1. RASTRIYA BAL SWASTHYA KARYAKRAM ( RBSK ) CHILD HEALTH SCREENING AND EARLY INTERVENTION SERVICES UNDER NRHM

2. INTRODUCTION Comprehensive child health care implies assurance of extensive health service for all children, from birth to 18 yrs of age for a set of health condition. These conditions are 4 Ds Diseases, Disabilities, Deficiencies Developmental delays. Universal screening would lead to early detection of medical conditions ,timely intervention ,ultimately leading to a reduction in mortality and morbidity and life-long disability. Under NRHM significant progress has been made in reducing, mortality in children over the last 7 years, Where as ,there is an escalation of reducing child mortality there is also a need to improve survival outcome. This would be reached by early detection and management of conditions that were not addressed. 3. WHY SCREENING OF 0 TO 18 YEARS AGE GROUP? Out of every 1000 babies born in this country, annually,6 to 7 have a birth defect. This would translate to around 17 lakhs birth defects ,annually in the country and accounts to 9.6% of all the newborn deaths . Various nutritional deficiencies affecting the preschool children range from 4% to 70%, developmental delays are common in early childhood affecting at least 10% of the children . These days if not intervened timely, may lead to permanent disabilities including cognitive, hearing, or vision impairment Also there are a group of diseases common in children like dental caries, rheumatic heart disease, reactive airway disease etc .Early detection and management of diseases including deficiencies bring added value in preventing these conditions, to progress to their more severe and debilitating form and there by reducing hospitalization and implementation of Right to Education. 4. Rastriya Bal Swasthya Karyakram (RBSK) is a screening programe aiming at early identification and early intervention for children, from birth to 18 years First level of screening is to be done at delivery points through existing Medical Officers, Staff nurses and ANMs .After 48 hours of birth till 6 weeks ,the screening of newborn will be done by ASHA, at home, as part of HBNC package. Outreach screening will be done by dedicated mobile block level team for the period of 6 weeks to 6 years at ANGANWADI centers and for children inthe age group 6 to 18 years atschool. Once the child is screened and referred, from any of these points of identification, it would be ensured that necessary treatment /intervention is delivered at zero cost to the family 5. HEALTH CONDITIONS TO BE SCREENED Child Health Screening and Early Intervention Services under RBSK envisages to cover 30 selected health conditions for screening ,early detection and free management. . 6. Selected health conditions for Child Screening and Early Intervening Services DEFECTS AT BIRTH 1.Neural tube defect. 2.Downs Syndrome. 3.Cleft Lip & Palate. 4.Club foot (Talipes) 5.Developmental Dysplasia of Hip. DEFICIENCIES 10.Anaemia especially Severe anemia. 11.Vitamin A Deficiency (Bitot spot) 12.Vitamin D Deficiency (Rickets)6.Congenital cataract.13.Severe Acute Mal nutrition (SAM)7.Congenital deafness.14.Goitre.8.Congenital heart disease. 9.Retinopathy of Prematurity 7. CHILD HOOD DISEASES15.Skin conditions(Scabies ,fungal infections ,and Eczema) 16.Otitis media 17.Rheumatic heart disease 18.Reactive airway disease. 19.Dental conditions.20.Convulsive disorders. DEVDELOPMENTAL DELAYS AND DIS ABILITIES 21.Vision impairment. 22.Hearing impairment. 23,Neuro-motor impairment. 24.Motor delay. 25.Cognitive delay. 26.Language delay.27.Behavior disorder (Autism). 28.Learning disorder. 29.Attention deficit hyperactivity disorder. 30.Congenital hypothyroidism ,sickle cell anemia, beta thalassemia (optional 8. Child screening under RBSK is at two levels Community level Facility level The community level screening will be done by Mobile Health Teams at Anganawadi Centres and Government and Government Aided schools. while facility based newborn screening at public health facility like PHC,CHC,DH, will be by existing man power like Medical Officers ,Staff Nursers, and ANMs. 9. SCREENING AT COMMUNUITY LEVEL SCREENING AT ANGANAWADI LEVELAll preschool children below 6 years of age would be screened by Mobile Block Health Team for the 4 Ds at Anganwadi centre at least twice a year. The tool for screening forsupported by pictorial, job aids0 to 6 years isspecifically fordevelopmental delay. For developmental delay the children would be screened using age specific tools and those suspected would be referred to DEIC for further management 10. SCREEENING AT SCHOOLSSchool children at 6 to 18 years would be screened by Mobile Health team for the 4 Ds at the local schools at least once in a year. SUGGESTED COMPOSITION OF MOBILE HEALTH TEAMS1.Medical Officer (AYUSH) ONE MALE AND ONE FEMALE 2.ANM /Staff Nurse.3.Pharmacist with computer knowledge. 11. PREPARATIOIN OF ANGANAWADI CENTRES AND SCHOOLS FOR HEALTH CHECK UP 1.As per the action plan the team should reach the sitewellbefore time. 2.There should be a display board outside the Anganwadi center and schools mentioning the time and dateof thecheckup. 3.For Anganwadi center a checkup list of beneficiaries between 0 to 3 years and 3 to 6years age group should be available withAnganwadi workers and ASHAs. 4.Necessary instruments and equipments should be present as per the list 12. METHODOLOGY TO BE USED FOR SCREENING 1.LOOK----Pictorial job aidA simple photograph of anewbornchildwithanyvisiblebirthdefect/abnormality is to be shown 2.ASK------simple questionnaire tool is to be used foridentificationofdiseases,deficiencies,developmental delays including disability. 3.PERFORM---- Clinical examination/simple tests to confirm the condition---Basic tests ca be used identification of deficiencies and diseasesfor 13. PROCEDURES AND PRECAUTIONS BEFORE MEASURING 1.TRAINED PEOPLE. 2.AGE ASSESSMENT. 3.WEIGH AND MEASURE ONE CHILD AT A TIME,--Do not weighormeasure a child if the parent refusesthe child is too sickthe child is physically deformed which will interfere with or give a measurement. 4.CONTROL OF THE CHILD. 5.EXPLAINING THE PROCESSS TO THE CAREGIVER.6.RECORDING MEASUREMENTS CAREFULLY. 7.STRIVE FOR IMPROVEMENTin correct 14. ILLUSTRATING CHILD STANDING MEASUREMENT PROCEDUREMeasuring Head circumference: Head circumference measurement of a childs headaround its widest distance from above the eyebrows and earsand around the back of the head. On thelower part of the forehead ,also referred to as theOccipito-frontal Circumference. This measurement is mainly to show the brain growth. Brain growth slows down once the child is 12 monthold and stabilizesby age 5.Any increase in size is called macrocephaly and any decrease is called microcephaly. 15. CHILD STANDING MEASUREMENT PROCEDURE 16. Contd.... 17. Contd.... . 18. Contd..... 19. Major contributors: 1. Geneticcaused when one or more work properly.gene doesnt 2. EnvironmentWomen exposed during pregnancy to Rubella/German measles, alcohol, smoking, drugs like painkillers, antidepressant, drugs for l asthma, corticosteroids, anti-convulsants, medicines for thyroid diseases uncontrolled l diabetes and obesity in mother. Some common birth defects are: 1.Neural tube defect 2.Downs Syndrome 3.Cleft lip and Palate 4.Club foot.5.Developmental Dysplasia of hip 6.Congenital Heart Disease 7.Congenital Cataract 20. PREVENTION OF BIRTH DEFECTS Defects present since birth can be major anomalies ,visible at birth, requiring immediate attention or invisible internal organ defects, which may be missed and brought to light later.70% of birth defects can be prevented during antenatal period through regular check and care. Taking 5 mg of folic acid daily , starting from the day of marriage till 3 months after testing positive for pregnancy.This will prevent neural tube defect in the newborn.Regular antenatal checkup at least three times during pregnancy, identification and keeping diabetes under controlHistory of using anticonvulsant drugs like valproate is found to increase the risk for birth defects.Medications mothers taking pain -killers, anti-depressants, drugs for asthma, medicines for thyroid disease must discuss with the doctor during antenatal visit.Family members to maintain positive environment at home by avoiding any maternal stress and domestic violence.maintain good hygiene by adopting safe sex practice and personal hygiene to prevent infection during pregnancy.Immunization like Rubella vaccine if given during adolescence can prevent a mother against certain infections , which in turn would prevent some birth defects.Smoking And Alcohol Consumption To Be Strictly Avoided during pregnancy. * contacts with cats to be avoided during pregnancy to prevent Toxoplasmosis infection.Maintain a healthy weight. 21. BASIC GENETICS What is DNA?Let us examine a group of cells in your Ear. They help in hearing. How do the cell know that their function is to support Hearing instead of making the heart beat. Instructions providing all the information necessary for a living organism to function, reside in the nucleus of every cell. 22. The instruction come in the form of a molecule called DNA. DNA encodes a detailed set of plans, like a blue print for building different parts of the cell 23. NEURAL TUBE DEFECTS The most common neural tube defects are Spina bifida Anencephaly/meningomylocoele.In spina bifida the tube does not close completely during the first month of pregnancy, there is usually nerve damage that causes at least some paralysis of the legs. In anencephaly, much of the brain does not develop . Babies with anencephaly are either stillborn or die shortly after birth. 24. NEURAL TUBE DEFECTS There are two types of NTDs: open, which are more common, and closed. Open NTDs occur when the brain and/or spinal cord are exposed at birth through a defect in the skull or vertebrae (back bones). Examples of open NTDs are anencephaly, encephaloceles, hydranencep haly, iniencephaly, schizencephaly, and spina bifida Rarer types of NTDs are called closed NTDs. Closed NTDs occur when the spinal defect is covered by skin. Common examples of closed NTDs are lipomyelomeningocele, lipomeningocele, and tethered cord. 25. Anencephaly Anencephaly (without brain) is a neural tube defect that occurs when the head end of the neural tube fails to close, usually during the 23rd and 26th days of pregnancy, resulting in an absence of a major portion of the brain and skull. Infants born with this condition are born without the main part of the forebrain the largest part of the cerebrumand are usually blind, deaf and unconscious. The lack of a functioning cerebrum will ensure that the infant will never gain consciousness. Infants are either stillborn or usually die within a few hours or days after birth. 26. oEncephaloceles Encephalocelesarecharacterizedbyprotrusions of the brain through the skull that are sac-like and covered with membrane.They can be a groove down the middle of the upper part of the skull, between the forehead andnose,ortheEncephalocelesarediagnosedback oftenimmediately.oftheobviousSometimesskull. and smallencephaloceles in the nasal and forehead are undetected. 27. Hydranencephaly Hydranencephaly s a condition in which the cerebral hemispheres are missing and instead filled with sacs of cerebrospinal fluid. Iniencephaly Iniencephaly is a rare neural tube defect that results in extreme bending of the head to the spine. The diagnosis can usually be made on antenatal ultrasound scanning, but if not will undoubtedly be made immediately after birth because the head is bent backwards and the face looks upwards. Usually the neck is absent. The skin of the face connects directly to the chest and the scalp connects to the upper back. The infant will usually not survive more than a few hours. 28. Spina bifida Spina bifida is further divided into two subclasses, spina bifida cystica and spina bifida occulta. Spina bifida cystica includes meningocele and myelomeningocele. Meningocele is less severe and is characterized by herniation of the meninges, but not the spinal cord, through the opening in the spinal canal. Myelomeningocele involves herniation of the meninges as well as the spinal cord through the opening. 29. Spina bifida occulta In this type of neural tube defect, the meninges do not herniate through the opening in the spinal canal. It is a common condition, occurring in 10 20% of otherwise healthy people. By definition,spina bifida occulta means hidden split spine. The most frequently seen form of spina bifida occulta is when parts of the bones of the spine, called the spinous process, and the neural arch appear abnormal on a radiogram, and is generally harmless. Usually the spinal cord and spinal nerves are not involved. The risk of recurrence in those who have a first degree relative (e.g. parent, sibling) is 510 times greater than that in the general population. The genetic risk of recurrence with symptomatic forms of spina bifida occulta is uncertain. 30. Take folic acid before you're pregnant Folic acid is B vitamin that every cell in your body needs for normal growth and development. If women of childbearing age take 400 micrograms of folic acid every day before and during early pregnancy, it may help reduce their babys risk for birth defects of the brain and spine called neural tube defects (NTDs). The neural tube is the part of a developing baby that becomes the brain and spinal cord. An NTD can happen when the neural tube doesnt close completely. 31. If all women take 400 micrograms of folic acid every day before getting pregnant and during early pregnancy, it may help reduce the number of pregnancies affected by NTDs by up to 70 percent.Some studies show that folic acid also may help prevent heart defects in a baby and birth defects in a babys mouth called cleft lip and palate 32. How can you get folic acid?Before pregnancy, take a multivitamin that has 400 micrograms of folic acid in it every day. Most multivitamins have this amount, but check the label to be sure. 33. Can you get folic acid from food?Yes. Some flour, breads, cereals and pasta have folic acid added to them. Look for fortified or enriched on the package to know if the product has folic acid in it. Even if you eat fortified or enriched foods, be sure to keep taking your multivitamin or prenatal vitamin with folic acid. You also can get folic acid from some fruits and vegetables. When folic acid is naturally in a food, its called folate. Foods that are good sources of folate are: 34. . Foods that are good sources of folate are: Beans, like lentils, pinto beans and black beansLeafy green vegetables, like spinach and Romaine lettuce AsparagusBroccoli Peanuts (But dont eat them if you have a peanut allergy)Citrus fruits, grapefruit Orange best)juicelike (Fromoranges concentrateand is 35. Action-Handle the infant with a sterile, nonlatex gloves and with sterile clothing and sheets .Cover the defect with non-adhesive dressing with sterile Ringers lactate solution or saline. Refer to district hospital ort nearest referral point for tertiary care 36. Signs and symptoms head may be smaller than normal. upward slanting eyes and inner corner of the eyes may be rounded instead of pointed Small ears Flattened nose. small mouth Excess skin at the nape of the neck singlecrease in the palm of hand (Simian Crease) wide, short hands with short fingers cleft in feet 37. ASK Is it your first child ? What is your age ? Does any other elder sibling of this child have any known birth defect ? Compared with other children, did any seriousdelay in sitting ,standing or walking? Can he name at least one object ( animal, toy, cup and spoon )? Does he speak at all ? Is speech is different from normal ? 38. ACTION check the muscle tone , decreased muscle tone at birth in Downs syndrome. The child has both legs extended and falling passively on the mat like as frog and the hands also helplessly , on ,the bed with very little spontaneous movement of the limbs. When this baby was lifted , the examiner had to give much support to the head and shoulders than is usual , to keep the infant from sliding out of her hands. Notice how the both arms fall aback and the babys chest seems to drape over the physicians hand. This is because the tone of the muscles , in the baby is less than what is normally seen in newborns 39. The goals of treatment for cleft lip and palate To ensure n the childs ability to eat, speak. Hear and breathe and to achieve a normalfacialappearance. Surgeriesare to be performed in this order;----between 1 and 4 months of ageCleft lip repair. Between 5 and 125 monthsCleft palate repair 40. 4 CLUB FOOT (Talipes) 41. Causes of Club Foot The exact cause of club foot is not known. An abnormality of the tendons and ligaments in the foot causes an abnormal structure and position of the foot. In some children, bones may also be abnormal in terms of shape, size, or position. There may be a link to maternal smoking during pregnancy. If the foot is abnormally positioned in the uterus during pregnancy, it may not grow into a normal shape, but this is not usually considered a "true" club foot. Club foot may, in rare instances, be associated with spinal deformities such as spina bifida or other neuromuscular diseases; however, in these cases, the foot is usually more deformed. 42. Clinically Perform the following 1, examine for asymmetrical thigh and glutealskin folds in supine and prone positions. 2, Measuring the length of the leg at the level of the knee in lying down position with the hip and knee joint Flexed. 3,Range of movement of the hip. 4, Examine the child in standing position for spinal curves. 5, Making the child walk for toe walking , limping or duck like walking 43. ACTION Refer all children who are born as breech presentation and are females. Refer all children with family history of congenital dysplasia of Hip. Refer all children with Asymmetrical thigh and gluteal skin foldsor shortening of the leg at the level of the knee joint or restricted movements of hip or increased spinal curves while standing or limping or duck like walking. Such children should be referred and followed at the age of 6 weeks, 3 months, 6 months ,and 12 months at District Early Intervention. 44. ACTION Refer all children who are born as presentation and are females.breech Refer all children with family history of congenital dysplasia of Hip. Refer all children with Asymmetrical thigh and gluteal skin folds or shortening of the leg at the level of the knee joint or restricted movements of hip or increased spinal curves while standing or limping or duck like walking. Such children should be referred and followed at the age of 6 weeks, 3 months, 6 months ,and 12 months at District Early Intervention. 45. CONGENITAL CATRACT 46. Clinical ---Perform. 1.Congenital cataract usually look different than other forms of cataract. 2.Grey or white cloudiness of the pupil( which is normally black ). 3.Infant doesnt seem to be able to see . 4:Red eye glow of the pupil is missing in photos , or is different between the two eyes. Tests Examine by a Torch may reveal white pupil. complete eye examination by an eye specialist. complete examination by a child specialist. ophthalmoscopy may be done. 47. Retinopathy of prematurity Retinopathy of prematurity (ROP) or Terry syndrome, previously known as retrolental fibroplasia (RLF), is a disease of the eye affecting prematurely-born babies generally having received intensive neonatal care, in which oxygen therapy is often used and advantageous. It is thought to be caused by disorganized growth of retinal blood vessels which may result in scarring and detinal detachment. ROP can be mild and may resolve spontaneously, but it may lead to blindness in serious cases. As such, all preterm babies are at risk for ROP, and very low birth weight is an additional risk factor. Both oxygen toxicity and relative hypoxia can contribute to the development of ROP. 48. CONGENITAL DEAFNESS 49. CONGENITAL HEART DEFECT 50. ACTION Refer all children who are born as presentation and are females.breech Refer all children with family history of congenital dysplasia of Hip. Refer all children with Asymmetrical thigh and gluteal skin folds or shortening of the leg at the level of the knee joint or restricted movements of hip or increased spinal curves while standing or limping or duck like walking. Such children should be referred and followed at the age of 6 weeks, 3 months, 6 months ,and 12 months at District Early Intervention. 51. Some photographs of the common skin condition in children 52. CHILD DEVELOPMENT 53. DEVELOPMENTAL DELAYS AND DISABILITY 54. Compiled , Prepared & Presented By Dr. K B Haridas Chief Medical Officer & Programme Manager RBSK 55. Thank you