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Impact of supervised nutrition supplementation and nutrition education through Child Development Centers (CDC’s) for improving preschool undernutrition in primary health care setting of Yavatmal District, Maharashtra, Central India

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Impact of supervised nutrition supplementation and nutrition education through Child Development Centers (CDC’s) for improving preschool undernutrition in primary health care setting of Yavatmal District, Maharashtra, Central India
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    Nitin N Ambadekar  et al JMSCR Volume 03 Issue 07 July   Page 6373 JMSCR Vol.||03||Issue||07||Page 6373-6384||July   2015 Impact of Supervised Nutrition Supplementation and Nutrition Education through Child Development Centers (CDC’s) for Improving Preschool Undernutrition in Primary Health Care Setting of Yavatmal District, Maharashtra, Central India Authors   Nitin N Ambadekar 1 , Vivekanand C Giri 2 , K.Z. Rathod 3 , Sanjay P Zodpey 4 , Sunita P. Bharati 5 1 MD, Additional District Health Officer, Dept of Public Health, Z.P, Yavatmal, Maharashtra, India 2 MD, Assistant Director, Central Leprosy Teaching Research Inst., MOHFW, GOI, Chengalpattu (TN) India 3 DPH, District Health Officer, Dept of Public Health, Z.P, Wardha, Maharashtra, India 4 M.D, Ph D, Director Public Health Education, & IIPH Delhi, Public Health Foundation of India, New Delhi, India 5 M.D, Assistant Professor, Dept of Anatomy, Shri Satya Sai Medical College & Research Institute, Ammapetai, Chennai Dept of Public Health, Govt. of Maharashtra, Yavatmal Corresponding Author  Dr. Vivekanand C. Giri Central Leprosy Teaching and Research Institute, Chengalpattu 603001, T.N. India Email:  drvivekgiri@gmail.com Abstract Introduction:   Under-nutrition remained one of the most common causes of morbidity and mortality among children throughout the world. 1.84 to 2.4 million of deaths occurred in India. Principle of CDC was to provide  supervised nutritious food to severely (G-III & G-IV) undernourished preschool children and imparting nutrition ed  ucation to mother/guardian of children. The present study aims to study the impact of ‘Child Development Centers’ in improving grade of severe undernourished preschool children(G -III/IV) in primary health care setting    Materials and Methods:    Present interventional study was carried out in primary health care setting in Yavatmal  District. The intervention was in the form of organization of Child Development Centre’s (CDC’s) at Primary  Health Centers (PHC) in which severe undernourished G-III and G-IV children were hospitalized for 21 days. There were three main interventions planned and implemented in CDC’s. First was supervised dietary  supplementation. This includes providing approximately eight feeds daily. Second was growth monitoring and medical management. Third intervention is in the form of nutrition education to parents along with participation of mother in preparation of various new food supplementation and maintaining community growth charts.   Results:   Severe undernourished children 547 children were a dmitted to CDC’s established at PHC’s in Yavatmal.  At the time of discharged from CDC 274 (50.1%) children had improvement in their grade of undernutrition. There was reduction of Grade III under nutrition from 75.4% to 47.3% and Grade IV from 11.5% to 3.8% after 21 days of intervention at CDC. At the time of discharge from CDC highest average daily weight gain was seen in children aged 7 to 12 months (5.28 gm per day per kg) and in G-IV children (6.14 gm per day per kg). www.jmscr.igmpublication.org Impact Factor 3.79 ISSN (e)-2347-176x    Nitin N Ambadekar  et al JMSCR Volume 03 Issue 07 July   Page 6374 JMSCR Vol.||03||Issue||07||Page 6373-6384||July   2015 Introduction Undernutrition remained one of the most common causes of morbidity and mortality among children throughout the world (1) . Almost 10 million children below the age of five years die every year from causes such as pneumonia, diarrhea and malaria. 1.84 to 2.4 million of these deaths occurred in India and carries the main burden of child deaths globally (2,3) . Undernutrition is an underlying cause in about one-third of deaths among less than five years of age (4,5,6) . Thus inadequate intake, infection and poor nutritional status are intimately linked and maintaining a good nutritional status was an integral part of improving child survival. Interventions to prevent under nutrition in all its forms should therefore receive the highest priority. Indian government and public health departments in India and particularly in Maharashtra were intensively working towards reduction of undernutrition. One of the significant government initiatives in this regard was introduction of Integrated Child Development Scheme (ICDS) and setting up of anganwadies in villages throughout the country. Public health Department in collaboration with ICDS was implementing childhood nutrition programs and providing health services. After the launch of National Rural Health Mission (NRHM) and with its emphasis on reducing infant mortality (IMR) and childhood mortality (CMR), reducing undernutrition became highest priority for health department. Keeping in view of the urgency and sensitive nature of problem Government of Maharashtra had established Rajmata Jijau Mother-Child Health and Nutrition Mission in year 2006. Most significant objective of the mission was to reduce the Grade III(G-III) and Grade IV(G-IV) under nutrition. As part of mission objective new initiative in form of Child Development Centers(CDC’s) were introduced to tre at Grade III & IV under nutrition (7-9) . Principle of CDC was to provide supervised nutritious food to severely (G-III & G-IV) undernourished preschool children and imparting nutrition education to mother/guardian of children so that the learnt knowledge and practices will be implemented when child was discharged from the PHC’s. Encouraged with the initial results in pilot phase, the CDC’s were implemented in step wise manner in districts after providing training to district officials, medical officers and ICDS functionaries. The present study aims to study the impact of ‘Child Development Centers’ in improving grade of severe undernourished preschool children(G-III/IV) in primary health care setting. The study also aims to study the impact of community based follow up and impact of nutrition education in further improving grades of undernutrition up to six months following discharge from CDC’s. Materials and Methods:  Present interventional study was carried out in  primary health care setting in Yavatmal District. The district is located in hilly area and there is  predominance of tribal population namely Gond, Kolam, Banjara etc. This study was planned to study the impact of intervention which was implemented by Government of Maharashtra as  per the guidelines of Rajmata Jijau Mother- Child Health and Nutrition Mission (7-9) . The intervention was in the form of organization of Child Development Centre’s (CDC’s) at Primary Health Centers (PHC) in which severe undernourished G-III and G-IV children were hospitalized for 21 days. CDC’s were established simultaneously in all PHC’ s of the district Yavatmal from 19.4.08 up to 10.5.08. Grade of undernutrition was decided based on weight for age criteria as per IAP classification as this was then followed by ICDS and Public Health Department for growth monitoring of under 6 year child ren. Components of CDC’s were supervised diet to children, medical care of ill children, regular growth monitoring during the stay at the CDCs as well as after being discharged. The community based monitoring of weight was done  by anganwadi workers. The medical and nutrition  protocol was followed as specified by Rajmata Jijau Mother- Child Health and Nutrition Mission. The dietary supplementation was given by anganwadi workers under the guidance of trained    Nitin N Ambadekar  et al JMSCR Volume 03 Issue 07 July   Page 6375 JMSCR Vol.||03||Issue||07||Page 6373-6384||July   2015 ANM’s and anganwadi supervisors. ANMs were supervising the preparation of dietary supplementation by Anganadi workers and also suppose to teach guardians of admitted children how to prepare the daily nutritious food for children and administering the medications to children. There were at least 8 feeds daily for the children (Annexure 1 and 2). Medical protocol was determined for individual children by medical officer and followed up under the supervision of PHC medical officer. Opinion of pediatrician was taken whenever required. A written permission was obtained from District official before embankment of this study. The study intervention was implemented through health machinery. All G-III & G-IV children were identified by anganwadi workers through district wide survey in rural area of Yavatmal district. Anganwadi workers weighed the preschool children enrolled with them in particular village. The weighing was taken at anganwadi centers using “Salter spring  balance scale” and age was taken from birth record available with Anganwadi centers and with ANM of that area. Grade was calculated using weight for age criteria since this was the criteria used to grade severe undernutrition cases at the ICDS centre’s,. Gradation of nutrition was calculated by anganwadi workers from the ready reference or growth charts available with them. In the survey out of 234273 under 6 children 2,32,602 (99%) under 6 years age children were weighed. Survey reported 548 (0.23%) G-III & G-IV children and was persuaded to admission in CDC at PHC’s except one between age group of   0 to 6 month who was referred to higher centre for management. The exclusion criteria includes critically ill child, parents not willing for admission and 0 to 6 month children. At the time of admission parents of the children were informed of the course of treatment and care at CDCs and verbal consent for admission was taken. At the time of admission to CDC children were examined again and anthropometric measurement was taken by Medical Officers. These resulted in re-classification of 72 children in to G-II but as these were of borderline category and for ethical issues these children were continued in to CDC’s. All efforts were taken and losses of wages were paid to parents so that  parents along with children could stay at CDC for 21 days. Out of 548 children identified 547 study subjects were admitted and out of these, 513(93.8%) remained admitted for 21 days in CDC. All children who were admitted at CDCs were followed up in community by anganwadi workers and 6 months follow up data was available for 530(96.9%). All the children i.e. all 547 identified were followed up in the community for assessing the outcome of the intervention. Weight was taken at the time of admission, at the time of discharge and every month their after for assessing the follow up weight gain. Before initiation of CDC’s training of all concerned medical officer’s (MO’s) and child development project officer’s (CDPO’s) was conducted for uniform operation of guideline. The trained MO’s conducted training at primary health centre (PHC) level for MPW, ANM, other PHC staff and CDPO’s organized training for mukhya sevika, aganwadi worker and anganwadi helper. District level supervisory teams were formed for uniform implementation of intervention at all CDC’s. The purpose of CDC and intervention plan of action to be followed at the CDCs were explained to local panchayat raj institution leaders, community leaders and parents of children eligible for admission in CDC. Children along with their mothers or parents were kept at the CDCs for 21 days duration. Anthropometric measurement was recorded on first day of admission to CDC at PHC. This was considered as baseline weight for measuring further changes in weight. Weight was taken with the use of electronic weighing machine at Primary Health Centre. Thre were three main interventions planned and implemented in CDC’s. First was supervised dietary supplementation. This includes providing approximately eight feeds daily to admitted children prepared in kitchen established at Primary Health Centre (PHC). Anganwadi    Nitin N Ambadekar  et al JMSCR Volume 03 Issue 07 July   Page 6376 JMSCR Vol.||03||Issue||07||Page 6373-6384||July   2015 workers prepared food under the supervision of health worker female of PHC and anganwadi supervisors who were trained. Protocol for  preparing food and schedule was as per Rajmata Jijau Mother-Child Health and Nutrition Mission and is given in annexure 1 and 2(7). Children were fed 6 to 8 times daily as per the schedule under direct supervision of health worker female and anganwadi workers. Second was growth monitoring and medical management which included electronic weighing of child daily, treatment of minor illness, correcting vitamin deficiency, management of hypoglycemia, hypothermia, dehydration, infection, and electrolyte deficiency. Each child was weighed daily and weight was marked on community growth chart so that mother knew importance of growth monitoring and also understood feeding with care which can make a difference in weight gain. Third intervention is in the form of nutrition education to parents along with participation of mother in preparation of various new food supplementation and maintaining community growth charts. Study subjects were discharged from CDC’s after 21 days. After discharge these children were followed up monthly by anganwadi workers along with anthropometric measurement. Efforts were made to ensure that all children admitted to CDC to remain present along with their parents. Final follow up weight was not available for 17(3.2%) children but in analysis all the children were included considering their last known weight measurement. Statistical analysis was done using Epi Info version 3.5.1. Results There were total 548 grade III & IV undernourished children identified through survey conducted by anganwadi workers prior to start of child development centers (CDC). Out of 548 severe undernourished children 547 children were admitted to CDC’s established at PHC’s in Yavatmal. CDC’s were started on 19.4.2008 and continued for 21 days up to 10.5.2008 at PHCs. After re-examination and weighing by medical officer undernutrition was re-classified into G-II 72(13.2%), G-III 412(75.3%) and G-IV 63 (11.5%). Though children were re-classified in PHC’s ,all including Grade II were admitted to CDC to avoid ethical issues. Majority of these children were in the age group 13 to 36 months i.e. 338 (61.8%) and were female children (71.7%). Among the admitted children schedule cast (SC) and schedule tribe (ST) were in majority i.e. SC -28.1%, ST-30.8% (Table 1). At the time of discharged from CDC 274 (50.1%) children had improvement in their grade of undernutrition. The improvement was considered when children in G-IV category at baseline moved to G-III/II/I and G-III children to G-II/I. The maximum improvement was seen in the age group of 13-36 months 177 (64.6%). There was reduction of Grade III under nutrition from 75.4% to 47.3% and Grade IV from 11.5% to 3.8% after 21 days of intervention at CDC. The observed reduction in grade of undernutrition was found to  be statistically significant. Further at the end of 6 months follow-up, in the community overall 361 (68.6%) children had improvement in grades of undernutrition (Table 2). Among the children having different grades of undernutrition at baseline significant improvement in grades was observed in G-IV, G-III undernourished children (p<0.001), while no improvement was observed in G-II undernouris-hed children at the end of CDC (Table 3). Also comparison was done between grades at the time of discharge from CDC and grades at the end of 6 months follow up in community. In this significant (p<0.001) improvement was observed for children in G-III & G-II but not for grade  –  IV (Table 3). At the time of discharge from CDC highest average daily weight gain was seen in children aged 7 to 12 months (5.28 gm per day per kg) and in G-IV children (6.14 gm per day per kg). In follow up period highest daily weight gain was observed in same age group (1.47 gm per day per kg) and in G-IV children (0.78 gm/day/ kg). There were no deaths among undernourished children admitted in CDC.    Nitin N Ambadekar  et al JMSCR Volume 03 Issue 07 July   Page 6377 JMSCR Vol.||03||Issue||07||Page 6373-6384||July   2015 Table 1:  Distribution of study subject according variables Variable Number (percentage) Age (In Months) 7-12 19 (3.5%) 13-36 338 (61.8%) 37-72 190(34.7 %) Sex Male 155(28.3%) Female 392 (71.7%) Cast SC 154(28.2%) ST 168(30.7%) Other 225(41.1%) Grade of malnutrition II 72 (13.2%) III 412(75.3%) IV 63(11.5%)    *All children admitted in CDC were considered for analysis. Table 2:  Improvement in grades of undernutrition* Age group (Months) Deterioration in grade No Improvement Improvement Total 07-12 0(0%) 8(3.0%) 11(4.0%) 19(3.5%) 13-36 5(55.6%) 156(59.1%) 177(64.6%) 338(61.8%) 37 -72 4(44.4%) 100(37.9%) 86(31.4%) 190(34.7%) Total 9(1.6%) 264(48.3%) 274(50.1%) 547(100%)
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