As per UN Convention on Rights of the Child, ‘child’
means someone below the age of 18 years with; (i) Right to
survival, (ii) Right to protection, (iii) Right to
participation and (iv) Right to development, and these rights are
enshrined in the constitution of India(1). Poverty, illiteracy and poor
environmental hygiene are factors detrimental to optimal child
development, especially so for the marginalized and vulnerable groups(2).
National Children’s Policy resolution states that in formulating programs
in different sectors, priority shall be given to programs relating to:
(a) preventive and promotive aspects of
child health;
(b) nutrition for infants and children in
the pre-school age along with nutrition for nursing and expectant
mothers;
(c) maintenance, education and training of
orphan and destitute children;
(d) crèches and other facilities for the
care of children of working or ailing mothers; and
(e) care, education, training and
rehabilitation of handicapped children.
Although the infant mortality in India has fallen
significantly, the neonatal mortality remains by and large static. We do
know that low birthweight contributes the maximum, directly or indirectly,
to the high neonatal mortality(3). In the IndiaCLEN multicentric Neonatal
Health Research Initiative (NHRI) study, the causes of neonatal deaths as
per verbal autopsy were respiratory distress syndrome (57%), low
birthweight (51%), birth injury/asphyxia (42%), neonatal sepsis complex
(36%), prematurity (29%), congenital malformations (13%), hypo-thermia
(12%), jaundice (4%), neonatal tetanus (3%), and causes not known (3%)(4).
However, the status and quality of neonatal and child health remains
unsatisfactory in India. The Indian Academy of Pediatrics and the National
Neonatology Forum had therefore, resolved in 2004, to consolidate their
ongoing partnership by looking at newer objectives and methods to improve
the existing status of neonatal and child health in India(5).
Parenting practices do play an important role in child
survival and development. In a recent publication on parenting practices
in Kerala(6), positive attitudes were observed in key indicators of
child-rearing practices among the mothers and no major difference was
observed among women of various sociodemographic backgrounds. Early
child-care practices were reaching high standards, even in tribal and
economically backward areas(6). In those parts of the country, where
maternal education is low, one of the strategies would be providing family
counselling by regularly visiting families having specially identified
persons such as pregnant mothers, postnatal mothers, 0-2 month old
(neonatal) babies, and 2-24 month old babies; and, observing and
monitoring their parenting behavior until such desirable changes are
evident(7).
Apart from perinatal causes, acute respiratory
infection, diarrhea, measles, malaria and the emerging problem of HIV/AIDS
are the major contributors for under-five morbidity. Yet, mal-nutrition is
the single most important underlying cause that pushes them to death. The
realization that under-five mortality can not be reduced without reducing
infant mortality, which in turn can not be reduced without reducing
neonatal mortality, lead to the addition of the neonatal component and
thus named as the Integrated Management of Neonatal and Childhood Illness
(IMNCI) in India. However, IMNCI requires three interdependent components
for success; (i) to improve the case management skills of health
workers; (ii) to provide essential drug supplies required for
effective case management; and (iii) to optimise care-seeking
behavior(8). Universal free immunization for all children has been the key
policy initiative of the Government of India for child survival and
protection. Despite huge success, the fact remains that majority (74%) of
the immunization associated injections are unsafe in India and, 46.1%
injections for fever/cough and diarrhea are used with no obvious
indication for injections(9). It is in this context that the Government of
India has introduced auto-disabled syringes for immunization purposes.
Growth monitoring has been the mainstay of child
development activities in the ICDS program, but recently serious concerns
have been raised regarding the utility and cost effectiveness of this
strategy. The Indian Academy of Pediatrics has made recommendations for
use of growth charts based on longitudinal Indian data(10). At the same
time, both the Ministry of Women and Child Development, and Ministry of
Health and Family Welfare, Government of India are in the process of
having a single uniform National growth chart based on the WHO Child
Growth Standards, for community level workers of both departments(11).
The advantage of the new WHO growth standards is that
normal early childhood growth under optimal environmental conditions is
depicted and can be used to assess children everywhere, regardless of
ethnicity, socioeconomic status and type of feeding. As expected, there
are notable differences with the NCHS/WHO reference that are particularly
important in infancy. Stunting will be greater throughout childhood when
assessed using the new WHO standards. The growth pattern of breastfed
infants will result in a substantial increase in rates of underweight
during the first half of infancy and a decrease thereafter. For wasting,
the main difference is during infancy when wasting rates will be
substantially higher. It will also result in a greater prevalence of
overweight that will vary by age, sex and nutritional status of the index
population(11). The introduction of the WHO Child growth standards offers
a golden opportunity to revisit, revamp and revitalize not only growth
monitoring, but also the whole early childhood care and education scene in
India.
The National Rural Health Mission (NRHM) launched by
the Government of India, aims to achieve the goal of the National
Population Policy and the National Health Policy through improved access
to affordable, accountable and reliable primary health services such as
women’s health, child health, water, sanitation and hygiene, immunization,
and nutrition. The Mission aims to achieve the same by undertaking
architectural correction of the health system to enable it to effectively
handle the increased allocation for public health. It also aims to bridge
gaps in rural healthcare through increased community ownership,
decentralization of the programs to the district level, inter-sectoral
convergence and improved primary health care(12). The Persons With
Disabilities Act (1995) in India has been a major milestone in the history
of development of services for the disabled. The section on "prevention
and early detection of disabilities" stipulates that all government and
local authorities within the limits of their economic capacity must
undertake various actions to prevent the occurrence of disabilities(13).
NRHM has adequate provisions for reducing mortality, morbidity and
disability in districts with poor indicators and this should be optimally
utilized by all district branches of Indian Academy of Pediatrics. At
least for those districts with better indicators, a clear strategy needs
to be adopted, not only to reduce disability, but also to proactively
promote development of children as well as adolescent future parents. Only
a life cycle approach can bring in dividends.
Life Cycle Approach with Community Participation
• Care of the Pregnant Woman: It is now clear
that improving not only the prenatal, natal postnatal care of pregnant
women and the concept of joyful pregnancy, but also the overall
reproductive health of women is important for a healthy progeny. The
priority would be community action plan for "prevention of mother to
child transmission of HIV/AIDS’’ in collaboration with the Reproductive
and Child Health (RCH) Program under Health Services Department.
• Care of Low Birth Weight (LBW)
babies (<2500 g): The early stimulation program for the low
birthweight babies, initiated and operationalised by the Child
Development Centre (CDC), which is a feasible and cost effective
community strategy, has shown that it is possible to reduce poor
intellectual performance by 40%(14). A feasible strategy would be
community action plan for the provision of CDC model early stimulation
program for low birth weight babies in collaboration with the ICDS
Project under Ministry of Women and Child Department(15).
• Caring for 0-3 year age group: The lack of a
comprehensive program for the age group 0-3 is being increasingly
realized. Community Extension Service program of CDC has shown that it
is feasible to organize intervention programs for the observed 2 to 3%
developmental delay among under 3 year olds(15). The need of the hour is
to include the 0-3 age group under the umbrella of ICDS projects under
Ministry of Women and Child Department.
• Caring for 3-6 year age group: ICDS
anganwadis are probably the only preschool service easily accessible to
majority of 3-6 old children below poverty line. The observed poor skill
development of anganwadi children as against private nursery school
children could be attributed to poor stimulating environment including
play materials. In the context of the current thinking to convert some
of the anganwadis as pre-schools, there is urgency to invest in
improving the pre-school environment of anganwadis(16).
• Caring for 6-10 year age group: The focus of
any primary education program including District Primary Education
Project (DPEP) has been on teacher training and improving physical
facility of primary schools. The observed 10% poor performance of
primary school children could be attributed to lower IQ of children and
poor stimulating home environment(17). Sarva Siksha Abhiyan program
under the Education Department offers the best opportunity to identify
and integrate children with mental subnormality to the mainstream
teaching.
• Caring for 10-18 year age group: Scholastic
performance offers an easy entry to adolescent issues ranging from
nutrition to sexuality. Scholastic backwardness observed among 10 to 20%
high school children could be attributed to poor study habits and
negative home environment including alcoholism of father(18). For too
long we have been teaching subject after subject without focusing on how
to learn. The Parent-Teacher Associations and the Education Department
need to take note of this aspect also.
Apart from the above medical model, measures are needed
that enable children to have a voice and keep their future open, and that
enable their families/institutions caring for them to ensure their full
development into balanced and productive individuals. Thus, a broader
vision of ‘child welfare’ than usual would be required, defining it as
encompassing not merely the physical and material well being of the child
but also her psychological and social wellness. ‘Child welfare’ would also
involve not just the strengthening of parenting capacities of adults
within families but also the energizing of social networks so that
children are cared for not just by their parents but also enjoy the added
security of the proximity of loving adults. This vision of ‘child
welfare’, therefore, calls for the multiplication of secure spaces for the
child, the interventions targeting not just children, but also adults,
with an eye to create an enabling environment for children. Thus,
rejuvenating and imparting parenting skills to couples forms a major
longerm goal along with provision of material, educational and health
support, or facilities for psychological care.
In the Indian context, it appears that reduction of low
birthweight should be the center point of our thoughts and actions,
whether it is for reduction of mortality, morbidity, childhood disability
and poor scholastic performance or for reduction of childhood onset adult
diseases like hypertension, dyslipidemia, type II diabetes and coronary
vascular diseases. The fetal origin hypothesis proposes that chronic
diseases originate through adaptations that the fetus makes when it is
undernourished and that adult disease is programed in utero. Low
birthweight has been said to program individuals to be at higher risk of
adult disease. However, this ‘programing’ only comes into action when
lifestyle is changed from one of deprivation to one of excess and also due
to poor health habits (e.g. smoking and low levels of physical
activity). This has major implications because as whole communities and
countries in the developing world experience greater economic and social
development there is likely to be a correspondingly massive increase in
populations suffering from adult diseases(19).
It is to be appreciated that low birthweight has an
intergenerational effect and interventions in one generation alone cannot
address the issue fully. Yet in order to reduce the burden of low
birthweight with the resultant consequences, it is important to understand
the community attributable risk factors for low birthweight. In a large
community study at Pune, India, a 29% LBW incidence was reported and this
study had described the following population attributable risks for LBW:
socioeconomic status (41.4%), severe anemia in pregnancy (34.5%), maternal
height (29.5%) and maternal pre-pregnant weight (22.9%), highlighting the
importance of improving pre-adolescent and adolescent girls’
nutrition(20). The strategy to achieve this would be the provision for
nutritional monitoring of adolescent girls using CDC-IAP Adolescent Health
Card (10 – 19 years) through ICDS network, health services and education
departments(21).
National Population Policy 2000 acknowledged that at
present there are no specific programs for health, nutrition or
development aspects related with adolescents and hence new activities were
undertaken in the 10th plan, with some success. But considering the
enormity of the problem, only synergy of action in the 11th plan between
professional bodies and Departments of Health, Women and Child
Development, Education and Youth Affairs, with a central coordinating role
played by the Ministry of Health and Family Welfare, would bring in a
change. But this then necessitates that our health infrastructure and
health management be made responsive and responsible.
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nursery school children – A comparison. Teens 2007; 1: 23-24.
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