RASTRIYA BAL SWASTHYA KARYAKRAM ( RBSK ) CHILD HEALTH SCREENING AND EARLY INTERVENTION SERVICES UNDER NRHM

1. RASTRIYA BAL
SWASTHYA
KARYAKRAM ( RBSK )
CHILD HEALTH
SCREENING AND
EARLY INTERVENTION
SERVICES UNDER
NRHM

2. 





INTRODUCTION
Comprehensive child health care implies assurance of
extensive health service for all children, from birth to
18 yrs of age for a set of health condition. These
conditions are 4 Ds
Diseases,
Disabilities,
Deficiencies
Developmental delays.
Universal screening would lead to early detection of
medical conditions ,timely intervention ,ultimately
leading to a reduction in mortality and morbidity and
life-long disability.
Under NRHM significant progress has been made in
reducing, mortality in children over the last 7 years,
Where as ,there is an escalation of reducing child
mortality there is also a need to improve survival
outcome. This would be reached by early detection and
management of conditions that were not addressed.

3. WHY SCREENING OF 0 TO 18 YEARS AGE
GROUP?
Out of every 1000 babies born in this country, annually,6 to 7
have a birth defect. This would translate to around 17 lakhs birth
defects ,annually in the country and accounts to 9.6% of all the
newborn deaths .
Various nutritional deficiencies affecting the preschool children
range from 4% to 70%, developmental delays are common in early
childhood affecting at least 10% of the children .
These days if not intervened timely, may lead to permanent
disabilities including cognitive, hearing, or vision impairment Also
there are a group of diseases common in children like dental
caries, rheumatic heart disease, reactive airway disease etc .
Early detection and management of diseases including
deficiencies bring added value in preventing these conditions, to
progress to their more severe and debilitating form and there by
reducing hospitalization and implementation of Right to Education.

4. Rastriya Bal Swasthya Karyakram (RBSK) is a screening programe
aiming at early identification and early intervention for children,
from birth to 18 years
 First level of screening is to be done at delivery points through
existing Medical Officers, Staff nurses and ANMs .After 48 hours
of birth till 6 weeks ,the screening of newborn will be done by
ASHA, at home, as part of HBNC package.
 Outreach screening will be done by dedicated mobile block level
team for the period of 6 weeks to 6 years at ANGANWADI
centers and for children in
the age group 6 to 18 years at
school.
 Once the child is screened and referred, from any of these points
of identification, it would be ensured that necessary treatment
/intervention is delivered at zero cost to the family

5. HEALTH CONDITIONS TO BE
SCREENED
Child
Health Screening and Early
Intervention
Services
under
RBSK
envisages to cover 30 selected health
conditions for screening ,early detection
and free management.
.

6. Selected health conditions for Child
Screening and Early Intervening
Services
DEFECTS AT BIRTH
1.Neural tube defect.
2.Down’s Syndrome.
3.Cleft Lip & Palate.
4.Club foot (Talipes)
5.Developmental Dysplasia
of Hip.
 DEFICIENCIES
10.Anaemia especially Severe
anemia.
11.Vitamin A Deficiency (Bitot
spot)
12.Vitamin D Deficiency
(Rickets)
6.Congenital cataract.
13.Severe Acute Mal nutrition
(SAM)
7.Congenital deafness.
14.Goitre.
8.Congenital heart disease.
9.Retinopathy of Prematurity

7. CHILD HOOD DISEASES
15.Skin conditions(Scabies ,fungal infections ,and Eczema)
16.Otitis media
17.Rheumatic heart disease
18.Reactive airway disease.
19.Dental conditions.
20.Convulsive disorders.
DEVDELOPMENTAL DELAYS AND DIS ABILITIES
21.Vision impairment.
22.Hearing impairment.
23,Neuro-motor impairment.
24.Motor delay.
25.Cognitive delay.
26.Language delay.
27.Behavior disorder (Autism).
28.Learning disorder.
29.Attention deficit hyperactivity disorder.
30.Congenital hypothyroidism ,sickle cell anemia, beta thalassemia
(optional

8. Child screening under RBSK is at two
levels
 Community level
 Facility level
The community level screening will be done by
Mobile Health Teams at Anganawadi Centres and
Government and Government Aided schools.
while facility based newborn screening at
public health facility like PHC,CHC,DH, will be by
existing man power like Medical Officers ,Staff
Nursers, and ANMs.

9. SCREENING AT COMMUNUITY LEVEL
SCREENING AT ANGANAWADI LEVEL
All preschool children below 6 years of age would
be screened by Mobile Block Health Team for the 4
Ds at Anganwadi centre at least twice a year.
The tool for screening for
supported by pictorial, job aids
0 to 6 years is
specifically for
developmental delay. For developmental delay the
children would be screened using age specific tools
and those suspected would be referred to DEIC for
further management

10.  SCREEENING AT SCHOOLS
School children at 6 to 18 years would be
screened by Mobile Health team for the 4 Ds
at the local schools at least once in a year.
 SUGGESTED COMPOSITION OF MOBILE HEALTH TEAMS
1.Medical Officer (AYUSH) ONE MALE AND ONE FEMALE
2.ANM /Staff Nurse.
3.Pharmacist with computer knowledge.

11. PREPARATIOIN OF ANGANAWADI CENTRES AND
SCHOOLS FOR HEALTH CHECK UP
1.As per the action plan the team should reach the site
well
before time.
2.There should be a display board outside the Anganwadi
center and schools mentioning the time and date
of the
checkup.
3.For Anganwadi center a checkup list of beneficiaries between
0 to 3 years and 3 to 6years age group should be available with
Anganwadi workers and ASHAs.
4.Necessary instruments and equipments should be present as
per the list

12.  METHODOLOGY TO BE USED FOR SCREENING
1.LOOK----Pictorial job aid—A simple photograph of a
newborn
child
with
any
visible
birth
defect/abnormality is to be shown
2.ASK------simple questionnaire tool is to be used for
identification
of
diseases,
deficiencies,
developmental delays including disability.
3.PERFORM---- Clinical examination/simple tests to
confirm the condition---Basic tests ca be used
identification of deficiencies and diseases
for

13. PROCEDURES AND PRECAUTIONS BEFORE MEASURING
1.TRAINED PEOPLE.
2.AGE ASSESSMENT.
3.WEIGH AND MEASURE ONE CHILD AT A TIME,--Do not weigh
or
measure a child if the parent refuses—the child is too sick—the child is
physically deformed which will interfere with or give a
measurement.
4.CONTROL OF THE CHILD.
5.EXPLAINING THE PROCESSS TO THE CAREGIVER.
6.RECORDING MEASUREMENTS CAREFULLY.
7.STRIVE FOR IMPROVEMENT
in correct

14. ILLUSTRATING CHILD STANDING MEASUREMENT
PROCEDURE
Measuring Head circumference:
Head circumference measurement of a child’s head
around its widest distance from above the eyebrows
and ears
and around the back of the head. On the
lower part of the forehead ,also referred to as the
Occipito-frontal Circumference. This measurement is
mainly to show the brain growth. Brain growth slows
down once the child is 12 month
old and stabilizes
by age 5.Any increase in size is called macrocephaly
and any decrease is called microcephaly.

15. CHILD STANDING MEASUREMENT PROCEDURE

16. Contd....

17. Contd....
.

18. Contd.....

26. Major contributors:
 1. Genetic—caused when one or more
work properly.
gene doesn’t
 2. Environment—Women exposed during pregnancy to
Rubella/German measles, alcohol, smoking, drugs like
painkillers, antidepressant, drugs
for l asthma,
corticosteroids, anti-convulsants, medicines for thyroid
diseases uncontrolled l diabetes and obesity in mother.
Some common birth defects are:
1.Neural tube defect
2.Down’s Syndrome
3.Cleft lip and Palate
4.Club foot.
5.Developmental Dysplasia of hip
6.Congenital Heart Disease
7.Congenital Cataract

27. PREVENTION OF BIRTH DEFECTS
Defects present since birth can be major anomalies ,visible at birth, requiring
immediate attention or invisible internal organ defects, which may be missed and brought
to light later.70% of birth defects can be prevented during antenatal period through regular
check and care.

Taking 5 mg of folic acid daily , starting from the day of marriage till 3 months after
testing positive for pregnancy.This will prevent neural tube defect in the newborn.

Regular antenatal checkup at least three times during pregnancy, identification and
keeping diabetes under control

History of using anticonvulsant drugs like valproate is found to increase the risk for
birth defects.

Medications mothers taking
pain -killers, anti-depressants, drugs for
asthma,
medicines for thyroid disease must discuss with the doctor during antenatal visit.

Family members to maintain positive environment at home by avoiding any maternal
stress and domestic violence.

maintain good hygiene by adopting safe sex practice and personal hygiene to prevent
infection during pregnancy.

Immunization like Rubella vaccine if given during adolescence can prevent a mother
against certain infections , which in turn would prevent some birth defects.

Smoking And Alcohol Consumption To Be Strictly Avoided during pregnancy. *
contacts with cats to be avoided during pregnancy to prevent Toxoplasmosis infection.

Maintain a healthy weight.

32. BASIC GENETICS
What is DNA?
Let us examine a group of cells in your Ear.
They help in hearing. How do the cell “know”
that their function is to support Hearing
instead of making the heart beat. Instructions
providing all the information necessary for a
living organism to function, reside in the
nucleus of every cell.

34. The instruction come in the
form of a molecule called DNA.
DNA encodes a detailed set of
plans, like a blue print for
building different parts of the
cell

71. NEURAL TUBE DEFECTS
The most common neural tube defects are
 Spina bifida
 Anencephaly/meningomylocoele.
In spina
bifida the
tube does not close
completely during the first month of pregnancy, there
is usually nerve damage that causes at least some
paralysis of the legs.
In anencephaly, much of the brain does not
develop . Babies
with anencephaly are
either
stillborn or die shortly after birth.

72. NEURAL TUBE DEFECTS
 There are two types of NTDs: open, which are
more common, and closed. Open NTDs occur
when the brain and/or spinal cord are
exposed at birth through a defect in the skull
or vertebrae (back bones). Examples of open
NTDs are
 anencephaly, encephaloceles, hydranencep
haly,
iniencephaly,
schizencephaly,
and spina bifida
 Rarer types of NTDs are called closed NTDs.
Closed NTDs occur when the spinal defect is
covered by skin. Common examples of closed
NTDs
are lipomyelomeningocele, lipomeningocele,
and tethered cord.

73.  Anencephaly
 Anencephaly (without brain) is a neural tube
defect that occurs when the head end of the
neural tube fails to close, usually during the
23rd and 26th days of pregnancy, resulting in
an absence of a major portion of the brain
and skull. Infants born with this condition are
born without the main part of the forebrain—
the largest part of the cerebrum—and are
usually blind, deaf and unconscious. The lack
of a functioning cerebrum will ensure that the
infant will never gain consciousness. Infants
are either stillborn or usually die within a few
hours or days after birth.

74. oEncephaloceles
 Encephaloceles
are
characterized
by
protrusions of the brain through the skull that
are sac-like and covered with membrane.
They can be a groove down the middle of the
upper part of the skull, between the forehead
and
nose,
or
the
Encephaloceles
are
diagnosed
back
often
immediately.
of
the
obvious
Sometimes
skull.
and
small
encephaloceles in the nasal and forehead are
undetected.

75.  Hydranencephaly
 Hydranencephaly s a condition in which
the cerebral hemispheres are missing and
instead filled with sacs of cerebrospinal fluid.
 Iniencephaly
 Iniencephaly is a rare neural tube defect that
results in extreme bending of the head to the
spine. The diagnosis can usually be made on
antenatal ultrasound scanning, but if not will
undoubtedly be made immediately after birth
because the head is bent backwards and the
face looks upwards. Usually the neck is
absent. The skin of the face connects
directly to the chest and the scalp connects
to the upper back. The infant will usually not
survive more than a few hours.

76.  Spina bifida
 Spina bifida is further divided into two
subclasses, spina bifida cystica and spina
bifida occulta.
 Spina bifida cystica
 includes meningocele and myelomeningocele.
Meningocele
is
less
severe
and
is
characterized by herniation of the meninges,
but not the spinal cord, through the opening
in the spinal canal. Myelomeningocele
involves herniation of the meninges as well
as the spinal cord through the opening.

77.  Spina bifida occulta
 In this type of neural tube defect, the meninges
do not herniate through the opening in the spinal
canal. It is a common condition, occurring in 10–
20%
of
otherwise
healthy
people.
By
definition,spina bifida occulta means hidden split
spine. The most frequently seen form of spina
bifida occulta is when parts of the bones of the
spine, called the spinous process, and the neural
arch appear abnormal on a radiogram, and is
generally harmless. Usually the spinal cord and
spinal nerves are not involved. The risk of
recurrence in those who have a first degree
relative (e.g. parent, sibling) is 5–10 times greater
than that in the general population. The genetic
risk of recurrence with symptomatic forms of
spina bifida occulta is uncertain.

78. Take folic acid before you're pregnant
Folic acid is B vitamin that every cell in
your body needs for normal growth and
development. If women of childbearing
age take 400 micrograms of folic acid
every day before and during early
pregnancy, it may help reduce their
baby’s risk for birth defects of the
brain and spine called neural tube
defects (NTDs). The neural tube is the
part of a developing baby that
becomes the brain and spinal cord. An
NTD can happen when the neural tube
doesn’t close completely.

79. If all women take 400 micrograms of folic
acid every day before getting pregnant and
during early pregnancy, it may help reduce
the number of pregnancies affected by
NTDs by up to 70 percent.
Some studies show that folic acid also may
help prevent heart defects in a baby and
birth defects in a baby’s mouth called cleft
lip and palate

80. How can you get folic acid?
Before pregnancy, take a
multivitamin that has 400
micrograms of folic acid in it
every day. Most multivitamins
have this amount, but check
the label to be sure.

81.  Can you get folic acid from food?
Yes. Some flour, breads, cereals and
pasta have folic acid added to them.
Look for “fortified” or “enriched” on the
package to know if the product has
folic acid in it. Even if you eat fortified
or enriched foods, be sure to keep
taking your multivitamin or prenatal
vitamin with folic acid.
You also can get folic acid from some
fruits and vegetables. When folic acid
is naturally in a food, it’s called folate.
Foods that are good sources of folate
are:

82. . Foods that are good sources of folate
are:
Beans, like lentils, pinto beans and
black beans
Leafy green vegetables, like spinach
and Romaine lettuce
Asparagus
Broccoli
Peanuts (But don’t eat them if you have
a peanut allergy)
Citrus
fruits,
grapefruit
Orange
best)
juice
like
(From
oranges
concentrate
and
is

96. Action-
Handle the infant with a sterile, nonlatex gloves and with sterile clothing
and sheets .
Cover the defect with non-adhesive
dressing with sterile Ringer’s lactate
solution or saline.
Refer to district hospital ort nearest
referral point for tertiary care

98. Signs and symptoms
 head may be smaller than normal.
 upward slanting eyes and inner corner of the eyes
may be rounded instead of pointed
 Small ears
 Flattened nose.
 small mouth
 Excess skin at the nape of the neck
 single
crease in the palm of hand (Simian Crease)
 wide, short hands with short fingers
 cleft in feet

100. ASK
 Is it your first child ?
 What is your age ?
 Does any other elder sibling of this child have
any known birth defect ?
 Compared with other children, did any serious
delay in sitting ,standing or walking?
 Can he name at least one object ( animal, toy,
cup and spoon )?
 Does he speak at all ? Is speech is different
from normal ?

103. ACTION
 check the muscle tone , decreased muscle tone at
birth in Downs syndrome.
 The child has both legs extended
and falling
passively on the mat like as frog and the hands
also helplessly , on
,the bed with very little
spontaneous movement of the limbs.
 When this baby was lifted , the examiner had to
give much support to the head and shoulders
than is usual , to keep the infant from sliding
out of her hands. Notice how the both arms fall
aback and the baby’s chest seems to drape over
the physician’s hand. This is because the tone of
the muscles , in the baby
is less than what is
normally seen in newborns

112. The goals of treatment for cleft lip and
palate
 To ensure n the child’s ability to eat, speak. Hear
and breathe and to achieve a normal
facial
appearance.
 Surgeries
are to be performed in this order;----
between 1 and 4 months of age—Cleft lip repair.
 Between 5 and 125 months—Cleft palate repair

113. 4 CLUB FOOT
(Talipes)

115. Causes of Club Foot
The exact cause of club foot is not known. An
abnormality of the tendons and ligaments in the foot
causes an abnormal structure and position of the
foot. In some children, bones may also be abnormal
in terms of shape, size, or position. There may be a
link to maternal smoking during pregnancy.
If the foot is abnormally positioned in the uterus
during pregnancy, it may not grow into a normal
shape, but this is not usually considered a "true" club
foot.
Club foot may, in rare instances, be associated with
spinal deformities such as spina bifida or other
neuromuscular diseases; however, in these cases, the
foot is usually more deformed.

123. Clinically –Perform the following
 1, examine for asymmetrical thigh and gluteal
skin folds in supine and prone positions.
 2, Measuring the length of the leg at the level of
the knee in lying down position with the hip and
knee joint Flexed.
 3,
Range of movement of the hip.
 4, Examine the child in standing position for
spinal curves.
 5, Making the child walk for toe walking , limping
or duck like walking

124. ACTION
 Refer all children who are born as breech presentation and are
females.
 Refer all children with family history of congenital dysplasia of
Hip.
 Refer all children with Asymmetrical thigh and gluteal skin folds
or shortening of the leg at the level of the knee joint or
restricted
 movements of hip or increased spinal curves while standing or
limping or duck like walking.
 Such children should be referred and followed at the age of 6
weeks, 3 months, 6 months ,and 12 months at District Early
Intervention.

131. ACTION
 Refer all children
who are born as
presentation and are females.
breech
 Refer all children with family history of congenital
dysplasia of Hip.
 Refer all children with Asymmetrical thigh and
gluteal skin folds or shortening of the leg at the
level of the knee joint or restricted
 movements of hip or increased spinal
curves
while standing or limping or duck like walking.
 Such children should be referred and followed at
the age of 6 weeks, 3 months, 6 months ,and 12
months at District Early Intervention.

132. CONGENITAL CATRACT

135. Clinical ---Perform.
 1.Congenital cataract usually look different than
other forms of cataract.
 2.Grey or white cloudiness of the pupil( which is
normally black ).
 3.Infant doesn’t seem to be able to see .
 4”:Red eye” glow of the pupil is missing in photos
, or is different between the two eyes.
Tests
 Examine by a Torch may reveal white pupil.
 complete eye examination by an eye specialist.
 complete examination by a child specialist.
 ophthalmoscopy may be done.

136. Retinopathy of prematurity
Retinopathy of prematurity (ROP) or Terry
syndrome, previously known as retrolental
fibroplasia (RLF), is a disease of the eye
affecting prematurely-born babies generally
having received intensive neonatal care, in
which oxygen therapy is often used and
advantageous. It is thought to be caused by
disorganized growth of retinal blood vessels
which may result in scarring and detinal
detachment. ROP can be mild and may resolve
spontaneously, but it may lead to blindness in
serious cases. As such, all preterm babies are
at risk for ROP, and very low birth weight is an
additional risk factor. Both oxygen toxicity and
relative hypoxia can contribute to the
development of ROP.

139. CONGENITAL DEAFNESS

144. CONGENITAL HEART DEFECT

150. ACTION
Refer all children
who are born as
presentation and are females.
breech
 Refer all children with family history of congenital
dysplasia of Hip.
 Refer all children with Asymmetrical thigh and
gluteal skin folds or shortening of the leg at the
level of the knee joint or restricted
 movements of hip or increased spinal
curves
while standing or limping or duck like walking.
 Such children should be referred and followed at
the age of 6 weeks, 3 months, 6 months ,and 12
months at District Early Intervention.

179. Some photographs of the common skin condition in
children

206. CHILD DEVELOPMENT

208. DEVELOPMENTAL DELAYS AND
DISABILITY

256. Compiled , Prepared &
Presented
By
Dr. K B Haridas
Chief Medical Officer & Programme Manager
RBSK

257. Thank you