ACKNOWLEDGEMENT

I’m thankful and highly indebted to Dr. C Gopalan, President,

Nutrition Foundation of India (NFI), and Dr. Prema Ramachandran,
Director, NFI for allowing me to pursue the summer internship at
their prestigious organization.

I am extremely thankful to Dr. Prema Ramachandran, Director, NFI,

and my Guide at the organization for her continuous support,
guidance and feedback. Her positive attitude and encouragement
helped me cross all the hurdles that I faced and enriched my
learning of the health care delivery at the public set up. Without her
valuable inputs and problem solving attitudes, my report would not
have been completed.

I am grateful to Ms. Anshu Sharma, Senior Scientific Officer and my

co-guide of the project for painstakingly explaining me details of the
project and understanding me during my problems. I am also
obliged to Mr. Kanti Prasad, Laboratory Technician and Ms. Karuna
Sharma, Scientific Assistant, for their contributions to the project
and help. I would thank heartily to Ms. Chanchal Kaira for her
constant motivation and her friendly nature always helped me do
my work positively. I’m really very thankful to all the staff of NFI.
Thank you very much.

I would like to thank my H.O.D., Dr. Dheer, Symbiosis Institute of

Health Sciences(SIHS) for agreeing to let me do my internship at
NFI. I would also like to thank the other staff members of SIHS for
helping me to get my internship at NFI. I would not do justice to
this project if I would not thank all my friends of Symbiosis without
whose help I would not have got solutions to my problems in my
limited period given to them. My special thanks to Kiran auntie , my
parents, my sisters, my tutors at meditation for not letting me loose
my focus at such a point of time. Without thanking the Almighty my
all work remains incomplete as without his guidance, enlightenment
and pious support I would not have been able to achieve my goals
and got instant solutions to my problems. Thank you Lord.
Dipika M.
 TABLE OF CONTENTS

Sr. No. Topics

1 Organization Profile
2 Purpose of Internship
3 Study part
A Background
B Hypothesis
C Objectives
D Materials & Methods
E Situation analysis of OPD
F Reorganization of OPD
G Results
H Costing of Reorganization
I References
4 Appendix
 MY LEARNING AT NFI

Coming to NFI was a wonderful experience and a chance to learn. For

me, this exposure was the first of its kind. Coming here and learning not
only theoretical knowledge but also a good field exposure, and application of
what we learned. Going to field and collecting data gave us the confidence to
interact with different people and it helped us to be more practical. Every
single day was challenging not only physically but mentally too. This was our
first chance to meet and interact with true Indians, the real population of
India and we are thankful to Dr. Prema Ramachandran for giving such
opportunity. Training at NFI Delhi, helped us in learning data entry on
Microsoft excel, power point presentation, haemoglobin estimation and a
good exposure of anthropometric measurements and instruments.
 ORGANIZATION PROFILE
Nutrition foundation of India (NFI) was founded in 1979 by Dr. C.
Gopalan with the active cooperation and support of a large body of scientists,
and leading citizens, deeply interested in the promotion of health and
nutritional well being of the people of India. Dr. Gopalan has headed and
guided the NFI as its president and director general since its inception.
The Nutrition Foundation of India (NFI) is a non-governmental voluntary
agency dedicated to the upliftment of the nutrition status of Indians. It plays
a catalytic role of advocacy and education to focus attention on major
nutritional problems; provides leads for practical action in overcoming these
problems; and combats inadequacies in the implementation of ongoing
nutrition programmes.
 OBJECTIVES

• To highlight and focus public and government attention on national

problems connected with malnutrition, assess their causation,
magnitude and implications, and offer short-term as well as long-term
action plans;

• To initiate, conduct and support coordinated action-oriented studies

and research on these problems through existing institutes, university
centres and other suitable bodies in order to evolve appropriate
solutions capable of application in the current context;

• To investigate means to offset existing deficiencies in the pattern of

predilection and distribution of foods and to ensure the wholesomeness
and nutritive value of foods sold for public consumption;

• To disseminate information on diet and nutrition, promote nutrition

education in schools and through mass media; publish periodically a
bulletin in order to disseminate information on important facets of
nutrition; and

• To interact with the Planning Commission and governmental and non-

governmental agencies in facilitating the formulation, implementation
and evaluation of nutrition programmes.
 SCIENTIFIC PROGRAMS
The scientific programs undertaken by NFI in pursuance of the above
objectives include:

1. Community based resource studies

2. Health/ nutrition education
3. Publication and dissemination of information
4. Extension of library and documentation facilities
5. Training
6. Conferences/ seminars/ Symposium

COMMUNITY BASED STUDIES

NFI organises from time to time, community based studies and research
projects. The major thrust areas of research have been:

1. Maternal and child nutrition

2. Major public health/ nutrition health problems and programs
3. Community health/ nutrition education programs
4. Nutrition of children and adolescents
5. Profiles of under nutrition in context of developmental transitions.
 HEALTH AND NUTRITION EDUCATION
PROGRAMS
A major objective of the Centre for Nutrition
Research and Education is the dissemination
of knowledge conducive to the promotion of
the optimal nutritional status of individuals
and population groups. For this purpose,
facilities
for community nutrition education have now
been augmented. An entire
spacious floor of the new building is set apart for the following
purposes:

• Nutrition education to people of different income groups, urban slums

and rural areas in health/nutrition welfare programmes.
• Diet counselling for individuals and groups.
• Dissemination of information on nutrition to students of schools and
colleges, and to the general public.

The facilities available at the Education/Extension unit include: a series

of exhibits on relevant health and nutrition related issues; a demonstration
unit for the purpose of counselling and demonstration of preparation of
nutritious recipes; and facilities.
 PURPOSE OF INTERNSHIP
Practical exposure is an integral part of our Masters Programme in
Hospital and Health care Management (MBA-HHC). As a part of the
curriculum, each student of final year is required to undergo
internship with required organizations for a period of two and half
months (17.5.2009 – 23.7.2009) . In order to use my
theoretical knowledge of health management administration in the
practical environment of a reputed organization, I did my summer
internship at Nutrition Foundation of India, New Delhi.

During my internship I carried out the following activities during the

internship period:

• Understood the functioning of the organization.

• Assisted in routine management and other activities of the
organization.
• Applied theoretical knowledge of health management to the
practical aspects of health administration.
• Identified a specific problem area or a department for
intensive study.

The topic for this study was decided in consultation with the Director
of the organization. The topic of my study was " Feasibility of
providing integrated health and nutrition care to preschool children
coming to an Urban Primary Health care institution”. A brief report
of the work done is presented.
 FEASIBILITY (PRACTICABILITY) OF
PROVIDING
INTEGRATED (incorporated) HEALTH
AND NUTRITION CARE TO PRESCHOOL
CHILDREN COMING TO AN URBAN
PRIMARY HEALTH CARE INSTITUTION
Background information on health and
nutritional status in infancy and early
childhood
Figure 1: Undernutrition prevalence in South Asian countries is much
higher than in Africa
Preschool children are one of the most nutritionally vulnerable
segments of the population. Nutrition during the first five years has
an impact not only on growth and morbidity during childhood, but
also acts as a determinant of nutritional status in adolescent and
adult life. Global comparative data indicate that contrary to common
perception, prevalence of underweight and stunting is highest in
South Asian children (Figure 1, ). Changes in prevalence of
undernutrition in under five children in different regions/ countries
of the world over the last three decades is shown in Figure 2.
India is home to the largest number of underweight and stunted
children in the world. Projected trends in number of underweight
under five children is given in Figure 3. In South Asia, especially
 India there will be a substantial reduction in undernutrition rates;
but Asia and India will continue to have by far the largest number of
underweight children in the world in 2015. Time trends in poverty,
undernutrition and mortality in developing countries is shown in
Figure 3: Current estimates of underweight and projected numbers of underweight children
under age five, 1990–2015 (WHO)

Table 1. Over the last four decades there has been a progressive
reduction in poverty, increase in energy intake and undernutrition
and infant and under five mortality in the developing countries.

1970197519801981198419851987199019931995199619992000200120032005 ARC
IMR (/1000) 108 88 71 67 62 60 -1.8
U5MR
167 133 105 98 91 87 -1.99
(/1000)
Energy
availability 211021462308 2444 2520 2602 2654 0.83
(Kcal)
Underweight
37.6 33.9 30.1 27.3 244 22.7 -2.99
(%)
Stunting
48.6 43.2 37.9 33.5 29.6 26.5 -2.03
(%)
Poverty
headcount 40.4 32.8 28.4 27.9 26.3 22.8 21.8 21.1 -2.45
(%)

Global pattern of undernutrition in relation to age in preschool

children is shown in Figure 4. Approximately 30% of children in
India are born with low birth weight; and the rest of the damage
happens during the first two years of life. By the age of two years
most growth retardation has already taken place and the linear
growth retardation appears to be irreversible.

Figure 4: Nutritional Status in relation to ages

Factors affecting infant nutrition

Growth during infancy and childhood depends on birth weight,

adequacy of infant feeding and absence of infection. Available data
 from studies, over the last five decades clearly indicate that in India
exclusively breast-fed infants thrive normally during the first six
months of life; however continued exclusive breast-feeding beyond
six months is associated with poor growth There is a progressive
increase in morbidity due to infections with increasing age and
introduction of milk and semisolid food to breast fed infants
Prevalence of undernutrition is higher in infants who had morbidity
during the last fortnight.

Time trends in infant feeding and infant nutrition in India

All major nutritional surveys in India have focused on dietary intake

and nutritional status of preschool children. Data on infant and
young child feeding practices and nutritional status of children under
6 years are available from NNMB, NFHS, DLHS. NFHS and DLHS
provide data at national and state level; in addition DLHS provides
district wise data which may help in decentralized district based
planning, monitoring and evaluation. All these surveys have shown
that in India, steps taken for the protection and promotion of
breast-feeding have been effective and breast-feeding is
almost universal; mean duration of lactation is over 2 years.
However, the message that exclusive breast-feeding up to six
months and gradual introduction of semisolids from six months are
critical for the prevention of undernutrition in infancy has not been
as effectively communicated. Exclusive breast-feeding among
infants in the age group of 0-6 months continues to be low. NFHS-3
Fig 5 Infant fee ding practices & prevalence
70 of undernutrition- NFHS- 3 Fig 6 Nutritional status of children in India
Urban Rural
60

50
60
52 53.4
40
percent

30 50 45.5 47 45.9
20

10 38.4
40
percent

0
breastmilk (6-9
Stunting (< 3

Wasting (< 3
Breastfeeding

Underweight
solid food and
solid or semi-
(0-5 months)

(< 3 years)
Exclusive

Receiving

years)

years)

30

19.1
20 17.3
Infant f eeding Prevalence of undernutrition 15.5
practices

10

0
stunted (%) underweight (%) wasted (%)

NFHS-1 NFHS-2 NFHS-3

 shows that inspite of the all IEC efforts on the need for timely
introduction of complementary food, only about half the children in
the age group of 6-9 months receive semisolid food (Figure 5). As
a result undernutrition rates continue to be high in the 0-3 year age
group (Figure 6). There
Figure 7. : Prevalence of undernutrition has been some reduction
(Weight-for-age)
60 in underweight rates
50 between NFHS 1 and 2
40 but not much change
percent

30 between NFHS 2 and 3.

20
There were small but not
consistent differences in
10
the stunting and wasting
0
0-5 m 6-11 m 12-23 m 24-47 m 48-71 m
rates between the three
% <-2SD % <-3SD surveys. Inappropriate
infant and young child
feeding and caring appears to be responsible for the relatively slow
reduction in undernutrition rates between the three NFHS surveys
(Figure 6). As a result of the faulty infant and young child feeding
practices, there is a steep increase in the prevalence of
undernutrition from 15.4 % at less than 6 months to 52.6 % in the
12- 23 months age group (Figure 7). Correction of these faulty
infant feeding practices through nutrition education will
prevent the steep increase in undernutrition in the critical
6-24 months age group. ( 1 soln)
Too early introduction of milk substitutes and too late introduction of
complementary food are associated with increased risk of infection.
If infections are not detected and treated effectively in the primary
health care settings,
they will result in Figure 8: Under-5 deaths preventable through universal coverage
undernutrition; severe with individual interventions (2000)

infection may lead to %

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
death. It is computed
that exclusive breast- Breastfeeding

feeding and Complementary feeding

appropriate Clean delivery

complementary Hib vaccine

Clean water, sanitation, hygiene

feeding will lead to a
Zinc
20% reduction in IMR
on
Int

nti
ve
er

Vitamin A
(2nd soln) (Figure 8). Antenatal steroids
Improvement in IYCF Newborn temperature management

Tetanus toxoid

Antibiotics for PRM

Measles vaccine

Nivirapine and replacement feeding

Insecticide-treated materials

Antimalarial IPT in pregnancy

through coordinated efforts of ICDS and NRHM can thus result in
substantial improvement in nutrition and health status and survival
during the critical first year of life.

(i) Dietary intake in Indian preschool children

Table 2 Average nutrient intakes among pre-school children

Age 1-3 years 4-6 years

Year 75-79 88-90 96-97 00-01 05-06 75-79 88-90 96-97 00-01 05-06

Protein (g) 22.8 23.7 20.9 19.5 20.2 30.2 33.9 31.2 28.2 28.7
Energy (Kcal) 834 908 807 729 719 1118 1260 1213 1066 1020
Vitamin A
(µg) 136 117 133 106 126 159 153 205 127 166
Thiamin (mg) 0.5 0.52 0.4 0.4 0.5 0.76 0.83 0.7 0.7 0.7
Riboflavin
(mg) 0.38 0.37 0.4 0.3 0.3 0.48 0.52 0.6 0.6 0.4
Niacin (mg) 5.08 5.56 4.6 5.1 5.2 7.09 8.4 7.4 8.1 7.9
Vitamin C
(mg) 15 14 15 17 17 20 23 25 24 25

Data from surveys carried out by National Nutrition Monitoring

Bureau (NNMB) on dietary intake in preschool children between
1975 and 2005 are given Table 2. There has not been a substantial
improvement in their dietary intake over the last two decades.

Data on energy intake in children, adolescents and adults in the

same families from NNMB survey done in 2005-06 is shown in Table
.3. Mean energy consumption, as %age of RDA is the least among
the preschool children; inspite of the fact that their requirement is
the lowest. The gap between RDA and actual intake is widest in
preschool children. It would appear that the problems in feeding a
young child with predominantly adult food with low energy and
nutrient density rather than poverty is the major factor responsible
for low dietary intake in preschool children.
Article I.

Table 3: Mean Energy Consumption- Children / Adolescents and

Figure 9: Trends Adults (%) of
in prevalence
Figure 10: Trends in prevalence (%) of
severe undernutrition in children undernutrition in children
60 100
Gender Boy and Girl Male 90 Female
50
Years 10- 13- 16-80 10- 13- 16-
1-3 4-6 7-9 12 15 17 70 ≥18 12 15 17 ≥18

%
40
60
Kcals
30 719 1020 1230 1423 1645 50
1913 2000 1389 1566 1630 1738
%

40
20 30
RDA 1240 1690 1950 2190 2450 2640
20
2425 1970 2060 2060 1875
10 10
% RDA 58.0 60.4 63.1 65.0 67.1 72.5
0 82.5 70.5 76.0 79.1 92.7
0
75- 88- 96- 00- 04- 92- 98- 05-
75- 88- 96- 00- 04- 92- 98-
79 90 97 01 05 93 99 79 90 97 01 05 93 99 06

NNMB NFHS NNMB NFHS

Underw eight Stunting Wasting Underw eight Stunting Wasting

Data from NNMB surveys have shown that over the last three
decades there has been a steep decline in the prevalence of
moderate and severe undernutrition as assessed by weight for age
and height for age. Inspite of the steep decline in the prevalence of
stunting over the last three decades, the change in the mean height
of children is very small. There has been a decline in underweight
children but even now nearly 50% of the children are underweight
as compared to the NCHS norms. There has been some reduction
in stunting rates similar to the reduction in underweight rates.
Wasting rates are much lower than the underweight and stunting
rates. It is noteworthy that there has been no change in wasting
rates over the same period. It is not clear how much of this is
attributable to the fact that Indian children are shorter as compared
to NCHS norms and will therefore weigh less, even though their
body weight is appropriate for their current height (Figure 9 and
10).

Integrated service delivery for children under NRHM

Data provided so far clearly indicate infant and young child

feeding practices are major determinants child morbidity as well as
child nutritional status. Undernutrition is associated with increased
susceptibility to infections and infections can aggravate under
nutrition. Ensuring that there every contactpoint between the
child and child’s mother is utiliseid to obtain information on
the current feeding practices, immunisation status and
illness care and providing appropriate counselling to
improve infant and young child feeding practices,timely
immunisation , screening all children for early detection of
undernutrition and its effective management , detection and
management of infections (my point) have been identified as
major components of child health under National Rural Health
Mission and its urban counter part , both in the hospital and
community settings. In the rural settings health and nutrition day
has been organised in order to provide such integrated care. It has
been suggested that primary health centres both urban and
rural should be reorganised to provide such integrated care by
appropriate modifications. This has so far not been operationalised
in most hospital settings. It is essential to operationalise this to
achieve the goals for child health and nutrition set in the Eleventh
Five Year plan and enable the country to achieve Millennium
Development goals.

HYPOTHESIS
By appropriate modifications and minimal additional resources it is
possible to reorganise the existing out patient services in the
primary health care institutions so that integrated child nutrition
and health care envisaged under NRHM is provided to all children
coming to the hospital .
 OBJECTIVES
General-
To assess the feasibility of reorganising the OPD routine in
primary healthcare institution so that all children who enter the
portals of the hospital irrespective of the reason they came to the
hospital get integrated child health and nutrition care .

Specific

 To study the present system of child care in urban primary

health centre

 To assess the feasibility is collecting data on infant/young

child feeding and caring practices, immunisations given, illnesses
if any and care during illness in all children coming to the
hospital.

 To assess nutritional status of all children

 To provide health and nutrition service based on the

assessed need

 To provide appropriate individualised counselling regarding

feeding and caring practices, immunisation and care during
illness and convalescence.
 MATERIAL AND METHODS
Locale of the study

Defense Colony Maternity Centre is an urban primary health care

institution under Municipal Corporation of Delhi. The centre has
good infrastructure and adequate manpower . The following
services are available in the centre

 Paediatric OPD 2 days a week

 Antenatal OPD 2 days a week
 OT 2 days a week
 Immunisation
 Delivery care : 24 hours
 Lab Investigations- Haemoglobin, blood sugar, blood group,
urine routine microscopic test, urine pregnancy test
 Family planning services including sterilization
 MTP services

Nutrition Foundation of India has been carrying studies on

operationalising screening for anaemia in pregnancy and
management of moderate anaemia in pregnancy in this centre
over the last four years. So far NFI has not undertaken studies in
the paediatric OPD. The paediatricians and the staff of the centre
are willing to assess the feasibility of delivering integrated health
and nutrition services to all children coming to the hospital
irrespective of the reason why they came to the hospital.

SITUATION ANALYSIS OF THE

PAEDIATRIC OPD
Paediatric OPD gets about 20-30 children on the OPD days. It is a
well attended OPD and may on some days over crowded . The
flow chart indicating the current system of care in the paediatric and
immunisation clinics is given in Flow Chart 1.
 On the

immunisation day the mothers bring infants to the OPD for

immunisation. There is a well organised immunisation clinic with
online data entry for immunisation. The infants get immunisation
done and return home. In such children there is no effort to obtain
data on infant feeding practices or care during illness and
convalescence and based on the findings provide advise on infant
and young child feeding ; children do not get assessed for their
nutritional status ; they do not get any advise on how to improve
their nutritional status.

Ill children are brought to the OPD and are examined by the
doctor and given appropriate treatment . However the opportunity
of hospital visits is not used to enquire about the infant and young
child feeding practices, immunisation status or assess nutritional
status of the child and give appropriate care and counselling . There
is no system to provide counselling regarding feeding and caring
during illness and convalescence .

Women coming to the antenatal or gynaec OPD bring their

children along . These children remain in the OPD along with the

EXISTING SYSTEM

Children brought for Children come with

Children brought for treatment of their parents
immunization illnesses

Examined by
Get immunization done doctors and Receive no care
appropriate
treatment given
mothers but do not get examined or given any screening or
advise.

It is thus obvious that in the existing system mothers bring the

child to the hospital for specific services; the hospital provides the
services and mothers and children return home. The opportunity to
obtain information on all aspects of child health and nutritional
status and providing appropriate counselling and care is missed.

One of the major factors that came in the way of implementing

holistic child care was the lack of manpower ; the second was the
feeling that many mothers may not be willing to spend additional
15 minutes to give details of the current practices and get
counselling and care. During June 2009 NFI had three summer
interns working in projects related to child health and nutrition and
was able to provide additional manpower to obtain detailed
information from mothers of all children , assess nutritional status of
all children and provide appropriate counselling. The Paediatricians
were able to alter their routine to some extent and emphasize to all
the mothers the importance of giving detailed information about
the child to the nutrition interns so that they could benefit from the
individualised counselling given by the interns.

REORGANIZATION OF THE OPD

After detailed discussion between the NFI team and the hospital
paediatricians and other staff it was decided that the feasibility of
modifying the OPD routine to provide integrated health and
nutrition care to all children coming to the hospital will be tried in
June 2009 .
 Steps taken before study was initiated
 A meeting held to discuss the project.
 Proposal of the project was sent across to Pediatrician at the PHC for
 The whole process of reorganisation and its potential benefits was discussed
with the Doctor In Charge and the changes were made by the officer in
charge
 The proforma for data collection was prepared , pretested , discussed with
the pediatrician in charge and finalized
 The doctor along with the NFI staff briefed the OPD staff about the proposed
reorganization
 For taking anthropometric measurements all the equipments were brought at
one room of the OPD, so that all the measurements are done
 All the equipments like weighing machine, microtoise for measuring height , ,
infanto-meter for measuring the length , were checked for accuracy and
sensitivity
 The nutrition interns practiced measuring weight, height/length; quality control
measures showed that they were able to maintain accuracy and consistency
in measurements .

A detailed work plan was drawn up. A proforma to obtain data on

infant and child feeding practices , immunisation status , health and
nutritional status was designed, pretested and finalised for use in
the OPD (Proforma given in Appendix I ).

All children who come to the hospital were registered at the

registration desk. Based on the reason for which the mothers
brought the children to the OPD, they were directed to the place
where the services were available ie infant who came for
immunisation was directed to the immunisation clinic ; those who
were ill were sent to the paediatrician for examination. As they
were waiting for their turn for these services the nutrition interns
obtained the detailed history, undertook assessment of nutritional
status. As soon as the child was given immunisation or treatment
for the illness, the interns provided the mother with appropriate
counselling (Revised routine in the OPD Flow Chart 2) on the
following aspects:
• Feeding practices
• Immunisation
• Health care during illness
• Diet during illness and convalescence
• How to improve nutritional status of undernourished children

Reorganisation of the routine in the OPD

 The staff in the OPD ensured that the proposed reorganization was
implemented effectively and consistently. They stream lined the
procedures so that neither the children nor the doctors had to spend
more time in the OPD. Even when there were nearly 20 children to be
attended to the whole team was able to cope with work load
 In all children (irrespective of the reason they came to the hospital)
information on immunization status, feeding and caring practices were
obtained; assessment of nutritional status was done in all.
 When they went to the physicians the physician could look at the
completed proforma and advise the mother taking these into account They
also informed the mother that they should go to the nutrition nterns
and get the benefit of detailed individualized counseling.
 The nutrition interns counseled the mothers about immunization , infant
and young child feeding , feeding during illness and convalescence and
how to improve nutritional status of the child within the existing
constraints ; they also answered the queries that the mothers posed
 The mother then collected the drugs prescribed by the doctor and went
home
 The Performa filling was done when the mothers were waiting to be
called for the consultation / immunization and so did not involve any
additional time spent tin the OPD. They did spend 5 more minutes with
the nutrition interns for counseling but they got excellent advice
 REORGANIZED SYSTEM

Children come with

Children brought for Children brought for
their mother
immunization treatment of illness

Registered Registered Registered

Mothers waiting for their Waiting for their turn Waiting for their turn
turn for ANC for immunization for monitoring

Collect information of feeding and caring practices, immunization

status, care during illness and convalescence.
Assess nutritional status (Height, weight, BMI)
Time taken between 10-15 minutes

Child gets immunized Doctors examines the

Mother get ANC child and prescribes
appropriate treatment
given

Nutrition interns look at the details in the proforma and provides

individualized counselling for each child regarding feeding,
caring, immunization how to improve nutritional status.
Time taken between 5-10 minutes

Mothers collect drugs, child’s drugs are also collected,

anthropometric assessments done, nutrition and health
education given, etc. and they leave the hospital happy and
satisfied.
 RESULTS
During the one month period of study 219 children were seen in the
OPD . Of these 70 came along with their mother, 94 were brought
for immunisation and 55 because of illness.

Socio-demographic Profile
The socioeconomic profile of these children is given in Table .
PARAMETER ACC Immunization Ill child
S.NO Parents N=94 (%) N=55
N=70 (%)
(%)
1 Household Type
a. Joint family 47.14 44.68 69.09
b. Nuclear family 52.86 55.32 30.91
2 Family Members
a. >=3 25.71 24.47 29.09
b. 4-8 57.14 61.70 63.64
c. <8 17.14 13.83 7.27
3. Age
a. 0-3 11.43 36.17 16.36
b. 4-6 2.86 8.51 7.27
c. 7-9 2.86 12.77 10.91
d. 10-12 1.43 3.19 5.45
e. 13-18 8.57 19.15 16.36
f. 19-24 20 3.19 16.36
g. 25-36 20 5.32 14.55
h. 37-48 21.43 6.38 10.91
i. 49-60 11.43 5.32 1.82
4. Sex
a. Male 47.71 43.62 45.45
b. Female 54.29 56.38 54.55
5. Literacy status
(Mother)
a. Illiterate 20 18.09 18.18
b. Upto 5 20 11.70 14.55
c. 5-12 50 57.45 61.82
d. College 10 12.77 5.45
6. Literacy status
 (Father)
a. Illiterate 2.86 7.45 10.91
b. Upto 5 14.29 11.70 14.55
c. 5-12 61.43 65.96 52.73
d. College 21.43 14.89 21.82
7. Work status (Father)
a. Not working 5.71 2.13 1.82
b. Unskilled 18.57 12.77 18.18
c. Semi-skilled 34.29 51.06 25.45
d. Clerk 15.71 11.70 20.00
e. Teacher 21.43 12.77 18.18
f. Professional 4.29 9.57 16.36
8. Work status (Mother)
a. Not working 97.14 93.62 94.55
b. Unskilled 2.86 2.13 3.64
c. Semi-skilled
d. Clerk
e. Teacher 1.82
f. Professional 1.06
9. Diet
a. Vegetarian 32.86 34.04 20
b. Non-vegetarian 67.14 65.96 80
10. Monthly income
a. >3000 3.45 1.39 11.11
b. 3000-6000 63.79 70.83 61.11
c. <6000 32.76 27.78 27.78
11. Locality
a. Slum 20 10.64 10.91
b. Developing 80 89.36 89.09
colony
12. Type of house
a. Kuccha 12.86 5.32 14.55
b. Semi-pucca 15.71 18.09 16.36
c. Pucca 71.43 76.60 69.09
13. Ownership
a. Own 44.29 43.62 50.91
b. Rented 55.71 56.38 49.09
14. No. of Rooms
a. One 42.86 46.81 56.36
b. TWO 31.43 24.47 25.45
c. Three 14.29 12.77 10.91
 d. More than 3 11.43 15.96 7.27
15. Toilet facility
a. Shared 21.43 20.21 29.09
b. Sulabh 14.29 6.38 7.27
c. Own flush 64.29 73.40 63.64
16. Transport
a. Public 60 47.87 61.82
b. Bicycle 10 24.47 18.18
c. Scooter 25.71 18.09 12.73
d. Car 4.29 9.57 7.27
17. Cooking fuel
a. Kerosene 7.14 4.26 9.09
b. Gas 91.43 94.68 90.91
c. Other 1.43 1.06 0.00
18. Drinking water
a. Public tap 30 27.66 32.73
b. Own 58.57 64.89 61.82
arrangement 11.43 7.45 5.45
c. Tanker
19. Entertainment
a. No 21.42 11.70 20
b. Radio 7.14 2.12 7.27
c. T.v ( b/w) 10 5.31 12.72
d. T.v (colour) 61.42 80.85 60
20. Kitchenware
a. Aluminium 2.85 3.19 3.63
b. Cast iron 1.06
c. Brass/ copper
d. Stainless steel 95.71 95.74 96.36
21. Smoking
a. yes 24.63 21.83 24.07
b. No 75.36 71.86 75.92

Majority of children were from the low or low middle income group
families . There were no significant differences in the profile of the
families to which the children belonged depending on the reason for
their coming to the hospital . From the sociodemographic profile it
is obvious that these children did not come from homes with
severe economic constraints and food insecurity. There were
significant differences in the age profile of children a attending
hospital for different reasons: children who came for immunization
were young infants ; those who accompanied their parents were
older.

AGE (m o nth s )

40
35
P ER C EN T A G E

30
25 A c c p ar ents
20 Immun is ation
15 Ch ild is ill

10
5
0
0 -3 4 -6 7- 9 10 -1 2 1 3 -1 8 19 - 24 2 5- 36 3 7- 48 49- 60
A GE

Infant and young child feeding practices

Time for initiation of different food-stuffs

Breast Formula Semi- Water Adult ICDS

milk Milk solids (136) food (n=30)
(n=135) (n=53) (n=83) (n=92)
4.9±2.85 6.3±1.53 3.5±2.75 7.6±1.45 7.3±1.85

Animal Cereals Fruit Vegetables Bread

milk (n=122) (n=120) (n=111) (n=117)
(n=111)
6.0±2.39 6.9±1.37 7.0±1.44 7.2±1.10 7.3±1.23

Breast feeding was universal . However majority of mothers had

introduced water, animal milk , formula milk between 4-6
months of age. Most of the mothers had introduced semisolid food
or modified family food to children between 6-9 months of age but
adequate complementary feeds were inadequate in quantity , fed
twice or thrice only and did not contain diverse ingredients needed
to meet the needs of a growing child They required intensive
counseling on appropriate infant and young child feeding practices .
Less than one eighth of the families accessed ICDS anganwadi
and availed food supplementation services.

Immunization rates

IMMUNISATION

100

80

60
PERCENTAGE
40

20

0
BCG DPT POLIO PULSE HEPB MEAS

% 96 92 93 92 79 68

TYPESOFIMMUNISATION
Majority had accessed immunization services during infancy . While
coverage under BCG was nearly universal but only 68% had
measles immunization. Complete immunization ( BCG, 3 doses of
OPV and DPT , measles) before first birth day was reported by
59% only. Reasons for the relatively low complete immunization
rate varied : from non awareness and difficulties in complying
with the suggested schedule . Health education on the importance
of complying with the immunization regimen can make a difference
in complete immunization rates.
 Morbidity due to infections

Morbidity due to infection

30

25

20

Percentage 15 Diarrhea
Fever
10
RES infection
5
Skin diseases
0
0-6 7-12 13- 19- 25- 31- 37- 43- 49- 55-
18 24 30 36 42 48 54 60
Age groups (months)

Morbidity due to infection was more often seen in under two

children. Diarrhea was the most common infection ; respiratory
infection came next . Mothers brought their children to hospital
fairly early during infection and followed the doctors treatment;
however they had very poor knowledge regarding care during
illness and convalescence . Health education can have some
impact on the care during illness and nutrition education can
improve feeding practices during illness and convalescence.
 Nutritional status

Mothers very readily got their children weighed; they also

cooperated for length measurement in infants and accepted taking
height readily. However they had very poor idea of growth
monitoring. For most of the mother it was the first occasion when
their children have been weighed and length/ height were taken
and information on their nutritional status and how to improve the
status by modifying some practices were given to them. If these
were done during every contact in the hospital it will be possible
to get the mother to take the right steps to improve the nutritional
status of the child within the constraints that exist at home.

Knowledge regarding health and nutrition care

Majority of the parents were aware of the importance of providing

appropriate health and nutrition care to their children and were
willing to do their best for their children. However they had several
misconceptions about appropriate infant and young child feeding
and caring practices. Inspite of living in the heart of the city with
excellent access to health care they have not made optimal use of
the available services. Less than 10 % accessed ICDS services.
They listened to the health and nutrition counseling and clarified
their doubts but how far they were able to implement the
suggestions given has to be ascertained . It is relatively easy to
improve knowledge of the aware and literate population but
repeated efforts are necessary to bring about the change in
attitude and practices. Persistent counseling on all occasions when
they bring their children to hospital can however may bring about
some change in both attitude and practices .

Costing of the reorganization

This reorganization was possible because during this period there
were three nutrition interns working with NFI. They could
comfortably ensure that the proforma was filled for all children
coming to the OPD, assess nutritional status of the children and
provide individualized counseling to all mothers.

It will not be possible to sustain the reorganization without

additional manpower. The minimum additional manpower required
will be two persons helping during the OPD hours: one for the
proforma filling, assessment of nutritional status and the second for
counseling women. It will be difficult to manage with one
additional person because she may be held up in completing the
Performa before the mother takes the child to the doctor and
mothers will have to wait for longer periods of time for getting the
counseling. In the hospital settings the staff nurse or the ANM
will be preferred for taking up the task as they are posted in
these positions and have the necessary knowledge and skills for
undertaking the task. However as apart of the reorganization it is
essential to run an orientation course for the staff so that all
members of the staff so that the procedures are streamlined and
the counseling is similar .

Currently the pediatric OPD operates on two days a week. The

feasibility of redeployment of an ANM and one staff nurse from
other areas in the hospital to the OPD for four hours in the
morning on these two days could be attempted initially . However
to sustain the programme and perhaps extend it also to the
antenatal OPD, would require posting of at least an additional ANM
to the institution. The salary coat of the person would vary in
different institutions but on average about Rs 10, 000/pm. They
could be utilized to assist in integrated health and nutrition
assessment and counseling not only to children but also to the
expectant mothers attending the urban primary health centre. The
training costs are to be met form the ongoing NRHM training
programme budget. All hospital is expected to have adult and baby
weighing balances and infanto-meters fro measuring length of the
infant. If an additional microtoise is required for measuring height it
can readily be purchased at the cost of about Rs 1,000.

Considering the importance of providing integrated health and

nutrition care to children and improving their health and nutrition
status as envisaged in the NRHM to enable the country to achieve
the goals set in Eleventh Five Year Plan, the additional investment
is minimal as compared to the potential benefits.

REFERENCES

 Tenth and Eleventh Five Year Plan

 Course Material of Symbiosis Institute of Health Science

 Nutrition and Child care: Shanti Ghosh

 Textbook of Human Nutrition

 WHO Global database of Malnutrition: WHO Publication

 Primary Health Care: New initiatives: Nutrition Foundation of

India, Symposium report (2006)

 Reports and Publication of NFI

APPENDIX
 PAEDIATRIC CARD - DEFENCE COLONY MATERNITY HOME
S.No. Date of registration : (dd mm yy)   Place of origin :
Name of child _____________Mother:_________________ Family : Type (J / N) Size (no.) : ____
Age ____ (in mth.) Address_____________________________________ Contact: _____________

Socio-demographic Profile

Literacy status of Woman 1. illiterate 2. can read/write

3. had schooling 4. College ___
If gone to school the highest grade completed ___
Literacy status of Husband 1. illiterate 2. can read/write
3.had schooling 4. College ___
If gone to school the highest grade completed ___
Work status (Husband) 1. not working 2. unskilled 3. semi-skilled
4. clerk/small business 5. teacher/business/office worker 6. professional ___
Work status (Wife) 1. house wife 2. unskilled 3. semi-skilled
4. clerk/small business 5. teacher/busine1ss/office worker 6. professional ___
Diet 1. vegetarian 2. non vegetarian ___
Monthly family income (Rs) ___
Which locality do you live in 1. slum 2. developing colony ___
Type of house 0. kuccha 2. semi pucca 4. pucca ___
Ownership of house 1. own 2. rented ___
No. of rooms in the house 1. one 2. two 3.three 4. more than three ___
Toilet facility in household 0. no facility 1.shared pit 2.sulabh/own pit
3. own flush ___
Means of transport 1. public transport 2. bicycle 3. scooter
4. car ___
Cooking fuel used at home 1. kerosene/charcoal 2. gas/ electricity
3. other ___
Drinking water source 1. public tap/handpump
2. own arrangement in house 3. Tanker water ___
Means of entertainment 1. radio 2. T.V. (b/w) 3. T.V. (colour) ___
Kitchenware in household 1. clay 2. aluminium 3. cast iron
4. brass/copper 5. stainless steel ___
Passive smoking 1. yes 2. no ___

Infant and young child feeding

Type of Number Time of initiation (month) Time of

food of feeds 13 19 25 37 stopping
7-
(current) 0 1 2 3 4 5 6 - - - - >48 (month)
12
18 24 36 48
Breast
milk
Formula
milk*
Semi
solids
* 1. Bottle 2. Spoon 3. Cup

Food Time of initiation (month)

7- 13- 19- 25- 37-
0 1 2 3 4 5 6 >48
12 18 24 36 48
Water
Animal milk*
Cereals/ Pulses
Fruits
Vegetables
Bread/ biscuit
Adult food
ICDS Supplementation
Formula complementary
Any other (e.g. non-veg)

* 1. Diluted 2. Undiluted
Supplements Month when initiated How often given Amount /Dose
1 IFA
2 Vitamin A
3 Any other, specify

Immunization

Vaccine Dose/date
BCG Measles
DPT 1 2 3
Polio 0 1 2 3 Pulse
Any
other

Morbidity

Reason for coming to DCMC:

1.Well Baby clinic 2. Immunization 3.Child is ill

4. Accompanying parents 5.Others specify

Morbidity due to infection in the last fortnight:

1. Diarrhea 2. Dysentery 3. Fever 4. Respiratory

infection
5. Eruptive fever 6. Skin diseases 7. Any other 8. None

Duration of illness in days ____

Severity:
1. Mild 2. Moderate 3. Severe

Person providing care:

1.Family 2. AWW 3. Quacks 4. Govt. doctor 5. Private doctor
6. Any other

Treatment given:
1. Home remedies 2. Home fluids 3. ORS 4. Antibiotics
5. Antipyretics 6. Unknown medicines from quacks 7. Cough syrup

Anthropometric indices

Age Wt Ht/ Lt MUAC Triceps Biceps Sub scapula Supra iliac

(in months) (Kgs) (cms) (cms) (mm) (mm) (mm) (mm)

Advice

Feeding practices
Immunization
Physical activity
Health care during illness
Diet during illness and convalescence
Life style
Diet