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TECHNICAL INSTRUCTION SERIES

NO. HD/FH/1/95

Revision No 3/2009

PROVISION OF CHILD HEALTH CARE

DEPARTMENT OF HEALTH
2009

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 Technical Instruction Series
Revision HD/FH/3/2009

PROVISION OF CHILD HEALTH CARE

I. Purpose

The purpose of this Technical Instruction is to define the policy and establish
uniform procedures for provision of a comprehensive child health care to
Palestine refugee children utilizing UNRWA primary health care facilities, which
is fully integrated within the Agency’s primary health care activities.

II. Objective

The main objective of this instruction is to provide technical and operational

guidelines to UNRWA health personnel on the basic principles of preventive
care, to infants and children in order to preserve, protect and promote their
health status and reduce infant and early child mortality, morbidity and
disability.

III. Applicability

This Technical Instruction is applicable in all Fields of UNRWA’s area of

operations.

IV. Eligibility

All Palestine refugee children below five years of age, be they children of
registered or unregistered families.

V. Cancellation

This instruction cancels and supersedes the previous instructions/guidelines on

the subject in particular the Technical Instruction Series No. HD/ FH/2/2000.

VI. Effective date: 1 March 2010.

VII. Introduction

 Children below 15 years of age represent 35% of the registered Palestine

refugee population. Approximately 40% of those children are under five years
of age. Because they are in a state of rapid growth and development, those
children have special needs and require access to high standards of integrated
comprehensive maternal and child health care.
 Notwithstanding that there has been a significant drop in infant and early
child mortality over the last six decades; nevertheless, there is room for further
reduction of neonatal mortality, which accounts for approximately two thirds of
infant mortality. This could be achieved through active maternal health
surveillance, effective preconception, pre-natal, per-natal and post-natal care
as well as through expanding and sustaining a high coverage of high quality
family planning service.

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 Likewise, there have been significant changes in the pattern of infant and child
morbidity and mortality. Diarrhoeal diseases, gastroenteritis and protein-energy
malnutrition which used to be highly prevalent and used to contribute to
approximately two thirds of infant mortality in the fifties and sixties of the last
century had been overtaken by low birth weight, pre-maturity and congenital
malformations which are more difficult to prevent and to treat.
 Immunization of infants and children against vaccine-preventable diseases is
optimal. However, we need to maintain active surveillance and sustain high
immunization coverage in order to achieve the WHO regional targets of
elimination/eradication of these diseases. In addition, morbidity and mortality
from other communicable diseases such as acute respiratory infections are still
relatively high and there is the risk of newly emerging and re-emerging
infectious diseases.
 Protein-energy malnutrition among children had been eliminated. However,
micronutrient deficiencies, which affect the physical and mental development
of children, are high. Nutritional surveys which were conducted among the
refugee population revealed that approximately 50 per cent of children below
three years of age still suffer from mild to moderate levels of anaemia.
 Crude birth rates are still relatively high and birth intervals short. Furthermore,
the availability of and access to intensive peri-natal care during delivery and
post-partum is still very limited, expensive and unaffordable. These factors still
contribute to a considerable proportion of maternal and peri-natal deaths,
many of which could be prevented.
 Owing to the poor environmental health conditions, intestinal infestations are
still high and clinical interventions to treat them remain of limited impact unless
marked improvement to environmental infrastructure could be attained.
Sustaining 60 years of notable achievements and attaining further
improvement in the health status of infants and children remains therefore,
much dependant on provision of high quality preventive care as early as
possible after birth until five years of age.

VIII. The strategy:

UNRWA provides child health care services as integral part of its

comprehensive maternal and child health care and family planning programme.
The strategy to preserve, protect and promote the health status of infants and
children comprises the following main components:
1. General appraisal of the health condition of the newborn as early as possible
after birth.
2. Regular monitoring of the growth and development of the child since the date
of initial registration until five years of age.
3. Special care for children at risk
4. Sustaining high immunization coverage against vaccine-preventable diseases.
5. Early detection and management of congenital and/or acquired morbidity
6. Other interventions including screening for child abuse and neglect, vitamin A,
supplementation, oral health and surveillance of the nutritional status of
children under five years through early identification and management of
micronutrient deficiencies, in particular iron deficiency anaemia.

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1. GENERAL APPRAISAL OF THE HEALTH CONDITION OF THE NEWBORN:
The Agency has always encouraged early registration of infants in order to
provide comprehensive child health care services, as early as possible, after
birth and to provide post-natal care to their mothers. For this purpose, women
registered for ante-natal care should be advised about the importance of early
registration soonest possible after delivery. A birth notification should be
adequate for provision of care without the need to wait until administrative
formalities for including the name of the newborn in the Registration Card are
completed.
Special attention should be paid to identification of the outcome of every and
each registered pregnancy as well as follow-up on the survival of live births
who register and default. In case of death, the causes should be properly
investigated and reported.

General appraisal of the health condition of and preventive care to the

newborn during the initial visit (first registration) should comprise the following
components:

1.1 History taking:

The mother:
 General information and full obstetric history: It is important that the
information recorded on the Child Health Record (CHR) with respect to
mothers who were registered for ante-natal care is compatible with that
available on the Maternal Health Record.
 Place and type of delivery.
 Any complications encountered during pregnancy, delivery or postpartumas
well as any complications/interventions with respect to the newborn, such as
birth trauma, asphyxia, aspiration pneumonia or history ofincubation.
 Information on the preceding child.

The newborn:
 General information: This includes the name, date of birth, birth weight and
gestational age at birth
 Relevant medical problems, incubation, medications and operations
 Feeding history with special reference to exclusive breast-feeding
 Vaccines that the newborn might have received during stay in hospital.

The family:
 History of major morbidity conditions such as: hypertension or diabetesof the
parents, epilepsy and physical or mental disability of other children, or any
other familial disease such as hereditary anemia.

1.2 Physical examination:

It is expected that all babies should be examined, weighed and measured as part
of the routine examination of the newborn soon after delivery. Results should be

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recorded in the Child Health Record (CHR) and the Mother and Child Health
Handbook.
Upon registration, infants should be examined thoroughly by the medical officer
for early detection and management of morbidity conditions. examination is best
conducted in a “head to toe” manner, i.e. starting with general observations,
then palpation of the head, examination of ears, eyes, measurement of head
circumference, then mouth, neck, then chest and heart, then abdomen, then
femoral pulses, hips and genitalia and down to legs and feet.
The findings should be properly documented on the relevant section of the child
health record (CHR).
Proper physical examination of the newly registered newborn infant should
include the following components:

1.2.1 Observation:
The opportunity of observing the overall condition of the infant is often best
undertaken at the beginning of the examination before proceeding to assess the
specific organs and systems. It is essential that the infant be completely
undressed in a warm and adequately illuminated environment. Particular
attention should be paid to:

 The level of consciousness and general appearance/behavior of the

infant,
 deformities and symmetry of body dimensions and body movements,
 The general nutritional status,
 Color of the skin (cyanosis, jaundice, etc.),
 Any sign(s) of clinical distress or deformity and
 Dysmorphic features e.g. Down’s syndrome

1.2.2 The head and neck:

 The anterior and posterior fontanels should be palpated and thestate of
the cranial sutures assessed.
 The eyes should be examined. Fundoscopy is usually onlyundertaken
where specific pathology is indicated/suspected byhistory or other
physical findings.
 Examination of the external auricle should be performed to detect any
deformity or skin tags. Examination by otoscope should also be
performed.
 The palate should be checked for anydefect, especially if there is a
harelip.
 The neck: should be examined for, cysts, torticollis and both clavicle
should be palpated for fractures

1.2.3 The Respiratory system:

 Inspection of the chest for any deformity/asymmetry, tenderness and
obvious signs of respiratory distress should be noted.
 breast congestion/engorgement is common in the newborn and milk may
be present but should not be expressed/manipulated

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Auscultation of the chest should be performed with particular attention to
relative air entry and adventitious sounds.

Percussion is of little benefit and should be avoided, particularly in

extremely low birth weight. The best abnormal physical signs to
look for are:
 fast breathing (count the breath in one minute and assess
according to table No 1:)
Table No 1, fast breathing by age

Child’s age Fast breathing

Up to 2 months 60 breaths / minute or more
2 months up to 12 months 50 breaths / minute or more
12 months to 5 years 40 breaths / minute or more
 C
 Chest in-drawing ( if the lower chest wall goes IN when the child
breaths IN)

1.2.4 Cardiovascular system:

 The apex beat or point of maximum impulse should be palpated prior to
any auscultation with the stethoscope.
 Peripheral pulses should be palpated.
 Careful auscultation of the heart should be performed, and the presence
ofany murmur should be noted.
 Abnormalities of cardiac rhythm should be carefully recorded.

1.2.5 The abdomen:

Abdominal examination is performed when the Medical Officer is standing on the
right side and the infant is quiet and cooperative as follows:

 Gentle palpation with the right hand begins in the left lower quadrant
proceeding to the left upper quadrant, palpating for any abnormal
masses or visceromegaly.
Again, beginning in the right lower quadrant, gentle palpation extend
towards the right upper quadrant, noting any masses and noting the
alignment of the liver edge from the mid-point of the right costal margin.
 Other forms of assessment including percussion or auscultation are
usually only indicated when other problems are noted in inspection such
as abdominal distention.
 Inspection of the umbilical stump and the possible presence of hernia.
 Do not push. Perform all palpations slowly and gently otherwise the infant
will resist and push its abdomen against you.

Liver edge may be normally found up to 2 finger breadth below right

costal margin.

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 1.2.6 The upper limbs:
 Palpation of the clavicles and shoulder girdle should be performed
following any traumatic delivery, particularly in large infants withhistory
of shoulder dystonia.
 Mobility of the shoulder and extension of the elbow should beassessed
along with counting the fingers and examination ofpalmar creases.

1.2.7 The Lower extremities:

 The femoral pulses should be palpated bilaterally and assessed (absence
of femoral pulse is significant in children with signs and symptoms of
cardiac disease).
 the feet and ankles should be examined for deformity and foot creases,
 tone and deep tendon reflexes should be assessed and
 The hips should be examined for clicks, limited abduction and asymmetry
of skin folds using Ortolani's and Barlow’s maneuveres. (This islikely to
make the infant cry and therefore is done after examiningtone and
reflexes. Usually, one of the last things to do.)

1.2.8 The genitalia:

The genitalia should be carefully assessed and particular attention should be paid
to any malformation/abnormality such as:

 Male: testicular descent, signs of hypospedias, ambiguity and inguinal or

scrotal hernia.
 Female: labia major for possible adhesions and inguinal hernia.

1.2.9 The central nervous system:

Apart from the initial observation of the infant's level of consciousness and
general state of behavior and tone, neonatal neurological assessment is
generally limited to primitive reflexes including grasp, suckling, and Moro
reflexes. More detailed neurological assessment may be indicated on ground of
birth history or other clinical findings.
Table No 2, reflexes to be examined

Reflex Technique Response

Rooting reflex Rub gently one side ofmouth The baby opens mouth and
 turnsto the stimulated side.
Suckling reflex Place clean finger inbaby’s mouth The baby will suck
Moro reflex Hold the baby supine with the head The arms and legs abduct
supported in one hand. Allow the head and extend. The movement
to drop 2 inches. should be symmetrical.

Palmar-grasp Press on palms ofInfant’s hand The baby grasps

Walking- Support the infant in an upright position The baby simulates walking
stepping reflex with feet touching a flat surface

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 1.2.10 Other investigations:
The necessary investigations should be ordered for children who need further
evaluation be it laboratory, radiology or specialist’s advice.
The most common problems of the newborns are outlined in the table below:
Table No 4, Common problems of newborns

Clinical Other Possible Problems to

Common Problems
Manifestations Consider
Jaundice - Physiological jaundice - Biliary atresia
- Haemolytic disease - Inborn metabolic disorders
- Systemic infection - Hepatitis
Respiratory - Respiratory distress syndrome - Congenital heart disease
Distress - Transient tachypnea
- Pneumonia
- Sepsis
Cyanosis - Cyanotic congenital heart disease - Congenital pulmonary defects
- Airway compromise - Diaphragmatic hernia
- Poor lung expansion
Convulsions or - Hypoglycaemia - Intracranial bleeding
Seizures - Febrile convulsions - Inborn metabolic disorders
Lethargy or Poor - Sepsis - Neuromuscular problems
feeding - Immaturity,
Sepsis - Bacterial infection, - Perinatal/maternal infections
- Viral infection - Congenital infections, “TORCH”
Bilious vomiting - Intestinal atresia,
- Volvulus
Non-bilious - Overfeeding, - Esophageal atresia
Vomiting - Gastro-esophageal reflux - Sepsis
- CNS problems
- Metabolic errors
- Pyloric stenosis

1.2.11 Measurements:
The initial neonatal examination should comprise careful measurement of the
length, body weight and head circumference of the newborn and recording this
information in the CHR and the MCH handbook.
1.3 Overall assessment:
Upon completion of the above-mentioned components, an overall assessment of
the health condition of the newborn should be made in order to identify infants
who are at high-risk with clear identification of the risk factor(s).
The findings of the examination as well as a comprehensive follow-up and
management plan should be recorded on the CHR and the MCH handbook.
Discussion with and counseling parents should be carried out at the end of the
examination to review outcomes and advise the parents on the recommended
management plan e.g. early surgical intervention for treatment of congenital
heart disease, harelip, cleft palate, un-descended testicle(s), early conservative
treatment of hip dislocation, proper dietary management, etc..

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1.4 Family planning counseling:

Counseling on family planning should be provided as an integral part of the child

health care. Counseling should be provided during the first visit as this is the
right time to counsel mothers on how to plan and space future pregnancy in
order to avoid too early, too close, too frequent and too late pregnancies which
might affect the health of the mother and/or the infant. Counseling should also
be provided during each repeat visit for growth monitoring. The result of the
counseling should be recorded on the CHR under the “Nurse’s Notes” or under
the “MO’s Notes” if the MO is providing the counseling.

2. REGULAR MONITORING OF GROWTH AND DEVELOPMENT:

2.1. General considerations:

a. Growth monitoring is an essential component of Primary Child Health Care.

It improves utilization of health services and will result in better nutritional
status and / or survival of infants and children, it improves coverage and
attendance at health centers and growth monitoring can identify ill children
who present with growth and developmental disorders.

b. The WHO child growth standards1:

In the past, growth references were developed using data from a single-
country sample of children presumed to be healthy. There were no specific
health behaviors required for children to be included in the reference
sample.

The result was a set of references that described the growth attained by
children raised on modes of feeding and care that were typical of a
particular time period and country.

The World Health Organization (WHO) has developed growth standards to

provide data describing how children should grow, by including in the
study’s selection criteria; certain recommended health behaviors (for
example, term babies, breastfeeding, standard paediatric care, and no
smoking environment).

1
de Onis M, Garza C, Victora CG, Bhan MK, Norum KR, editors. WHO Multicentre Growth Reference Study
(MGRS): Rationale, Planning and Implementation. Food Nutr Bull 2004;25 (Suppl

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In addition to standards for physical growth, the WHO Child Growth Standards
include the following six gross motor developmental milestones that healthy
children are expected to achieve during specified age ranges between 4 and 18
months:
Figure No 1, Gross motor developmental milestone

1. Sitting without support, 2. Standing with assistance,

At 6 ±(1.1) months 7.6 ±(1.4) months

3. Hands-and-knees crawling, 4. Walking with assistance,

8.5 ± (1.7) months 9.2 ± (1.5) months

5. Standing alone, 6. Walking alone,

11 ± (1.9) months 12.1 ± (1.8)

c. Correct measurement, plotting, and interpretation are essential for

identifying growth problems; basic growth assessment involves measuring
a child’s weight, length or height, head circumference and developmental
gross motor milestones and comparing these measurements to growth
standards.

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d. The main objectives of monitoring growth and development are:

 To provide a diagnostic tool for health and nutrition surveillance of

infants and children.
 Teach mothers, families how food habits can affect child growth and
thereby encourage best feeding practices.
 Provide regular contact of beneficiaries with Primary Health care
services.
 Growth monitoring can serve as an entry point to families and the
community to ensure involvement, participation and social action
 Growth monitoring can determine whether a child is growing “normally”
or has a growth problem or trend towards a growth problem that can
be achieved by:
o Measuring weight, length/height and head circumference;
o Plotting these measurements on growth charts; and
o Interpreting growth indicators.

e. If a child has a growth problem or trend towards a growth problem, action

should be taken to address the causes of poor growth. Growth monitoring
that is not supported by appropriate response programmes are not
effective in improving child health.

f. Identified children with severe forms of growth problems should be referred

for specialized care.

g. If the child is obese, mothers should be counseled on proper feeding

practices and healthy lifestyle in addition to medical assessment and
specialized care

h. Non-severe problems can be managed through counseling, including age-

appropriate advice on feeding and physical activity

i. Growth monitoring of children should be carried out during

immunization visits in the 1st year (a total of 6 visits), every three
months in the 2nd year and every six months thereafter to 5
years.

j. The mother should be encouraged to visit the growth monitoring clinic at

any time that she has concerns about her child's growth or development

k. The first two years of a child’s life are as crucial for mental development as
they are for physical development. Early detection of abnormalities might
affect the future of the child if managed timely and appropriately including
hearing and vision. Follow-up of the developmental gross motor milestones
should be assessed, plotted and followed up in the relevant chart in the
Child Health Record and the MCH handbook.

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 2.2 Expected benefits of Growth monitoring and promotion:

 Reduction in malnutrition, morbidity and mortality among infants and

children.
 Early intervention
 Improved knowledge about the effect of diet and illness on growth
nutrition and health counseling to meet individual needs.
 Opportunity to assess interventions.
 Greater utilization of preventive health care services.
 Fewer referral for curative care; cost savings community mobilization to
address underlying socio-economic causes and poor health

Figure No 2, Monitoring of growth and development

Assess and conduct measurement

Normal growth Deviation from normal:

Advise and give next appointment Interpretation of deviations in term

of health status and take decision

2.3 Birth-weight:

The birth-weight is the most sensitive indicator, which reflects the health
condition of the mother, the infant and the future health and development of
the child. The first step in growth monitoring should start by finding out the
birth weight, which should be recorded to the nearest 100gm, if delivery took
place in a hospital or a maternity. Mothers should be encouraged to ask the
birth attendant to record the birth weight in the relevant section of the MCH
handbook. The birth weight can be categorized in:

a. Normal birth-weight: Normal birth-weight is defined as that falling between

2500 -<4000 gm. It reflects that the health of the newborn and the mother
are of acceptable standards.

b. High birth-weight: Birth-weight is considered high if it is > 4000 gr. Fasting

plasma glucose should be carried out for mothers of such infants, at
the time of registration of the new born, to rule out diabetes mellitus.

c. Low birth-weight: Low-Birth-Weight (LBW) is defined as infants with birth

weight less than 2500 gr. The low birth weight infant could either be a
premature or small for gestational age. It is an important indicator of the

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 health and socio-economic status of the population. Together with other
indicators, it often reflects the level of access to early and continuous
maternal care during pregnancy. It is also an indicator of maternal nutrition
and health as they are reflected in birth outcome(s). The incidence of low-
birth-weight in the Agency area of operation is estimated at approximately
6-8%.
Different studies conducted by the Agency have shown that the main cause
of peri-natal, neonatal and post-neonatal deaths is low birth weight and
prematurity.

In order to prevent the progression of LBW to chronic growth problem, the

following preventive measures should be taken:

 Close supervision and follow-up of LBW infants in the special clinic for
children with growth problems.

 Close monitoring of growth and development to detect timely deviations

from the standard measurements.

 Iron supplementation and treatment of iron deficiency anaemia among

mothers and children.

 Dietary counseling of mothers of infants at risk of developing growth

problems.

2.4 The growth chart

2.4.1. General considerations:

a. A growing child is a healthy one, growth is very sensitive to external
factors, such as nutrition and disease, and growth monitoring is therefore
of great value in child health care.

b. Malnutrition can be detected by means of growth monitoring long before

its clinical signs and symptoms become apparent.

c. Growth will be monitored by measuring weight for age, length/height for

age, weight for length/height, developmental gross motor milestones and
head circumference.

d. The most appropriate method for growth assessment is by means of

growth charts. For purposes of comparison, WHO standard growth charts
which shows the limits of normal growth will be used for monitoring.

e. In growth monitoring, the child's anthropometric measurements are

plotted on the growth charts at the intervals mentioned above and the
points joined up to form a growth curve.

f. The direction of the growth curve (trend), rather than the position of
single plot, is of key importance. A rising growth curve means a healthy
child, a flat growth curve is a warning signal while a growth curve that
turns downwards calls for immediate action.

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 g. Health staff must be trained to use the growth chart, not only in
identification, management and monitoring of child health, but also as a
tool for health education of mothers.

Each mother should be informed about the results of her child’s

growth assessment.

2.4.2. Anthropometric measures:

Growth indicators are used to assess growth considering a child's age and
measurements. There are four main types of anthropometric measures,
which are commonly used as indicators of size and development: Weight-
for-age, Length or height-for-age, Weight-for-height and head
circumference for age.

Uses of the growth chart:

The growth charts are designed to enable health staff to assess normal
growth, and determine deviations in individuals and interpret these in terms
of health status, as well as to make decisions regarding alternative types of
care and referral procedures if required.
The charts provides the mother and the health staff with a visual record of
the nutritional and health status of the child, together with a history of
important events, such as immunizations, breast-feeding and introduction
of complementary feeding. It also offers a means of assuring continuity of
care between the various levels of service with which the child has contact.
Finally, it serves as a useful vehicle for health education and counseling.

2.4.3. UNRWA’s growth chart:

The growth charts used by UNRWA were derived from the WHO Multi-
centre Growth Reference Study (MGRS) and assess the growth of the child
from birth up to 5 years. There are six gender specific growth charts:

 Weight for age chart for girls and boys

 length/height for age chart for girls and boys
 Weight for length chart girls and boys
 Weight for height chart girls and boys
 Head circumference for age girls and boys
 Developmental gross motor milestones for age chart

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a. Figure No 4, weight for age chart for girls and boys,

b. Figure No 5, length/height for age chart for girls and boys,

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c. Figure No 6, Weight for length chart girls and boys,

d. Figure No 7, Weight for height chart girls and boys

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 e. Figure No 8, Head circumference for age girls and boys.

f. Figure No 9, Developmental gross motor milestones for age chart

Gender-specific Child Health Records are used by the Agency; one for boys
(blue colour) and another for girls (pink). These records should be retained as
part of the health centre based records.

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 2.4.4 Measurements on the child's growth:

Anthropometric measurements must be as accurate as possible on the other

hand plotting results on the charts should be precise as well; nurses should
be well acquainted with the process of measurement, plotting of results,
interpretation of findings and counseling of mothers

The following are the steps for plotting measurements in the relevant charts
of the CHR and the MCH handbook:

Step 1: calculate child's age. For this purpose the WHO Child Age Calculator
can be used. This is a rotating disk for calculating a child’s age in completed
weeks, months, or years and months as follows:

 Determine the child’s date of birth.

 Determine and note down the number of full years the child has
completed,
 If the child is one or more years old, you will turn the disk to
calculate the number of additional months completed.
 If the child is less than one year old, you will use the disk to count
the number of months since birth.
 Turn the disk until the bold arrow points to the child’s birthday
(month and day) on the stationary circular calendar.
 Locate today’s date on the stationary calendar and count on the
rotating disk how many months the child has completed since birth
 Record age in the "measurement and visit note" table in the child
health record (CHR) and in the MCH handbook.

Nurses should be trained and acquainted on the use of the WHO calculator
Figure No 10, WHO child age calculator

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Step 2: For newly registered infants, record the birth weight at the first
border of the first column, which represents the date of birth.

Step 3: Check that the scale is well calibrated (reads zero when empty
before and after each measurement).

Step 4: Undress the child. Weigh the baby without clothes or only in light
panties to the nearest 100 grams.
Record the child's weight to the nearest 100 grams in the "measurement and
visit note" table of the child health record.

Step 5: Measure the child's length or height to the nearest 1 millimeter. A

child's length is measured lying down for children less than 2 years while
height is measured standing for children 2 years or older. If a child less than
2 years old is measured standing add 0.7 cm and if a child more than 2 years
old is measured lying subtract 0.7 cm. The child's shoes, socks and hair
ornaments should be removed

Record the child's length/height to the nearest millimeter in the

"measurement and visit note" table of the child health record.

Figure 11, measurement of length and height

Step 6: Measure Head Circumference: (occipital-frontal circumference)

(OFC).
Figure 12, measurement of head circumference

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 Non-stretch measuring tape should be placed around the largest area of
the head, beginning above the eyebrows and ears, and continuing around
the back of the head as shown in fig No 12, the photo above, measure to
the nearest centimeter and record it in the "measurement and visit note"
table of the child health record

2.4.5 Plotting measurements on the growth chart:

Select the appropriate growth chart to plot the measurements recorded in
the "measurement and visit note" table according to the following steps:

A. Plotting in the weight-for-age chart figure No 4: This chart shows

the body weight relative to age in a given point in time.

Step 1: Find the line that corresponds to the reference value and follow it
across until it meets the column of the current month.

Step 2: Identify the weight level upward in the box corresponding to the
measured value above the line.

Step 3: Identify the time interval across the column corresponding to the
first, second, third or fourth week of the month.

Step 4: Place a dot on the point which corresponds to the weight and age
of the infant and draw a line between the birth weight (previous weight)
and the current weight. Dots should be apparent and visible over the curve

Step 5: During repeat visits, follow the above steps to weigh the child
properly. A progression of dots can be joined-up to form a growth curve or
trend. It is this curve which will reveal the health and nutritional status of
the child in relation to the reference values, mentioned above and the
growth pattern of the child.

B. Plotting in the length/height-for-age chart figure No 5: This chart

shows the child's length or height in relation to the child's age at a given
visit.

Step 1: Find the line that corresponds to the reference value and follow it
across until it meets the column of the current month.

Step 2: Identify the length/height upward in the box corresponding to the

measured value above the line.

Step 3: Identify the time interval across the column corresponding to the
first, second, third or fourth week of the month.

Step 4: Place a dot on the point, which corresponds to the length/height

and age of the infant and plot a line between the current length/height and
the previous one.

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 Step 5: During repeat visits, follow the above steps to measure
length/height of the child properly. A progression of dots can be joined-up
to form a trend.

C. Plotting in the weight – for - length /height charts, figures No 6,7

& 11: There are 2 charts (0-2 years, 2-5 years) which reflect the
relationship between the body weight and the attained growth in
length/height.

Step 1: Plot the length/height on the horizontal line to the nearest

centimeter. Find the line that corresponds to the reference value and follow
it across until it meets the column of the current weight.

Step 2: Place a dot on the point, which corresponds to the length/height

and weight of the infant and draw a line between the current dot and the
previous one.

Step 3: During repeat visits, follow the above steps to measure

length/height for weight properly. A progression of dots can be joined-up to
form a trend

D. Plotting in the head circumference – for – age chart figure No 8:

This chart reflects the head circumference growth in relation to the age.

Monitoring children for head circumference development should

be carried out at registration, at 6 months, at 1 and 2 years

E. Windows of achievement for six gross motor milestones figures

No 1 & 9: this chart will be used by health staff as guidance to monitor
the physical development of the child.

2.4.6 Interpreting the growth chart:

General considerations:

 The curve line on the growth charts reflects the child's growth status.
In general growth curves are interpreted as follows:

 Health staffs are expected to interpret each plot and trend on growth
charts and identify whether a child is growing normally, has a growth
problem, or is at risk of a growth problem.

 Observe the child and note clinical signs of oedema, marasmus,

kwashiorkor and marasmus – kwashiorkor. These are serious conditions
which require urgent specialized care regardless of the child's weight.

 Z- score lines on the growth charts are numbered positively (2,3) or

negatively (-2,-3)

 The line labeled 0 on the growth chart is the median which is, generally
speaking, the average. The other lines, called z-score lines, indicate

22
 distance from the average. A point or trend which is far from the
median, such as +3 or -3 indicates a growth problem.

 The growth curve of a normally growing child will usually follow a track
that is roughly parallel to the median. The track may be above or below
the median.

 Any quick change in trend (the child's curve turns upward or downward
from its normal track) should be investigated to determine its cause and
remedy any problem.

 A flat line indicates that the child is not growing. This is called
stagnation and may also need to be assessed and investigated.

 The growth curve that crosses a z-score line may indicate risk. A health
staff can interpret risk based on where (relative to the median) the
change in trend began and the rate of change.

 If the plot is exactly on the Z-score line, it is considered in the less

severe category. For example, weight for age on the -3 line is
considered underweight and not severely under-weight
2
Table No 5, Summary of growth indicators

Z-score Growth indicators

length/ht.-for-age weight-for-age wt-for-length/ht.
Above 3 (See note 1) (See note 2) Obese
Above 2 Overweight
“0”median
Below −2 Stunted Underweight Wasted
Below −3 Severely stunted Severely Severely wasted
(See note 3) underweight

Note 1: Child in this range is very tall. Tallness is rarely a problem, unless it is so excessive that it may
indicate an endocrine disorder such as a growth-hormone-producing tumor. Refer a child in
this range for assessment if you suspect an endocrine disorder (e.g. if parents of normal
height have a child who is excessively tall for his or her age).
Note 2: A child whose weight-for-age falls in this range may have a growth problem, but this is better
assessed from weight-for-length/height.
Note 3: It is possible for a stunted or severely stunted child to become overweight.

Interpretation of findings in each specific growth chart:

It is very important to consider the child’s whole situation when interpreting trends on
growth charts. All growth charts should be considered and evaluated altogether.
Normal findings in one chart will not necessarily be normal for others, e.g. a stunted
child may have a normal weight-for-height, but have low weight-for-age due to
shortness).

2
WHO Child Growth Standards, Interpreting growth indicators

23
A. Weight-for-age chart: This parameter is influenced by both the height
and the weight of the child. It reflects the long and short-term health
status of the child and it is not used to describe obesity.
Most newborns lose between 5-10% of their birth weight in the first few
days, then return to birth weight at 7-10 days of age. Early weight loss
>10% is considered excessive. Such excessive loss and / or failure to
regain weight at 7-10 days indicate breast feeding problems or underlying
neonatal illness).
The child doubles his birth weight at 4-5 months, triple birth weight at 1
year and quadruple birth weight at 2 years.

The weight-for- age chart shows body weight relative to age in comparison
to the median (0 line) and accordingly we will have three categories as
follows:

 Normal weight: A child whose weight-for-age is between the line -2

and + 2
 Underweight: A child whose weight-for-age is between the line -2 and
-3
 Severely underweight: A child whose weight-for-age is below the
line -3

B. Length /Height-for-age chart: This parameter reflects the attained

linear growth and its deficit indicates long-term cumulative inadequacies of
health or nutrition. Two related terms are used when describing this
parameter: length and height. Length is the measurement while in a
recumbent position and is used for children under 2 years of age, while
height refers to standing position. Stunting is likely to be due to a
pathological process from the past or a continuous process.

The chart shows growth in length and height relative to age in comparison
to the median (0 line) and can be categorized as follows:

 Normal height: A child whose length/ height-for-age is between the

line -2 and + 2
 Stunted: A child whose length or height for age is between the line -2
and above -3
 Severely stunted: A child whose length or height for age is below -3

C. Weight-for-Length/height: This parameter reflects body weight to

length/height. Its use carries the advantage of requiring no knowledge of
age. However it is not substitute for the other indicators. Low weight for
height is called thinness if normal or wasting if pathological and can reflect
a recent or chronic condition. Prevalence in non-disaster areas is around
5%. Lack of evidence of wasting in a population does not imply the
absence of current nutritional problems

The average length at birth is 50cm, 75cm at one year and almost double
the birth length at 4 years. Those charts show body weight relative to

24
 length or height in comparison to the median (0 line) accordingly children
are categorized as follows:

 Normal : A child whose weight for length/height is between the line -2

and +2
 Wasted: A child whose weight for length/height is between the line -2
and above -3
 Severely wasted. A child whose weight for length/height is below the
line – 3. This should be referred for urgent specialized care.
 Overweight: A child whose weight for length/height is between the
line +2 and +3
 Obese: A child whose weight for length/height is above the line +3

D. Head circumference (HC)-for-age: the average HC at birth is 35 cm. It

increases at the range of 1cm/month for first year (2cm/month for first
three months, then slower thereafter). The total increase for the rest of
life is about 10cm. Any deviation upwards or downwards should call for
investigation (macrocephaly, microcephaly or early closure of fontanele)

E. Developmental surveillance and screening: Developmental

surveillance should be an integral component of every growth monitoring
visit. The WHO chart on windows of achievement for six gross motor
milestones (figure No 9) can be used to monitor child's development and
to identify children who appear to be at risk of a developmental
disorder.When a child has a developmental problem, the medical officer
should conduct developmental and medical evaluations to identify the
specific developmental disorders and related medical problems and if
needed refer for further developmental intervention.

2.4.7 Low Birth weight/Preterm infants:

LBW/prematurity is the main cause of infant mortality among

Palestine refugee's community. Assessment of growth, feeding,
and development should be based on a corrected age for preterm
infants. Use of the actual date of birth to calculate age, will lead to
inappropriate assessment and advice.

a. Growth monitoring: Low birth weight preterm infants have

different patterns of growth than term infants during the first year of
life, even with plotting corrected for gestational age. however when
plotting on growth charts the corrected-age-technique up to two years
of age should be used as follows:

b. A full term pregnancy is estimated to be 40 weeks from the

mother's last menstrual period.
c. The Corrected age (CA) otherwise known as Gestationally
Corrected Age (GCA) or sometimes just Gestational Age (GA) is based
on the age the child would be if the pregnancy had actually gone to
term.

25
 d. Chronological age (CH) is a term that is used to indicate the age
from the actual day the child was born.
e. An accurate EDD (Expected Date of Delivery) corrected age is
calculated by using that date as a birth date. For example an infant with
an EDD of March 1, who was born on January 1, will have a corrected
age of 3 months on June 1.

Corrected Age (CA) = Chronological Age (CH) – weeks or months

premature

Example: Sara was born at 28 weeks gestation, then she was 12 weeks pre-
term (40 weeks - 28 weeks = 12 weeks = 3 months). Today it is 7
months past the day she was actually born (Chronological age=7
months). CA = 7 months - 3 months= 4 months, then Sara is 4 months
corrected age
 Immunization schedule for preterm infants: regardless of
intrauterine age or birth weight, the full dose of all immunizations
should be given as with term infants

2.4.8 Key messages for mothers on Growth and Feeding:

Health staff should be trained to explain the results and the significance
of growth assessment to the mothers. That is based essentially on the
direction and position of the growth curve which can take three
directions, upwards, horizontal or flat and downwards.

The corresponding fundamental messages are the following:

 If a child’s growth curve is climbing upwards in the same direction as

the reference curve, this is good. The child is growing adequately.
 If the growth curve is horizontal, this means the child has stopped
growing. This is a warning sign.
 If the growth curve is moving downwards, the child condition is
worsening. This is very dangerous even if she/he is still within the
normal range. The child needs immediate help.
 The direction of the curve should also help in evaluating the
effectiveness of corrective measures

Based on the findings health staff should:

 Interview the mother to investigate causes of malnutrition/obesity,
 Give advices related to specific causes of under/over-nutrition,
 Give appropriate feeding recommendations for a child’s age.

26
3. SPECIAL CARE FOR CHILDREN AT RISK:

Risk assessment:

The following categories of children should receive special attention and care:

 Children with identified growth problems

 Children with disabilities (cerebral palsy)
 Children with severe chronic illnesses
 Children with congenital defects
 Children with health related educational and behavioural
Problems (attention-deficit/hyperactivity or learning disorders)
 LBW/premature
 Fifth child or more.
 Undernourished/growth problems among brothers or sisters.
 Birth interval of less than 2 years.
 Twins
 3 or more children died in the family
 Single parent as in mother’s or father’s death or divorce.

The goal in managing a child with special healthcare needs is to maximize the
child’s potential for productive adult life

Special care for children with growth problems::

Children with growth problems are defined as those whose growth is below or
above what is ought to be for their age and sex, by WHO growth standards.

(A) OBJECTIVES:

The objectives of the special care for children with growth-related problems are:

a. To prevent normal children from developing growth related problems,

b. to identify infants/children with growth problems and to prevent further
deterioration,
c. to assess why the child is not growing properly and,
d. To manage growth related problems appropriately.

(B) CLASSIFICATION:

Infants/children who are either about to develop growth related problems or

are actually with growth problems and who need special attention are
classified in 2 main groups as follows:

 All infants and children categorized as underweight, severely

underweight, stunted, severely stunted, wasted, severely wasted and
obese.

27
  Infants with normal growth that on successive visits did not grow well
(stagnant/flat curve) or sustained drop in weight (descending curve) or
sustained excessive weight growth, even before reaching the abnormal
level of growth. In order to identify the cause and manage it timely
before they become with growth problem.

(C) CASE ASSESSMENT:

Case assessment is FINDING OUT WHY THE CHILD IS NOT GROWING

PROPERLY. Medical Officers and nurses should remember that failure to grow
is often the first or the main visible sign or symptom of an underlying
disease. Even in such rare diseases as a brain tumor or brain abscess or
kidney disease, the very first sign that something is wrong, before any
neurological or other symptoms, may be growth retardation.

Children with growth problems deserve the most careful attention

we can give them.

Following are the steps in case assessment through which the Medical Officer
must undertake:

a. Careful medical and family history taking.

b. Detailed dietary history: best ascertained by asking the mother what did
she feed the child today/yesterday.
c. Thorough physical examination, all systems
d. Appropriate laboratory tests such as CBC, stool for parasites, and urine if
possible for sugar, albumin and bacteria.
e. Home visit to the family by the nurse, if possible, to explore the
socioeconomic factors and to consider referral for Relief & Social Services
as special hard case.

(D) MANAGEMENT:

a. General considerations:
If we get the right diagnosis we usually face two types of patients:

 The minority in whom the underlying cause is untreatable and we can

only alleviate its effects such as Down’s syndrome (mongolism, trisomy)
or cerebral palsy. In this case we can provide the parents with
psychological support and sensible advice on how to care for the child
including adequate feeding. Thus, nutritional support, (education and
supplements) is part of the management.

 The majority in whom the cause is treatable. Therefore, the medical

officer should address the root cause as soon as possible, e.g. correcting
congenital malformations, treating intestinal parasites, or chronic or
repeated acute infections, correcting iron deficiency, advising on care of
children with malabsorption syndromes such as celiac disease, etc...

28
 Whatever the pathological condition indicates; or in the case of real social
problems then planning with the staff nurse some modification of the
problem in favor of the child.

Even difficult pathological conditions, e.g. congenital heart disease,

deserve examination by an expert in the field and support to have
necessary surgery. By treating the underlying cause and offering
nutritional support (education, supplements, iron) at the same time, we
will succeed in getting most children back into the normal path of growth.

In three out of four children, any of the 5 steps mentioned under case-
assessment above, or any combination of 2 or 3 or all, will help to identify
the reason why the child is not growing properly.

In a minority of children it will still remain a mystery. This minority must

be sent to a specialist/pediatrician with a copy of the full history and a
request for further evaluation and opinion, to be sent back to the
referring Medical Officer for action.

b. Dietary management:

Full dietary history should be taken to identify if there is wrong

practice(s) in the way of feeding the infant such as: not exclusive
breastfeeding inadequate weaning practices, giving tea before or
immediately after meals…….etc.
The main points in dietary counseling and management are:

 Breast feeding: Exclusive breast-feeding until 6 months of age.

Mothers should be encouraged to breastfeed as often as the baby wants
day and night, while fluids and other foods should not be given. Mothers
should be advised to continue breastfeeding up to the age of 2 years or
beyond

 Complementary feeding: This should be given at the right time, the

proper quantities and type. Advise mothers:
o To start with small amount of soft well mashed food, and to increase
the amount gradually
o To introduce new foods one at a time then to wait a few days to be
sure that the child can tolerate a new food before introducing
another type,
o To give soft varied appetizing, favorite foods.
o To feed the child from his own plate, remove any distraction and
encourage him to eat without forcing and
o After illness advise mothers to give food more often than usual.

 Iron and vitamin supplementation, Iron and especially vitamin A,

are useful not only in supporting dietary management but also in
providing protection against infections.

29
 c. Treatment of associated morbidity conditions:

Treatment of the most common health conditions associated with growth

problems is essential for improvement of the health status of the child:

 Anaemia as per technical instructions No. HD/FH/1/2000 on Prevention

and Treatment of Iron-deficiency Anaemia.
 Other morbidity conditions such as congenital heart disease, chronic
infections (tonsillitis, adenoids, chronic ear infections etc).

d. Protective immunization:
Growth retardation is not a contraindication to immunization of
infants/children against vaccine-preventable diseases. On the contrary,
immunization would prevent these children from added reasons for
deterioration of their conditions.

e. Follow-up:
 Identified children with growth problems should be immediately
referred to the Staff Nurse in the health centre, where she should repeat
the anthropometric measurement to confirm the diagnosis and jointly
with the MCH medical officer, develop an individualized plan of
management with full participation of the mother.

 Special care for children with growth problems should be offered as an

integral part of the child health care. The open door policy and the
appointment system should be implemented.

 The child should be monitored on monthly basis. However, where the

condition of the child is serious or life-threatening, monitoring should be
carried out at shorter intervals.

 The child must continue to be seen monthly until its anthropometric

measurements are within the ‘normal’ zone. After recovery, the child still
needs to be seen regularly, and if it is not brought for as long as 2
months, the family, wherever is possible, should be visited.

4. SUSTAINING HIGH IMMUNIZATION COVERAGE AGAINST VACCINE-

PREVENTABLE DISEASES:

Health staff should exert maximum efforts in order to sustain the high
immunization coverage rates according to the updated schedule in each Field. In
this regard the “Technical Instruction Series on Immunization Programme” can be
used as a guide. Moreover special efforts are needed to detect pockets of un-
immunized children and carry out catch up immunization.
Vaccination of pre-term (PT) and low birth weight (LBW) infants
Medically stable preterm (PT) and low birth weight (LBW) infants should receive all
routinely recommended childhood vaccines at the same chronological age as
recommended for full-term (FT) infants. Under most circumstances, gestational
age at birth and birth weight should not be limiting factors when deciding whether
a PT or LBW infant is to be immunized on schedule.

30
 Vaccine dosages normally given to FT infants should not be reduced or divided
when given to PT and LBW infants. The severity of vaccine-preventable diseases in
PT and LBW infants precludes any delay in initiating the administration of these
vaccines.However, it has been noticed that the regular attendance usually drops
immediately upon completion of the immunization schedule. Therefore, mothers
should be educated on the importance of continuity of care and growth monitoring
even after completion of full immunization series.

5. EARLY DETECTION OF CONGENITAL AND/OR ACQUIRED MORBIDITY:

One of the main objectives of the child health care is to detect morbidity conditions
as early as possible in order to take necessary actions to alleviate the disease
burden.
Surveys reveal that many sick children are not properly assessed and treated and
their parents are poorly advised. In order to contribute to improved growth and
development of children and to reduce deaths and the frequency and severity of
illness and disability, health care providers should make the best use of available
resources in particular, the medical history and signs and symptoms in addition to
laboratory services and specialist care to determine the best course of
management.

5.1 Assessment of a sick child (2 months to 5 years of age):

The first step is to ask the mother what are the child’s problems and determine if
this is an initial or follow-up visit for this problem,

 Assessment of a child with danger signs:

If the child is convulsing or if he is lethargic or unconscious or if the mother report

that he/she is unable to drink or breastfeed, vomiting every thing or had
convulsions. In this case the child is classified with danger signs and needs
urgent referral
 Assessment of a child with cough or difficult breathing:

o Ask the mother if the child has cough or difficult breathing, if yes, ask for
how long? ( try to keep the child calm)
o Count the breath (RR) in one minute: The increase in the respiratory rate is
the earliest sign of pneumonia. It could be detected 2 days before the
appearance of pathological changes in chest X- ray, and the presence of
crepitation on auscultation.
o sign of pneumonia should be considered if the child aged 2-12 months has a
RR of > 50 breaths/minute , or if a child aged 12 months- 5 years has a RR
> 40 breaths/minute.
o Look for chest in-drawing: lower chest wall goes IN when the child breathes
IN
o Look and listen for stridor: this is a harsh noise made when the child
breathes IN
o Look and listen for wheeze: this is a soft musical noise when the child
breathes OUT

31
 A child with severe pneumonia should be given antibiotics, start the first dose
in the health centre, and referred to hospital

 Assessment of a child with diarrhea:

o If the child has diarrhea ask for stool consistency, frequency, duration and if
there is blood in stool?
o Look at the child general condition; is the child lethargic or unconscious?
Restless and irritable? With sunken eyes? If the child is not able to drink or
drinking poorly? Drinking eagerly, thirsty?
o Pinch the skin of the abdomen – Does it go back very slowly > 2 seconds,
slowly or immediately.

A child with diarrhea is assessed for

a) Signs of dehydration.
b) How long the child has diarrhea.
c) Blood in the stool to determine if the child has dysentery.

a) Signs of dehydration: There are 3 possible classifications of

dehydration in a child with diarrhea, assess the child according to the
following table:
Table No 6 assessment of a child for signs of dehydration

signs classifications treatment

Two or more of the following signs:
 Lethargic or unconscious
Severe Plan C (give fluids and refer
 Sunken eyes
dehydration urgently to hospital)
 Not able to drink or drinking poorly
 Skin pinch goes back very slowly
Two or more of the following signs:
 Restless , irritable
Some Plan B ( treat the child with
 Sunken eyes
dehydration ORS solution)
 Drinks eagerly , thirst
 Skin pinch goes back slowly
No enough signs to classify as some or No Plan A ( give extra fluid and
severe dehydration dehydration continue feeding)

b) For how long? If the child who has diarrhea for 14 days or more
classified as having persistent diarrhea. There are 2 possible classifications
for persistent diarrhea assesses the child according to the following table:
Table No 7 assessment of a child with chronic diarrhea

signs classifications treatment

Dehydration present Severe persistent diarrhea Treat dehydration and refer to hospital
Advice the mother on feeding and
No Dehydration persistent diarrhea
follow-up in 5 days

32
 c) Blood in stool: There is only one classification “dysentery”

Assess the child according to the following table:

Table No 8 assessment of a child with bloody diarrhea

signs classifications treatment

Antibiotic recommended for shigellosis for 5
Blood in stool Dysentery
days, follow-up in 2 days

 Assessment of a child with throat problem:

o Throat problem should be checked in all children even if they do not
complain of sore throat.
o Ask if the child have fever, sore throat?
o Feel for enlarged tender lymph node on the front of the neck
o Look for red (congested) throat and for white or yellow exudates on the
throat and tonsils
Assess the child according to the following table:
Table No 9 assessment of a child with throat problem

signs classifications treatment

Fever or sore throat and two of the following:
Benzathine penicillin,
 Red (congested) throat Streptococcal
paracetamol ,safe remedy,
 white or yellow exudates on the throat sore throat
follow-up in 5 days
 enlarged tender lymph nodes on the neck
Non
sore throat or there is no enough signs Paracetamol, safe home
streptococcal
to classify as streptococcal sore throat remedy, follow-up in 5 days
sore throat
 Most children below 5 years old with a sore throat usually have a viral
infection and should not be treated with antibiotics.

 Assessment a child with ear problem

The main signs and symptoms of ear problems are pain, discharge, tenderness and
hearing loss.
o If there is pain, swelling and tenderness behind the ear the child is with
mastoiditis and should be given antibiotic and referred to hospital
o If there is pain and pus discharge for less than 14 days, the child is with
acute ear infection and should be given broad spectrum antibiotic and
analgesic, advised for ear wicking and to be followed up after 5 days
o If there is pus discharge without pain for more than 14 days, the child is with
chronic ear infection and should be advised for ear wicking and followed up
after 5 days
o If the child is with signs of hearing loss, he/she should be referred for
hearing assessment as early as possible

A child with ear problem is assessed for:

o Agonizing ear pain
o Ear discharge and if present for how long?
o Tender swelling behind the ear

33
 Assess the child according to the following table
Table No 10, Assessment of a child with ear problem

signs classifications treatment

st
Tenderness, swelling behind the ear Give 1 dose antibiotic,
Mastoiditis
Refer urgently to hospital
Give antibiotic for 10 days,
Agonizing ear pain or/and pus is seen
Acute ear infection paracetamol, dry the ear by
draining from the ear for < 14 days
wicking, follow – up in 5 days
Pus is seen draining from the ear for > 14 dry the ear by wicking,
chronic ear infection
days or more follow – up in 5 days

o Assessment a child with fever: as reported by the caregiver, or feels hot,

or temperature 37.5 or above)
If the child has fever
o Ask for how long?
o Look or feel for stiff neck( rigidity) and assess the child as follows:

Table No 11, Assessment of a child with fever

signs classifications treatment

Any danger signs or stiff neck
Apparent bacterial cause of fever is
present, e.g: pneumonia, dysentery,
acute ear infection, streptococcal sore
throat, and other apparent causes
No apparent bacterial cause of fever
Very severe Give 1st dose antibiotic, paracetamol
febrile disease and refer urgently to hospital
Treat apparent cause of fever with
Fever possible
antibiotics, paracetamol and follow
bacterial infection
– up in 2 days if fever persist
Fever bacterial Paracetamol and follow – up in 2
infection unlikely days if fever persist

5.2 . Assessment a sick young infant (age up to 2 months)

o Ask if the infant has had convulsions;

o Ask if the infant is unable to feed?
o Look if the infant is convulsing now,
o count the breath in one minute - repeat the count if the count is ≥ 60
breaths/minute
o Look for: bulging fontanel, red or draining umbilicus, severe chest indrawing,
skin pustules, lethargic or unconscious , abnormal or abscent infant's
movements.
o Measure temperature.
Any sick young infant should be assessed for possible bacterial infection as follows:
Table No 12, Assessment a sick young infant (age up to 2 months)

signs classifications treatment

Any of the following signs:Convulsions or Possible serious Give 1st dose
lethargic or unconscious or not able to feed or bacterial infection antibiotic, treat to
severe chest in-drawing or bulging fontanel or prevent low blood
the umbilicus redness extending to the skin or sugar, and refer
fever or low body temperature or movements urgently to the
only when stimulated or no movements at all hospital

34
Red umbilicus or draining pus or skin pustules Local bacterial infection Give antibiotic
5.3 Hyperbilirubinemia in the newborn infant "neonatal jaundice":

Jaundice occurs in most newborn infants. Most jaundice is benign, but

because of the potential toxicity of billirubin, newborn infants must be
monitored to identify those who might develop severe hyperbilirubinemia
and, in rare cases, acute bilirubin encephalopathy or kernicterus.
Routine measurement of total serum billirubin (TSB) is not recommended,
and clinical judgment should be used to determine the need for a bilirubin
measurement. However If there is any doubt about the degree of jaundice,
the TSB level should be measured. Visual estimation of bilirubin levels can
lead to errors, particularly in darkly pigmented infants
The infant should be referred immediately to the hospital for phototherapy
and or blood exchange if:
o the infant is less than 24 hours age with Jaundice in face or
o more than 24 hours age with Jaundice in palms and soles
o or the TSB level is 20 mg/dl (428 micromoles/L) or higher at any time,
o Mothers should be advised to breastfeed their infants at least 8 to 12
times per day for the first several days and to avoid the harmful routine
supplementation with water or dextrose water.

Table No. 13, when the newborn should be referred to hospital which is
age / total serum bilirubine (TSB) level dependent

Exchange Transfusion if Exchange Transfusion and

Age / hours Phototherapy
Intensive Phototherapy Fails Intensive Phototherapy
≤ 24 * - - -
25 - 48 ≥ 15mg/dl ( 260 µmol/l) ≥ 20mg/dl ( 340 µmol/l) ≥ 25mg/dl ( 430 µmol/l)
49 - 72 ≥ 18mg/dl ( 310 µmol/l) ≥ 25mg/dl ( 430 µmol/l) ≥ 30mg/dl ( 510 µmol/l)
>72 ≥ 20mg/dl ( 340 µmol/l) ≥ 25mg/dl ( 430 µmol/l) ≥ 30mg/dl ( 510 µmol/l)
* Term infants who are clinically jaundiced at ≤ 24 hours old are not considered health and
require further evaluation

5.4 Childhood obesity:

The adverse consequences of childhood obesity, such as development of

hypertension, hyperlipidaemia, type 2 diabetes and the tendency for
childhood obesity to persist into adult obesity are under-recognized. The
likelihood of persistence of obesity to adulthood increases with age of the
child and with severity of the obesity

Screening children for obesity was introduced in order to assist in early

identification and to provide health care providers with guidance for
standards of screening, evaluation, and treatment of obesity in the pediatric
population

Monitoring children for overweight by using the Weight-for-

Length/height charts, should be conducted during each growth monitoring
visits in particular for children older than one year of age

35
Identification: Obese children are those with more than + 3 Z score line in
the reference chart weight for height/length.

Management: If a child is identified with obesity or at-risk for obesity a

medical evaluation should be conducted as follows:

a. The medical officer should rule out secondary causes of childhood obesity
such as:
 Genetic causes: Prader-Willi, Bardet-Biedl, and Cohen diseases.
 Endocrinology causes: hypothyroidism and Cushing syndrome.

b. Assess the psychological causes of obesity in patients and family

members such as low self-esteem, eating disorders, and depression.
c. Assess for complications associated with obesity such as sleep apnea,
metabolic syndrome, fatty liver, cholelithiasis, type II diabetes, polycystic
ovary syndrome , Blount's disease (tibia vara), and slipped capital femoral
epiphysis.

Children who may have serious obesity-related morbidity that requires weight
loss should be referred to specialist.

d. Health staff should develop a management plan jointly with the family
which should include the following elements:

o Management plan and counseling programs should be based on the fact

that positive change can be achieved by long-term permanent
behavioral changes and not rapid weight loss or short-term diets.

i. Dietary energy restriction: Counsel the mother on dietary

choices and relationship to overweight status and advice on low fat,
low cholesterol, reduced sugar diet and nutritional requirements.
Encourage planned meals, especially eating breakfast, discourage
skipping meals, discourage eating while watching television, avoid
the use of food as a reward or punishment and stock refrigerator
with healthy food,
ii. increase in physical activity: regular exercise programs with
moderate physical activity most days of the week. and
iii. decrease in sedentary behaviour: Reducing physical inactivity
(e.g., watching television and playing computer games)

This must not compromise normal growth and development. In children,

growth is only possible if energy intake exceeds energy output. For these
reasons, weight maintenance is often a suitable goal, rather than
weight loss.

 The family should be alerted and educated/counseled on the medical

complications related to overweight including risk of adulthood obesity,
HTN, dyslipidemia, heart disease, diabetes in addition to psychosocial

36
 complications related to obesity such as depression, confidence issues,
and poor self-esteem.

5.5 Congenital heart disease:

Routine examination may reveal cyanosis, respiratory distress or tachypnea.

Infants with serious CHD may present with failure to thrive, tachypnea (with
feeding), persistent recession, chest infection, sweating, and cyanosis.

Diagnosis of congenital heart diseases may be missed in the first few weeks
of life because the infant is asymptomatic, therefore, it should be examined
between 6-8 weeks of age which should include auscultation for murmurs.

Presence of a heart murmur could either be due to:

 Innocent murmurs.
 Cardiac septal defects, atrial septal defects (ASD); patent ductus
arteriosus (PDA) (very common in preterm infants).
 Other significant problems to consider such as fallot tetralogy, coarctation
of the aorta and valvular stenosis
Congenital heart diseases should be looked for as early as possible in life.

5.6 Developmental dysplasia of the hip (DDH):

DDH represents a spectrum of anatomic abnormalities in which the femoral

head and the acetabulum are aligned improperly or grow abnormally. DDH
can lead to premature degenerative joint disease, impaired walking, and
pain.

Risk factors for DDH include female gender, family history of DDH, breech
positioning, and in utero postural deformities. However, the majority of cases
of DDH have no identifiable risk factors.

 The incidence of hip instability could be as high as 1% and 1-1.5 cases of

dislocation per 1000 newborn.
 The incidence of developmental dysplasia of the hip is higher in girls. Girls
are especially susceptible to the maternal hormone relaxin, which may
contribute to ligamentous laxity with the resultant instability of the hip.
 The left hip is involved 3 times as commonly as the right hip, perhaps
related to the left occiput anterior positioning of most non-breech
newborns. In this position, the left hip resides posterior against the
mother’s spine, potentially limiting abduction.

Developmental dysplasia of the hip includes frank dislocation (luxation),

partial dislocation (subluxation), and instability wherein the femoral head
comes in and out of the socket. The earlier a dislocation of hip is detected,
the simpler and more effective is the treatment, while if detected late, the
child may end up limping, even after several operations. Treatments for DDH
include both non-surgical and surgical options. Non-surgical treatment with

37
 abduction devices is used in early treatment and includes the commonly
prescribed Pavlik method. Surgical intervention is used when DDH is severe
or diagnosed late or after an unsuccessful trial of non-surgical treatments.
The most common methods of screening are serial physical examinations of
the hip and lower extremities, using the Barlow and Ortolani procedures, and
ultrasonography:

The Barlow examination is performed by adducting a flexed hip with

gentle posterior force to identify a dislocatable hip.

The Ortolani examination is performed by abducting a flexed hip with

gentle anterior force to relocate a dislocated hip.
Medical officers are requested to perform the Ortolani and Barlow tests
gently, carefully and correctly on each newly registered newborn. to role out
DDH.

The Ortolani test is performed as follows:

 The newborn should be in the supine position and the examiner’s index
and middle fingers placed along the greater trochanter with the thumb
placed along the inner thigh.
 The hip is flexed to 90° but not more, and the leg is held in neutral
rotation.
 The hip is gently abducted while lifting the leg anteriorly.
 With this maneuver, a “cluck” is felt as the dislocated femoral head
reduces into the acetabulum. -This is a positive Ortolani.

5.7 Anaemia and other blood disorders:

a. Iron deficiency Anaemia: Please refer to the “Technical Instruction Series on

Prevention and Treatment of Iron - Deficiency Anaemia”

b. Haemoglobinopathies: All anaemic children who do not respond to iron

supplementation should be investigated for other types of anaemia, which
could be due to haemoglobinopathies. Many different types of abnormal
haemoglobin have been described, the most important of which are:

 Thalassaemia: Thalassaemia is common in the Mediterranean region and

is inherited by autosomal recessive genes. Those with the heterozygous
state have thalassaemia minor, and are asymptomatic or have mild
anaemia. Their red cells contain up to 20% Hb F.
Those with homozygous state, thalassaemia major develop severe
haemolysis and anaemia in infancy. The children grow poorly and develop
massive hepatosplenomegaly. Hyper-plasia of the bone marrow leads to
thickened skull bones. Suspected children should be referred to the
National Thalassaemia Centres for confirmation of diagnosis and
management.

38
  Sickle cell disease: In this abnormality HbS is present in place of HbA. At
low oxygen tension, the cell becomes crescent or sickle shaped and likely to
haemolyse.
In the hetrozygotes type about 30% is of HbS which may show sickling, but
are usually asymptomatic while the homozygotes develop recurrent
episodes of haemolysis during infancy.

In addition to the problems of haemolytic and aplastic episodes, children

with sickle cell disease may also develop intravascular thrombosis, which
presents with severe abdominal pain resembling an acute abdominal
emergency. Children with sickle cell anaemia are also at an increased
susceptibility to severe bacterial infections, particularly Streptococcus
pneumonia.

For management of an infant/child with sickle cell disease, the Medical

Officer must:

 Perform appropriate tests on the patient or the family to establish

definitive diagnosis of the type of sickle cell disease,
 Start penicillin prophylaxis prior to age 4 months and make every effort
to assure compliance, and
 Provide supportive counselling to parents and other family members.

Children with thalassaemia or sickle cell disease should not be

given iron preparations as this might aggravate the problem of
increased iron in the body due to haemolysis.

6. Other interventions

6.1 Screening for child abuse and neglect

Child maltreatment, including violence in home or other institutions, is not

well documented and understood. However, the absence of data does not
mean the absence of the problem. It is a well recognized problem to warrant
further attention

Factors associated with child abuse or neglect which should be taken into
consideration during the provision of services includes:
 History of domestic violence
 Low Socio-economic profile
 Young maternal age,
 Low maternal education,
 Large family size,
 Birth spacing less than 18 months
 Single or separated parent
 Parental psychiatric disorders
 Presence of a step-parent
 Infant premature, low birth weight
 Infant mentally or physically handicapped
 Infant never breastfed
 Difficult child behaviour ,

39
 During the provision of services, medical officers and nursing staff should be
alert to physical and behavioral signs and symptoms associated with abuse or
neglect. Patients in whom abuse is suspected should receive proper
treatment for physical injuries and proper counseling and if needed referral
to specialized centers.

To implement an effective screening program at health centre level the

following steps should be undertaken

 Training of staff, especially in the areas of understanding the concept of

child abuse and neglect, associated factors, counseling of mothers and
families within the CRC (Convention of the Rights of the Child) and the
specific cultural context of the Palestine refugee community; Training is
the most important first step for the understanding and addressing
children’s needs; and for the development of an effective system of
management and referral;
 Establish effective cooperation and networking with different providers
across all sectors in particular with organizations dealing with child abuse
and neglect.

6.2 Vitamin A supplementation:

Evidence of sub-clinical vitamin A deficiency in the child population is known

to decrease immunity, increase the risk, severity and mortality from
infections; additionally vitamin A deficiency can contribute to nutritional iron
deficiency anaemia by its adverse effects on iron metabolism.
Vitamin A supplementation of the Palestine refugees children is strongly
justified given the current climate of generalized poverty, food insecurity and
levels of infection.
WHO recommends universal vitamin A supplementation in areas of the world
where there is a moderate or severe degree of deficiency for those groups
who have particular vulnerability such as young children and also lactating
mothers.

The strategy

Intermittent administration of high dose vitamin A every 6 months which can

be linked to routine attendance for immunization and growth monitoring

Table No. 14, Schedule of Vitamin A administration:

Infants at 9 months of age: 100,000 IU orally at time of Measles immunization

Children after 15 months of age
Children at 20 months age:
School children:
Nursing mothers:
200,000 IU orally at MMR/ immunization
200,000 IU orally and every 6 months thereafter
during the growth monitoring visits up to 5 years
200,000 IU every 6 months ( twice during the
school year) up to the 6th grade
200,000 IU orally within 6-8 weeks after delivery

40
6.3 Oral health

6.3.1 Childhood caries:

Dental caries is perhaps the most prevalent infectious disease in children.

Early childhood caries (ECC) can be a particularly virulent form of caries,
beginning soon after tooth eruption, developing on smooth surfaces,
progressing rapidly, and having a lasting detrimental impact on the dentition.

Oral health is closely related to general health and it is essential to the

general well being of individuals and their quality of life. Caries in primary
teeth can affect children’s growth, result in significant pain, potentially life-
threatening infection, and diminish overall quality of life.

6.3.2. Epidemiology:

Dental caries affect 60–90% of schoolchildren and the vast majority of

adults. Prevalence and incidence of dental caries and periodontal diseases
are linked to socio-economical condition. People from more disadvantaged
and fragile groups of the society face the huge burden of oral diseases when
public and community-based services are not implemented.

In 2005, WHO highlighted priority actions to improve oral health

programmes recommending the “integration of oral health into
national and community health programmes based on oral health,
general health and quality of life interrelationship”.
In May 2007, the World Health Assembly declared that “the economic burden
of oral disease is predicted to grow rapidly worldwide, particularly in
disadvantaged and poor populations, unless oral preventive programmes are
implemented” recommending to strengthen oral health programmes at all
levels

6.3.3 Etiology of dental caries

Notwithstanding that dental decay is a multi-factorial disease and needs the

formation of dental plaque, substrate and time. However dental caries results
from an overgrowth of specific organisms that are part of normal human oral
flora. Streptococci Mutans (SM) is considered to be a principal indicator group
of bacterial organisms responsible for dental caries.

6.3.4 Mode of transmission:

Vertical Transmission of SM from mother to infant, the higher the levels of

maternal salivary SM, the greater the risk of the infant being colonized. Along
with salivary levels of SM, mother's oral hygiene, periodontal disease, snack
frequency, and socio-economic status also are associated with infant
colonization.

Horizontal transmission: peer to peer transmission between members of

similar group of children.

41
6.3.5 Risk assessment:

Dental caries affects the general population but is more likely to occur in
infants who are:
 of low socioeconomic status,
 who consume a diet high in sugar,
 whose mothers have a low education level and high caries rate. and
 children with special heath care needs.

6.3.6 Preventive strategies:

Caries is a disease that is preventable. Dental decay is one of the clearest
examples of so-called “behavioral” diseases and its preventive measures are
few, simple, worldwide recognized, and effective.These measures are based
on nutrition, hygiene, fluoride and sealants.
Early risk assessment allows for identification of parent-infant groups who are
at risk for ECC and would benefit from the following early preventive
intervention.

A. For mothers:
Guidance and health education for the mother should include the following:
a. Education: Preventive measures can be effective only educating
community. Maternal and child health staff, have the “golden chance” to
focus on oral health prevention activity starting from pregnancy and child
health care thereafter. This is the only effective basis for effective and
sustainable development.
b. Oral hygiene: Dental hygiene starts from the early age with toothbrush
and toothpaste. Mothers should educate children to a correct brushing
technique as soon as possible to remove plaque avoiding dental decays and
periodontal diseases. Toothpaste is the most effective vehicle to add
fluoride to the mouth in order to prevent dental decays.

Tooth-brushing and flossing by the mother on a daily basis.

c. Diet: Sugar is highly related with dental decay etiology. Oral

Streptococcus Mutants metabolize sugar from food and produce acids. These
acids de-mineralize tooth enamel. After sugar intake, the demineralization
process quickly starts and saliva mainly needs 30 minutes to neutralize acid
pH and start re-mineralization. So, intake frequency, affects tooth enamel
more than the quantity of consumed sugar. If the number of intakes is 5/day
it means that demineralization process will occur for 2.5 hours leaving
enough time for the re-mineralization process (depending on fluoride
exposure) but having several snacks during the day will lead to a higher
demineralization without enough time for re-mineralization.

Dietary education for the parents includes the cariogenicity of

certain foods and beverages, role of frequency of consumption of
these substances, and the demineralization/ re-mineralization
process.

42
d. Fluoride: Fluoride is considered an essential drug by WHO, tablets,
drops, pipe water, salt/milk, rinsing, toothpaste, sealant are different possible
vehicles. Systemic use is effective from pregnancy to school entrance and it
has two main ways of action:

 Tooth mineralization before eruption (systemic way) and to re-

mineralization after eruption.
 As an antimicrobial agent, stopping acid secretion from the bacteria.

Mothers should be motivated to use fluoridated toothpaste to help

enamel re-mineralization.

e. Caries removal: Routine professional dental care for the mothers can
help keep their oral health in optimal condition. Removal of active caries is
important to suppress maternal SM reservoirs and has the potential to
minimize the transfer of SM to the infant,

f. Delay of colonization: Education of the parents, especially mothers, on

avoiding saliva-sharing behaviors (eg, sharing spoons and other utensils,
sharing cups, cleaning a dropped pacifier or toy with their mouth) can help
prevent early colonization of SM in their infants.

B. For children:

Guidance for children 0 to 5 years of age includes:

a. Oral hygiene: Oral hygiene measures should be implemented no

later than the time of the eruption of the first primary tooth.
Advice the mother on:
o that cleansing the infant’s teeth as soon as they erupt with either a
washcloth or soft toothbrush will help reduce bacterial colonization
o Children's teeth should be brushed twice daily with fluoridated
toothpaste and a soft, age-appropriate sized toothbrush.
o Flossing should be initiated when adjacent tooth surfaces can not
be cleansed with a toothbrush.

Teeth need to be brushed at least twice a day without thorough

rinsing.

b. Diet: High-risk dietary practices appear to be established early, probably

by 12 months of age, and are maintained throughout early childhood.
Frequent night time bottle feeding, free breast-feeding, and extended and
repeated use of cup are associated with, but not consistently implicated in
ECC. Likewise, frequent consumption of snacks or drinks containing
fermentable carbohydrates (eg, juice, milk, formula, soda) also can increase
the child's caries risk. Mothers should be counseled on the common bad habit
to sleep with the baby-bottle containing sweet drinks or to suck a pacifier
covered with honey or sugar that lead to severe decay of temporary teeth
causing pain, abscess, fistula, chewing inability, and high need for treatment

43
 c. Fluoride: Optimal exposure to fluoride is important to all infants and
children, local and systemic use is effective from pregnancy to school
entrance

 The use of fluoride for the prevention and control of caries is documented
to be both safe and effective.
 Twice-daily brushing with fluoridated toothpaste is recommended for all
children as a source of fluoride and effective preventive procedure.
 Professionally-applied fluoride, as well as at-home fluoride treatments,
should be considered for children at high caries risk based upon caries
risk assessment.
 Systemically-administered fluoride should be considered for all children
drinking fluoride deficient water (<0.6 ppm). Caution is indicated in the
use of all fluoride-containing products.
 Fluorosis has been associated with cumulative fluoride intake during
enamel development, with the severity dependent on the dose, duration,
and timing of intake.

Topical Fluoride Varnish: upon the availability of resources, topical

fluoride varnish can be applied by the MCH nurse to the dentition of the child
twice yearly for children after the first year of age

d. Sealant: Sealant is a physical barrier to plaque and from the public health
point of view sealants are recommended for the whole target population as a
primary preventive measure (like vaccine). National programs worldwide
reported high results in decays prevention with sealants.
Sealant must involve the first permanent molar (6-7 years, first
grade and possibly the 2nd grade) and the second (12-13 years, 7th
grade). It prevents decays to beginning from the most vulnerable
areas of the tooth in childhood when hygiene habits are not so well-
built.

e. Injury prevention: Health staff should provide age-appropriate injury

prevention counseling for oro-facial trauma. Counseling would include play
objects, pacifiers, car seats, and electric cords.

f. Oral habits: Non-nutritive oral habits (eg, digit or pacifier sucking,

bruxism or teeth grinding, abnormal tongue thrust) may apply forces to teeth
and dento-alveolar structures. It is important to discuss the need to wean
infants from these habits before malocclusion or skeletal dysplasias occur.

6.3.7 The strategy:

a. Since MCH medical officers and nurses are more likely to see new
mothers and infants than are dentists, it is essential that they are trained

44
 to be aware of the infectious etiology and associated risk factors of ECC,
make appropriate decisions regarding timely and effective intervention,

b. Dental surgeons and dental hygienists should provide training and

technical support to MCH staff for the implementation of an effective oral
health preventive program for mothers, infants and children under care

c. Joint efforts should be coordinated to approach the community and

widespread health educational messages.

d. Growth monitoring and immunization sessions are a chance to educate

and strongly motivate mothers to consider their children’s oral health. It
could also be a good opportunity to establish oral health preventive
interventions and screening for early childhood caries.

e. Oral health promotion should be reinforced through the close

collaboration between the MCH staff and dental clinic staff and other
health components of the health center.

f. Oral health education should be an integral part of the regular health

education activities of the family health programme.

g. The infectious and transmissible nature of bacteria that cause ECC and
early intervention be part of the mother’s counseling.

h. Every infant should receive an oral health risk assessment by 12 months

of age. This initial evaluation should be conducted by MCH staff and
consists of the following:
 Assessing the patient’s risk of developing oral disease using a caries risk
assessment;
 Providing education on infant oral health; and
 Evaluating and optimizing fluoride exposure.

i. By 2 years of age comprehensive oral health assessment should be

conducted by the dental surgeon/dental hygienist. The following should
be accomplished during this session:
 Recording thorough medical and dental histories;
 Completing a thorough oral examination;
 Assessing the infant’s risk of developing caries and determining an
appropriate prevention plan and interval for periodic reevaluation
based upon that assessment;
 Providing counseling regarding dental and oral development, fluoride
status, non-nutritive sucking habits, teething, injury prevention, oral
hygiene instruction, and the effects of diet on the dentition;
 Planning for periodic comprehensive oral health care; and
 Referring patients to the appropriate health professional if
intervention is necessary.

45
IX. Responsibility:

1. The Chief, Family Health assisted with the Maternal and Child Officer at
HQ level and the Field Family Health Officer at Field level are responsible
for the planning, implementation, supervision and evaluation of the programme
as well as for staff training and development. The Field Family Health Officer
will coordinate programme activities closely with the Field Nursing Officer.

2. Area Health Officers (where such posts exist) should share in all activities
relevant to technical guidance, supervision and training of health centre staff in
the area to which assigned.

3. Medical Officers:

On 1st registration visit:

 Check on relevant information/history with respect to the mother, the child and
the family,
 review the growth monitoring findings/curve and detect deviations from
normal,
 perform complete physical examination as per Para 1.2 above,
 record his/her conclusions and management plan on the CHR,
 provide family planning counseling,
 provide oral health prevention counseling for mothers and
 provide the relevant health education/advice pertinent to the infant’s condition.

On repeat visits:

 Give special attention and care to children identified with growth-related

problems.
 follow-up on at-risk children.
 provide medical care to sick children.
 follow-up on developmental milestones.
 check the validity, accuracy and completeness of statistical reports before
submission to the Field Office and
 check the child health record and provide nursing staff with feedback and
guidance

4. Dental surgeon

Assisted by the dental hygienist, where available and dental nurse the dental
surgeon is expected to conduct the following activities

 Provide training and technical support to MCH staff for the implementation of
an effective oral health preventive program for mothers infants and children,
 coordinated joint efforts to implement community preventive oral health
program in the catchments area of their health facility,

46
 supervise and implant an MCH oral health promotion program in close
collaboration with the MCH staff and other components of the health center
including the risk assessment at one year of age,
 support the integration of the oral health education in the regular health
education activities of the MCH programme,
 provide counseling for pregnant women during the regular screening program
in particular about the infectious and transmissible nature of bacteria that
cause ECC and early preventive interventions,
 conduct a comprehensive oral health assessment/screening for all children at
the age of 2 years,
 recording of advises, findings and plan of management in the CHR and
 participate in all activities related to oral health research.

5. Nurses:

On 1st registration:

 Obtain the required information with respect to the child and the mother and
record it on the CHR and on the MCH handbook,
 record the birth-weight, length, head circumference on the first line of the first
column of the growth chart, which represents zero age,
 weigh the child and record the weight on the CHR and the MCH handbook,
 plot a curve connecting the previous anthropometric measurement and the
current once in the respected chart,
 notice any gross abnormalities,
 provide due immunizations and record them on the child Health Record and the
Mother and Child Health Handbook.
 provide family planning counseling,
 provide oral health prevention counseling for mothers and children,
 provide counselling on exclusive breast-feeding as well as on prevention and
home management of acute respiratory infections and diarrhoeal diseases.
 advise pregnant women on the importance and utilization of the MCH
handbook
 record all notes under the “Nurse’s Notes” in the CHR and
 Complete the Daily Journal of Work on Infant and Child Health Care, catalogue
No. 06.3.710(B) in each session and the upper section of the form at end of
the month.

On repeat visits:

 monitor child growth,

 monitor developmental milestones. (Please refer to Annex I),
 identify deviations from normal growth and development,
 provide due immunization,
 provide nutritional advice,
 provide family planning counseling,
 conduct an oral health risk assessment at one year of age and provide oral
health prevention counseling for children and mothers,

47
 upon the availability of resources, apply topical fluoride varnish to the dentition
of the child twice yearly after the first year of age,
 mark the records of children with growth problems by coloured tags and
ensure that these records could be easily retrieved for follow-up,
 refer the child to the Medical Officer whenever necessary,
 complete the laboratory referral for haemoglobin testing in accord with the
frequencies outlined in the relevant technical instructions,
 follow up of defaulters including home visits to children at risk or with special
needs and
 give an appointment for the next visit by date and hour and record this on the
Mother and Child handbook.

6. Health Centre Clerks:

 Maintain all Child Health Records upon their completion at the child health
clinic. The records should be kept in separate group categories, namely, 0-1, 1-
2 and 2-5 according to the month and year of,
 transfer the records of infants who completed their age category to the
corresponding age group,
 hand over records of children who did not attend, according to the pre-fixed
appointment, to the nurse for follow up and necessary action,
 Segregate the records of defaulters, on regular basis, for follow-up.
 keep aside records of children who completed 60 months of age in separate
boxes and label them by the corresponding year. The records should be kept
for one year and
 transcribe information relevant to previous immunizations from the Child Health
Record to the respective Clinic Record in the Family File.

X. Recording and Reporting:

1. Records

1.1. The Field Family Health Officer and the Field Nursing Officer have
collective responsibility for completion and checking the validity,
accuracy and completeness of data reported from all health
centres/MCH centres.
Any irregularities or inconsistencies should be adequately investigated
and validated prior to submission of reports to Headquarters. They are
also responsible for review of trends such as drop in attendance rates,
drop in immunization from expected rates etc. and to take appropriate
actions as, when and where necessary.

1.2. The following records should be completed with respect to every infant
on first registration and should be maintained until the child completes
60 months of age as long as he/she is in regular attendance for
preventive care and monitoring:-

a. Child Health Record for Girls 0 – 5 Years-Catalogue, No. 06.7.698.1.

b. Child Health Record for Boys 0 – 5 Years-Catalogue, No. 06.7.696.1

48
 c. MCH handbook
d. Birth and Immunization Register-Catalogue, No. 06.7.693.1

1.3. Records of children who complete 60 months of age should be kept

aside for two years as they represent a main source of information on
the health condition of the child and immunization record upon entry to
school.

1.4. For infants/children who do not attend for two successive visits, every
possible effort should be exerted to establish the reasons for failure to
attend be it death of the infant/child, change of place of residence,
family problems etc.

1.5. Records of children who do not attend regularly to the MCH clinic
(defaulters) should be kept aside in accord with the provisions of para
A.2 of the Guidelines on MCH Reporting System. Data on such children
should not be included in the statistical returns. In case regular
attendance is resumed, the frozen record should be reactivated rather
than a new record originated.

1.6. Child Health Records for children with Growth Problems and special
health care needs should be labeled and kept separately for easy
follow-up, reference and reporting.

2. Reports

2.1. The following reports on Infant and Child Health Care should be
completed, on monthly basis by all health centres/points and MCH
centres and submitted to the Field Office for compilation and
subsequent transmittal to Headquarters.

a. Infant and Child Health Care-Catalogue No.06.3.710.1(B)

b. Children with growth problem report below 5 Yrs - Form No. 7(C)
c. Infant mortality below 1 Year - Catalogue No. 06.7.694.1
d. Child mortality 1 – 5 Years - Catalogue No. 06.7.695.1

2.2. Quarterly report from the Field to Headquarters:

Infant and Child Health Care - Electronic file

XI. Evaluation:

The main objectives of programme evaluation are to assess morbidity and

mortality patterns among children less than five years of age, to monitor and
maintain progress so far achieved, and to identify the appropriate interventions
needed to further improve the quality of child health care and achieve the
desired outcomes.

49
1. Evaluation techniques

1.1. Regular evaluations will be carried out at the end of each calendar year
and will be based on data collected through the routine reporting
system and rapid assessment techniques.

1.2. Special surveys will be carried out, as and when indicated, to obtain
specific data.

2. Indicators

The indicators, which will be used for programme evaluation, will comprise the
following:

a. Low birth weight incidence rate.

b. Birth-weight proportionate mortality rates.
c. Proportionate infant mortality rates, including neonatal and post neonatal
mortality rates.
d. Early childhood mortality rate.
e. Age-specific and gender specific growth problems rates.
f. Percentage of infants below 12 months fully immunized.
g. Percentage of children below 18 months fully immunized.
h. Coverage of infant health care services.
i. Prevalence of anaemia among children 6-24 months of age.
j. Proportion of infants registered for care within the neonatal period.
k. Incidence rate of congenital heart disease.
l. Gender-specific incidence rate of hip dislocation.

Dr. Guido Sabatinelli

Director of Health
December 2009

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