Prof. Pratibha Singhi
-
Upload
jacob-ruiz -
Category
Documents
-
view
31 -
download
0
description
Transcript of Prof. Pratibha Singhi
Prof. Pratibha Singhi Professor, Chief Pediatric Neurology and
Neurodevelopment, Department of Pediatrics,
Postgraduate Institute of Medical Education and Research, Chandigarh- INDIA
“AT RISK” CHILDREN
Plan of Talk
• What is “At Risk”.
• Why is it so important in first 3 yrs of life
• Why are under three’s more vulnerable
• What are the risk factors.
• What is the current status.
• How to reach the under 3s.
• What needs to be done.
“At risk” is a concept that reflects a chance or a probability of adverse
outcome, the outcome is determined by a
balance of adverse and protective factors
“AT RISK” Definition• How do you define ? No consistent definition
WHO IS “AT RISK”?
• All children are at risk in some way or another
• Some children face much higher risks
• WHAT ARE CHILDREN AT RISK OF?
• Poor life outcomes - death, inadequate development, school
failure, economic dependency, etc
Why is Under 3 so important
There is a high correlation between the density of the
neural connections and one’s specific knowledge,
abilities or skills
Critical periods
Time window during which a specific function develops normally
provided conditions are favorable
Neuroplasticity - Synaptogenesis and Synaptic Pruning
Age of two, child’s brain contains twice as many
synapses and consumes twice as much energy as the
adult brain.
Developmental and environmental changes increase
or decrease the strength or efficacy of synapses as
well as lead to the addition or pruning of synapses.
It is easier to expand a child’s future proficiencies by
using the existing fertile neural networks
Brain Development in Infants And Early Childhood
Learning with all five senses
• During the first 3 years of life, children experience the world
in a more complete way than children of any other age.
• The brain takes in the external world through its system of
sight, hearing, smell, touch and taste.
• Infant - social, emotional, cognitive, physical and language
development are stimulated during multisensory experiences.
• Infants and toddlers need the opportunity to participate in a
world filled with stimulating sights, sounds and people.
Early abuse and emotional deprivation are extremely
damaging
0 1 4 8 12 16
AGE
Human Brain Development – Synapse Formation
Sensory Pathways(vision, hearing)
LanguageHigherCognitive Function
3 6 9-3-6
Months Years
C. Nelson, in From Neurons to Neighborhoods, 2000
Con
cep
tion
Cortical organization, especially for the sensory systems, is often described in
terms of maps.
Cortical Maps
Brain Development in Early Life Sets Trajectories for Development Throughout
Life
Foundations of brain architecture
Genetic factors
Biological factors
Psychosocial factors
Brain architecture
The foundations of brain architecture are laid down early in life through dynamic interactions of genetic, biological, and psychosocial influences,
and child behaviour
Attachment
• Attachment - deep emotional bond with a specific
person that lasts over time and spaces
• Stays with us for our lifetime and guides our behavior
• Secure attachments – greater independence and socio-
emotional competence and a secure base
Risk factors
Poverty Mental illness
Young age Stress
Poor pre-natal care and nutrition
Low self-esteem
Domestic violence Poor parenting skills
Poor physical health Unemployment
Low educational status Homelessness
Childhood experience of abuse
Single parent
High family conflict Poor family attachment/bonding
Parental / Family
Child risk factors
Poverty Adverse prenatal period (infections, drugs, hypertension)
Poor nutrition Stress and depression
Pre-mature/low-birth weight Domestic violence
Unwanted pregnancy Maternal smoking or substance abuse
Girl child Disability
Poverty
Chaotic or unsafe home environment
Isolation
Household composition
Community rates of poverty, crime, unemployment,
Environmental risk factors
At risk children
Low birth
weight
Malnutrition Anemia
Vit A deficiency
Orphans,street children
Sexual exploitation
Disabilities,Other chronic
medical conditions-
epilepsy
Disasters - floods,Famines,
Earthquakes, Nuclear explosion
Drug trafficking
Unwanted, girl child
Iodine , Micronutrient,
deficiency
Commercial exploitation
Poverty
Data from Guatemala show a linear decrease in adolescents’ school achievement and cognition with an increase in risk factors encountered by age 3 years. Child Dev 1996; 67: 314–26Infant Behav Dev 1992; 15: 279–96
Current Status• Global
• Millions of children, particularly in Africa and Asia, lack access to quality
health-care services, micronutrient supplementation, education, improved
water sources and sanitation facilities, and adequate shelter.
• In excess of 140 million under fives are underweight for their age, 100
million children of primary school age are not enrolled in primary school.
• 500 million to 1.5 billion children experience violence annually.
• Around 150 million children aged 5–14 are engaged in child labour
• India
• Every fifth child in the world and every third malnourished child in the
world lives in India, Every second Indian child is underweight, three out of
four children in India are anaemic.
• Every second new born has reduced learning capacity due to iodine
deficiency
Causes of mortality under 5yrs of age
Globally > a third of deaths are due to underlying malnutrition
Childhood Malnutrition
• Worst-affected region is not Africa but South Asia!!.
• Underweight children - Africa 30%, South Asia - over 50%.
• Bangladesh and India,- proportion of malnourished children significantly higher than in
even the poorest countries of the sub-Sahara.
• Not just because of sheer size of its populations but even the proportion affected is far
higher
• Half of the world's malnourished children are to be found in just three countries -
Bangladesh, India, and Pakistan.!!!
Malnutrition Among Children
Under Five Years %
• Stunted 48
• Wasted 20
• Underweight 43
Childhood Malnutrition – long term effects
• Beyond the age of 2-3 years, the effects of chronic malnutrition are
irreversible -
• Cognitive impairments
• Greater risk of infection
• Less physical capacity for work
• Less Educational attainment- stunted children in the first two years of life
have lower cognitive test scores, delayed enrolment, higher absenteeism
and more class repetition compared with non stunted children.
To break the intergenerational transmission of poverty and
malnutrition, children at risk must be reached during their first two years
of life
(N Engl J Med 1991; 325: 231–7.)
(J Nutr. 125: 2221S-2232S, 1995)Int. J. Environ. Res. Public Health 20118, 590-612; oi:10.3390/ijerph8020590
Malnutrition and infections – a Vicious circle !!
• Poor immune response
• Unusual organisms
• Severe infections
• Poor outcome
• Recurrent infections—further malnutrition
Malnutrition - impact on behaviour
Children malnourished at age 3 were more
likely than other children to be aggressive
or hyperactive at age 8,
To exhibit externalizing behaviors at age
11,
Exhibit conduct disorder and
Hyperactivity at age 17.
Crime times Volume 11, Number
1, 2005
Child malnutrition is a gender issue in India and is Intergenerational
Prevention of chronic fetal
malnutrition is a high
priority for developing
countries !!
Anemia in Children and Anemia in Pregnancy
• 70% of children age 6-59 months are anaemic.
• Severe 3%, Moderate 40% , Mild 26%
• Iron deficiency anemia in early life - altered behavioral and neural development.
• Irreversible effect that may be related to changes in chemistry of neurotransmitters,
organization and morphology of neuronal networks, and neurobiology of myelination.
• India –
• 58.7% of pregnant women, 63.2% lactating mothers are anaemic.
• Iron deficiency in pregnancy affects cells which are involved in building the embryonic brain
during first trimester - most sensitive to low iron levels.
• Critical period starts in the weeks prior to conception and extends through the first trimester
till the onset of the second trimester.
• Iron deficiency which starts in the third trimester
does not seem to harm the developing brain.
Iodine deficiency
• Iodine deficiency during pregnancy can cause abortion, CP and MR-
single largest preventable cause of mental retardation in the world
Fifty per cent of children born every year in India are unprotected against
Iodine Deficiency Disorders such as brain damage, deaf mutism, dwarfism
and severely depleted levels of productivity.
• The degree of impairment in function is related to the severity of iodine
deficiency. Even marginal degrees of iodine deficiency have a measurable
impact on human development
• Only 71% of households currently consume adequately iodized salt.
Vitamin A Deficiency
• 62% of pre-school children are deficient in vitamin A
- Leading to an annual 330,000 child deaths.
• Night blindness - first sign of vitamin A deficiency.
• Xerophthalmia and complete blindness can also occur .
• Approx 250,000 to 500,000 malnourished children in the developing
world go blind each year from a deficiency of vitamin A.
- Approx half of them die within a year of becoming blind.
• Vitamin A deficiency reduces immunity
• The Unites Nations Special Session on Children in 2002 set the
elimination of vitamin A deficiency by 2010.
- but have we achieved it??
Prevalence of vitamin A deficiency. Source: WHO
Vitamin deficiency
Vitamin C – Scurvy Vitamin D – Rickets
NUTRITIONAL DEFICIENCIES AND COGNITION
• Nutritional deficiencies-
• General - protein energy malnutrition (PEM)
• Stunting – (chronic PEM)
Consistent predictor Vs wasting
• Low birth weight
• SGA babies (12 long studies)
• Lack of breast feeding (14 studies)
• Specific - deficiency of iodine, trace metals, essential fatty acids
• Prolonged anemia
? Confounding environmental variables
Developmental delay and Childhood Disability
• Factors adversely affecting development
• Perinatal: traumatic labour, hypoxic ischemic encephalopathy,
intraventricular hemorrhage,
• Postnatal: neonatal seizures, infections, symptomatic hypoglycemia,
hyperbilirubinemia
• Miscellaneous:
Socio-environmental influences-
- Low socioeconomic status -
- A key determinant of development during the first 5 years
- Child abuse & neglect
Disease states-e.g. severe epilepsy, certain neurological infections &
disorders, chronic debilitating illness
Childhood Disability – Associated problems
Speech and Language
Hearing and Vision
Epilepsy ,
Behavior Problems
Feeding and Nutrition
Co-morbidities
Non Accidental Injury
• Death due to abuses – most common in infancy
- of severe head injuries in infancy 95% are due to abuse
• Pattern of NAH injuries in infancy –
• Skull rib and long bone fractures,
bruising anywhere
retinal hemorrhages
subdural hematomas
• Poverty, Drugs and alcohol, unwanted child
Long-Term Consequences of Child Abuse and Neglect
• Factors Affecting -
• The child's age and developmental status when the
abuse or neglect occurred
• The type of abuse (physical abuse, neglect, sexual
abuse, etc.)
• Frequency, duration, and severity of abuse
• Relationship between the victim and his or her abuser
• (Chalk, Gibbons, & Scarupa, 2002 )
• Physical, psychological, behavioral, and societal
consequences
Non-organic failure to thrive
• Typically develops in the early months of postnatal life; may develop later
• Long term deficits in physical growth, cognitive functioning and emotional
and social development, inadequate nutrition
• Development delays ,behavioural and emotional signs are frequent
• Risk factors -
• Poor Maternal attachment
- Unwanted pregnancy or the result of rape or abuse
- Maternal postnatal depression, drug or alcohol abuse,
- Domestic violence,
• Less frequent verbal and physical contact less positive reinforcement and
warmth
• Lack of parenting skills, emotional hostility, parental indifference,
withdrawal and rejection common features of NOFIT emotional abuse and
neglect - links with physical and sexual abuse
Disasters
• Sikkim earthquake
• More than 200,000 hit by floods in India, Nepal
• Kathmandu July 13, 2011
• Millions of Pakistan children at risk of flood diseases
Asia Pacific region vulnerability
Over 50% of the total world disasters
Over 70% of lives lost to disasters occur
in this region
75% of global flood mortality risk is in
Bangladesh, China and India
GDP losses of between 2-20%
Consequences -Child – Poverty, malnutrition,
diseases, separation from parents, loss of school etc etc
How to Reach In homes
Anganwadis
Construction sites
At Risk Children
Slums
Day-care-centres
Creches
Follow up clinics
the reality…
…and the inequity…
Can be enrolled for Child to Child Education
programme !
Little Mothers !
What needs to be donePolicy and Action Implications
• Ongoing care from the beginning of pregnancy
through the birth of a child and into adolescence
particularly the girl child
• Antenatal care
• Perinatal care
• Early detection and early intervention
• Provision of child care support to working
mothers
• Promote female literacy / family education /life
skills
• LIFE CYCLE APPROACH !
Physical
Motor
Social
Cognitive
Emotional
Sensory
Child Development
ECD Multidimensional and
Multifactorial
EIP
Teach mothers to interact and communicate better with
their children
Provide information to parents on child management and development
Provide appropriateexpectations for children
and general social support
Enhance the child ‘s intellectual language and social competence
Remove externalrisk factors
Place children in developmentally enriching
settings
Train parents in responsiveness and effectiveness
Provide continuouspositive redirection
and focused building skills
The value and availability of early intervention programs
The benefits of EIP clearly depend on early detection and early referral
PED 96, 95, 97, 2001. PED REV 2000 & 2001
Optimize theabilities of the
families to meetthe special needsof their children
Educational
Neuro-protection
Early interventio
n
Early education (advantage of cerebral
plasticity)
(All interventions to promote normal development and
prevent disability) organizational, therapeutic,
environment – modifying measures
Programs involving parents
most successful !!
Health and
nutrition
Conducive Environme
nt
• Deprived of a stimulating environment, a child’s brain
suffers -children who don’t play much or are rarely touched
– adverse effects on development
• Rich experiences produce rich brains
• Importance of hands-on parenting
• An urgent need for well designed preschool programs
Importance of A Stimulating Environment
Health PromotionHealth Promotion: the science and art of helping people
change their lifestyle to move towards state of optimal health
Strengthen health systems by involving communities in preventative public health interventions
Change attitudes towards the girl child
Partnerships
• Government Department
• Health authorities & Trust
• Primary Health care team
• Hospitals
• Professions allied to medicine
and early childhood education
• Local authorities
• Community groups & Voluntary
organizations
• Schools
• Mass Media
Building and connecting bridges
It is partnership at different levels and
among different stakeholders including government, medical
associations, academics and civil society that is
difficult to realize.
Key stakeholders
Policy and Action Implications
• Universal immunization
• Addressing malnutrition
• Most of these children can be successfully treated at home
with ready-to-use therapeutic foods (RUTF).
• Vitamin A syrup to all children 9-59 months in priority states.
• Zinc supplementation along with Oral Rehydration Salts (ORS)
for the treatment of childhood diarrhoea in priority states.
• Iodized salt –compulsory, cheap.
• Double fortified salt (DFS), iodine and iron, for the most vulnerable.
• Expand iron and folic acid (IFA) programs
for preschool children, adolescent girls, pregnant and lactating women.
• Wheat flour fortification,
• Micronutrient supplementation programs .
Convention on the Rights of the Child
• 20th anniversary - 20 November 2009,
• Signed by every country in the world, and currently ratified into law by all
but two
• Activities covered
• Exclusive breastfeeding
• Vaccines, Routine immunization
• Malaria prevention
• Micronutrient Supplementation
• Improved drinking water
• Primary school enrolment and completion
• Gender parity in primary education
• Reduction of HIV prevalence and HIV treatment
• Child protection as a holistic concept, offering children the right to be
safeguarded against a broad spectrum of violence, exploitation, abuse,
discrimination and neglect
ICDS
• Launched on 2nd October 1975,, ICDS Scheme
world’s largest programmes for early childhood development..
• Objectives:
• Improve the nutritional and health status of children in the age-group
0-6 years;
• Lay the foundation for proper psychological, physical and social
development of the child;
• Reduce the incidence of mortality, morbidity, malnutrition and school
dropout;
• Achieve effective co-ordination of policy and implementation amongst
the various departments to promote child development; and
• Enhance the capability of the mother to look after the normal health
and nutritional needs of the child through proper nutrition and health
education
ICDS
• Services:
• Supplementary nutrition,
• Immunization,
• Health check-up,
• Referral services,
• Pre-school non-formal education and
• Nutrition and health education
Helping children with special needs
Children With Special needs Learning
Conclusions
• Under three children are in the critical phase of development
and are vulnerable in the context of being at risk.
• Reaching this age group has many challenges.
• Infants cannot be considered in isolation, involvement of
parents particularly mothers, and even grandparents is
extremely important.
• Early comprehensive intervention programmes are required.
• Female literacy, health, family education, and parenting skills
are important issues.
• Building partnership between stake holders is essential for
any meaningful action.
Thank you