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General statistics Nutrition statistics Structure of malnutrition management Current changes in management Shakti Krupa Charitable Trust and Hospital My project Future management of malnutrition Our future involvement
Government of India
(GOI)
Nutrition Statistics
Anthropometric Measures
Underweight Weight for Age Acute and Chronic malnutrition Height for Age Linear growth retardation, past growth failure Recurrent or chronic illness Weight for Height Acute malnutrition Measure of muscle wasting Acute malnutrition
Stunting-
Wasting-
30
37 38 40 41 42 43
45
48 56 57 60
DLHS-3 (2007-08)
NFHS-3, 2005-06
Gujarat
DLHS-2, 2002-04
55.4 %
Normal % [Green]
55.4 %
25.9 % 12.9 %
5.8%
Wasting (%)
Normal %
28.3 %
44.6%
SUW/ MUW Moderate Acute Malnutrition (MAM) % Severe Acute Malnutrition (SAM) %
16.3 %
Underweight (%)
18.7%
NFHS-3, 2005-06
There is a strong inverse relationship between undernutrition in children and the level of wealth of the households that they live in. However, even in the wealthiest households (households in the highest wealth quintile), one-quarter of children are stunted and one-fifth are underweight.
DLHS 3, 2007-08
Breastfeeding Statistics
100
1. Initiation of Breastfeeding within 1 hour of birth 2. Exclusive Breastfeeding upto 6 months of life
50
48
48
28
Most mothers (57 percent) gave their babies something other than breast milk to drink in the first three days after birth.
Source: DLHS-3 (2007-08)
NFHS-3, 2005-06
Courtyard shelter
Role: health worker chosen from the community 4 months training in health, nutrition and child-care Importance: link to rural and healthcare needs, builds community trust, good advocate, affordable/accessible Each AWC covers 1,000 population, Each AWW covers 150-200 children Supervised and trained by ICDS government officials/agents
AWC services
Growth Monitoring* Supplementary Nutrition Program in the AWC for 6 month to 6 yrs old: a) Energy dense Bal Bhog (3.5kg)/ month to 6mos to 3 yrs b) Hot cooked food to 3 yrs to 6 yrs c) Energy dense Take Home Ration (THR) for severe underweight children Milk to children 3-6 yrs, twice a week. Fruits to children 3- 6 yrs, twice a week Nutri-Candy with micronutrients (Iron, Folic acid, Vitamin A and Vitamin C) for age group of 3 to 6 years Mobile Anganwadi scheme for NREGA/Migrants population. Conditional Cash Transfer Scheme- cash incentive for pregnant mothers to have institutional births
AWC services
To create awareness about nutrition in the community. To counsel on Infant and Young Child Feeding (IYCF) practices. To mobilize the community to access health and nutrition services. To escort mothers with malnourished children to nearest care centers & to motivate mothers to stay during the intervention To ensure that children are followed up at care centers
*Growth Monitoring
In 2008, ICDS adopted the new WHO Child Growth Standards (launched April 27, 2006).
Weight-for-age Height-for-age Weight-for-height
Measure physical growth and nutritional status of children from birth to 5 years age using anthropometric measures Using a Mamta Card to keep record
Despite >80% of children under age six years lived in enumeration areas covered by an anganwadi centre in the 12 months prior to the NFHS-3
Community Health Center (CHC) Primary Health Center (PHC) Child Development and Nutrition Centers (CDNC)
Recent Changes
In 2009, the WHO came out with updated growth standards with new cut-off values, and with anthropometric measures The Government of Gujarat is now adopting this model to propose a new measure of growth monitoring and management guidelines for malnutrition referral and intervention
Severe Acute Malnutrition (SAM) if : W/H < -3SD &/or MUAC <11.5cm &/or Bilateral pitting oedema
Mission
To strengthen growth monitoring and evaluation system and bringing in subject specialist. Ensuring growth monitoring and promotion by improving
Survey efficiency Weighing efficiency Plotting of weights on growth charts, and Identification of undernourished children and detection of growth faltering and stagnation and focusing on the most vulnerable- SAM, MAM, SUW and MUW
Developing and Integrating appropriate Referral and Practice Guidelines as outlined in the WHO child growth standards and the identification of severe acute malnutrition in infants and children.
Children admitted with defined SAM criteria with Medical Complications Children admitted with defined SAM & MAM criteria without Medical Complications* *Medical complication: infection, edema, failure of appetite test
District Hospital/Medical College (Baroda)Nutrition Rehabilitation Centers (NRCs) Who qualifies: SAM criteria with severe Medical Complications/ Failed Appetite test/Oedema Duration: 25 days. Costs approx Rs 250/ child/ day Daily visit by a Trained Doctor Mother/guardian with child and compensated Rs 100/day for wage loss.
Community (CDNCs) Child Malnutrition Treatment Centres (CMTCs) Who qualifies: SAM criteria with medical complications Duration: 21 days Costs approx Rs 200/ child/ day Daily visit by a Trained Doctor Mother/guardian accompany onsite, compensated Rs 100/d for wage loss.
Village (Sub-centres) Village Child Nutrition Centres (VCNCs) at AWCs Who qualifies: SAM & MAM criteria without Medical Complications Duration : 30 days Cost approx Rs 40/child/day managed by AWW, AWH & ASHA.
NRC
CMTC
For children admitted at -3 SD weight-for-height defined by the WHO standards, a discharge at -2 SD and at -1 SD corresponds on average to a weight gain of 9% and 19% respectively.
www.shaktikrupa.org
Private K-12 School 50-bed adult hospital Community Health Center 3 Ambulances Helipad Farm for agricultural empowerment Government recognized
The Staff
Dr. Singh (OBGyn) and Dr. Nilesh (internist) with nursing staff. Also pictured: Meghna and Dr. Maloney
Swaddle technique
F-100 formula: 100 kcal and 2.9g protein/kg/100ml Monitoring of vital signs and
Established Follow-up
There hasnt been any.hadnt
My Project
The Plan: To follow up on the 144 children treated at the CDNC at Shree Chhotubhai Hospital for 10 days in 2011 The Follow-up: weight, MUAC, dietary history, recent illnesses The Team: 1 driver, 1 sister (nurse), 1 wardboy, myself The Equipment: 1 electronic weight scale, MUAC tape, 1 heavy duty vehicle, and a lot of patience The Route: 7 day adventure to 28 of 36 villages in the Sinor Taluka
Parul, Nurse
Bhagu, Driver
(hes usually more happy than depicted here)
Anganwadi Centers
step one
Village-to-Village
step two
House-to-House
step three
Were able to find 85 of 144 children = 59% Children not accounted for:
12 children in those 8 villages we did not go to 2 children passed away* Children were out of town for Holi celebration Children were with their parents in the farm
Results
Of the 85 children found and measured by MUAC: 63 were green (74.6%) 15 were yellow = moderate acute malnutrition (17.4%) 7 were red = severe acute malnutrition (8%)
No child had edema on exam One child with a mild skin infection
*2 children expired, cause unknown, unrecorded - 1 was taken to a nearby hospital the other was not hospitalized. - From word of mouth, they both had an infection
Reported Illness in past 2 weeks: ARI: 36/85, (42%) Diarrhea: 20/85, (23.5%) Fever: 22/85 (26%)
Education
Workshops for teaching new VCNC guidelines at to the village workers Improve approach of teaching feeding practices to families
Training Day
At a Taluka Level
Electronic Data Collection as a means for:
Efficient and simple ways to record anthropometric measures Quick reference Ease of follow-up Database for research
At a District Level
Building NRCs in more accessible locations while providing adequate treatment, with appropriate resources and management Advantages: closer outreach to the rural population, decreased transportation cost, ease of navigation, trust in a community stronghold
Equipped w/ a: NICU, PICU, an operating room, 4 general wards and 4 special rooms
Main entrance
Our Involvement
References
International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 200506: India: Volume I. Mumbai: IIPS. WHO child growth standards and the identification of severe acute malnutrition in infants and children. World Health Organization, United Nations Children's Fund. Publication 2009. District Level Health Survey 3 (DLHS) website: rchiips.org World Health Statistics 2012. Global Health Indicators. www.who.int/healthinfo Guidelines on Facility Based Management of Malnourished Children. Commission of Health, Government of Gujarat, Gandhinagar. 2012.
Questions?
Every revolution has to originate from villages; only then can it be successful. Mahatma Gandhi
Thank You!