UNDER-FIVE HEALTH SERVICES

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UNDER-FIVE HEALTH SERVICES

• By
• Prof. Dr. Asmaa Abdel Aziz
• Dr. Allaa Hassan

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The reasons why the under-five needs a special
health care program
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1-They represent a large sector of the total
population. 2- They are vulnerable group as
they undergo physical and mental development,
which call for preventive care 3-High morbidity
from infectious ,nutritional parasitic diseases
4-High mortality In developing countries, 50
of total deaths occur among under five compared
tolt 5 in the developed countries
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5-Most morbidity and mortality in children are
preventable by the primary level of prevention
e.g. immunization, sound nutrition, health
education and environmental sanitation. 6-Prevent
ion of certain adulthood health problems could be
initiated in childhood period. e.g., early
treatment of streptococcal infection prevents
rheumatic heart disease. Moreover, obesity,
hypertension, cardiovascular diseases may be
initiated in early life.
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Infant Health Services
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Infant Health Services These are the health
services that are provided to babies during the
first year of life.. The babies receive the
services in the infant welfare clinic or the
well-baby clinic. This is provided through
Family Health Units or centers
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Functions of the infant welfare clinic The main
functions can be summarized as follows
1- Preventive care.
2- Monitoring of growth and development.
3- Record keeping.
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Preventive Care
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1 - Preventive Care It includes
a) Immunization. c) Health education.
b) Health check up. d) Nutritional education.
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• Immunization
• Immunization against tuberculosis,
  diphtheria, pertussis, neonatal tetanus,
  poliomyelitis, measles , viral hepatitis B and
  Hib.
• Children can be protected by a fairly cheap
  and simple program on immunization before they
  are one year old. (See EPI)

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b) Health check up A newborn has to be examined
at least twice once within the first twenty-four
hours after birth and just before discharge.
Monthly health check-ups should be done during
infancy Practically , it is advisable to carry
check up during routine immunization sessions.
The health check- up can be very helpful in
identifying at risk children, who can be followed
by appropriate screening or diagnostic tests and
/ or paid home visits if needed.
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• Criteria for identifying at risk children
• Birth weight lt 2500 grams.
• Twins.
• Birth order gt 5th.
• Artificial feeding.
• Weight below 60 of the expected weight for age.
• Failure to gain weight for three successive
  months.
• Children having protein energy malnutrition
  (PEM).
• Children having frequent diarrhea or ARI.
• Infants of working mothers.

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• c) Health education
• Important areas of health education include
• Child rearing cleaning, bathing, as well as the
  importance of exposure to the ultraviolet rays of
  the sun.
• Immunization benefits, timing and possible side
  effects.

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• d) Nutritional education Breast-feeding
• Breast Feeding Guidelines
• Begin breast feeding as soon as possible within
  the first half-hour after delivery.
• Breast feeding should be on demand,
• Exclusive breast feeding through the first 6
  months of life.
• Complementary semi-solid food should be started
  after 6 months of age, but the breast should be
  offered first.
• Breast-feeding should be continued throughout the
  second year of life.
• Position the infant so that its mouth covers both
  the nipple and areola, and latches on properly.
• Avoid the use of bottles or pacifiers.
• The mothers food should meet her needs during
  lactation.

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• Supplementary foods.
• Guidelines for safe supplementary feeding
• Started at the age of 6 months when the iron
  stores in the liver are depleted so the infant
  needs a diet rich in iron.
• Abrupt weaning should be avoided.
• Continue breast- feeding until the end of the 2nd
  year of life, together with supplements.
• Ensure cleanliness hygiene during food
  preparation.

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• Offer freshly prepared food to the infant.
• Introduce only one new food at a time.
• Introduce small quantities of the new food
  first.
• then gradually increased.
• Introduced foods by plate and spoon
• No new food should be given if the baby is ill.
• Avoid infant starvation during diarrhea

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Growth development Monitoring
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2- Growth and development Growth implies,
principally, an increase in the size of the body
as a whole or of its individual parts.
Development is mainly related to the nervous
system. It means acquiring functions and skills
that involves motor, social, emotional and
intellectual abilities of the child.
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Growth monitoring Growth monitoring is the best
available indicator of the overall nutritional
status of the child.
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• Assessment of growth
• The most commonly used measure is the weight for
  age ( growth chart) because it is
• A very Sensitive measure of growth,
• Easy
• Accurate.

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The ideal birth weight is about 3.5 kg
Time Weight gain
1st four months 750 gms / month
2nd four months 500gms/ month
3rd four months 250gms/ month

• The infant can
• Double his birth weight by 5-6 months,
• Triple by the end of first year and
• Quadruple by the age of two years.

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Growth chart Growth chart is the simplest,
inexpensive, effective and tool for monitoring
the childs health nutritional status so that
changes can be interpreted over time
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• Description of the chart
• There are two weight-for-age curves on the chart.
  
• The upper one shows the median or reference
  weight-for-age curve (50th percentile).
• The lower curve (3rd percentile) shows the lower
  end of range of healthy weight.
• Reference curves are based on data from a large
  sample taken from a population of well nourished,
  healthy children.
• The zone of normality for most children lies
  between the upper the lower curves.

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• In growth monitoring, the weight of the child is
  plotted on the growth chart at
• Monthly intervals during the first year of life,
• Every 3-6 months during the second year of life,
• Every 6 months thereafter up to five years of
  age.
• A child whose weight is above the 97th percentile
  or below the 3rd percentile is said to be outside
  the normal range.

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Interpretation on different shapes of growth
charts
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• A Healthy child
• A healthy child whose his growth curve is in the
  zone of normality which rises at the same rate as
  the reference curves means.
• LBW babies could achieve a healthy growth if
  their growth curves are raising parallel to the
  reference curves.

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• Growth faltering
• A growth curve that shows a slower rise relative
  to the reference curves is called growth
  faltering.
• A flat growth curve means growth failure i.e. the
  child has stopped growing.

A growth curve that turns downward denotes
under-nutrition and weight loss. It calls for
urgent action.

• A growth curve that rises faster than the
  reference curves. This might be a
• sign of recovery from under nutrition and illness
  
• or it might be a warning sign of over weight

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Flattening or falling of the childs weight curve
may precede clinical signs of malnutrition by
weeks or even months. The physician should check
the causes of growth failure, e.g., failure of
breast feeding, infections, improper weaning
practices, inadequate food supplementationetc.
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• Uses of growth chart
• Monitoring of the growth progress in children
• A screening tool for case finding.
• A diagnostic tool to help the family physician
  to assess factors behind abnormal growth.
• A tool for action to help health workers take
  the proper action .
• An educational tool for health workers, parents
  to understand the nature of growth

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• It helps decision- making in establishing
  priorities for child health care and in planning
  programs for prevention and control of
  malnutrition.
• An evaluation tool to measure the output of
  health services .
• A research tool for comparing children growth
  patterns within and between the countries or
  regions.

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Record Keeping
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• Record keeping
• Each child should have a special welfare card
  including the followings
• Name of the child
• Date of birth
• Type place of delivery and attendant at labor.
• Health conditions at birth birth weight and
  length, presence of birth injuries or anomalies.
• Diseases, hospitalization and/or operations.
• Immunizations.
• Monthly serial measurements of weights ( Growth
  chart)
• Developmental milestones.
• Familial, social and nutritional data.

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Preschool Health Care
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Preschool Health Services Preschool children are
those aged one to less than six years.
Characteristics of preschool period
1- High morbidity.
2- Malnutrition
3- Injuries
4- High mortality
5- Growth and development
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1-High morbidity of infectious and parasitic
diseases

• Communicable diseases such as ARI, chicken pox,
  whooping cough, German measles... etc. Diarrheal
  diseases, enterica and hepatitis A.
• Skin diseases such as impetigo, scabies and
• fungal diseases.
• Parasitic infestations such as oxyuris and
• ascaris.

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2- High prevalence of malnutrition

• The malnutrition diseases among preschool
  children are
• Protein energy malnutrition
• Micronutrient deficiency iron deficiency anemia,
  vitamin A deficiency iodine deficiency.
• Rickets.

• Causes of Malnutrition among preschool children
  
• Hyperactivity and lack of interest in food.
• Faulty feeding habits.
• High prevalence of infectious and parasitic
  diseases

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3- High incidence of injuries

• The common accidents are
• Falling downstairs causing head injuries or
  fractures.
• Household intoxication
• ( drugs, kerosene, potash , insecticides).
• Burns or scalds.
• Electric shock.

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4- High MortalityPreschool Mortality Rate
Total number deaths of preschool children in a
year locality X 1000 Total number of preschool
children in the same year locality

• Causes of death
• ARI
• neonatal and perinatal causes
• Gastroenteritis and dehydration
• Injuries

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5- Growth and development

• Growth
• By the end of the second year, the birth weight
  gets quadrupled.
• After the second year the increase is steady at
  an annual rate of about 2.5 kg in weight and 7.5
  cm in height until the adolescent.
• Development
• Motor skills are usually more coordinated in the
  second year relative to the first year.
• The behavioral development of the child must be
  assessed

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Care of the preschool
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Care of preschool children includes

• Preventive activities
• Care in illness
• Treatment of dental problems
• Health education

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1-Preventive activities

• During the preschool period Two visits every
  year should be paid to Family Health Unit or
  Center

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Components of preventive care for preschool
children

• Assessment of the growth and development of the
  child using growth charts and developmental
  tables.
• Screening for detection of
• Growth defects
• Visual defects.
• Hearing defects
• Speech defects.
• Orthopedic defects.
• Dental appraisal
• Laboratory investigations, e.g. blood, urine and
  stool.
• Communicable disease prevention (EPI)

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II. Care in illness Treatment of minor diseases
and referral of cases needing specialized care.
III. Treatment of dental problems
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Health Education

• Health education areas are
• Growth and development.
• Communicable disease prevention.
• Diet during infection.
• Injury prevention.
• Initiating healthy food habits for mothers and
  children

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Indicators to Assess Child health care
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1- Infant Mortality Rate

• The total number of infant death in a year
  locality x1000
• The total number of live birth in the same year
  locality

0 7 days
28 days One
year Early neonate Late
neonate Post neonate
Neonate


Infant


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What is the infant Mortality Rate In KSA?
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The main causes of infant mortality are

• ARI (acute respiratory infections bronchitis and
  bronchopneumonia).
• Gastroenteritis and dehydration.
• Neonatal causes Low birth weight, birth injuries
  , asphyxia, congenital anomalies,

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Measures for reducing infant MortalityI- General
measures

• Improvement of socioeconomic standards and
  environmental sanitation infant mortality is the
  most important indicator of Community
  development.
• Education of women increases womens awareness
  regarding breast feeding ,personal hygiene,
  better utilization of health services, better
  care of their children

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• II- Specific measures
• Maternal care
• Antenatal, natal and postnatal care.
• Adequate maternal nutrition.
• Infant care
• Prevention of infections( immunization against
  target diseases).
• Early detection and proper management of ARI and
  gastroenteritis.
• Breast-feeding and safe weaning practices.
• Growth monitoring.
• Special care to LBW (low birth weight) babies

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2- Neonatal Mortality Rate
Total number of neonatal deaths(0-lt28 days of
life) in a year locality X 1000
Total number of live births in the same year
locality
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• Neonatal mortality rate can be divided into
• Early neonatal mortality deaths in the first
  week of life.
• Late neonatal mortality deaths from 7 to 28 days
  of life.
• The main causes of neonatal mortality are
• 1-Low birth weight and prematurely.
• 2-Congenital anomalies.
• 3-Asphyxia neonatorum.
• 4-Birth injuries ( head injuries).
• 5-Neonatal infections neonatal tetanus,
  septicemia, meningitis, pneumonia diarrhea

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Services aiming at reducing neonatal mortality
include 1-Antenatal, natal and postnatal
services. 2-Special care of LBW
babies 3-Improving quality of obstetric care to
prevent birth injuries , asphyxia.
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3- Post neonatal Mortality Rate
Total number of post neonatal deaths (28days-ltI
year) in a year locality X 1000
Total number of live births in the
same year locality
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The main causes of post neonatal mortality are
1-ARI.
2-Gastroenteritis and
dehydration.
3-Congenital anomalies
Prematurity
Services aiming at reducing post neonatal
mortality Same as what have been discussed in
infant mortality rate
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5- Under-five Mortality Rate
Total number deaths of under five children (0-lt5
year) in a year locality X 1000
Total number of live births in the
same year locality

• The main causes of under- five mortality rate
  are
• ARI
• neonatal and perinatal causes
• Gastroenteritis and dehydration
• Injuries

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Thank You