregivers about the right method
to observe and elicit information for various milestones at a particular age. This is explained
in detail in the Learning Tool for Milestone Assessment (LTMA) that is included as

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Annexure-9. Local toys and household item will be used to elicit information on milestones.
The common items required for ECD screening is given in Annexure- 8.
c. Inform mothers/caregivers to record their observations in the MCP Card- Record
observations for each activity in the child’s MCP card on the first day that their child
performs these activities and leave the box blank in the MCP card against the specific activity
the child is unable to perform. d. Verify the milestone assessment records undertaken by
mothers/caregivers- ASHA/MPW during the home visits, will verify the milestones by
examining the child for all the activities as listed for a particular age of the child and record in
the MCP card.
e. Verify the records for activity that is left blank by the mother/caregiver – Confirm
whether the mother/caregiver has missed recording any particular activity or the child is
unable to perform a particular activity and fill accordingly.
f. Provide parenting tips to support early childhood development in children as given in
the MCP card and given in the section on ‘Parenting Tips’ in this chapter. Discuss ways to
help child see, hear, feel and move, appropriate for child’s age and ask caregiver to do play or
communication activity, appropriate for age as per the parenting tips provided in MCP card.
g. Sensitise the parents/caregivers about the “warning” signs as given in the MCP card.
Inform the families to contact any member of primary healthcare team or AWW or yourself
immediately for providing support and appropriate treatment in case they notice even a single
‘warning’ sign for a particular age.
4. Follow- up with primary healthcare team for achievement of any particular milestone
which the child was unable to perform.
5. Undertake home visit to the child who has been noticed with a ‘warning sign’ and
immediately inform the RBSK team /PHC-MO after verification. Undertake follow-up of
referred children for monitoring their developmental milestones.
6. Organize mothers/caregivers’ group meeting or during VHSND session in coordination
with AWW to demonstrate activities for responsive parenting for promoting Early Childhood
Development.

Chapter 11: Child Health Screening and Early

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Intervention Services

According to WHO4, in India, more than 1.7 million children are born with birth defects
every year. The term 'birth defect' encompasses a diversity of health conditions including
physical malformations such as cleft lip or palate, chromosomal abnormalities such as Down
syndrome, functional defects including sensory deficits such as congenital deafness. Birth
Defects have been recognized globally as a major contributor to neonatal and infant mortality
and disability. Congenital anomalies may be the result of one or more genetic, infectious,
nutritional or environmental factors, it is often difficult to identify the exact causes. Iodine,
vitamin A, and iron are the most important in global public health terms; their deficiency
represents a major threat to the health and development of populations worldwide,
particularly children and pregnant women in low-income countries5. Developmental delays
are common in early childhood and no timely intervention may lead to permanent disabilities
including cognitive, hearing or vision impairment.

Also, there are group of diseases common in children viz. dental caries, rheumatic heart
disease, reactive airways diseases etc. Early detection and management diseases including
deficiencies bring added value in preventing these conditions to progress to its more severe
and debilitating form and thereby reducing hospitalization costs.

11.1 About Rashtriya Bal Swasthya Karyakram (RBSK)

Rashtriya Bal Swasthya Karyakram (RBSK) is an important initiative aimingat early

identification and early management of selected chronic health conditions under 4 ‘D’s
namely Defects at birth, Deficiencies, Diseases, Development delays including disability
from birth to 18 years of age. Universal screening would lead to early detection of medical
conditions, timely intervention, ultimately leading to a reduction in mortality, morbidity and
life-long disability.
The programme is to improve the quality of life of children and to reduce out of pocket
expenditure of poor families in identification and management of common chronic health
condition in children from birth to 18 years.
RBSK covers all the cost involved in screening, diagnosis, treatment (medication and
surgery) and referral.

11.2 Target Group and screening process

The services aim to cover children from 0-18 years of age. The programme has set the annual
target of screening 32.81 crores children – 15.88 crores children till age 6 (Census of India C
13 table for single age returns of census 2011) and 16.93 crores children enrolled in
Government and Government aided schools. The 0-6 years children are to be screened atleast
twice a year and 6-18 years to be screened atleast once in a year.

4
https://www.who.int/india/events/world-birth-defects-day-2020
5
https://www.who.int/news-room/fact-sheets/detail/malnutrition

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Target group for Child Health Screening and Early Intervention Service under RBSK

Categories Age Group Service providers

Children born at delivery Birth to 48 hours Doctors, ANMs and staff
points in public Nurses
health facilities
Children born at home or From 48 hours to 6 ASHA workers
those discharged from Public weeks during HBNC
health facilities
Preschool children in rural 6 weeks to 6 years Mobile Health Team (MHT)
areas and urban
slum
School children enrolled in 6 years to 18 years Mobile Health Team (MHT)
class 1st and
12th in Government and
Government
aided schools
The broad category of age group and screening approach is as below:
Child screening under RBSK is at two levels - community level and facility level. While
facility based new born screening, at public health facilities like PHCs / CHCs/ DH, will be
by existing health manpower, the community level screening will be conducted by the Mobile
health teams.
▪ Screening for Defect at birth in babies born at public health facilities and home-

Birth to 6 weeks

o Facility based Screening: Facility based new born screening at public health facilities
like PHCs / CHCs/ DH, by existing health staff like Medical Officers, Staff Nurses &
ANMs/MPW-F and refer birth defects to the District Early Intervention Centres (DEIC)
in District Hospitals through comprehensive defect at birth screening guidelines under
RBSK mainly for visible and functional birth defects.
o Community Based Screening: ASHAs during home visits for newborn care will use the
opportunity to screen especially the babies born at home and institutions till 6 weeks of
age. ASHAs are trained with simple tools for detecting gross birth defects and to use
specific guidelines regarding this.

▪ The child health screening services at the community level for 6 weeks to 18 years are
provided through dedicated RBSK mobile health teams placed in every block. The block
level dedicated RBSK mobile medical health teams comprise of four health personnel viz.
two AYUSH doctors (One Male, One Female), ANM (MPW-F)/ SN, and a Pharmacist
(with proficiency in computer for data management). In case a Pharmacist is not
available, other paramedics such as lab Technician or Ophthalmic Assistant with
proficiency in computer for data management may be considered. At least, two dedicated
Mobile Health Teams in each Block are engaged to conduct screening of children.

The RBSK Mobile Health Teams carry out outreach screening of-

A. All the children in rural areas and urban slum- 6 weeks to 6 years, at least twice a year, at

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 nearest Anganwadi centres, screened by Mobile Block Health teams for Defect at birth,
deficiencies, diseases and developmental delays. The tool for screening is supported by
pictorial, job aids specifically for developmental delays. For developmental delays
children would be screened using age specific tools specific and those suspected would be
referred to DEIC for further management.

B. Children 6 years to 18 years enrolled in Government and Government aided schools for
Defect at birth, deficiencies, diseases, developmental delays including disability, adolescent
health at Government and Government aided schools at least once a year. The tool used is
questionnaire (preferably translated to local or regional language) and clinical examination.
The children suspected with Defect at birth, deficiencies, diseases, developmental delays
including disability, are referred to District Early Intervention Centre (DEIC) established at
every district hospital for further management- confirmation of diagnosis and treatment. It is
important to note that the 0-6 years age group will be specifically managed at DEIC level
while for 6-18 years age group, management of conditions will be done through existing
public health facilities. DEIC will act as referral linkages for both the age groups. Once the
child is screened and referred from any of these points of identification, it is ensured that the
necessary treatment/intervention is delivered at zero cost to the family under National Health
Mission.

11.3 District Early Intervention Centre

District Early Intervention Centres (DEIC) are being made operational in all districts of
the country for providing management of cases referred from the blocks and will also link
identified children with tertiary level health services, in case surgical management is
required.

A team consisting of Paediatrician, Medical officer, Dental officer, Staff Nurses, Paramedics
from multiple discipline are engaged to provide a holistic service to children in these centres.

The purpose of DEIC is to-

A. Confirm the preliminary findings of children suspected with selected health
conditions under RBSK
B. Provide referral support to children detected with health conditions to identified
secondary tertiary care facilities in case surgical management is required. Necessary
treatment costs at pre-determined rates would be provided under National Rural
Health Mission to tertiary level institutions whether in Government or Private sector.
C. Provide comprehensive trans-disciplinary early intervention services especially for
below 6 years of children suffering from developmental delays.

11.4 Health conditions screened under RBSK

Child Health Screening and Early Intervention Services under RBSK envisages to cover 30
selected health conditions for screening, early detection and free management. States
and UTs may also include diseases namely Hypothyroidism, Sickle cell anaemia and Beta
Thalassemia based on epidemiological situation and availability of testing and specialized
support facilities within State and UTs. Selected health conditions covered under RBSK for
for RBSK Screening and Early Intervention Services are as below:

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Selected Health Conditions for RBSK Screening and Early Intervention Services
Defects at Birth Deficiencies
1. Neural tube defect 10. Anaemia especially Severe anaemia
2. Down's Syndrome 11. Vitamin A deficiency (Bitot spot)
3. Cleft Lip & Palate / Cleft palate alone 12. Vitamin D Deficiency (Rickets)
4. Talipes (club foot) 13. Severe Acute Malnutrition (SAM)
5. Developmental dysplasia of the hip 14. Goitre
6. Congenital cataract
7. Congenital deafness
8. Congenital heart diseases
9. Retinopathy of Prematurity
Childhood Diseases Developmental delays and Disabilities
15. Skin conditions (Scabies, fungal infection and 21. Vision Impairment
Eczema) 22. Hearing Impairment
16. Otitis Media 23. Neuro-motor Impairment
17. Rheumatic heart disease 24. Motor delay
18. Reactive airway disease 25. Cognitive delay
19.Dental conditions 26. Language delay
20. Convulsive disorders 27. Behaviour disorder (Autism)
28. Learning disorder
29. Attention deficit hyperactivity disorder
30. Congenital Hypothyroidism, Sickle cell anaemia, Beta thalassemia (Optional)

Under the National Hearth Mission, Government of India is committed to eliminate

Tuberculosis under National strategic plan (NSP) for 2017- 25 and achieve Leprosy Free
India. Early detection and compete treatment of new cases, especially in children are critical
steps towards this objective. Screening of children for childhood Tuberculosis (TB) and
childhood Leprosy through RBSK Mobile Hearth teams is now introduced for early
detection of TB and Leprosy. Once identified, RBSK Mobile Health Teams would be
referring children suspected with these conditions to respective District/Block officials for
the Tuberculosis and Leprosy programmes for adequate confirmation of preliminary
findings from RBSK Mobile Health Teams and management of the same for identified
children and families as per respective National Disease Control Programme Guidelines.

11.5 Role of ASHA in RBSK in the SHC-HWC service area-

▪ Identify birth defects among 0-6 week old babies through home visits under HBNC and
identification of age-specific development delays underHBYC. She will link the
identified children with available service provisions under RBSK.
▪ Inform children with any developmental ‘warning sign’ as given in the MCP card or
birth defect noticed during home visits to ANM/MPW-F, ASHA Facilitator and the
CHO for appropriate management. Follow-up of children with any 4Ds or further
management and care.
▪ Sensitise mother/caregivers regarding age- appropriate early stimulation of children till 3
years as per MCP card.
▪ Maintain line list of 0-6 years children with special focus on SNCU/NBSU/NRC
discharged infants for regular follow-up for any 4Ds. Also, maintain line list of 6-18
years children.
▪ Explain the screening programme to parents/caregivers of children (6 weeks to 18 years)
and mobilise them to attend the screening camps by the dedicated mobile health team at
nearest Anganwadi centres and local government schools.

0
▪ Maintain biannual screening attendance of 6 weeks to 6 years children and annual
screening attendance for 6-18 years. Focus especiallyon SNCU/NBSU/NRC discharged
infants or those identified with any 4Ds.
▪ Help parents of identified children in accessing referral services, if required.

Role of CHO under child health screening and early intervention services
▪ Support and supervise the primary healthcare in undertaking activities under RBSK.
▪ Ensure ASHA maintains line list of 0-6 years children with special focus on
SNCU/NBSU/NRC discharged infants for regular follow-up for any 4Ds. Also, maintain
line list of 6-18 years children.
▪ Regular communication with RBSK mobile health team regarding their calendar of visit
schedule. Ensure that RBSK mobile health teams schedule of visits is communicated to
ASHA/MPW well in advance so that ASHA can mobilise mother/caregivers to attend
the screening at local anganwadi centre and govt and govt aided schools as per schedule.
▪ Ensure that ASHAs maintain biannual screening attendance of 6 weeks to 6 years
children and annual screening attendance for 6-18 years. Focus especially on
SNCU/NBSU/NRC discharged infants or those identified with any 4Ds.
▪ Ensure that ASHAs particularly mobilise the children with low birth weight, who are
malnourished and children from households known to have any chronic illness (e.g.
tuberculosis, leprosy etc.).
▪ Maintain records of children below 3 years of age identified with any developmental
‘warning signs’ as per MCP card or identified with birth defect noticed during home
visits for appropriate follow-up at District Early Intervention Centre and/or paediatric
department at DH (where DEIC is yet to be established).
▪ Maintain records of children and adolescents who have been referred for specific health
conditions under RBSK by RBSK mobile health team for secondary tertiary care and
ensure service access free of cost.
▪ Visit the AWC or school where screening is planned and monitor attendance and
mobilisation. Coordinate with the Nodal teachers, AWW, primary healthcare team and
VHNSC members for ensuring the mobilization of target children and adolescents on
MHT camp date.
▪ Inform the PHC-MO regarding identified children with 4Ds with referral to DEIC.

ANNEXURES

Annexure 1- Roles and Responsibilities of ASHA and MPW

(Female and Male) in delivery of neonatal, infant and childhood
services

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 Role of ASHA Role of MPW-Female and Male

▪ Line-listing of all newborns and children in the ▪ Provide supportive supervision to ASHAs in
designated service area with updation as required to effectively carrying out her activities;
undertake joint visits with ASHAs to the
facilitate access for availing essential child health
houses having children in providing services.
services. ▪ Undertake general OPD services and support
▪ Registration of child births and child deaths. CHO in providing child-related health
Timely reporting of child births/deaths in her services.
service area to staff at SHC-HWC and her support ▪ Assessment and management of danger
structure. signs/symptoms in newborn and children
▪ Timely information to healthcare staff at SHC- visiting the SHC-HWC or referred by ASHAs
and prompt referral with pre-referral treatment
HWC and supervisors regarding any unusual health
as per protocol (with referral as required to
problems/disease outbreaks affecting children in the HWC-PHC/higher facility).
community. ▪ Act in synergy with ASHA and AWW for
▪ Early registration of children to the nearest AWC active management of malnutrition in children
for availing the services- supplementary nutrition, and for community-based management of
pre-school non-formal education, nutrition and SAM children during home visits.
health education, immunization, health check-up ▪ Conduct facility level immunization session.
and referral services - all linked to ICDS. Prepare microplanning for routine
▪ Create awareness, mobilization of immunization and conduct immunization
mothers/caregivers for health and nutrition related session as planned. Ensuring availability of
services/ campaigns available at the village/HWC- logistics at immunization session site and
SHC/HWC-PHC and the need for timely use of indent as required. Recording, reporting and
these services. tracking of dropouts. Regular review and
▪ Provision of essential newborn care services under update of micro plans with CHO.
HBNC through 7 home visits in case of home ▪ Identification, management and reporting of
delivery and 6 home visits in case of institutional Adverse Event Following Immunization
delivery. Filling of Mother-Newborn Home Visit (AEFI).
▪ Organize the monthly Village Health
Card (HBNC card/form) capturing information
Sanitation and Nutrition Day (VHSND) and
regarding newborn care and helps identify danger provide child services as enlisted in the
signs/symptoms in child. monthly VHSND such as routine
▪ Provision of home visits under HBYC at - 3rd immunisation, counselling sessions, treatment
month, 6th month, 9th month, 12th month and 15th for minor illness, and access to child health
month to provide services related to nutrition, care services.
▪ Provide services to those children who missed
health, early child development and WASH.
the immunization outreach services or VHSND
▪ Identification of danger signs/symptoms in session and could not avail of the services
newborn, young infant and children and provision offered there.
of appropriate and timely care as per protocol (with ▪ Support and ensure that children undergo
referral as required to SHC-HWC). screening for Defect at birth, Deficiencies,
▪ Identification of birth defects/congenital anomalies Diseases, Development delay including
and link identified children with available service disability under RBSK.
▪ Recording of information of child details and
provisions under Rashtriya Bal Swasthya
provision of child services in the MCP card.
Karyakaram (RBSK). ▪ Help ASHA with replenishment of medicines
▪ Mobilize children for screening under RBSK- in her kit.
2
 screening of children for Defect at birth, ▪ Undertake field/home visits for providing
Deficiencies, Diseases, Development delay home-based services to sick new born/low-
including disability. birth weight babies/malnourished children who
▪ Identification and management of common of need referral but are unable to go or did not go
neonatal and childhood illnesses- fever, diarrhoea, for the medical reference (as indicated by
pneumonia, etc. and provision of appropriate and ASHA) - ensure they get care at a higher
timely care as per protocol (with referral as required centre.
to the SHC-HWC). ▪ During home visits also motivate families with
▪ Follow-up of SNCU discharge babies and LBW whom ASHA is having difficulty in motivating
babies. for changing health-seeking behaviours for
▪ Timely referral and follow-up of SAM children their children.
▪ Support ASHA to ensure home based care for
regarding their nutrition intake. Act in synergy with
new born and young children. In cases where
AWW and MPW for active management of ASHA is not able to manage with home-based
malnutrition in children and for community-based care, you should provide appropriate treatment
management of SAM children during home visits. or refer to higher centres.
▪ Mobilization and follow up for immunization ▪ Verbal autopsy/or at least preliminary inquiry
services. Reporting of Adverse Events Following into any child death.
Immunization (AEFI) in any child in the community ▪ Surveillance for unusually high incidence of
cases of child related illnesses- diarrhoea,
to the healthcare staff at SHC-HWC.
dysentery, fever, jaundice, diphtheria,
▪ Arranges referral or accompanies mothers/families whooping cough, tetanus, polio, etc. with
of sick children requiring treatment/admission to the timely notification to CHO and PHC-MO.
pre-identified health facility. Inform the CHO/MPW ▪ Identify, screen and referral of infants with
if any child is taken to health facility for treatment birth defects, sick neonates and children with
by the family. deficiency conditions and developmental
delays. Undertake screening for nutrition
related problems (anaemia, undernutrition,
▪ Support treatment compliance through periodic
overweight and obesity, vitamin deficiency
follow- ups of children discharged from health disorders, iodine deficiency disorders) among
facilities. the children.

▪ Generate awareness and provide counselling support ▪ Undertake household survey with ASHAs for
to mother/caregivers/family members during your detailed mapping, enumeration and enrolment
home visits- of children covered in SHC-HWC service area
➢ Components of essential newborn and child care- for identifying children at risk of diseases.
danger signs in child, keeping baby warm, eye/cord
care, immunization, prevention of childhood ▪ Coordination and Capacity building of ASHAs
infections/illnesses, IFA supplementation, and AWWs.
deworming, etc.
➢ Infant and Young Child Feeding practices- ▪ Provide counselling support to
Promotion and importance of early and exclusive mother/caregivers/family members during
breastfeeding for children up to 6 months of age, outreach services and at HWC-SHC- danger
age-appropriate and timely introduction of
signs in newborn and children, keeping baby
nutritionally adequate complementary feeding with
warm (Kangaroo Mother Care), IYCF
dietary diversity on completion of six months of age
practices, importance of nutrition in children,
with continued breastfeeding for two years or
beyond, active feeding for children during and after care during diarrhoea, use of ORS with zinc,
illness importance of feeding during illness. care during common childhood illnesses,

3
➢ Adoption of healthy dietary habits in children, prevention of fluorosis, childhood anaemia,
prevention of childhood anaemia by consumption of Vitamin A supplementation, use of fortified
iron-rich and Vitamin C rich foods, fortified foods, foods, importance of safe hygiene practices,
consumption of Vit-A rich foods, etc. hand-washing, immunization, etc.
➢ Importance of Early Childhood Development,
screening of 4Ds under RBSK, following safe and ▪ Take lead role in planning and conducting
hygiene WASH practices- hand-washing, health and nutrition promotion activities such
consuming safe drinking water, maintain as organising monthly campaigns, health
personal/environmental hygiene, etc. education/ health events on child-related
Pre-school and School Child Health: Biannual
themes at the village/HWC-sub-centre these
Screening, School Health Records, Eye care, De-
services.
worming.

▪ Help in organising the monthly VHSND session, ▪ Maintenance of child records and reports and
mobilise the beneficiaries for attending the session timely submission of reports to CHO for
monitoring purposes and enabling tracking of
and help in access to child health care services and
undertake joint counselling sessions. performance.
▪ Holds discussion/meeting related to child health
▪ Regular updating and maintenance of
interventions with members during the VHSNC
HMIS/RCH data/RCH Portal.
meetings. Record and maintain minutes of the
meetings. Effective utilisation of VHSNC untied ▪ Ensure timely documentation and registration
funds.
of all births and deaths under the jurisdiction
▪ Support the primary healthcare team in undertaking of SHC-HWC.
health promotion activities such as organising
▪ Maintenance of detailed records- line listing of
monthly campaigns, health events and health
children, due list of children who require
campaigns on child-related themes and identifying
immunization, health events, etc.
the marginalized and vulnerable population to
attend these events and services at SHC-HWC. ▪ Support the CHO in effectively providing child
▪ Maintenance of essential child-related care services at the SHC-HWC with the spirit
records/formats for monitoring purposes. of team work.
▪ Attends monthly review meetings at the SHC and
PHC-HWC. ▪ Attend VHSNC meetings and ensure that the
▪ Supports the CHO/MPW/ASHA Facilitator in minutes of meetings are recorded and
undertaking various child-related activities at the maintained.
community and facility level.
▪ Support the CHO in ensuring that the SHC-
HWC untied funds are utilized as per riles and
guidelines.

▪ Attends monthly review meetings at the SHC

and PHC-HWC.

4
Annexure 2- Counselling regarding Feeding Problem,
important messages for breastfeeding, correct positioning and
attachment for breastfeeding

1. Counsel the mother of a young infant with the classification ‘feeding problem’

1.1. Principles of Communication while Counselling

▪ ASK and LISTEN to what the mother has to say.

▪ PRAISE the mother ONLY for something helpful she has done. Be sure that the
praise is genuine, and only praise actions that are indeed helpful to the child.

▪ ADVISE, limit your advice to what is relevant to the mother at this time. If possible,
use pictures or real objects to help explain. Advise against any harmful practices that
the mother may have reported, for example giving honey or sugar water. Do not make
the mother feel guilty but explain why the practice is harmful.

▪ CHECK UNDERSTANDING, ask questions to find out what the mother understands
and what needs further explanation. Avoid asking questions that can be answered with a
simple yes or no. If you get an unclear response, ask another checking question. Praise
the mother for correct understanding or clarify your advice as necessary.

1.2. Counsel using the following important messages for breastfeeding

Refer to page 10 of MCP card, available with the family for counselling the mother and
caregivers on breastfeeding. You should reinforce the following key messages to promote
breastfeeding amongst the mother/ caregivers-

▪ Early initiation of breastfeeding immediately after birth or definitely within 1 hour of

birth provides ‘colostrum’ (mother’s first milk) to the newborn that helps in fighting
diseases. Colostrum- the first thick yellowish milk is essential for the newborn’s
nutrition and protection against infections and diseases. This also encourages flow of
breastmilk, prevents engorgement of breasts and keeps the newborn warm and promotes
bonding between the mother and the newborn.
▪ Breastmilk helps to promote the overall growth and development of the child (i.e.
physical, psychological, social, motor and mental development), protects against
dangerous illnesses, protects against obesity, hypertension (blood pressure), diabetes
mellitus, etc. during adulthood.
▪ Mother should breastfeed as often as the child wants in day and night. Frequent
feeding helps mothers to produce more breastmilk. Continue even during diarrhoea or
any other illnesses to help the child to get optimal nutrition and recover from the illness
faster.
5
▪ Breast feeding mother should eat extra and drink plenty of fluids to provide adequate
milk for the child during this time.
▪ Mother should pay attention to/observe early signs of hunger in the child like
restlessness, opening mouth and turning head from side to side, putting tongue in and
out and sucking on fingers or fists. Crying is a late sign of hunger.
▪ Mother should smile, talk and look into child’s eyes while breastfeeding, encouraging
the child to communicate (but not rock the child while breastfeeding).
▪ Counsel and reassure the mother in busting the myth that she does not have enough
milk for the growing child. Almost all mothers produce enough breast milk for one or
even two children up to 6 months of age.
▪ Usually, even when a mother thinks that she does not have enough breast milk, her
child is in fact getting all that she/he needs.
▪ Build her confidence and support her to breastfeed by increasing the number of times
she feeds the child. She should also be advised to take adequate rest. Support the
mother in recovering from childbirth and advocate to the family members the
importance of adequate rest and nutrition for the mother.
▪ Also, encourage the family to support the mother by sharing her workload so that she
can successfully breastfeed her child. Mothers also resume work during this time. You
can counsel them to feed the child before going and after coming back. Also suggest
these mothers to express milk for the day which can be given to the child by other
caregivers. Reassure the family members and seek their support for the mother in
providing additional care to low birth weight baby.
▪ Advise the mother regarding storage of Expressed Breast Milk (EBM)-
➢ Can be kept in a covered container at room temperature (< 25o C) for up to 6 hours.
Need not require heating when stored at room temperature.
➢ Milk not fed/if not used within 6 hours of expressing, should be discarded.
➢ Can be stored in the main compartment of a regular refrigerator (2°C to 4°C) for 24
hours.
➢ Refrigerated breast-milk can be used after thawing so that its temperature is similar to
room temperature.

1.3. Teach Correct Positioning and Attachment for Breastfeeding

Demonstrate various positions for breastfeeding a baby to the mother

To obtain maximum benefit of breastfeeding, the baby should be held in the correct position
and be put correctly to the breast. Provide counselling on different positions for
breastfeeding and help to adopt the suitable position. Tell her to alternate the breast the baby
begins with. But make sure that the baby empties the first breast completely before
switching to another breast. This ensures that baby gets the hind milk which is rich in fat
and keeps the baby satisfied. Let the baby finish the first breast (about 10 to 15 minutes)
before offering the second.

Demonstrate the four key points in position

6
▪ Baby’s head and body should be straight
▪ Baby’s face should face mother’s breast
▪ Baby’s body should be close to her body
▪ Mother should support the baby’s whole body

Show the mother how to support her breast with the other hand
Explain the mother that she should-
o Put her fingers below her breast
o Use her first finger to support the breast
o Put her thumb above the areola helping to shape the breast
o Not keep her fingers near the nipple

Assess if the infant is sucking and swallowing effectively

Effective sucking Ineffective sucking

Infant takes several slow deep sucks Infant suckles for a short time but tires out
followed by swallowing, and then pauses. and is unable to continue for long enough.

Good attachment Poor attachment

Showing the mother how to help the baby to attach

Ask the mother to-
▪ Express a little on to her nipple
▪ Touch the baby’s lips with her nipple
▪ Wait until the baby’s mouth is opening wide, and the tongue is down and forward
▪ Move the child quickly onto her breast, aiming the nipple
towards the baby’s palate and his lower lip well below the nipple

Look for signs of good attachment

The four key signs of good attachment are:
▪ More areola is visible above the baby’s mouth than below it
▪ Baby’s mouth is wide open
▪ Baby lower lip is turned out wards
▪ Baby’s chin is touching the breast
▪ No pain while breastfeeding

7
If the attachment or suckling is not good, try again. If still not suckling effectively, ask the mother to
express breast milk and feed with a cup and spoon in the clinic. If able to take with a cup and spoon
advise mother to keep breastfeeding the young infant and at the end of each feed express breast milk
in a cup and feed with a paladai/ spoon. If not able to feed with a paladai/ spoon, refer to hospital.

Annexure 3- Preparation of ORS using an ORS packet

Steps involved in teaching the mother/caregiver on preparation of ORS

1. Wash your hands thoroughly with soap and water.
2. Pour the entire content of one packet of ORS powder into a clean container (a mixing
bowl or jar) for mixing the ORS. The container should be large enough to hold atleast 1
litre.

8
3. Measure 1 litre of clean drinking water. Use the cleanest drinking water. Use the common
containers available at home to measure 1 litre of water.
4. Pour the water into the container in which you poured ORS. (If you have ORS packets
for 1/2 litre of water then take 1/2 litre water.)
5. Mix well until all the powder in the container has been mixed with water and none remain
at the bottom of the container.
6. Taste ORS solution before giving it to the child. It should taste like tears - neither too
sweet nor to salty. If it tastes too sweet or too salty then throw away the solution and prepare
ORS solution again.
7. The container of ORS solution should be kept covered. Any ORS solution which is left
over after 24 hours should be thrown away.
Remember
▪ Ask the mother/caregiver to give one teaspoon of the solution to the child. This
should be repeated every 1-2 minutes (an older child who can drink it in sips should
be given one sip every 1-2 minutes).
▪ In case of a diarrhoeal or vomit episode during ORS administration, the child and
mother/caregiver and the area should be thoroughly cleaned. Wait for 10 minutes.
▪ After washing hands again with soap and water, the mother/ caregiver should
administer ORS more slowly than before. Breastfed babies should be continued to be
given breast milk in between ORS.

Annexure 4 - Zinc Supplementation for 14 days for a child

having diarrhoea

Zinc is an important part of the treatment of diarrhoea. Zinc helps in overall growth and
development and supports in proper functioning of the immune system. Zinc helps to lessen
the amount of fluid lost during diarrhoea so that the diarrhoea is less severe. Zinc for 14
days shortens the number of days of diarrhoea. It increases the child’s appetite and makes
the child stronger. Zinc also helps prevent diarrhoea in the future.

9
For these above reasons, we give zinc to children with diarrhoea. Zinc is only given to
children 2 months up to 5 years for 14 days. The mother/caregiver will need to be taught
(explained below) the right way to administer zinc tablets at home for a child suffering
from diarrhoea (with no dehydration).
Provide the mother/ caregiver with 14 tablets as required for the 14 days.
One zinc tablet in the blister pack contains 20 mg of zinc. Before you give a child, the zinc
supplement, check the expiration date on the package. Do not use a zinc supplement that
has expired.
Help the mother/caregiver give the first dose of zinc to the child by
demonstrating the steps on giving the zinc tablet to the child.
1. If zinc is to be administered to children 2 – 6 months age
a. Half- tablet (i.e. 10 mg) is to be given.
Help the caregiver cut it into two parts. Discard the remaining half tablet.
b. Take a clean teaspoon.
c. Request the mother to express milk from her breast into the spoon and then add ½ tablet.

2. If Zinc is to be administered to children 6 months to 5 years age, the dose is full

tablet (20 mg).
a. Take a clean teaspoon, place one tablet in the spoon.
b. Pour potable clean drinking water or expressed breast milk carefully on the tablet taking
care that the milk/water does not reach the brim of the spoon.

3. The tablet will dissolve in milk or water. Shake the spoon slowly till the tablet dissolves
completely. Do not use fingertip or any material to dissolve the tablet.
4. The mother/caregiver does not need to crush the tablet before giving it to the child.
5. Now, help the mother/caregiver give her child the first dose of zinc. Tell the
mother/caregiver to hold the child comfortably and ask her to feed the solution to the child.
6. The child might spit out the zinc solution. If so, then use the spoon to gather the zinc
solution and gently feed it to the child again. If this is not possible and the child has not
swallowed the solution, give the child another dose.
7. If there is any powder remaining in the spoon, let the child lick or add little more breast
milk or water to dissolve it and then ask the mother/caregiver to give it again.
8. Counsel the mother/caregiver to administer zinc once a day for a total of 14 days to
children of all ages (2 months - 5 years of age).
9. Give the caregiver enough zinc for 14 days. Explain how much zinc to give, once a day.
Emphasize that it is important to give the zinc for the full 14 days, even if the diarrhoea
stops. This will help her child have less diarrhoea in the months to come. The child will
have a better appetite and will become stronger.

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10. Advise the mother/ caregiver to keep all medicines out of reach of children. She should
also store the medicines in a clean, dry place, free of mice and insects.

Annexure 5- Method of administration of IFA syrup

ASHA will demonstrate to the mothers/caregivers to provide IFA syrup through the auto-
dispenser bottle.
Steps involved in teaching the mother/caregiver in giving IFA syrup-

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1. The cap/auto-dispenser/dropper provided with the IFA syrup bottle should be filled up
to the mark of 1 ml and the content to be given to the child twice a week. The IFA syrup
bottles have an auto-dispenser so that only 1 ml of syrup will be dispensed at a time
(having the required dosage for children).
2. Fix the two days for giving the IFA dose so that mother/caregiver can remember the
days. E.g. Wednesday and Saturday of each week (as mentioned in the MCP card).
3. A child should be given 1 ml of IFA syrup at least one hour after consumption of food
(breastfed/ given semisolid food/solid food). Do NOT give IFA with milk since milk
hinders the absorption of iron in the body.
4. Child should not be given IFA on an empty stomach.
5. Child must be held in the mother’s/caregiver’s lap. Encourage the child to open the
mouth. If the child does not open the mouth, press the cheeks gently together for the mouth
to open.
6. Shake the IFA syrup bottle well before use. Ensure that mother/caregiver measures the
dose correctly.
7. Explain the mother/caregiver that the entire dose of IFA syrup should be administered
into the child’s mouth and watch the child swallow the entire dose.
8. Teach the mother/caregiver to mark a tick (√) in the compliance card as given on page 27
in the MCP card after giving the dose for the month-wise bi-weekly IFA syrup
supplementation.
9. Inform the mother/caregiver that the child may have black stools after IFA and this is
normal.
10. Teach regarding preservation of IFA bottle – in a cool and dark place, away from reach
of children, keeping the lid of the bottle tightly closed each time after administration, etc.
11. Inform them to immediately contact you/MPW/ASHA in case of any problem after
consumption of iron folic acid syrup by the child.
12. Inform them to contact either ASHA/MPW for a new IFA syrup bottle if the bottle.
finishes.
13. If child has high fever, inform the mother/caregiver to omit the dose on that day and
continue with subsequent doses.

Annexure 6- Counselling regarding safe WASH practices

Ensure that the family is counselled regarding safe WASH practices as listed in the table
below.

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Annexure 7- Importance of Nutrition in Childhood

The nutritional needs of the human body change across the lifecycle. Good nutrition is
fundamental in achieving positive health, functional efficiency and productivity. Childhood
is a period of continuous growth and development. The requirement of nutrients of a child
depends on his/her age, physiological status and physical activity. To cope up with the
growing needs, children require extra nutrients namely carbohydrates, protein, fats, vitamins
and minerals. You have learnt regarding the nutritional needs of children during the six-
months training in Certificate Programme in Community Health.

During preschool years, the child starts exploring his environment and gets exposed to the
school situation. These years are usually the ones that create a number of concerns about
food intake as the child’s appetite is erratic, with the result the child may often eat one meal
well but refuses the next. Food preferences may change from time to time, that may range
from day to day or week to week. Certain foods are accepted only when cooked or served in
a particular way. Due to poor eating habits, children particularly pre-schoolers, are more
easily prone to nutritional deficiencies. However, by school age, children have established a
particular pattern of meal intake but wide variations in food intake may exist, with some
children consuming more food and others consuming smaller amounts. At the same time,
they are burdened by heavy school work, homework and projects, class competition and
proneness to nutritional deficiencies.

During both these periods, they get influenced by lot of factors like their families eating
habits, peers, television exposure and not to forget the everlasting impact of attractive
packaged food/processed food related advertisements. These all have a great impact on the
food preferences of children. During these years, as eating habits for life are still being
shaped, eating a balanced diet, coupled with good eating habits, a good packed school lunch
combined with some amount of nutrition awareness goes a long way in improving their
nutritional status.
Families and schools both play an important role in shaping the food habits, which are
passed from generation to generation. In addition to consumption of a nutritious diet,
appropriate lifestyle practices and involvement in physical activity such as games/sports
should be encouraged among children.
Important points to be considered while planning diet for children
1. Serve well prepared foods having variety in colour, texture, taste and flavour as children
tend to get bored easily.
2. Familiar foods are better liked, and, hence, small portions of new foods should be
introduced only with already well- accepted foods.
3. Easily handled foods that are easy to pick and eat to be given as packed lunch for school.
Packed school lunch should consist of all the four groups and be filling, quick to eat and yet
nutritionally adequate. Vegetables in any form should be incorporated in the food
preparation as children generally dislike eating vegetables.
4. Choose healthy food items from the family meal over packaged/processed foods high in
fat, salt, and sugar.

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5. Provide the child physical comfort in sitting with use of unbreakable bowls and cutlery
for self-feeding.
6. Adequate amount of fluid intake should be encouraged throughout the day. Fluids like
plain water, buttermilk, lassi, milk, soups, lemon water, coconut water, etc. should be given.
Avoid consumption of carbonated beverages like cold drinks, sodas and sweetened fruit
juices. However, fluid consumption should be limited immediately before meals.
7. Encourage a comfortable and pleasant atmosphere for eating meals as the whole family.
Sitting down together is also important to help behavioural development and for the
reinforcement of family values. Young children should be encouraged to eat with the rest of
the family from the family meal as the interactions between family members are a part of
normal development.
8. If child is into sports or other physical activities then he will need lots of energy-packed
foods throughout the day. Vitamin D rich foods like fish, eggs, liver, sunlight exposure
between 11 am to 1 pm is required for the formation of the healthy growing bones and teeth.
9. Snacks taken in between meals is common during this age group and should not replace a
main meal. They should be wholesome and nutritious. Many snacks that provide no
nutrition and only calories should be avoided. Snacks like sandwiches, fruit chat, roasted
makhanas, pav bhaji with added vegetables, dhokla, paneer/vegetable cutlets, well-cooked
eggs, bread poha, bhel puri, khandvi, besan cheela, poha/suji upma with vegetables, dal
cheela, kathi rolls with stuffing, idli-sambhar, chana chaat, idli with vegetables, dahi wada,
appams, kheer/payasam, lassi/milk shake/ nimbu pani/jal jeera/aam panna /thandai/kanjee,
etc. can be given to the child. Remember to use mostly healthy cooking methods like
steaming, roasting, or shallow-frying (cooking in a small amount of oil) rather than deep-
frying method at home.

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Annexure 8 - Common Items Required For Early Childhood
Screening

Annexure 9 - Learning Tool for Milestone Assessment

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