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Introduction & issue of malnutrition♦ In India, about 1/3rd population is food insecure leading to inadequate food intake.♦ Jharkhand is a state in eastern India.
Public health profile of state♦ 1/3rd of population do not have access to safe drinking water.♦ ½ of population below the poverty line- food insecurity♦ ½ of children <3yrs malnourished♦ highest mortality rates for children under five♦ ½ children do not have full immunization against childhood diseases.
MalnutritionWhen a person – is not getting enough food or not getting the right sort of food. – food lacks in proper amounts of micronutrients - vitamins and minerals to meet daily nutritional requirements. – Disease is contributing factor and result . Even if people get enough to eat
Why Monitor Growth♦ Growth is the most sensitive indicator of health (normal growth only occurs if a child is healthy)♦ Growth assessment is an essential part of the examination or investigation of any child.♦ Allows objective detection of growth disorders at population level at earliest opportunity.♦ Early identification and treatment improves outcome.♦ Identify under or over nutrition
What is Growth monitoring♦ Weighing of the child at regular interval – by plotting of that weight on a graph (called growth chart) – For observing changes in weight & – giving advice to the mother based on this weight change is called ‘Growth Monitoring’.
♦ In growth monitoring a change in weight over a period of time is more important than the weight .
Methods of growth monitoring ♦ Length for age or Stunting (Health dept.) – whether an infant is an appropriate length for their age ♦ Weight for age (ICDS): – whether an infant is an appropriate weight for their age
♦ Weight for length(Wasting): – whether the weight and length of an infant are in proportion♦ Mid upper arm circumference for age(quick identification): – be especially useful at the onset of a crisis
Growth chart♦ Growth chart represent curves (Weight for age) with reference population and can be used to identify the child’s rank relative to other children of the same sex and similar age.
Growth chart monitoringGrowth Monitoring is done♦ by the Anganwari Worker (AWW) along with ANM.♦ On Village Health Nutrition Day every month.
GM processGM includes♦ plotting the child’s weight on the ‘Mother and Child’ Protection Card, by Anganwadi worker♦ analyzing the growth of the child by comparing with reference population♦ discussing the progress of the child with the caretaker
Reading♦ Upward growth curve- Normal♦ Flat growth curve- Dangerous♦ Downward growth curve- very dangerous♦ Plotted weight in Orange zone-moderate under nutrition♦ Plotted weight in yellow zone- severe under nutrition
Good Upward slope of • Group Counseling curve • Supplementary nutrition (if above six months)Dangerous Flat growth • Investigate – talk with the curve caregiver o If sick – follow IMNCI protocol and refer if neededModerate Plotted weight • Referral to a health centreundernutrition in Orange zone • Follow up visits at home • Group Counselling • Supplementary nutrition (if above six months)Severe Plotted weight • Referral to a health centreundernutrition in yellow zone • Follow up visits at home • Extra Nutrition supplements • Group Counselling • Supplementary nutrition (if above six months)
MUAC measurement♦ For children aged 6 to 59 months♦ used for detecting individuals in need of treatment.♦ good indicator of muscle mass
Process of measurement♦ Ask the mother to remove clothing that may cover the child’s left arm.♦ Calculate the midpoint of the child’s left upper arm by first locating the tip of the child’s shoulder with your finger tips. Bend the child’s elbow to make the right angle .
♦ Pull the thread from tip of the shoulder till elbow.♦ Fold the thread to half to estimate the midpoint and again pull it from shoulder tip. Mark the midpoint with a pen on the arm.♦ Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make sure the numbers are right side up. Make sure the tape is flat around the skin.♦ When the tape is in the correct position on the arm with correct tension, read and call out the measurement to the nearest 0.1cm .♦ Immediately record the measurement
Interpretation of Mid-Upper ArmCircumference (MUAC) indicators♦ < 110mm (11.0cm), ∀ RED COLOUR, ∀ indicates Severe Acute Malnutrition (SAM) ∀ immediate referrel for management and treatment.
♦ between 110mm (11.0cm) and 125mm (12.5cm) – RED COLOUR (3-colour Tape) or ORANGE COLOUR (4-colour Tape), – indicates Moderate Acute Malnutrition (MAM)- – immediate referrel for supplementation.
♦ between 125mm (12.5cm) and 135mm (13.5cm), – YELLOW COLOUR, – indicates child at risk for acute malnutrition- – counselling & followed-up for Growth Promotion & Monitoring (GPM).
♦ MUAC over 135mm (13.5cm), – GREEN COLOUR, – indicates that the child is well nourished
♦ Health department♦ ANM♦ Services – Record of height and weight of children at periodic intervals – Reading of growth chart – General check up for detection of diseases – Treatment of diseases like ARI, diarrhoea etc – Deworming – Prophylaxis against vitamin A deficiency and aneamia – Children under six: vaccinations – BCG, OPV, DPT, and measles – Referral services
Growth Monitoring & Promotion comprises -package of activities♦ regularly measuring the weight of children;♦ plotting the information on a growth chart to make abnormal growth visible;♦ if growth is abnormal (usually faltering), the health worker does something, in concert with the mother;♦ as a result of these actions, the childs nutrition improves, the child receives appropriate social or medical support, or doctors are able to diagnose early serious disease.
Proximal causes Proximal causes Proximal causes 1.No guidelinesLimited materials available for 11.Less than one third of AWWs hadfor Growth maintenance and functional weighing repairs of weighing scales for both infantsMonitoring scales-Maintenance and children. and replacement still at · 2. The turnaround CDPO or District level time for repairs of causing time-lags. scales exceeded 3 ♦2. Unable to facilitate months. delivery of new Mother 3.24 out of 60 AWWs and Child Protection interviewed reported cards to AWCs. not having the new growth charts
Proximal causes Proximal causes Proximal causes 1.Funds for SNP are 11.Only 3 of 60 AWWsGrowth Monitoring insufficient and not interviewed, received SNtagged to available in time. funds on time. 2. Inordinate delay in filling • 2. 24 of 60 AWWsSupplementary vacant supervisory positions reported unavailability offood distribution. resulting in overburdened funds is the main supervisors and poor obstacle in SN supervision. distribution. • 3. Despite the rules 26 of 60 AWWs report procuring food materials on credit • 4. A little more than half of the sanctioned supervisor positions were filled as of March 2011 • 5.No Mid-Level Training Centers (MLTCs) in the state • Supervisors interviewed reported a
Proximal causes Proximal causes Proximal causes 1.Some AWWs not 11. Half of AWWsIncomplete and or trained in GM and most interviewed reportedinaccurate lacking a follow-up on problems with growth GM training . monitoring.knowledge on 2.Inordinate delay in 2. Only one tenth ofGrowth filling vacant supervisory positions resulting in AWWs recalled receiving any training on theMonitoring, overburdened growth charts. supervisors and poorplotting and supervision. 3. No guidelines for counseling, referral andinterpreting the follow-up services for children with falteringgrowth trajectory growth at the field. 4. Only three of the 24 supervisors recalled being trained on new growth charts. 5.Only half of the 10 CDPOs interviewed mentioned ‘growth
Proximal causes Proximal causes Proximal causes Poor eventChaotic Village managementHealth and Unable to facilitate delivery of new MotherNutrition Day and Child Protection cards to AWCs.